TIME History

Watch: The Forgotten Genius Who Figured Out How the Heart Works

A video from the World Science Festival tells the story of William Harvey, a forgotten pioneer in human anatomy

In the 17th-century, William Harvey, an English physician, worked to debunk the misconceptions that phlegm and bile were at the root of all health problems.

He was a leading figure in cardiology at the time, and it is to him that we owe the discovery of blood circulation. Almost forgotten now, Harvey was a trailblazer back then, or as the World Science Festival sees it, “he ruffled a lot of feathers, but eventually became a major influence on modern medicine.”

Watch the video above for more on his controversial, and until now overlooked, legacy.

TIME

Why You Shouldn’t Read a Tablet Before Bed

If reading is your way of easing into sleep, pick up a printed book instead of a digital one

There’s nothing wrong with settling down with a good book at the end of day to melt away tension and help you to unwind. But if you’re picking up an e-reader or a tablet, then you’re doing it all wrong.

That’s what Anne-Marie Chang, associate professor of biobehavioral health at Penn State University, and her colleagues found when they compared digital readers with the printed word. Reporting in the Proceedings of the National Academy of Sciences, they say that people who use the electronic devices such as an iPad had more disrupted sleep patterns and were more tired the next morning than those who read from traditional books.

Chang, who conducted the study while at Brigham and Women’s Hospital, designed the trial to be as objective as possible. What Chang found was a marked difference between each participant’s sleep patterns and alertness depending on whether they read from a digital reader or from a book. When they read from an iPad, their evening levels of melatonin failed to drop as much as they should, while they remained at expected levels when they read from a book. That led to a delay in body’s biological signal to go so sleep of about an hour and a half, making the participants more alert and therefore not ready for bed.

And when the scientists looked at their sleep patterns, they found that the differences went even deeper. When the volunteers read from electronic devices, they had shorter REM sleep, the stage in which memories are consolidated and the brain refreshes itself, than when they read from printed books. This occurred even though the volunteers slept for the same amount of time, eight hours, every night.

MORE: 3 Reasons To Keep Your Phone Away from the Bed

What’s more, the effect of those differences in sleep patterns spilled over into the next morning. When they read from digital readers, the participants reported feeling sleepier and were less alert (as measured on standardized testing of alertness) than when they used books. “What was surprising to me was that we would see effects the next day. There was no difference in total sleep duration between the two conditions, but there was a significant amount of REM sleep difference,” says Chang. “This may indicate that these effects are longer term than we thought.”

Previous studies showed that one reason for the disrupted sleep linked to the electronic devices may be due to the type of light they use. It’s in the blue wavelength, and some researchers have connected this light to a disruptions in the melatonin system, similar to those Chang found in the study. She says it’s also possible that having the light shine directly into the eyes, as backlit electronic readers do, may also keep the body’s sleep signals from activating — reading lamps or room lights reflect light so aren’t as disruptive to the body’s wake-sleep cycle.

The findings hint at why sleep — getting enough, and getting good quality sleep — is becoming more a of challenge and potentially a growing health problem. “There is an easy answer but it’s not a popular one that’s easy to hear,” says Chang. “Using electronic devices is not a train that is slowing down any time soon. So the important thing is to know more about them, and how they are affecting our lives, our health and our well being.” And in the meantime, maybe put the tablet down in the hours before you go to bed. Or buy a book.

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TIME
TIME States

Federal Court Strikes Down North Carolina Abortion Ultrasound Law

The law required abortion providers to show and describe an ultrasound to the pregnant woman, even if she refuses to look or listen

(RICHMOND, Va.) — A federal appeals court has struck down a North Carolina law requiring abortion providers to show and describe an ultrasound to the pregnant woman, even if she refuses to look or listen.

The unanimous ruling Monday by a three-judge panel of the 4th U.S. Circuit Court of Appeals in Richmond upheld a lower court ruling that the mandate violates abortion providers’ free-speech rights.

Appeals court Judge J. Harvie Wilkinson III wrote that the law “is ideological in intent and in kind.” He says the ultrasound mandate goes far beyond what most states have done to ensure that a woman gives informed consent to an abortion.

U.S. District Judge Catharine Eagles struck down the law in January. The state appealed.

