Corey Baker, a gay man in Columbus, Ohio, has seen many dating app profiles that include phrases like “Blacks — don’t apply.” Sometimes when he declines invitations, he said, men lash out with insults like “you’re an ugly Black person anyway.” And some of his friends have been slammed with the N-word in similar situations.

Many of these events occurred “when I didn’t think I was attractive or deserving of love,” he said. And they took an emotional toll. “If you’re experiencing a wall of people saying they’re not attracted to you, I think that does impact your mental health,” said Baker, who is 35 and a school librarian.

The notion of kinder, gentler rejections on hookup sites might seem like an oxymoron. Yet experts in sexual health — as well as users of gay meeting apps, like Baker — say the harshness of much online behavior can exacerbate low self-esteem and feelings of depression or anxiety. That toxic combination can also lead to impulsive and potentially unsafe sexual choices.

In response, Building Healthy Online Communities, or BHOC, an organization in the San Francisco Bay Area focused on HIV and STD prevention, has launched an effort to boost niceness on apps designed for men who have sex with men. “People in the LGBTQ community face discrimination externally, but we also have to acknowledge that there is discrimination within the community,” said BHOC director Jen Hecht.

Through surveys and focus groups, BHOC asked more than 5,000 users of nine gay apps how the sites could support better online behavior related to race, appearance, HIV status, age, disability, gender identity and other factors. It also sought advice on technical improvements the apps could make, such as offering users greater flexibility in conducting searches for contacts.

“If I can filter out people who wrote ‘no fats, no fems, no black people,’ I don’t even have to deal with seeing it,” wrote one respondent quoted in BHOC’s report on the data gathered from app users. Representatives for some of the participating apps said they welcomed the collaboration. “We’ve had a non-bullying policy since day one,” said David Lesage, marketing and social media director for Adam4Adam.

Mean online behavior is, of course, not limited to apps for men. When asked last month by email whether meeting sites that cater to the general population should also be trying to address the issue, Evan Bonnstetter, Tinder’s director of product policy, responded that the company was “unable to participate in this opportunity.” (Bonnstetter has since left Tinder.) Bumble, another site popular with heterosexuals, did not respond to a request for comment.

Gay and bisexual men, like other groups that face discrimination, have higher rates of depression, substance misuse and related mental health concerns. But John Pachankis, an associate professor at the Yale School of Public Health who studies gay men’s health, said his research has identified aggressiveness within the gay community as a major problem.

“I was initially quite surprised that gay men were consistently noting their treatment at the hands of other gay men as being a predominant stressor,” Pachankis said. Apps, he added, “are a site of a lot of potential rejection in a short amount of time in a way that is particularly anonymous and efficient and can be really detrimental.”

In one study, Pachankis and his colleagues simulated a gay app environment in which some research participants were exposed to dismissive comments and others to approving comments. (The comments were all computer-generated.)

In subsequent responses on questionnaires, the men exposed to the dismissive comments reported greater emotional distress and expressed more skepticism about the benefits of condoms. They were also more likely to choose riskier options in a card-playing game.

Given that the app environment is the source of stress, Pachankis said, it makes sense for BHOC and other public health organizations to try to influence it

Some respondents quoted in the BHOC report dismissed the initiative as silly or unwarranted. “If someone does not meet the preferences specified by the user for being ‘fat,’ ‘too old,’ or not the right ‘race,’ then too bad,” wrote one. “I find this overreach in striving to be PC as offensive and ridiculous.”

But most respondents recognized that apps could support better online behavior and reduce unnecessary pain, Hecht said.

“It’s a society-wide problem, and I do agree that gay men’s dating apps are not going to single-handedly address it, but that doesn’t mean they can’t play a role,” she said. “To the extent that the users get to control and customize, that will increase their positive experiences on the apps and decrease the likelihood that they’ll have these negative experiences.”

One popular recommendation from respondents was to allow all users, and not just paying customers, to block anyone they feel is being abusive. Another was to allow users to restrict who can see profile fields with potentially sensitive information, such as HIV status or gender identity. Respondents also believed apps could help diminish the pain of rejection by providing neutral, pre-written messages for users to send, such as “sorry, it’s not a match.”

Grindr, one of the participating apps, does not include standard rejection statements but is exploring this option to help users on both sides of what is inevitably a “high-intensity moment,” said Jack Harrison-Quintana, the company’s director of equality.

“It’s very easy to feel very rejected because you are getting rejected,” Harrison-Quintana said. “People experience a lot of hurt from things that are said to them online, and that is what we are trying to address.”

Jehangeer Ali Syed, an international development consultant in Washington, D.C., said he has been disturbed by being treated as an “exotic element” in online exchanges. Although he is not from the Middle East, some men “sexually objectify me as an ‘Arab stallion,'” said the 36-year-old Pakistani. “I have been called a ‘sand-[N-word],’” he added.

This sort of encounter, he said, “makes you doubt yourself, makes you feel insecure and makes you question if I’m doing anything wrong.”

BHOC noted in its report that many respondents were unaware of existing app features that could help them customize and control their experiences. The report called for apps to expand their educational efforts about these possibilities.

That suggestion resonated with Grindr’s Harrison-Quintana. Grindr already includes some of the options recommended in the report, he said, but it could do a better job of communicating with customers. “It’s not just about implementing features, it’s also about maybe letting users know those features are available to them,” he said.

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After Andersen returned to her job as an information systems project manager in the San Francisco Bay Area, she struggled with profound fatigue, cognitive difficulties and other disabling complaints. For six months, she tried to keep awake during meetings and finish basic tasks that took much longer than before.

Finally, she decided to retain legal help so she could take advantage of the disability insurance coverage offered as an employee benefit. “I realized this is not going to be a short-term thing,” Andersen said.

Hundreds of thousands of people around the world are experiencing what is being called “long covid” — a pattern of prolonged symptoms following an acute bout of the disease. Many have managed to continue working through accommodations like telecommuting, cutting down on hours and delegating responsibilities.

Others have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits. But as they pursue the application process, they are discovering a particular set of challenges.

Given the lack of testing in the first months, many “long haulers,” like Andersen, have no laboratory proof of infection. While antibody tests can provide such evidence, their accuracy varies. Moreover, many of the reported symptoms, including fatigue and cognitive impairment, are subjective and not clearly linked to specific organ damage.

Beyond that, compiling a thorough record for a disability application and navigating the bureaucratic hurdles require sustained brain power, something many long-haul patients can no longer muster. Barbara Comerford, a New Jersey disability lawyer, said she received dozens of inquiries starting last fall from long haulers seeking advice on filing for disability and often citing what is being called “brain fog” as their main complaint.

“Most are people calling to say, ‘I thought I could do it. I can’t. My mind doesn’t function for more than really brief periods of time,’” Comerford said. She gave a presentation to the New Jersey State Bar Association in mid-February on how to develop evidence for such cases.

In the U.S., close to 30 million people have tested positive for the coronavirus, although many cases of infection are asymptomatic. What proportion might be affected by long-term illness isn’t known. Scientific understanding of the phenomenon is in its infancy.

In January, that around three-quarters of more than 1,700 covid patients who had been hospitalized in Wuhan, China, reported at least one ongoing symptom six months later. More recently, investigators from the University of Washington that around 30% of 177 patients who had tested positive for the coronavirus still reported symptoms when they were surveyed one to 10 months later.

The Social Security Administration provides long-term disability to American workers who qualify under , but applicants often get turned down on the first try. A few states, including California and New York, provide short-term disability benefits, in some cases for up to a year.

Tens of millions of Americans also have private disability coverage, most often as part of their employment benefit packages.

The maximum currently available to an individual through the Social Security Disability Insurance program is just over $3,000 a month. A typical private long-term disability plan might cover 60% of a beneficiary’s base salary, with a much higher maximum amount.

Sandy Lewis, a pharmaceutical industry researcher, fell ill last March with what she assumed was covid. She recovered but relapsed in April and again in May.

Through her employer-based insurance coverage, she received short-term disability for November and December, but the insurer, Prudential Financial, rejected her request for an extension. Soon after, she was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS, a debilitating illness that can be triggered by viral infections.

Lewis, who lives outside Philadelphia, is planning to appeal Prudential’s rejection of the short-term extension and apply for long-term disability. But the matter is unlikely to be resolved before fall. The situation has left her feeling “devastated,” she said, and in serious financial distress.

“This has been such an arduous journey,” she said. “I have no income and I’m sick, and I’m continuing to need medical care. I am now in a position, at 49 years old, that I may have to sell my home during a pandemic and move in with family to stay afloat.”

In Lewis’ case, a Prudential reviewer noted that her symptoms were “subjective” and that there were “no physical exam findings to correlate with any ongoing functional limitations,” according to Cassie Springer Ayeni, an Oakland disability lawyer who is representing her as well as Andersen.

Prudential would not comment on a specific case. Evan Scarponi, chief claims officer, said in a statement that “our collective understanding of covid-19 and any associated long-term effects are still evolving” but that Prudential is “well-versed in evaluating both subjective and objective aspects of disability claims.”

Lawyers and advocates in the field expect the numbers of covid-related long-term disability applicants to rise this year. But it’s still too soon to detect any such increase, said a spokesperson for the American Council of Life Insurers, a trade association. Workers typically must be unable to work for half a year before becoming eligible for long-term disability benefits, and applying can itself be a lengthy process.

Brian Vastag, a former Washington Post science and health reporter with ME/CFS, stopped working in 2014 and then sued Prudential after it rejected his long-term disability claim. Insurance companies, he said, can easily find reasons to dismiss applications from claimants with chronic illnesses characterized by symptoms like fatigue and cognitive impairment.

“The insurance companies will often say, ‘There’s no objective evidence, so we have nothing to support your claim,’” said Vastag, who in 2018. “I’m worried about the long-covid patients who can’t work anymore.”

Claimants can appeal a rejection. If the insurer rejects the appeal, claimants have the right to sue, as Vastag did. However, most such cases fall under the . Because this federal law requires a losing insurer to pay the unpaid claims but does not provide for punitive or compensatory damages, critics argue it incentivizes the denial of coverage.

In the event of litigation, the court’s role is to assess the already existing evidentiary record. That means it is essential to present a robust case in the initial application or during the administrative appeal before any litigation begins, said Ayeni, the disability lawyer for Andersen and Lewis.

“It’s the only shot to build a record for the courts, to develop a full body of evidence,” she said.

However, a successful disability case ultimately depends on documenting inability to work, not on obtaining a specific diagnosis. To augment the medical evidence, Ayeni often sends clients for neuropsychological testing, investigations of lung function and other specialist assessments. She also gathers affidavits from family members, professional colleagues and friends to confirm patients’ accounts.

In Rickie Andersen’s case, the strategy worked. Recognizing how complicated the application process was likely to be, she sought legal help early on. The insurer contracted by her employer approved her for short-term benefits late last year and granted her application for long-term benefits in February.

“I knew all of it was completely exhausting, so it wasn’t something I thought I could do on my own,” Andersen said.

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Among them: Many people were wary of the unpleasant procedure, called a nasopharyngeal swab. It can be performed only by trained health workers, putting them at risk of infection and adding costs. And the swabs and chemicals needed to test for the virus almost immediately were in short supply.

Some places, like Los Angeles County, of saliva and sputum, with the process supervised at drive-thru testing sites by trained personnel swathed in protective gear. Meanwhile, researchers began investigating other cheaper, simpler alternatives to the tried-and-true approach — including dribbling saliva into a test tube.

But the transition has not been immediate. Regulators and scientists are generally cautious about new, unproven technologies and have an understandable bias toward well-established protocols.

“Saliva is not a traditional diagnostic fluid,” said Yale microbiologist Anne Wyllie, part of a team whose saliva-based test, called SalivaDirect, received emergency use authorization from the Food and Drug Administration in August. “When we were hit by a virus that came out of nowhere, we had to respond with the tools that were available.”

Eight months into the pandemic, the move toward saliva screening is gaining traction, with tens of thousands of people across the country undergoing such testing daily. However, saliva tests still represented only a small percentage of the more than 900,000 tests conducted daily on average at the end of September.

Yale is providing its protocol on an open-source basis and recently designated  as capable of performing the test. Besides the Yale test, the FDA has authorized emergency use of several others, including versions developed at Rutgers University, the University of South Carolina and SUNY Upstate Medical University. A further advance,Ìý,Ìý be headed for FDA authorization, too.

Since the start of the pandemic, the Trump administration’s approach to testing has been hampered by missteps and controversy. As a key health agency during an unprecedented emergency, the FDA’s effectiveness relies on public trust in how it balances the need for speed in authorizing innovative products, like saliva tests and vaccines, with ensuring safety and effectiveness, said Ann Keller, an associate professor of health policy at the University of California-Berkeley.

“You obviously want to get new tests into the mix quickly in order to address the emergency, but you still need to uphold your standards,” Keller said. The White House’s public pressure on the FDA has complicated the agency’s efforts by undermining its credibility and independence, she said.

Respiratory viruses colonize areas inside the nasal cavity and at the back of the throat. Besides the nasopharyngeal approach, nasal samples obtained with shorter and less invasive swabs have proven effective for the coronavirus and have become widely adopted, although they also generally require a health care worker’s involvement. The millions of rapid tests that will be distributed across the country, per , rely on nasal swabs.

In the early months of the pandemic, some studies reported significant levels of the virus in oral secretions. In , for example, the virus was found in the saliva of 11 of 12 patients with confirmed coronavirus infection.

In Los Angeles, , more than 10,000 samples are collected per day, said Fred Turner, chief executive of Curative, the company that developed it.

Turner sees an advantage to the swabbing strategy. The self-swab procedure takes only 20 to 30 seconds, while producing enough saliva for testing can take people two to three minutes, and sometimes longer, he said. “That might not sound like much difference,” Turner said, “but it is when you’re trying to push 5,000 people through a test site.”

Curative’s three labs process tens of thousands of tests from jurisdictions across the country in addition to L.A., Turner said. A , which is expected to become available at state labs around New York, also uses an oral swab.

For the Curative test, a health care worker is supposed to oversee the sample collection —reminding people to cough to bring up fluids, for example. When investigators at the University of Illinois launched what they called a “Manhattan Project” to develop a saliva test by mid-June, they hoped to make it possible for people to visit a collection site, drool into a test tube, seal it and drop it off without the aid of a health care worker.

The university is now testing more than 10,000 people a day at its three campuses and is seeking to expand access to communities across the state and country, said chemistry professor Paul Hergenrother, who led the research team. Like the similar Yale test, it is being made freely available to other laboratories. The University of Notre Dame, in Indiana, recently adopted it.

Like tests using nasopharyngeal and other kinds of nasal swabs, these saliva tests are based on PCR technology, which amplifies small amounts of viral genetic material to facilitate detection. Both the Yale and University of Illinois tests have managed to simplify the process by eliminating a standard intermediate step: the extraction of viral RNA. Their protocols also don’t require viral transport media, or VTM — the chemicals generally used to stabilize the samples after collection.

“You don’t need swabs, you don’t need health care workers, you don’t need VTM, and you don’t need RNA isolation kits,” Hergenrother said.

In , the Yale team reported detecting more viral RNA in saliva specimens than in nasopharyngeal ones, with a higher proportion of the saliva tests showing positive results for up to 10 days after initial diagnosis.

The National Basketball Association provided $500,000 in support for the Yale project, said David Weiss, the NBA’s senior vice president for player matters. He said the Yale team’s decision to eliminate the process of RNA extraction, which separates the genetic material from other substances that could complicate detection, involved trade-offs but did not compromise the value of the test.

“Any molecular test that has an RNA extraction step is almost by definition going to be more sensitive, but it will also be more expensive and take longer and use supplies that are in shorter supply,” he said. “If we’re trying to look at surveillance testing to open up schools and nursing homes, a test that’s still very sensitive and a lot cheaper is an important innovation.”

Prices for coronavirus tests vary widely, running upward of $100. Tests based on the Yale or University of Illinois protocols, which require only inexpensive materials, could be available for as little as $10. The Curative testing service, which includes collection and transportation of samples as well as the laboratory component, averages around $150 per test depending on volume, said Clayton Kazan, chief medical director of the L.A. County Fire Department, which uses the tests.

Despite the advances in sample collection, tests using PCR — polymerase chain reaction — technology still require laboratory processing. Researchers have been investigating other approaches, including saliva-based antigen tests, that could be self-administered at home and would provide immediate results. (While PCR can detect coronavirus genetic material, antigen tests look for viral proteins that can signify a current infection.)

At least it is seeking emergency use authorization for a saliva antigen test, although two others have dropped plans to develop their own versions as infeasible, . Meanwhile, scientists at Columbia University, the University of Wisconsin and elsewhere are investigating the use of saliva with other kinds of rapid-test technologies.

“There’s tons of interest” in an at-home saliva test, noted Yvonne Maldonado, chief of pediatric infectious diseases at Stanford University School of Medicine.

“People really do want to get that pregnancy-type kit out there,” she said. “You could basically send people a little packet with little strips, and you pull off a strip every day and put in under your tongue.”

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“They say, ‘I haven’t had any contact since I saw you last, so there’s no need to do any STD tests,’” said Klausner, an adjunct professor of epidemiology and infectious diseases at UCLA.

But attitudes among these patients are shifting, Klausner has noticed, now that California and other states are loosening policies on social distancing. “People are starting to think about a return to engaging [in sex],” he said, “and are asking me, are there ways they can remain safe” from COVID-19?

Concerns about sexual intimacy during an epidemic are universal and not limited to gay men, of course. Public health experts, including those long involved in HIV prevention, recognize that a proportion of all people are likely to ignore or reject categorical mandates about sexual behavior — whether they involve using condoms or limiting contact because of social distancing norms.

“It didn’t work when we had to deal with HIV, and it won’t work in dealing with COVID,” said Pierre-Cédric Crouch, a clinical nurse researcher at the University of California-San Francisco, and an expert in HIV prevention.

The coronavirus is known to spread through oral and nasal secretions but not specifically through sexual intercourse. In New York City, the health department issued that counsel against sex with those outside your household but advise those who choose otherwise to “have as few partners as possible.”

The guidelines, which note that “kissing can easily pass the virus,” suggest that people “make it [sex] a little kinky” by being “creative with sexual positions and physical barriers, like walls, that allow sexual contact while preventing close face to face contact.” In the Netherlands, the government has advised single people considering sex to find a symptom-free sexual partner.

For many gay men, especially in urban areas, sexual exploration with multiple partners is a way of life, whether single or not. Many committed male couples maintain open relationships.

Research supports the notion that gay men tend to have more sexual partners than do heterosexuals. A 2012 among adults ages 18 to 39 noted that men who have sex with men (a phrase often used in scientific studies that focus on sexual behavior rather than sexual identity) “reported significantly more lifetime partners than heterosexual men and women at all ages.” In the 35-39 age group, the median lifetime number of sexual partners reported by men who have sex with men was 67, compared with 10 for heterosexuals, according to the study.

Damon Jacobs, a therapist with many gay clients, lives alone in Brooklyn and remained celibate for the first month of the lockdown. At that point, he said, he reached out to a regular and trusted sexual partner.

“He’d also been alone for four weeks except for going outside for groceries, and he also had zero symptoms,” said Jacobs, 49.

“So we got together and started hanging out again,” Jacobs added. More recently, he has met up with several other partners after asking about their social distancing practices. He has also found many of his clients dealing with similar issues after months of being on their own.

“Human beings can cope with certain levels of pain and suffering for a specific amount of time if they perceive an ending,” said Jacobs. After more than two months, he added, people who have been physically isolated are “starved for touch.”

A mid-April provided a snapshot of how the coronavirus had affected sexual behavior. While about half reported fewer sexual partners than before the pandemic, only 1% reported more, with 48% reporting no change. (The survey did not ask about the number of partners or whether sex was with a household member.)

Many gay men remain cautious. Lewis Nightingale, a retired graphic designer in San Francisco who lived in New York during the early years of the AIDS epidemic, said he had spent much more time using online apps such as Grindr and Scruff to flirt and sext with other men.

He has received, and turned down, occasional invitations to meet up in person, he said. As an older man, he knows he is in a higher risk group for coronavirus complications. But refraining has been challenging, he said, since expressing himself sexually has played such a big part in his life. “For a lot of gay men, sex is pretty essential for a feeling of connection, for excitement, for validation,” said Nightingale, who has been in a relationship for 16 years.

Last month, Eric, a 42-year-old male escort in Manhattan who asked that his last name not be used, began weighing when and how to return to work. A former occupational therapist whose husband is a physician, he shut down business in mid-March and finally started seeing clients again earlier this month.

For now, he plans to limit scheduled appointments. He intends to see only those he knows well enough to believe they are truthful about routinely wearing masks and being symptom-free. And he is meeting people at his home rather than in a hotel room or their place. “I figure if I have people coming here, I’m only exposed to that person’s germs,” he said.

Eric also plans for now to avoid clients who have attended recent protests against police brutality. “I support the protests 1,000%, but I think they are probably pretty good breeding ground for the virus,” he said. “I don’t want to take that risk.”

In advising his gay patients about sexual activity, Klausner, the Los Angeles physician, said he tries to put the risk in context. The majority of coronavirus cases, he noted, have emerged from workplace and residential settings, such as meatpacking plants and nursing homes, as well as big indoor gatherings, such as concerts and religious services. Although the virus can be transmitted one-to-one in more intimate contexts, he said, “individual risk is really driven by people’s potential exposure to these crowded settings.”

A common misperception — that actions can be clearly defined as risky or not risky — can hamper understanding of other people’s actions, said Julia Marcus, a Harvard epidemiologist and HIV prevention expert. As restrictions on social distancing relax, she said, almost everyone will be making choices and engaging in activities that involve some level of risk — yet will likely be judged by various standards.

“There are very few zero-risk situations,” she said. Unfortunately, she added, “the gay guys are going to be shamed for hooking up, while the straight people having dinner together are less likely to be shamed.”

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Since late March, three Southern California jurisdictions ― Los Angeles County, and the cities of L.A. and Long Beach ― have offered a more palatable alternative to this nasopharyngeal sampling, whose very name poses a challenge. At 21 drive-thru sites,

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San Francisco’s public health department and the San Francisco AIDS Foundation have long promoted what is known as preexposure prophylaxis, or PrEP, for those at high risk of contracting HIV. With regular PrEP, the daily pill is taken indefinitely. But both organizations now endorse a strategy that requires taking just four pills timed to a specific sexual encounter — two within two to 24 hours before sex and one on each of the two following days.

They believe this approach will make PrEP more palatable to people who are ambivalent about the medication because of the cost, fear of potential side effects, mistrust of pharmaceutical companies or a general dislike of taking drugs.

The new strategy, called “2-1-1” or “on-demand” PrEP, is becoming popular overseas but has gotten little traction in the United States thus far. It has been proven effective only among men who have sex with men and is currently not recommended for women.

Proponents say the approach can work well for men whose encounters are intermittent and predictable: people in long-distance relationships who know when they will be with their partners, for example, or individuals who occasionally go out to pursue sexual activity.

The approach is not suitable for those who cannot plan for sex at least two hours in advance.

“There are people who really object to taking a pill every day if they’re not having sex that frequently,” said Dr. Oliver Bacon, a deputy director and physician at the San Francisco Department of Public Health. The on-demand approach, he added, “extends PrEP to people who actually need it based on the sex they’re having but wouldn’t take a daily pill.”

Since the Food and Drug Administration approved daily PrEP use for HIV prevention in 2012, more than 200,000 people in the U.S., most of them men who have sex with men, have taken the drug. But people are at risk for HIV infection and could benefit from the treatment, according to the Centers for Disease Control and Prevention.

The list price of the PrEP drug, sold by Gilead Sciences under the brand name Truvada, is when taken daily — though patients generally do not pay that much out of their own pockets.

Insurers typically cover much or most of the cost, but many have been onto patients in recent years. Help may be on the way, however.