TIME Diet/Nutrition

Should You Eat Whatever You Want for the Holidays?

With a fresh start in sight, will a few days of holiday bingeing really hurt?

Welcome to Should I Eat This?—our weekly poll of five experts who answer nutrition questions that gnaw at you.

should i eat whatever i want
Illustration by Lon Tweeten for TIME

3/5 experts say no.

It’s the holidays and you’re an adult, so chances are you’ll be stuffing your face far more than your stocking. But is eating whatever you want until the New Year a good idea?

Most experts agree it’s not. But the blow-your-diet debate was a closer race than we expected.

First, let’s start with the finger-waggers.

Eating whatever you want will definitely cause weight gain, says Kate Patton, registered dietitian with Cleveland Clinic’s Heart and Vascular Institute (and a nutrition expert without much faith that your holiday pleasure foods are broccoli and Brussels sprouts). “Though a 1-pound weight gain over the holiday season may not seem like much, the truth is most Americans do not lose that pound,” she says. Let enough free-for-all holidays go by—remember, we have about a dozen a year—and that weight gain will catch up to you and increase your risk of high blood pressure, high cholesterol and type 2 diabetes, she says.

Jo-Ann Jolly, registered dietitian at American University, agrees. “From my experience with weight loss counseling, clients who use their upcoming New Year’s resolution as an excuse to binge eat beforehand tend to have very poor long-term compliance,” she says. “Definitely allow yourself a treat once or twice a week, but listen to your hunger cues and practice mindful portioning to avoid holiday binges.”

That’ll help you stick to your dietary resolutions when they roll around on January 1, which is a proven powerful day for committing to big-picture changes. Hitting the reset button won’t be as jarring if you’ve been maintaining your weight. “Our bodies don’t take a vacation and can’t distinguish between holiday calories and non-holiday calories,” says registered dietitian Andrea N. Giancoli.

Three experts suggested prioritizing your favorite foods as a good way to eat what you really want, not what happens to be in front of you. Even an expert who approved of holiday dietary amnesty, Texas Children’s Hospital registered dietitian Roberta H. Anding, qualified her thumbs up with the caveat that you exercise portion control and eat only your favorite offenders. “My favorite is chocolate, so I don’t eat treats that aren’t chocolate,” she says.

But don’t despair, moderate holiday gourmands. You have someone squarely on your side. “At the holidays, you should enjoy,” says Dr. David Katz, MD, director of the Yale University Prevention Research Center. “That includes—within reason—eating what you want.” In his piece defending the end-of-December culinary carte blanche, Katz argues that eating whatever we want during the holidays gives us pleasure, and pleasure reduces stress. If you’re devoting too much brainpower trying to decide what foods you need to avoid, you’re likely to miss out on the cheery social connections that actually improve your health.

But (and of course there’s a but) the trick is to eat well all year long, so by the time the holidays roll around, you’ll actually crave healthier food. “Focus on eating wholesome foods in sensible combinations every day—and then you will find that eating what you want on a holiday does not involve debauchery,” Katz says. “You will love foods that love you back.”

Read next: Should I Drink Diet Soda?

TIME Diet/Nutrition

7 Holiday Drinks With Way More Calories Than You Think

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7 sips you're better off skipping

Coffeeshops offer lots of indulgent holiday beverages, but don’t be fooled: you can make them in the cozy comfort of your kitchen, too. Watch out for these surprisingly calorie-laden cold-weather drinks.

1. Eggnog

Eggnog doesn’t pull its rich creaminess out of thin air. With all that milk, cream, sugar and eggs, just a cup is heavy with a whole lot of calories: 224, to be exact, plus about 11 grams of fat.

2. Hot chocolate

Just 16 ounces of homemade hot chocolate will run you 385 calories—and that’s without the whipped cream.

3. Gingerbread latte

The Starbucks holiday favorite clocks in at 360 calories for a grande, with whole milk and whipped cream—plus 17 grams of fat. You’d be better off eating the real thing. A homemade square has 263 calories and 12 grams of fat.

4. Fa La Latte

The creation from Caribou Coffee comes with espresso, egg nog, whipped cream, nutmeg—and a whopping 650 calories.