Following a recommendation by the U.S. Preventive Services Task Force that doctors offer PrEP to at-risk patients, most health plans will be — though not the clinical and lab services that accompany its use.

And Gilead agreed earlier this year to enough Truvada to cover 200,000 patients annually for up to 11 years, though critics argue that cutting the price would be a more effective way to increase access.

Gilead declined to comment on the on-demand approach for using the drug.

Don Kirchman, a self-employed building developer in San Francisco who is on Medicare, started the on-demand regimen last year after discussing it with his doctor. He had previously taken Truvada daily, but then experienced heart trouble and a related drop in sexual interest and activity.

The new approach meets his current needs, because he prefers not to take unnecessary medication and is concerned about his out-of-pocket drug costs, he said. “There are times when I don’t feel like I’m in a sex cycle or I have a health issue that I’m concentrating on, so I’m not putting my attentions towards dating or hooking up,” Kirchman said.

In San Francisco, the health department issued an HIV update in February for local providers, suggesting they “consider” on-demand PrEP for men who were “ambivalent” about taking a pill every day. The department’s City Clinic began offering the option as a second-best choice for those reluctant to adopt the standard PrEP method.

In March, the San Francisco AIDS Foundation began formally enrolling men for on-demand PrEP at its Strut clinic in the city’s Castro district. In contrast to the health department, the foundation has presented on-demand and daily strategies as equal options. In the first two months, about a fifth of those who got PrEP at the clinic chose to take it on demand.

Since 2015, has found on-demand PrEP to be effective at preventing HIV. Advocacy groups and health agencies in France, Netherlands, Australia and elsewhere have promoted it. The World Health Organization this week during an international AIDS conference in Mexico City.

So far, neither the CDC nor the FDA has endorsed the on-demand approach. But Bacon, of the San Francisco public health department, said the city’s experience is being closely watched and he has fielded questions about the initiative from health officials in New York, Seattle and elsewhere.

A big challenge public health officials face with PrEP is that its adoption has been among men of color than among whites. African Americans and Latinos are more likely to have undiagnosed or untreated HIV, so boosting awareness and use of PrEP is viewed as a key strategy for preventing infections.

Chicago physician John Schneider said the African-American gay and bisexual men he sees at a South Side clinic tend to distrust the health care establishment, including drug companies, because of a legacy of medical discrimination. “Patients don’t like taking a lot of pharmaceutical products,” he said.

Though Schneider generally recommends the standard once-a-day PrEP regimen, he said he sometimes suggests the on-demand approach for patients whose sexual behavior is compatible with it, if they struggle with taking a pill every day.

Some people who want PrEP but prefer to minimize their consumption of it have adopted a different non-daily strategy: a four-day-a-week approach known in the United Kingdom as the “T’s and S’s,” in which pills are taken on Tuesdays, Thursdays, Saturdays and Sundays.

Earlier found that four pills a week conferred a high level of protection.

Timothy Price, an HIV prevention coordinator at the Northeast Indiana Positive Resource Connection, a Fort Wayne HIV/AIDS services organization, said he had relied on the T’s and S’s to limit his consumption of Truvada after a dispute with his insurance company involving prescription refills.

Price, a 56-year-old gay man, said he understood the science and knew he could safely reduce his intake to make his pills last longer. “I had a long period of time when they refused to fill it, so I decided after that I needed to build up some kind of cushion,” he said.

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Because of her developmental disability, Ava, now 15, requires general anesthesia for non-routine dental work. The dentist, like most of his peers, was not equipped to provide it.

The girl’s parents, schoolteachers who live in Huntington Beach, Calif., called other dental offices in the region. They were turned down dozens of times before finally finding a dentist prepared to work with an anesthesiologist to treat their daughter.

But there was a hitch: Insurance would not cover general anesthesia for root canals. So Ava’s parents decided to pay the $2,400 from their savings to ensure their daughter received prompt care.

“What about kids who don’t have parents who are professionals or who have no one to advocate for them?” wondered Donny Terranove, Ava’s father.

People with autism, cerebral palsy and other developmental disorders face enormous barriers to adequate and timely dental care — on top of their other challenges. Many dentists either avoid treating these patients or lack the skills needed to do so. Some patients with developmental disabilities are unable to endure even regular dental exams or cleanings without general anesthesia.

But most dentists don’t offer it and getting insurance to cover it for routine dental work is often a struggle.

Because it is difficult for them to get treatment, people with developmental disorders suffer “a high burden of dental disease,” according to a of over 4,700 patients published in the Journal of the American Dental Association. One-third of the patients studied suffered from untreated cavities, and 80% from serious gum infections.

“Many individuals with developmental disabilities cannot personally maintain their own dental hygiene,” according to by the California Legislative Analyst’s Office (LAO). “Often they need extra appointments or special accommodations that dentists are unable or unwilling to provide.”

In many cases, patients need these extra appointments to help them get accustomed to the environment of a dental office, including the equipment, procedures and personnel. This can help minimize their anxiety and reduce the need for deep sedation or general anesthesia.

But sometimes there is no alternative to anesthesia.

Mike Loughran, 54, of Tacoma, Wash., has a 14-year-old son with Down syndrome and autism. After years of failed attempts to complete a basic checkup, Loughran and a willing dentist concluded that the child should have general anesthesia for any and all dental work. That led to hefty charges.

For one routine, 45-minute exam that uncovered no problems, the anesthesia bill was $1,155. Loughran’s insurer, Tricare, adjusted it down to $912 — a sum he described as “very reasonable.” But the hospital charged nearly $21,000 for the operating suite. Tricare agreed to coverage and negotiated the price down to about $15,000. That left Loughran with a $2,500 out-of-pocket copayment. He later got the state’s Medicaid program to cover most of that amount as his son’s secondary insurer.

Still, Loughran was taken aback by the astronomical amount charged for his son’s care. “The whole idea of it costing that much to get a dental exam, and you’re supposed to do that a couple of times a year — it was just stunning when I got the bill,” he said. “I don’t think I would take him to the operating room anymore.”

Without access to regular cleanings and other preventive care, “you get to the point that you need anesthesia because you’ve had a little problem that’s gotten big,” said Eileen Crumm, executive director of Family Resource Navigators, an advocacy group in Alameda County.

To accommodate the many patients who do need general anesthesia, some hospitals and regional centers for the disabled allocate a limited amount of surgical time for dental care. But because of the strong demand for these services, it can take many months or even more than a year to reserve an available operating slot, patient advocates say.

Like the Terranoves, Mariana Murillo had trouble finding appropriate care a few years ago for son Oscar, 20, who has cerebral palsy and cannot communicate verbally. Oscar, a teenager at the time, was in pain from impacted wisdom teeth, and his regular dentist said an oral surgeon would have to extract them. But Murillo, who lives in Lompoc, Calif., had difficulty finding one who would accept Denti-Cal, the state’s Medicaid-funded dental coverage for low-income people.

Murillo ended up paying $1,600 out-of-pocket to an oral surgeon. The surgeon agreed to extract Oscar’s four wisdom teeth while the boy was already under general anesthesia for the removal of a benign growth on his tongue — a procedure covered by Oscar’s medical insurance.

“Our financial situation is not great, but it was not too bad,” said Murillo. “Knowing Oscar was going to be free of that pain, we decided to do it.”

In some states, officials and private-sector organizations are trying to address this large unmet need among patients who may suffer in silence, unable to articulate their distress.

New Mexico, for example, has a that entitles dentists who have completed a special training program to an extra fee of $90 each time they treat a patient with developmental disabilities. And New York University’s College of Dentistry recently opened a strictly for the care of people with disabilities.

In California, most patients with developmental disabilities are eligible for care under Denti-Cal, but only a fifth of dentists in the state accept it. And only a fifth of developmentally disabled patients with Denti-Cal received even one dental service in 2014, 2015 or 2016, according to the LAO report.

Last year, to increase payments to Denti-Cal providers for the 2018-19 fiscal year — up $70 million from the amount of tobacco tax money it had earmarked for that purpose the previous year. Federal matching dollars bring the total amount of new money for the program to as much as $600 million. The most recent boost will help pay for the additional time needed to treat patients with special needs, as well as for anesthesia.

A particularly difficult challenge for patients with developmental disabilities is the transition from pediatric to general dentists as they age, said Dr. Joseph Castellano, president of the American Academy of Pediatric Dentistry, who practices in Laredo, Texas. That’s because pediatric specialists generally receive some training in working with that population, whereas general dentists tend to have little or no such experience.

“A lot of times [patients] will just stay in the [pediatric] practice,” Castellano said. “We know the patients and are comfortable with them, and they and the families are comfortable with us.”

Dr. Wade Banner, a Southern California dentist, took the matter into his own hands in 2014, when he launched a mobile dental program and began making house calls to patients with developmental disabilities. Banner, who has a nephew with autism, said he wanted patients to receive basic care in an environment where they felt most comfortable and were less likely to require major sedation.

Noting the paucity of providers for patients who need general anesthesia, Banner said, “one of my main goals in starting house-call dentistry was to prevent them from having to be put to sleep, if at all possible.”

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On Nov. 6, the Service Employees International Union-United Healthcare Workers West union hopes to deliver a stinging blow with a ballot measure designed to limit clinic profits.

Proposition 8, or the “Fair Pricing for Dialysis Act,” would cap dialysis clinic profits at 115 percent of the costs of patient care, with revenue above that amount to be rebated primarily to insurers. Medicare and other government programs, which pay significantly lower prices for dialysis, would not receive rebates.

It’s been a costly campaign, suggesting high stakes for both sides. The union, which sponsored the initiative and represents and other health care workers in California, so far has invested nearly $17 million in the effort.

Two leading national for-profit dialysis companies, DaVita and Fresenius Medical Care, dominate California’s market and are fighting back hard, contributing more than $40 million and $22 million respectively to defeat the measure. Overall, dialysis companies have raised more than $72 million to oppose the initiative.

In California, close to 70,000 patients need regular dialysis, which essentially performs the function of kidneys for patients whose own kidneys are failing. DaVita and Fresenius control 70 percent of the nation’s market. Between them, they reported more than $4 billion in operating profits last year.

Proponents say the initiative would spur clinics to reduce executive salaries, increase investment in patient care and lower the prices for patients with private insurance.

“It will allow these companies to make good profits, but not the obscene profits they make now,” said Steve Trossman, a spokesman for the union and the “Yes on 8” campaign.

Opponents argue the issue is too complicated to be decided at the polls and that it could reduce patients’ access to care, causing the vast majority of clinics to lose money and forcing many to shut down.

Fresenius and Davita referred questions on the initiative to the “No” campaign. But in an , DaVita CEO Kent Thiry said the passage of the initiative in California would have mostly “unsustainable” effects on dialysis centers.

A win for the union, known as SEIU-UHW, could encourage similar efforts elsewhere, said Laurel Lucia, director of the health care program at the Center for Labor Research and Education at the University of California-Berkeley.

“The initiative addresses a national problem,” she said. “If the policy is implemented successfully here, it wouldn’t be surprising if it spread to other states.”

Similar measures pushed by the union in Ohio and Arizona did not make the ballots for this November’s election.

The initiative is part of the union’s wide-ranging campaign to force changes in the dialysis industry. In August, California legislators approved a bill promoted by the union that would have effectively capped reimbursement rates for dialysis clinics. While that was perceived as a solid victory for SEIU-UHW, Democratic Gov. Jerry Brown vetoed the measure last month.

A few years ago, SEIU-UHW began organizing among dialysis clinic workers, raising concerns about poor sanitation, high infection rates, understaffing, exorbitant prices for those covered by private insurance and other problems. The union ramped up its efforts on the ballot measure after legislative attempts to address some of the issues stalled last year.

Since 2012, the union has spent tens of millions of dollars on multiple state and local ballot initiatives in California relating to a wide range of health care issues, including access to affordable insurance, hospital and clinic funding, and training for in-home supportive services.

In 2013, for instance, SEIU-UHW launched ballot measures in California targeting hospital pricing and executive pay, and opponents accused the union of abusing the ballot process to force compliance with its demands.