5. Ho Ho Mint Mocha

Another choice from Caribou’s holiday menu is espresso-spiked mint hot chocolate with whipped cream and crushed candy canes, all for 550 calories.

6. Dessert wine

A 3.5-ounce glass of sweet after-dinner wine has 165 calories. You can get more wine for fewer calories (and isn’t that always the goal?) by drinking a glass of regular white wine. A 5-ounce pour has 123 calories and just a gram of sugar.

7. Caramel Apple Spice

Far from counting as a serving of fruit, this Starbucks’ take on a hot apple cider—steamed apple juice, cinnamon syrup, caramel and whipped cream—costs 360 calories for a grande.

 

TIME Infectious Disease

Why Hepatitis C Drugs May Soon Get Far Less Expensive

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Hepatitis C treatment no longer means daily injections and low cure rates that characterized the disease in the past. Now, newer oral drugs on the market require only a 12-week course, but their prices are shocking. Gilead Sciences has two drugs for hepatitis C, both costing astronomical amounts: one drug, Harvoni, costs $95,500 for 12 weeks, and the other, Sovaldi, costs $84,000. That’s $1,000 per pill.

But for the 3.2 million Americans living with chronic hepatitis C, a liver disease primarily spread via the blood of an infected person, a new business deal may mean more affordable care.

Another drug called Viekira Pak, developed by the pharmaceutical company AbbVie, got the green light from the U.S. Food and Drug Administration on Friday, Dec. 19. But many were disappointed upon discovering that the drug would cost $83,319 for a 12-week course, only slightly less than Sovaldi. The medical community had hoped that market competition would drive prices much, much lower.

That hope may soon become a reality, though. A new business deal between AbbVie and pharmacy benefit manager Express Scripts may lower the costs much further. As the New York Times reports, Express Scripts has negotiated a large discount from AbbVie. In return, Express Scripts will make Viekira Pak the exclusive drug option for the 25 million people it serves.

As the Times reports, Express Scripts’ chief medical officer Dr. Steve Miller has been one of the loudest proponents for cheaper prices for hepatitis drugs, given that they’ve become too expensive for some individuals and insurance providers.

The agreed-upon discount has not yet been released, but the hope is that it’s significant enough that the deal could lead other drug makers to lower their costs in response.

TIME Mental Health/Psychology

How to Not Lose it When People Are Driving You Insane

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Is your family already driving you insane? Read on

This holiday, make it a priority to not rip your hair out.

To help you survive the season, we asked psychologist Pauline Wallin, author of Taming Your Inner Brat, for some tips on how to avoid some of the most common pitfalls of the holidays. (But if Aunt Susie drinks too much egg nog, we can’t help you).

If your family is driving you crazy…
One of the best parts of the holidays can also be one of the worst parts of the holidays. Spending quality time with family doesn’t happen often for most of us, but with the expectations of the holidays and the increased amount of face time, it’s easy for someone to lose their lid. Here’s how to cool it.
For parents: You have guests coming, and the bums you call your children are doing a lousy job at cleaning. To avoid this stresser, lay out your expectations early. “When you feel like other people are driving you crazy, it’s often because they don’t have the same sense of urgency that you do,” says Wallin. Instead, tell your kids ahead of time that the house needs to be clean by 10 a.m., or that you are going to be stressed and would appreciate it if they stay out of your way. It’s an easy way to start out on the same page.
For kids and teens: If you really don’t want to go to Aunt Susie’s for dinner, get over it by finding a way to make it count. Think of it as a gift to your family to spend time with them without giving anyone ‘tude. If you’re really feeling irked, ask kindly for a little time alone. Go on a walk, read a book for an hour, or offer to get out of the house and grab groceries.

If someone spills something or you burn the roast…
Take a picture of it. Seriously, pull out that smart phone and snap a photo of the disaster. “If you’re going to laugh about it later, you might as well laugh about it now,” says Wallin. No dinner party is immune to a rip or spill or the tragic loss of the Christmas goose. Laugh it off, post it to Instagram, and move on.

If you’re stressed about the cost of all those presents…
Do you remember what you received for Christmas last year? Probably not. Wallin says one of the most common stressers she sees among patients around the holidays is financial stress. “But never once have I heard someone say, ‘I’ve never forgiven them for not getting me the new iPhone.'” We tend to put a lot of weight on the presents, but guests are more likely to remember the moments shared than what was in the stocking. So try not to stress about finding the perfect gift, and there’s zero shame in bargain hunting.