According to Thad Kousser, a professor at the University of California-San Diego and an expert in the legislative process, the strategy of using ballot measures for political leverage is standard practice and not unique to SEIU-UHW. Even if the dialysis initiative is defeated, Kousser said, the effort will likely provide the union with a bargaining edge in future negotiations.

“It strengthens the union’s hand for future bargaining, even if it doesn’t win now,” Kousser said.

The union says it uses ballot measures to improve health conditions for all state residents, not just its members. “We made a decision as a union a number of years ago that in order to be successful, we couldn’t just be worried about our own members and our own narrow interests and have blinders,” Trossman said.

Nonsense, say critics.

“The spin from the SEIU-UHW is that the union is crusading for a healthier California, not trying yet again to get leverage over health-care employers,” declared an last year in the San Diego Union-Tribune. “Californians with failing kidneys have enough worries. They should not be political pawns.”

The “No on 8” campaign, citing findings from the Centers for Medicare & Medicaid Services, notes that California’s clinics rate higher than those in other states on quality-of-care measures, such as avoiding unnecessary transfusions, preventing infections and maintaining proper blood levels of calcium levels.

“The ‘Yes on 8’ people talk about a crisis in dialysis and that’s not even close to being the truth,” said Kathy Fairbanks, spokeswoman for the “No” campaign.

But other research, such as a 2014 study of Medicare beneficiaries nationwide, found that patients treated at for-profit clinics had higher hospitalization rates than those in not-for-profit centers.

In June, found DaVita liable for the deaths of three patients who suffered cardiac arrests following dialysis treatment, ordering the company to pay almost $400 million in damages. Witnesses had accused DaVita of failing to provide sufficient warning to doctors about the possible risks of a medication commonly used during dialysis. The company said at the time it would appeal. In 2016, Fresenius agreed to pay  to resolve thousands of lawsuits involving the same medication.

In the heated battle over next month’s ballot measure, both sides have lined up many dozens of endorsements from community and statewide organizations. Proponents have strong labor and Democratic Party support. The California Medical Association, and some other medical groups, along with many veterans’ and business organizations, back the “No” campaign, arguing that the change would put dialysis patients at risk.

The “No” campaign has spent millions on

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Pacing back and forth, the Florida dentist leading the two-day course advised the participants to stop thinking of themselves as tooth technicians and reposition themselves as “physicians of the mouth.”

“There is a medical part of our practice and a dental part,” said the presenter, Chris Farrugia, as audience members tapped on their keyboards or scribbled notes. “You have teeth, [and] you got the ‘other stuff.’ It’s the other stuff that medical insurance pays for.”

Faruggia’s seminar is a sign of a growing trend in dental offices, as providers seek greater reimbursement for expensive services and patients balk at big bills. Around the internet, firms have popped up claiming expertise in medical billing for dentists and offering courses and consulting services.

The reason is simple: Medical insurance is generally much more generous in its coverage than dental insurance.

Unlike medical coverage, dental insurance is mostly geared to the healthy — something many people don’t realize until they experience serious oral problems and get socked with unexpected costs. Standard dental insurance covers cleanings, fillings and other routine care. But major work like a crown or a bridge is often covered only at 50 percent and implants generally aren’t covered at all. And dental insurance is usually capped at $1,000 or $1,500 per year.

As a result, people who require extensive reconstructive work often pay many thousands of dollars, or sometimes tens of thousands, in out-of-pocket expenses. Many other people, even with dental coverage, go without care because they cannot afford the large balances or co-pays for crowns, root canals and other major procedures.

Because of these differences in reimbursement, Farrugia told his seminar attendees, dentists should first consider what medical insurance might cover and then bill the dental plan for the rest.

For example, he said, dentists should seek medical coverage for the full head, neck and mouth exams they perform when they see a new patient, since the goal is to assess more than just the teeth. Medical insurers should also cover oral problems attributable to an underlying medical condition, such as diabetes or dry mouth, a common side effect of many medications, Farrugia said.

Besides sparing patients the pain of big bills, the strategy can also boost income for dentists, said Farrugia, who estimated that revenues for his practice rose almost 10 percent the first year he fully implemented medical billing. Patients, too, can learn to file claims for medical reimbursement if their dentists won’t, he said.

On its website, the explains that health insurance should cover costs that are “medically necessary” and lists more than a dozen categories of procedures that could qualify. Among them: treatment related to inflammation and infection, dental repair due to injury, certain periodontal surgery procedures and appliances for sleep apnea.

Kristine Grow, a spokeswoman for America’s Health Insurance Plans, the industry trade association, did not dispute that some dental procedures could be covered by medical insurance. However, she cautioned that medical insurers were always on the lookout for abuse.

“Claims that are billed inappropriately or submitted fraudulently hurt everyone because they raise costs,” Grow said. “It’s important to note that procedures not related to an emergency event or trauma may not be medically necessary, and therefore would not be covered by medical insurance,” she added.

Asked about the potential for abuse, Farrugia said: “There are unethical providers in all health care services, and dentistry is not immune to that. You will always have some that try to game the system.”

Farrugia adopted medical billing several years ago after paying more than $100,000 for a CT scanner that produces 3-D images of the bone in the mouth and jaws.

“It occurred to me that this was a medical device,” he said of the CT scanner. “I’m a licensed health care provider, I’m providing this within the scope of my license. They can’t discriminate against me.”

Once he investigated the matter, Farrugia discovered that medical insurance could be asked to cover not just CT scans but a wide range of services regularly performed by dentists. He buried himself in the arcana of coding, ultimately writing three workbooks for dentists about medical billing.

At first it was trial-and-error, and Farrugia learned that claims often get rejected if they do not cite a medically legitimate reason for the procedure as well as the appropriate code.

These days, Farrugia bills medical plans $744 for a CT scan (medical code: CPT 70486), receiving an average reimbursement of about $500. Medical plans generally require pre-authorization for non-emergency CT scans, he said, so his office staff had to learn how to explain why the scan was medically required — such as to assess bone quality.

The same procedure can be billed to a dental plan (dental code: D0367), but the average reimbursement is $125 — if the plan covers CT scans at all.

Others are following his example. Iowa dentist Richard Downs attended one of Farrugia’s medical billing seminars last year in Chicago. “I’d never heard these things before,” he said.

He said he recently sought and received prior authorization from a medical insurer for $60,000 to cover multiple implants and other costs for a woman whose dental woes stemmed from severe atrophy of the jaw and other medical problems.

During a break in the seminar, San Ramon, Calif., dentist Rashpal Deol said Farrugia’s approach made sense. “We look at the soft tissues in the mouth, the muscles, the bone, the TM [temporomandibular] joint, and the head and neck area,” he said. “You always check the lymph nodes, we do oral cancer screening, so that is a comprehensive medical exam.”

Other seminar attendees also were enthusiastic, if a bit daunted. “People go to school to learn medical coding,” said Kelly Bradshaw, a staff member at a Santa Rosa, Calif., dental practice. “To try to bridge that gap in order to help our patients is intimidating. You have to be open-minded to look at things in different ways.”

Margaret Busch, an office manager for an Arizona dentist, said she planned to start medical billing as soon as she returned from the seminar.

“I’ve been making a list of people that we can go back and probably get money for,” she said, mentioning patients who have had CT scans and those with dental problems related to medical conditions like diabetes.

“I think they’ll be excited,” she said.

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This was how I learned all about the Great Divide between medicine and dentistry — especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.

For millions of Americans — blessed in some measure with good genes and good luck — dental insurance works pretty well, and they don’t think much about it. But people like me learn the hard way that dental insurance isn’t insurance at all — not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year — and that’s considered a decent plan.

Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren’t covered at all.

In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional .

Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.

My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis — a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. suffer from mild to severe forms of it.

My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries — and that was just the beginning. I’ve since had five more implants, more gum and bone grafts and many, many new crowns installed.

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At least I’ve been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children’s dental services, on whether to offer benefits for adults. And many dentists won’t accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.

The program typically pays as little as half of what they get from patients with private insurance. For example, as Kaiser Health News reported in 2016, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared with the $150 and $800 that private patients typically pay.

“It’s really a labor of love to do it,” said Dana Lubet, a recently retired dentist in Madison, Wis., who estimated Medicaid paid only a third of his costs. Accepting too many, he said, “could easily kill your practice.”

A few years ago, while in his mid-50s, Nick DiGeronimo, a facility maintenance worker at a New Jersey sports center, obtained private insurance coverage through the Affordable Care Act, hoping to get treatment for progressive tooth decay.

He needed two implants but, to his dismay, the plan did not cover them. To pay the $10,500 bill, he had to take out loans. “Dental insurance is basically useless,” said DiGeronimo. “It’s a sham, a waste of money, and another case of the haves versus the have-nots.”

As for older Americans, many lose employer-based dental coverage when they retire even as they suffer from increasing dental problems. Among those 65 and older, 70 percent have some form of periodontal disease, according to the Centers for Disease Control and Prevention. Yet basic Medicare plans do not include dental coverage, although options exist for seniors to purchase it.

Overall, in 2015, almost 35 percent of American adults of working age did not have dental insurance. By contrast, only about 12 percent of American adults under 65 in 2016. That lack of coverage and treatment can diminish economic and social opportunities — for instance, it can be costly at work or in a job interview not to smile because of unsightly or missing teeth.

Eventually, poor prevention and treatment can become a medical problem — leading to serious, and occasionally deadly, health consequences. In an infamous 2007 case — described by in her book “Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America” — Deamonte Driver, a 12-year-old boy in Maryland, died after a tooth infection spread to his brain. The family’s Medicaid coverage had lapsed.

Research has demonstrated links between periodontal infections and chronic conditions like and . Studies have found between periodontitis and adverse pregnancy outcomes, such as premature labor and low birth weight. Tooth problems also hinder chewing and eating, affecting nutritional status.

The split between the medical and dental professions, however, has deep roots in history and tradition. For centuries, extracting teeth fell to tradesfolk like barbers and blacksmiths — doctors didn’t concern themselves with such bloody surgeries.

In the U.S., the long-standing rift between doctors and dentists was institutionalized in 1840, when the University of Maryland refused to add training in dentistry and oral surgery to its medical school curriculum — leading to the creation of .

Dentists have in some ways benefited from the separation — largely escaping the corporate consolidation of American medicine, with many making good livings in smaller practices. Patients often willingly pay out-of-pocket, at least to a point.

Some people deliberately forgo dental coverage, considering it less urgent than having insurance against medical catastrophes. “You might not get a job as hostess at the restaurant, but by the same token people that have a lot of missing teeth live to tell the tales,” Lubet said.

With fluoridation and advances in treatment, many Americans have come to take the health of their teeth for granted and shifted their attention to more cosmetic concerns. And the dental field has profited from the business.

In my experience, which includes extensive travel in other countries, Americans often seem disoriented or even horrified when confronted with imperfect dentition. During my period of intense dental care here, I hated wearing temporaries and often braved the public with missing front teeth. I found myself routinely reassuring people that, yes, I knew about the gap, and yes, I was having it dealt with.

Meanwhile,Ìýthe bold line between what is covered or what is not often strikes patients as nonsensical.

Last fall, Lewis Nightingale, 68, a retired art director in San Francisco, needed surgery to deal with a benign tumor in the bone near his upper right teeth. The oral surgeon and the ear, nose and throat doctor consulted and agreed the former was best suited to handle the operation, although either one was qualified to do it.

Nightingale’s Medicare plan would have covered a procedure performed by the ear, nose and throat doctor, he said. But it did not cover the surgery in this case because it was done by an oral surgeon — a dental specialist. Nightingale had no dental insurance, so he was stuck with the $3,000 bill.

If only his tumor had placed itself just a few inches away, he thought.

“I said, what if I had nose cancer, or throat cancer?” Nightingale said. “To separate out dental problems from anything else seems arbitrary. I have great medical insurance, so why isn’t my medical insurance covering it?”

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Corey Baker, a gay man in Columbus, Ohio, has seen many dating app profiles that include phrases like “Blacks — don’t apply.” Sometimes when he declines invitations, he said, men lash out with insults like “you’re an ugly Black person anyway.” And some of his friends have been slammed with the N-word in similar situations.

Many of these events occurred “when I didn’t think I was attractive or deserving of love,” he said. And they took an emotional toll. “If you’re experiencing a wall of people saying they’re not attracted to you, I think that does impact your mental health,” said Baker, who is 35 and a school librarian.

The notion of kinder, gentler rejections on hookup sites might seem like an oxymoron. Yet experts in sexual health — as well as users of gay meeting apps, like Baker — say the harshness of much online behavior can exacerbate low self-esteem and feelings of depression or anxiety. That toxic combination can also lead to impulsive and potentially unsafe sexual choices.

In response, Building Healthy Online Communities, or BHOC, an organization in the San Francisco Bay Area focused on HIV and STD prevention, has launched an effort to boost niceness on apps designed for men who have sex with men. “People in the LGBTQ community face discrimination externally, but we also have to acknowledge that there is discrimination within the community,” said BHOC director Jen Hecht.

Through surveys and focus groups, BHOC asked more than 5,000 users of nine gay apps how the sites could support better online behavior related to race, appearance, HIV status, age, disability, gender identity and other factors. It also sought advice on technical improvements the apps could make, such as offering users greater flexibility in conducting searches for contacts.

“If I can filter out people who wrote ‘no fats, no fems, no black people,’ I don’t even have to deal with seeing it,” wrote one respondent quoted in BHOC’s report on the data gathered from app users. Representatives for some of the participating apps said they welcomed the collaboration. “We’ve had a non-bullying policy since day one,” said David Lesage, marketing and social media director for Adam4Adam.

Mean online behavior is, of course, not limited to apps for men. When asked last month by email whether meeting sites that cater to the general population should also be trying to address the issue, Evan Bonnstetter, Tinder’s director of product policy, responded that the company was “unable to participate in this opportunity.” (Bonnstetter has since left Tinder.) Bumble, another site popular with heterosexuals, did not respond to a request for comment.

Gay and bisexual men, like other groups that face discrimination, have higher rates of depression, substance misuse and related mental health concerns. But John Pachankis, an associate professor at the Yale School of Public Health who studies gay men’s health, said his research has identified aggressiveness within the gay community as a major problem.

“I was initially quite surprised that gay men were consistently noting their treatment at the hands of other gay men as being a predominant stressor,” Pachankis said. Apps, he added, “are a site of a lot of potential rejection in a short amount of time in a way that is particularly anonymous and efficient and can be really detrimental.”

In one study, Pachankis and his colleagues simulated a gay app environment in which some research participants were exposed to dismissive comments and others to approving comments. (The comments were all computer-generated.)

In subsequent responses on questionnaires, the men exposed to the dismissive comments reported greater emotional distress and expressed more skepticism about the benefits of condoms. They were also more likely to choose riskier options in a card-playing game.

Given that the app environment is the source of stress, Pachankis said, it makes sense for BHOC and other public health organizations to try to influence it

Some respondents quoted in the BHOC report dismissed the initiative as silly or unwarranted. “If someone does not meet the preferences specified by the user for being ‘fat,’ ‘too old,’ or not the right ‘race,’ then too bad,” wrote one. “I find this overreach in striving to be PC as offensive and ridiculous.”

But most respondents recognized that apps could support better online behavior and reduce unnecessary pain, Hecht said.

“It’s a society-wide problem, and I do agree that gay men’s dating apps are not going to single-handedly address it, but that doesn’t mean they can’t play a role,” she said. “To the extent that the users get to control and customize, that will increase their positive experiences on the apps and decrease the likelihood that they’ll have these negative experiences.”

One popular recommendation from respondents was to allow all users, and not just paying customers, to block anyone they feel is being abusive. Another was to allow users to restrict who can see profile fields with potentially sensitive information, such as HIV status or gender identity. Respondents also believed apps could help diminish the pain of rejection by providing neutral, pre-written messages for users to send, such as “sorry, it’s not a match.”

Grindr, one of the participating apps, does not include standard rejection statements but is exploring this option to help users on both sides of what is inevitably a “high-intensity moment,” said Jack Harrison-Quintana, the company’s director of equality.

“It’s very easy to feel very rejected because you are getting rejected,” Harrison-Quintana said. “People experience a lot of hurt from things that are said to them online, and that is what we are trying to address.”

Jehangeer Ali Syed, an international development consultant in Washington, D.C., said he has been disturbed by being treated as an “exotic element” in online exchanges. Although he is not from the Middle East, some men “sexually objectify me as an ‘Arab stallion,'” said the 36-year-old Pakistani. “I have been called a ‘sand-[N-word],’” he added.

This sort of encounter, he said, “makes you doubt yourself, makes you feel insecure and makes you question if I’m doing anything wrong.”

BHOC noted in its report that many respondents were unaware of existing app features that could help them customize and control their experiences. The report called for apps to expand their educational efforts about these possibilities.

That suggestion resonated with Grindr’s Harrison-Quintana. Grindr already includes some of the options recommended in the report, he said, but it could do a better job of communicating with customers. “It’s not just about implementing features, it’s also about maybe letting users know those features are available to them,” he said.

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After Andersen returned to her job as an information systems project manager in the San Francisco Bay Area, she struggled with profound fatigue, cognitive difficulties and other disabling complaints. For six months, she tried to keep awake during meetings and finish basic tasks that took much longer than before.

Finally, she decided to retain legal help so she could take advantage of the disability insurance coverage offered as an employee benefit. “I realized this is not going to be a short-term thing,” Andersen said.

Hundreds of thousands of people around the world are experiencing what is being called “long covid” — a pattern of prolonged symptoms following an acute bout of the disease. Many have managed to continue working through accommodations like telecommuting, cutting down on hours and delegating responsibilities.

Others have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits. But as they pursue the application process, they are discovering a particular set of challenges.

Given the lack of testing in the first months, many “long haulers,” like Andersen, have no laboratory proof of infection. While antibody tests can provide such evidence, their accuracy varies. Moreover, many of the reported symptoms, including fatigue and cognitive impairment, are subjective and not clearly linked to specific organ damage.

Beyond that, compiling a thorough record for a disability application and navigating the bureaucratic hurdles require sustained brain power, something many long-haul patients can no longer muster. Barbara Comerford, a New Jersey disability lawyer, said she received dozens of inquiries starting last fall from long haulers seeking advice on filing for disability and often citing what is being called “brain fog” as their main complaint.

“Most are people calling to say, ‘I thought I could do it. I can’t. My mind doesn’t function for more than really brief periods of time,’” Comerford said. She gave a presentation to the New Jersey State Bar Association in mid-February on how to develop evidence for such cases.

In the U.S., close to 30 million people have tested positive for the coronavirus, although many cases of infection are asymptomatic. What proportion might be affected by long-term illness isn’t known. Scientific understanding of the phenomenon is in its infancy.

In January, that around three-quarters of more than 1,700 covid patients who had been hospitalized in Wuhan, China, reported at least one ongoing symptom six months later. More recently, investigators from the University of Washington that around 30% of 177 patients who had tested positive for the coronavirus still reported symptoms when they were surveyed one to 10 months later.

The Social Security Administration provides long-term disability to American workers who qualify under , but applicants often get turned down on the first try. A few states, including California and New York, provide short-term disability benefits, in some cases for up to a year.

Tens of millions of Americans also have private disability coverage, most often as part of their employment benefit packages.

The maximum currently available to an individual through the Social Security Disability Insurance program is just over $3,000 a month. A typical private long-term disability plan might cover 60% of a beneficiary’s base salary, with a much higher maximum amount.

Sandy Lewis, a pharmaceutical industry researcher, fell ill last March with what she assumed was covid. She recovered but relapsed in April and again in May.

Through her employer-based insurance coverage, she received short-term disability for November and December, but the insurer, Prudential Financial, rejected her request for an extension. Soon after, she was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS, a debilitating illness that can be triggered by viral infections.

Lewis, who lives outside Philadelphia, is planning to appeal Prudential’s rejection of the short-term extension and apply for long-term disability. But the matter is unlikely to be resolved before fall. The situation has left her feeling “devastated,” she said, and in serious financial distress.

“This has been such an arduous journey,” she said. “I have no income and I’m sick, and I’m continuing to need medical care. I am now in a position, at 49 years old, that I may have to sell my home during a pandemic and move in with family to stay afloat.”

In Lewis’ case, a Prudential reviewer noted that her symptoms were “subjective” and that there were “no physical exam findings to correlate with any ongoing functional limitations,” according to Cassie Springer Ayeni, an Oakland disability lawyer who is representing her as well as Andersen.

Prudential would not comment on a specific case. Evan Scarponi, chief claims officer, said in a statement that “our collective understanding of covid-19 and any associated long-term effects are still evolving” but that Prudential is “well-versed in evaluating both subjective and objective aspects of disability claims.”

Lawyers and advocates in the field expect the numbers of covid-related long-term disability applicants to rise this year. But it’s still too soon to detect any such increase, said a spokesperson for the American Council of Life Insurers, a trade association. Workers typically must be unable to work for half a year before becoming eligible for long-term disability benefits, and applying can itself be a lengthy process.

Brian Vastag, a former Washington Post science and health reporter with ME/CFS, stopped working in 2014 and then sued Prudential after it rejected his long-term disability claim. Insurance companies, he said, can easily find reasons to dismiss applications from claimants with chronic illnesses characterized by symptoms like fatigue and cognitive impairment.

“The insurance companies will often say, ‘There’s no objective evidence, so we have nothing to support your claim,’” said Vastag, who in 2018. “I’m worried about the long-covid patients who can’t work anymore.”

Claimants can appeal a rejection. If the insurer rejects the appeal, claimants have the right to sue, as Vastag did. However, most such cases fall under the . Because this federal law requires a losing insurer to pay the unpaid claims but does not provide for punitive or compensatory damages, critics argue it incentivizes the denial of coverage.

In the event of litigation, the court’s role is to assess the already existing evidentiary record. That means it is essential to present a robust case in the initial application or during the administrative appeal before any litigation begins, said Ayeni, the disability lawyer for Andersen and Lewis.

“It’s the only shot to build a record for the courts, to develop a full body of evidence,” she said.

However, a successful disability case ultimately depends on documenting inability to work, not on obtaining a specific diagnosis. To augment the medical evidence, Ayeni often sends clients for neuropsychological testing, investigations of lung function and other specialist assessments. She also gathers affidavits from family members, professional colleagues and friends to confirm patients’ accounts.

In Rickie Andersen’s case, the strategy worked. Recognizing how complicated the application process was likely to be, she sought legal help early on. The insurer contracted by her employer approved her for short-term benefits late last year and granted her application for long-term benefits in February.

“I knew all of it was completely exhausting, so it wasn’t something I thought I could do on my own,” Andersen said.

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Among them: Many people were wary of the unpleasant procedure, called a nasopharyngeal swab. It can be performed only by trained health workers, putting them at risk of infection and adding costs. And the swabs and chemicals needed to test for the virus almost immediately were in short supply.

Some places, like Los Angeles County, of saliva and sputum, with the process supervised at drive-thru testing sites by trained personnel swathed in protective gear. Meanwhile, researchers began investigating other cheaper, simpler alternatives to the tried-and-true approach — including dribbling saliva into a test tube.

But the transition has not been immediate. Regulators and scientists are generally cautious about new, unproven technologies and have an understandable bias toward well-established protocols.

“Saliva is not a traditional diagnostic fluid,” said Yale microbiologist Anne Wyllie, part of a team whose saliva-based test, called SalivaDirect, received emergency use authorization from the Food and Drug Administration in August. “When we were hit by a virus that came out of nowhere, we had to respond with the tools that were available.”

Eight months into the pandemic, the move toward saliva screening is gaining traction, with tens of thousands of people across the country undergoing such testing daily. However, saliva tests still represented only a small percentage of the more than 900,000 tests conducted daily on average at the end of September.

Yale is providing its protocol on an open-source basis and recently designated  as capable of performing the test. Besides the Yale test, the FDA has authorized emergency use of several others, including versions developed at Rutgers University, the University of South Carolina and SUNY Upstate Medical University. A further advance,Ìý,Ìý be headed for FDA authorization, too.

Since the start of the pandemic, the Trump administration’s approach to testing has been hampered by missteps and controversy. As a key health agency during an unprecedented emergency, the FDA’s effectiveness relies on public trust in how it balances the need for speed in authorizing innovative products, like saliva tests and vaccines, with ensuring safety and effectiveness, said Ann Keller, an associate professor of health policy at the University of California-Berkeley.

“You obviously want to get new tests into the mix quickly in order to address the emergency, but you still need to uphold your standards,” Keller said. The White House’s public pressure on the FDA has complicated the agency’s efforts by undermining its credibility and independence, she said.

Respiratory viruses colonize areas inside the nasal cavity and at the back of the throat. Besides the nasopharyngeal approach, nasal samples obtained with shorter and less invasive swabs have proven effective for the coronavirus and have become widely adopted, although they also generally require a health care worker’s involvement. The millions of rapid tests that will be distributed across the country, per , rely on nasal swabs.

In the early months of the pandemic, some studies reported significant levels of the virus in oral secretions. In , for example, the virus was found in the saliva of 11 of 12 patients with confirmed coronavirus infection.

In Los Angeles, , more than 10,000 samples are collected per day, said Fred Turner, chief executive of Curative, the company that developed it.

Turner sees an advantage to the swabbing strategy. The self-swab procedure takes only 20 to 30 seconds, while producing enough saliva for testing can take people two to three minutes, and sometimes longer, he said. “That might not sound like much difference,” Turner said, “but it is when you’re trying to push 5,000 people through a test site.”

Curative’s three labs process tens of thousands of tests from jurisdictions across the country in addition to L.A., Turner said. A , which is expected to become available at state labs around New York, also uses an oral swab.

For the Curative test, a health care worker is supposed to oversee the sample collection —reminding people to cough to bring up fluids, for example. When investigators at the University of Illinois launched what they called a “Manhattan Project” to develop a saliva test by mid-June, they hoped to make it possible for people to visit a collection site, drool into a test tube, seal it and drop it off without the aid of a health care worker.

The university is now testing more than 10,000 people a day at its three campuses and is seeking to expand access to communities across the state and country, said chemistry professor Paul Hergenrother, who led the research team. Like the similar Yale test, it is being made freely available to other laboratories. The University of Notre Dame, in Indiana, recently adopted it.

Like tests using nasopharyngeal and other kinds of nasal swabs, these saliva tests are based on PCR technology, which amplifies small amounts of viral genetic material to facilitate detection. Both the Yale and University of Illinois tests have managed to simplify the process by eliminating a standard intermediate step: the extraction of viral RNA. Their protocols also don’t require viral transport media, or VTM — the chemicals generally used to stabilize the samples after collection.

“You don’t need swabs, you don’t need health care workers, you don’t need VTM, and you don’t need RNA isolation kits,” Hergenrother said.

In , the Yale team reported detecting more viral RNA in saliva specimens than in nasopharyngeal ones, with a higher proportion of the saliva tests showing positive results for up to 10 days after initial diagnosis.

The National Basketball Association provided $500,000 in support for the Yale project, said David Weiss, the NBA’s senior vice president for player matters. He said the Yale team’s decision to eliminate the process of RNA extraction, which separates the genetic material from other substances that could complicate detection, involved trade-offs but did not compromise the value of the test.

“Any molecular test that has an RNA extraction step is almost by definition going to be more sensitive, but it will also be more expensive and take longer and use supplies that are in shorter supply,” he said. “If we’re trying to look at surveillance testing to open up schools and nursing homes, a test that’s still very sensitive and a lot cheaper is an important innovation.”

Prices for coronavirus tests vary widely, running upward of $100. Tests based on the Yale or University of Illinois protocols, which require only inexpensive materials, could be available for as little as $10. The Curative testing service, which includes collection and transportation of samples as well as the laboratory component, averages around $150 per test depending on volume, said Clayton Kazan, chief medical director of the L.A. County Fire Department, which uses the tests.

Despite the advances in sample collection, tests using PCR — polymerase chain reaction — technology still require laboratory processing. Researchers have been investigating other approaches, including saliva-based antigen tests, that could be self-administered at home and would provide immediate results. (While PCR can detect coronavirus genetic material, antigen tests look for viral proteins that can signify a current infection.)

At least it is seeking emergency use authorization for a saliva antigen test, although two others have dropped plans to develop their own versions as infeasible, . Meanwhile, scientists at Columbia University, the University of Wisconsin and elsewhere are investigating the use of saliva with other kinds of rapid-test technologies.

“There’s tons of interest” in an at-home saliva test, noted Yvonne Maldonado, chief of pediatric infectious diseases at Stanford University School of Medicine.

“People really do want to get that pregnancy-type kit out there,” she said. “You could basically send people a little packet with little strips, and you pull off a strip every day and put in under your tongue.”

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“They say, ‘I haven’t had any contact since I saw you last, so there’s no need to do any STD tests,’” said Klausner, an adjunct professor of epidemiology and infectious diseases at UCLA.

But attitudes among these patients are shifting, Klausner has noticed, now that California and other states are loosening policies on social distancing. “People are starting to think about a return to engaging [in sex],” he said, “and are asking me, are there ways they can remain safe” from COVID-19?

Concerns about sexual intimacy during an epidemic are universal and not limited to gay men, of course. Public health experts, including those long involved in HIV prevention, recognize that a proportion of all people are likely to ignore or reject categorical mandates about sexual behavior — whether they involve using condoms or limiting contact because of social distancing norms.

“It didn’t work when we had to deal with HIV, and it won’t work in dealing with COVID,” said Pierre-Cédric Crouch, a clinical nurse researcher at the University of California-San Francisco, and an expert in HIV prevention.

The coronavirus is known to spread through oral and nasal secretions but not specifically through sexual intercourse. In New York City, the health department issued that counsel against sex with those outside your household but advise those who choose otherwise to “have as few partners as possible.”

The guidelines, which note that “kissing can easily pass the virus,” suggest that people “make it [sex] a little kinky” by being “creative with sexual positions and physical barriers, like walls, that allow sexual contact while preventing close face to face contact.” In the Netherlands, the government has advised single people considering sex to find a symptom-free sexual partner.

For many gay men, especially in urban areas, sexual exploration with multiple partners is a way of life, whether single or not. Many committed male couples maintain open relationships.

Research supports the notion that gay men tend to have more sexual partners than do heterosexuals. A 2012 among adults ages 18 to 39 noted that men who have sex with men (a phrase often used in scientific studies that focus on sexual behavior rather than sexual identity) “reported significantly more lifetime partners than heterosexual men and women at all ages.” In the 35-39 age group, the median lifetime number of sexual partners reported by men who have sex with men was 67, compared with 10 for heterosexuals, according to the study.

Damon Jacobs, a therapist with many gay clients, lives alone in Brooklyn and remained celibate for the first month of the lockdown. At that point, he said, he reached out to a regular and trusted sexual partner.

“He’d also been alone for four weeks except for going outside for groceries, and he also had zero symptoms,” said Jacobs, 49.

“So we got together and started hanging out again,” Jacobs added. More recently, he has met up with several other partners after asking about their social distancing practices. He has also found many of his clients dealing with similar issues after months of being on their own.

“Human beings can cope with certain levels of pain and suffering for a specific amount of time if they perceive an ending,” said Jacobs. After more than two months, he added, people who have been physically isolated are “starved for touch.”

A mid-April provided a snapshot of how the coronavirus had affected sexual behavior. While about half reported fewer sexual partners than before the pandemic, only 1% reported more, with 48% reporting no change. (The survey did not ask about the number of partners or whether sex was with a household member.)

Many gay men remain cautious. Lewis Nightingale, a retired graphic designer in San Francisco who lived in New York during the early years of the AIDS epidemic, said he had spent much more time using online apps such as Grindr and Scruff to flirt and sext with other men.

He has received, and turned down, occasional invitations to meet up in person, he said. As an older man, he knows he is in a higher risk group for coronavirus complications. But refraining has been challenging, he said, since expressing himself sexually has played such a big part in his life. “For a lot of gay men, sex is pretty essential for a feeling of connection, for excitement, for validation,” said Nightingale, who has been in a relationship for 16 years.

Last month, Eric, a 42-year-old male escort in Manhattan who asked that his last name not be used, began weighing when and how to return to work. A former occupational therapist whose husband is a physician, he shut down business in mid-March and finally started seeing clients again earlier this month.

For now, he plans to limit scheduled appointments. He intends to see only those he knows well enough to believe they are truthful about routinely wearing masks and being symptom-free. And he is meeting people at his home rather than in a hotel room or their place. “I figure if I have people coming here, I’m only exposed to that person’s germs,” he said.

Eric also plans for now to avoid clients who have attended recent protests against police brutality. “I support the protests 1,000%, but I think they are probably pretty good breeding ground for the virus,” he said. “I don’t want to take that risk.”

In advising his gay patients about sexual activity, Klausner, the Los Angeles physician, said he tries to put the risk in context. The majority of coronavirus cases, he noted, have emerged from workplace and residential settings, such as meatpacking plants and nursing homes, as well as big indoor gatherings, such as concerts and religious services. Although the virus can be transmitted one-to-one in more intimate contexts, he said, “individual risk is really driven by people’s potential exposure to these crowded settings.”

A common misperception — that actions can be clearly defined as risky or not risky — can hamper understanding of other people’s actions, said Julia Marcus, a Harvard epidemiologist and HIV prevention expert. As restrictions on social distancing relax, she said, almost everyone will be making choices and engaging in activities that involve some level of risk — yet will likely be judged by various standards.

“There are very few zero-risk situations,” she said. Unfortunately, she added, “the gay guys are going to be shamed for hooking up, while the straight people having dinner together are less likely to be shamed.”

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Since late March, three Southern California jurisdictions ― Los Angeles County, and the cities of L.A. and Long Beach ― have offered a more palatable alternative to this nasopharyngeal sampling, whose very name poses a challenge. At 21 drive-thru sites,

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San Francisco’s public health department and the San Francisco AIDS Foundation have long promoted what is known as preexposure prophylaxis, or PrEP, for those at high risk of contracting HIV. With regular PrEP, the daily pill is taken indefinitely. But both organizations now endorse a strategy that requires taking just four pills timed to a specific sexual encounter — two within two to 24 hours before sex and one on each of the two following days.

They believe this approach will make PrEP more palatable to people who are ambivalent about the medication because of the cost, fear of potential side effects, mistrust of pharmaceutical companies or a general dislike of taking drugs.

The new strategy, called “2-1-1” or “on-demand” PrEP, is becoming popular overseas but has gotten little traction in the United States thus far. It has been proven effective only among men who have sex with men and is currently not recommended for women.

Proponents say the approach can work well for men whose encounters are intermittent and predictable: people in long-distance relationships who know when they will be with their partners, for example, or individuals who occasionally go out to pursue sexual activity.

The approach is not suitable for those who cannot plan for sex at least two hours in advance.

“There are people who really object to taking a pill every day if they’re not having sex that frequently,” said Dr. Oliver Bacon, a deputy director and physician at the San Francisco Department of Public Health. The on-demand approach, he added, “extends PrEP to people who actually need it based on the sex they’re having but wouldn’t take a daily pill.”

Since the Food and Drug Administration approved daily PrEP use for HIV prevention in 2012, more than 200,000 people in the U.S., most of them men who have sex with men, have taken the drug. But people are at risk for HIV infection and could benefit from the treatment, according to the Centers for Disease Control and Prevention.

The list price of the PrEP drug, sold by Gilead Sciences under the brand name Truvada, is when taken daily — though patients generally do not pay that much out of their own pockets.

Insurers typically cover much or most of the cost, but many have been onto patients in recent years. Help may be on the way, however.

Following a recommendation by the U.S. Preventive Services Task Force that doctors offer PrEP to at-risk patients, most health plans will be — though not the clinical and lab services that accompany its use.

And Gilead agreed earlier this year to enough Truvada to cover 200,000 patients annually for up to 11 years, though critics argue that cutting the price would be a more effective way to increase access.

Gilead declined to comment on the on-demand approach for using the drug.

Don Kirchman, a self-employed building developer in San Francisco who is on Medicare, started the on-demand regimen last year after discussing it with his doctor. He had previously taken Truvada daily, but then experienced heart trouble and a related drop in sexual interest and activity.

The new approach meets his current needs, because he prefers not to take unnecessary medication and is concerned about his out-of-pocket drug costs, he said. “There are times when I don’t feel like I’m in a sex cycle or I have a health issue that I’m concentrating on, so I’m not putting my attentions towards dating or hooking up,” Kirchman said.

In San Francisco, the health department issued an HIV update in February for local providers, suggesting they “consider” on-demand PrEP for men who were “ambivalent” about taking a pill every day. The department’s City Clinic began offering the option as a second-best choice for those reluctant to adopt the standard PrEP method.

In March, the San Francisco AIDS Foundation began formally enrolling men for on-demand PrEP at its Strut clinic in the city’s Castro district. In contrast to the health department, the foundation has presented on-demand and daily strategies as equal options. In the first two months, about a fifth of those who got PrEP at the clinic chose to take it on demand.

Since 2015, has found on-demand PrEP to be effective at preventing HIV. Advocacy groups and health agencies in France, Netherlands, Australia and elsewhere have promoted it. The World Health Organization this week during an international AIDS conference in Mexico City.

So far, neither the CDC nor the FDA has endorsed the on-demand approach. But Bacon, of the San Francisco public health department, said the city’s experience is being closely watched and he has fielded questions about the initiative from health officials in New York, Seattle and elsewhere.

A big challenge public health officials face with PrEP is that its adoption has been among men of color than among whites. African Americans and Latinos are more likely to have undiagnosed or untreated HIV, so boosting awareness and use of PrEP is viewed as a key strategy for preventing infections.

Chicago physician John Schneider said the African-American gay and bisexual men he sees at a South Side clinic tend to distrust the health care establishment, including drug companies, because of a legacy of medical discrimination. “Patients don’t like taking a lot of pharmaceutical products,” he said.

Though Schneider generally recommends the standard once-a-day PrEP regimen, he said he sometimes suggests the on-demand approach for patients whose sexual behavior is compatible with it, if they struggle with taking a pill every day.

Some people who want PrEP but prefer to minimize their consumption of it have adopted a different non-daily strategy: a four-day-a-week approach known in the United Kingdom as the “T’s and S’s,” in which pills are taken on Tuesdays, Thursdays, Saturdays and Sundays.

Earlier found that four pills a week conferred a high level of protection.

Timothy Price, an HIV prevention coordinator at the Northeast Indiana Positive Resource Connection, a Fort Wayne HIV/AIDS services organization, said he had relied on the T’s and S’s to limit his consumption of Truvada after a dispute with his insurance company involving prescription refills.

Price, a 56-year-old gay man, said he understood the science and knew he could safely reduce his intake to make his pills last longer. “I had a long period of time when they refused to fill it, so I decided after that I needed to build up some kind of cushion,” he said.

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Because of her developmental disability, Ava, now 15, requires general anesthesia for non-routine dental work. The dentist, like most of his peers, was not equipped to provide it.

The girl’s parents, schoolteachers who live in Huntington Beach, Calif., called other dental offices in the region. They were turned down dozens of times before finally finding a dentist prepared to work with an anesthesiologist to treat their daughter.

But there was a hitch: Insurance would not cover general anesthesia for root canals. So Ava’s parents decided to pay the $2,400 from their savings to ensure their daughter received prompt care.

“What about kids who don’t have parents who are professionals or who have no one to advocate for them?” wondered Donny Terranove, Ava’s father.

People with autism, cerebral palsy and other developmental disorders face enormous barriers to adequate and timely dental care — on top of their other challenges. Many dentists either avoid treating these patients or lack the skills needed to do so. Some patients with developmental disabilities are unable to endure even regular dental exams or cleanings without general anesthesia.

But most dentists don’t offer it and getting insurance to cover it for routine dental work is often a struggle.

Because it is difficult for them to get treatment, people with developmental disorders suffer “a high burden of dental disease,” according to a of over 4,700 patients published in the Journal of the American Dental Association. One-third of the patients studied suffered from untreated cavities, and 80% from serious gum infections.

“Many individuals with developmental disabilities cannot personally maintain their own dental hygiene,” according to by the California Legislative Analyst’s Office (LAO). “Often they need extra appointments or special accommodations that dentists are unable or unwilling to provide.”

In many cases, patients need these extra appointments to help them get accustomed to the environment of a dental office, including the equipment, procedures and personnel. This can help minimize their anxiety and reduce the need for deep sedation or general anesthesia.

But sometimes there is no alternative to anesthesia.

Mike Loughran, 54, of Tacoma, Wash., has a 14-year-old son with Down syndrome and autism. After years of failed attempts to complete a basic checkup, Loughran and a willing dentist concluded that the child should have general anesthesia for any and all dental work. That led to hefty charges.

For one routine, 45-minute exam that uncovered no problems, the anesthesia bill was $1,155. Loughran’s insurer, Tricare, adjusted it down to $912 — a sum he described as “very reasonable.” But the hospital charged nearly $21,000 for the operating suite. Tricare agreed to coverage and negotiated the price down to about $15,000. That left Loughran with a $2,500 out-of-pocket copayment. He later got the state’s Medicaid program to cover most of that amount as his son’s secondary insurer.

Still, Loughran was taken aback by the astronomical amount charged for his son’s care. “The whole idea of it costing that much to get a dental exam, and you’re supposed to do that a couple of times a year — it was just stunning when I got the bill,” he said. “I don’t think I would take him to the operating room anymore.”

Without access to regular cleanings and other preventive care, “you get to the point that you need anesthesia because you’ve had a little problem that’s gotten big,” said Eileen Crumm, executive director of Family Resource Navigators, an advocacy group in Alameda County.

To accommodate the many patients who do need general anesthesia, some hospitals and regional centers for the disabled allocate a limited amount of surgical time for dental care. But because of the strong demand for these services, it can take many months or even more than a year to reserve an available operating slot, patient advocates say.

Like the Terranoves, Mariana Murillo had trouble finding appropriate care a few years ago for son Oscar, 20, who has cerebral palsy and cannot communicate verbally. Oscar, a teenager at the time, was in pain from impacted wisdom teeth, and his regular dentist said an oral surgeon would have to extract them. But Murillo, who lives in Lompoc, Calif., had difficulty finding one who would accept Denti-Cal, the state’s Medicaid-funded dental coverage for low-income people.

Murillo ended up paying $1,600 out-of-pocket to an oral surgeon. The surgeon agreed to extract Oscar’s four wisdom teeth while the boy was already under general anesthesia for the removal of a benign growth on his tongue — a procedure covered by Oscar’s medical insurance.

“Our financial situation is not great, but it was not too bad,” said Murillo. “Knowing Oscar was going to be free of that pain, we decided to do it.”

In some states, officials and private-sector organizations are trying to address this large unmet need among patients who may suffer in silence, unable to articulate their distress.

New Mexico, for example, has a that entitles dentists who have completed a special training program to an extra fee of $90 each time they treat a patient with developmental disabilities. And New York University’s College of Dentistry recently opened a strictly for the care of people with disabilities.

In California, most patients with developmental disabilities are eligible for care under Denti-Cal, but only a fifth of dentists in the state accept it. And only a fifth of developmentally disabled patients with Denti-Cal received even one dental service in 2014, 2015 or 2016, according to the LAO report.

Last year, to increase payments to Denti-Cal providers for the 2018-19 fiscal year — up $70 million from the amount of tobacco tax money it had earmarked for that purpose the previous year. Federal matching dollars bring the total amount of new money for the program to as much as $600 million. The most recent boost will help pay for the additional time needed to treat patients with special needs, as well as for anesthesia.

A particularly difficult challenge for patients with developmental disabilities is the transition from pediatric to general dentists as they age, said Dr. Joseph Castellano, president of the American Academy of Pediatric Dentistry, who practices in Laredo, Texas. That’s because pediatric specialists generally receive some training in working with that population, whereas general dentists tend to have little or no such experience.

“A lot of times [patients] will just stay in the [pediatric] practice,” Castellano said. “We know the patients and are comfortable with them, and they and the families are comfortable with us.”

Dr. Wade Banner, a Southern California dentist, took the matter into his own hands in 2014, when he launched a mobile dental program and began making house calls to patients with developmental disabilities. Banner, who has a nephew with autism, said he wanted patients to receive basic care in an environment where they felt most comfortable and were less likely to require major sedation.

Noting the paucity of providers for patients who need general anesthesia, Banner said, “one of my main goals in starting house-call dentistry was to prevent them from having to be put to sleep, if at all possible.”

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On Nov. 6, the Service Employees International Union-United Healthcare Workers West union hopes to deliver a stinging blow with a ballot measure designed to limit clinic profits.

Proposition 8, or the “Fair Pricing for Dialysis Act,” would cap dialysis clinic profits at 115 percent of the costs of patient care, with revenue above that amount to be rebated primarily to insurers. Medicare and other government programs, which pay significantly lower prices for dialysis, would not receive rebates.

It’s been a costly campaign, suggesting high stakes for both sides. The union, which sponsored the initiative and represents and other health care workers in California, so far has invested nearly $17 million in the effort.

Two leading national for-profit dialysis companies, DaVita and Fresenius Medical Care, dominate California’s market and are fighting back hard, contributing more than $40 million and $22 million respectively to defeat the measure. Overall, dialysis companies have raised more than $72 million to oppose the initiative.

In California, close to 70,000 patients need regular dialysis, which essentially performs the function of kidneys for patients whose own kidneys are failing. DaVita and Fresenius control 70 percent of the nation’s market. Between them, they reported more than $4 billion in operating profits last year.

Proponents say the initiative would spur clinics to reduce executive salaries, increase investment in patient care and lower the prices for patients with private insurance.

“It will allow these companies to make good profits, but not the obscene profits they make now,” said Steve Trossman, a spokesman for the union and the “Yes on 8” campaign.

Opponents argue the issue is too complicated to be decided at the polls and that it could reduce patients’ access to care, causing the vast majority of clinics to lose money and forcing many to shut down.

Fresenius and Davita referred questions on the initiative to the “No” campaign. But in an , DaVita CEO Kent Thiry said the passage of the initiative in California would have mostly “unsustainable” effects on dialysis centers.

A win for the union, known as SEIU-UHW, could encourage similar efforts elsewhere, said Laurel Lucia, director of the health care program at the Center for Labor Research and Education at the University of California-Berkeley.

“The initiative addresses a national problem,” she said. “If the policy is implemented successfully here, it wouldn’t be surprising if it spread to other states.”

Similar measures pushed by the union in Ohio and Arizona did not make the ballots for this November’s election.

The initiative is part of the union’s wide-ranging campaign to force changes in the dialysis industry. In August, California legislators approved a bill promoted by the union that would have effectively capped reimbursement rates for dialysis clinics. While that was perceived as a solid victory for SEIU-UHW, Democratic Gov. Jerry Brown vetoed the measure last month.

A few years ago, SEIU-UHW began organizing among dialysis clinic workers, raising concerns about poor sanitation, high infection rates, understaffing, exorbitant prices for those covered by private insurance and other problems. The union ramped up its efforts on the ballot measure after legislative attempts to address some of the issues stalled last year.

Since 2012, the union has spent tens of millions of dollars on multiple state and local ballot initiatives in California relating to a wide range of health care issues, including access to affordable insurance, hospital and clinic funding, and training for in-home supportive services.

In 2013, for instance, SEIU-UHW launched ballot measures in California targeting hospital pricing and executive pay, and opponents accused the union of abusing the ballot process to force compliance with its demands.

According to Thad Kousser, a professor at the University of California-San Diego and an expert in the legislative process, the strategy of using ballot measures for political leverage is standard practice and not unique to SEIU-UHW. Even if the dialysis initiative is defeated, Kousser said, the effort will likely provide the union with a bargaining edge in future negotiations.

“It strengthens the union’s hand for future bargaining, even if it doesn’t win now,” Kousser said.

The union says it uses ballot measures to improve health conditions for all state residents, not just its members. “We made a decision as a union a number of years ago that in order to be successful, we couldn’t just be worried about our own members and our own narrow interests and have blinders,” Trossman said.

Nonsense, say critics.

“The spin from the SEIU-UHW is that the union is crusading for a healthier California, not trying yet again to get leverage over health-care employers,” declared an last year in the San Diego Union-Tribune. “Californians with failing kidneys have enough worries. They should not be political pawns.”

The “No on 8” campaign, citing findings from the Centers for Medicare & Medicaid Services, notes that California’s clinics rate higher than those in other states on quality-of-care measures, such as avoiding unnecessary transfusions, preventing infections and maintaining proper blood levels of calcium levels.

“The ‘Yes on 8’ people talk about a crisis in dialysis and that’s not even close to being the truth,” said Kathy Fairbanks, spokeswoman for the “No” campaign.

But other research, such as a 2014 study of Medicare beneficiaries nationwide, found that patients treated at for-profit clinics had higher hospitalization rates than those in not-for-profit centers.

In June, found DaVita liable for the deaths of three patients who suffered cardiac arrests following dialysis treatment, ordering the company to pay almost $400 million in damages. Witnesses had accused DaVita of failing to provide sufficient warning to doctors about the possible risks of a medication commonly used during dialysis. The company said at the time it would appeal. In 2016, Fresenius agreed to pay  to resolve thousands of lawsuits involving the same medication.

In the heated battle over next month’s ballot measure, both sides have lined up many dozens of endorsements from community and statewide organizations. Proponents have strong labor and Democratic Party support. The California Medical Association, and some other medical groups, along with many veterans’ and business organizations, back the “No” campaign, arguing that the change would put dialysis patients at risk.

The “No” campaign has spent millions on

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Pacing back and forth, the Florida dentist leading the two-day course advised the participants to stop thinking of themselves as tooth technicians and reposition themselves as “physicians of the mouth.”

“There is a medical part of our practice and a dental part,” said the presenter, Chris Farrugia, as audience members tapped on their keyboards or scribbled notes. “You have teeth, [and] you got the ‘other stuff.’ It’s the other stuff that medical insurance pays for.”

Faruggia’s seminar is a sign of a growing trend in dental offices, as providers seek greater reimbursement for expensive services and patients balk at big bills. Around the internet, firms have popped up claiming expertise in medical billing for dentists and offering courses and consulting services.

The reason is simple: Medical insurance is generally much more generous in its coverage than dental insurance.

Unlike medical coverage, dental insurance is mostly geared to the healthy — something many people don’t realize until they experience serious oral problems and get socked with unexpected costs. Standard dental insurance covers cleanings, fillings and other routine care. But major work like a crown or a bridge is often covered only at 50 percent and implants generally aren’t covered at all. And dental insurance is usually capped at $1,000 or $1,500 per year.

As a result, people who require extensive reconstructive work often pay many thousands of dollars, or sometimes tens of thousands, in out-of-pocket expenses. Many other people, even with dental coverage, go without care because they cannot afford the large balances or co-pays for crowns, root canals and other major procedures.

Because of these differences in reimbursement, Farrugia told his seminar attendees, dentists should first consider what medical insurance might cover and then bill the dental plan for the rest.

For example, he said, dentists should seek medical coverage for the full head, neck and mouth exams they perform when they see a new patient, since the goal is to assess more than just the teeth. Medical insurers should also cover oral problems attributable to an underlying medical condition, such as diabetes or dry mouth, a common side effect of many medications, Farrugia said.

Besides sparing patients the pain of big bills, the strategy can also boost income for dentists, said Farrugia, who estimated that revenues for his practice rose almost 10 percent the first year he fully implemented medical billing. Patients, too, can learn to file claims for medical reimbursement if their dentists won’t, he said.

On its website, the explains that health insurance should cover costs that are “medically necessary” and lists more than a dozen categories of procedures that could qualify. Among them: treatment related to inflammation and infection, dental repair due to injury, certain periodontal surgery procedures and appliances for sleep apnea.

Kristine Grow, a spokeswoman for America’s Health Insurance Plans, the industry trade association, did not dispute that some dental procedures could be covered by medical insurance. However, she cautioned that medical insurers were always on the lookout for abuse.

“Claims that are billed inappropriately or submitted fraudulently hurt everyone because they raise costs,” Grow said. “It’s important to note that procedures not related to an emergency event or trauma may not be medically necessary, and therefore would not be covered by medical insurance,” she added.

Asked about the potential for abuse, Farrugia said: “There are unethical providers in all health care services, and dentistry is not immune to that. You will always have some that try to game the system.”

Farrugia adopted medical billing several years ago after paying more than $100,000 for a CT scanner that produces 3-D images of the bone in the mouth and jaws.

“It occurred to me that this was a medical device,” he said of the CT scanner. “I’m a licensed health care provider, I’m providing this within the scope of my license. They can’t discriminate against me.”

Once he investigated the matter, Farrugia discovered that medical insurance could be asked to cover not just CT scans but a wide range of services regularly performed by dentists. He buried himself in the arcana of coding, ultimately writing three workbooks for dentists about medical billing.

At first it was trial-and-error, and Farrugia learned that claims often get rejected if they do not cite a medically legitimate reason for the procedure as well as the appropriate code.

These days, Farrugia bills medical plans $744 for a CT scan (medical code: CPT 70486), receiving an average reimbursement of about $500. Medical plans generally require pre-authorization for non-emergency CT scans, he said, so his office staff had to learn how to explain why the scan was medically required — such as to assess bone quality.

The same procedure can be billed to a dental plan (dental code: D0367), but the average reimbursement is $125 — if the plan covers CT scans at all.

Others are following his example. Iowa dentist Richard Downs attended one of Farrugia’s medical billing seminars last year in Chicago. “I’d never heard these things before,” he said.

He said he recently sought and received prior authorization from a medical insurer for $60,000 to cover multiple implants and other costs for a woman whose dental woes stemmed from severe atrophy of the jaw and other medical problems.

During a break in the seminar, San Ramon, Calif., dentist Rashpal Deol said Farrugia’s approach made sense. “We look at the soft tissues in the mouth, the muscles, the bone, the TM [temporomandibular] joint, and the head and neck area,” he said. “You always check the lymph nodes, we do oral cancer screening, so that is a comprehensive medical exam.”

Other seminar attendees also were enthusiastic, if a bit daunted. “People go to school to learn medical coding,” said Kelly Bradshaw, a staff member at a Santa Rosa, Calif., dental practice. “To try to bridge that gap in order to help our patients is intimidating. You have to be open-minded to look at things in different ways.”

Margaret Busch, an office manager for an Arizona dentist, said she planned to start medical billing as soon as she returned from the seminar.

“I’ve been making a list of people that we can go back and probably get money for,” she said, mentioning patients who have had CT scans and those with dental problems related to medical conditions like diabetes.

“I think they’ll be excited,” she said.

This <a target="_blank" href="/health-care-costs/physicians-of-the-mouth-dentists-absorb-the-medical-billing-drill/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This was how I learned all about the Great Divide between medicine and dentistry — especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.

For millions of Americans — blessed in some measure with good genes and good luck — dental insurance works pretty well, and they don’t think much about it. But people like me learn the hard way that dental insurance isn’t insurance at all — not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year — and that’s considered a decent plan.

Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren’t covered at all.

In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional .

Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.

My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis — a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. suffer from mild to severe forms of it.

My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries — and that was just the beginning. I’ve since had five more implants, more gum and bone grafts and many, many new crowns installed.

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At least I’ve been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children’s dental services, on whether to offer benefits for adults. And many dentists won’t accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.

The program typically pays as little as half of what they get from patients with private insurance. For example, as Kaiser Health News reported in 2016, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared with the $150 and $800 that private patients typically pay.

“It’s really a labor of love to do it,” said Dana Lubet, a recently retired dentist in Madison, Wis., who estimated Medicaid paid only a third of his costs. Accepting too many, he said, “could easily kill your practice.”

A few years ago, while in his mid-50s, Nick DiGeronimo, a facility maintenance worker at a New Jersey sports center, obtained private insurance coverage through the Affordable Care Act, hoping to get treatment for progressive tooth decay.

He needed two implants but, to his dismay, the plan did not cover them. To pay the $10,500 bill, he had to take out loans. “Dental insurance is basically useless,” said DiGeronimo. “It’s a sham, a waste of money, and another case of the haves versus the have-nots.”

As for older Americans, many lose employer-based dental coverage when they retire even as they suffer from increasing dental problems. Among those 65 and older, 70 percent have some form of periodontal disease, according to the Centers for Disease Control and Prevention. Yet basic Medicare plans do not include dental coverage, although options exist for seniors to purchase it.

Overall, in 2015, almost 35 percent of American adults of working age did not have dental insurance. By contrast, only about 12 percent of American adults under 65 in 2016. That lack of coverage and treatment can diminish economic and social opportunities — for instance, it can be costly at work or in a job interview not to smile because of unsightly or missing teeth.

Eventually, poor prevention and treatment can become a medical problem — leading to serious, and occasionally deadly, health consequences. In an infamous 2007 case — described by in her book “Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America” — Deamonte Driver, a 12-year-old boy in Maryland, died after a tooth infection spread to his brain. The family’s Medicaid coverage had lapsed.

Research has demonstrated links between periodontal infections and chronic conditions like and . Studies have found between periodontitis and adverse pregnancy outcomes, such as premature labor and low birth weight. Tooth problems also hinder chewing and eating, affecting nutritional status.

The split between the medical and dental professions, however, has deep roots in history and tradition. For centuries, extracting teeth fell to tradesfolk like barbers and blacksmiths — doctors didn’t concern themselves with such bloody surgeries.

In the U.S., the long-standing rift between doctors and dentists was institutionalized in 1840, when the University of Maryland refused to add training in dentistry and oral surgery to its medical school curriculum — leading to the creation of .

Dentists have in some ways benefited from the separation — largely escaping the corporate consolidation of American medicine, with many making good livings in smaller practices. Patients often willingly pay out-of-pocket, at least to a point.

Some people deliberately forgo dental coverage, considering it less urgent than having insurance against medical catastrophes. “You might not get a job as hostess at the restaurant, but by the same token people that have a lot of missing teeth live to tell the tales,” Lubet said.

With fluoridation and advances in treatment, many Americans have come to take the health of their teeth for granted and shifted their attention to more cosmetic concerns. And the dental field has profited from the business.

In my experience, which includes extensive travel in other countries, Americans often seem disoriented or even horrified when confronted with imperfect dentition. During my period of intense dental care here, I hated wearing temporaries and often braved the public with missing front teeth. I found myself routinely reassuring people that, yes, I knew about the gap, and yes, I was having it dealt with.

Meanwhile,Ìýthe bold line between what is covered or what is not often strikes patients as nonsensical.

Last fall, Lewis Nightingale, 68, a retired art director in San Francisco, needed surgery to deal with a benign tumor in the bone near his upper right teeth. The oral surgeon and the ear, nose and throat doctor consulted and agreed the former was best suited to handle the operation, although either one was qualified to do it.

Nightingale’s Medicare plan would have covered a procedure performed by the ear, nose and throat doctor, he said. But it did not cover the surgery in this case because it was done by an oral surgeon — a dental specialist. Nightingale had no dental insurance, so he was stuck with the $3,000 bill.

If only his tumor had placed itself just a few inches away, he thought.

“I said, what if I had nose cancer, or throat cancer?” Nightingale said. “To separate out dental problems from anything else seems arbitrary. I have great medical insurance, so why isn’t my medical insurance covering it?”

This <a target="_blank" href="/insurance/when-is-insurance-not-really-insurance-when-you-need-pricey-dental-care/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">