If your to-do list alone is freaking you out…
This year, instead of making a “To Do” list, make a “To Don’t” list. “Decide what you’re not going to do, and just let it go,” says Wallin. “It’s a tremendous sense of relief.” If you can’t figure out when you’re going to have time for caroling, just skip it. If you don’t have time (or don’t want to make time) for home-baked cookies, don’t both! You don’t have to do everything. If it’s more stress than it’s worth, it won’t be that fun.

If you’re not feeling any warm, fuzzy, holiday feelings…
Instead of scrambling to make everything perfect, carve out time to just sit and talk to friends and family. “We get so busy that we forget the holidays are about people,” says Wallin. Get everyone off the grid and ask for cell phones to be put away while you play a game or watch a movie. Even just taking 20 minutes to sit with a family member you don’t regularly see is a great way to remember to the real meaning of the season.

TIME

Medicine Is About to Get Personal

Dr. Garrison Bliss is shaking up how primary-­care medicine works Photographs by Gregg Segal for TIME

How can Americans get better health care for less money? There's a quiet experiment going on among primary-care physicians, and the results are intriguing

Nowhere outside the pages of dickens is there a more aptly named fellow than Garrison Bliss. A trim, gray man, he has twinkling eyes and a face lit by a smile of such authenticity that it makes you think of Shaker furniture. But he’s a doctor, not a mystic. And he’s smiling because he believes he and his cousin have found the answer to one of the toughest questions in health care.

The idea is deceptively simple: Pay frontline doctors a fixed monthly fee directly instead of through the byzantine insurance bureaucracy. Make the patient, rather than the paperwork, the focus of the doctor’s day. The result will be happier doctors, healthier patients and a striking reduction in wasted expense.

In one of the more intriguing experiments in the medical industry, Qliance Health, the company Bliss co-founded with his cousin Dr. Erika Bliss, 47, is applying this idea to managing the health of roughly 35,000 patients–about half of them on Medicaid. If it can work for them in Seattle, they say, maybe it could work for everyone.

How the Bliss cousins arrived at this notion is a more complicated story. But it’s one worth telling, because it says a lot about how the U.S.–normally adept at hooking up the buyers and sellers of goods and services–managed to make such a mess of its medical economy. The story starts with the fact that Garrison Bliss, 69, wasn’t always so happy.

He is a primary-care physician, and a career in primary care has become a recipe for misery in the U.S. Nearly a third of all frontline physicians ages 35 to 49 expect to quit within the next five years, according to a 2012 survey by the Urban Institute. Young healers who start with dreams of being Marcus Welby often sour when they meet the realities of the job–which can include seeing patients every 11 minutes and having their performance assessed by how many MRIs they order.

Like so many others in his field, Bliss came to feel that he wasn’t in the business of caring for patients at all. His job was to feed payment codes into the grinding machinery of the insurance companies, rushing from exam room to exam room, ordering tests, making referrals, scheduling follow-up visits in which the cycle would be repeated. He knew that a proper exam, with time for counseling and questions, can take 45 minutes or more. Yet even a 15-minute session became a luxury.

“There are no insurance codes for ‘cure,'” Bliss likes to say.

One day about 20 years ago, two of Bliss’s colleagues announced that they were stepping off the treadmill to create a new kind of practice. They invited a small number of their wealthiest patients to become members of a premium health care group. For a five-figure annual fee, those patients would have immediate access to the doctors. They would be able to schedule appointments on short notice and would never again languish in a waiting room. Should they need to see a specialist, their primary-care doctor would be happy to accompany them as an advocate and translator. This model, which was soon emulated by upscale doctors across the country, came to be called concierge medicine.

Coddling the rich was not Bliss’s bliss. Still, he was intrigued. Could the same idea work at a more affordable price? What if, instead of charging $1,000 per month for each membership, he charged $65? He didn’t have to decorate his clinic like a Canyon Ranch spa or set up shop on Seattle’s most expensive real estate. If he brought down the overhead, would ordinary people pay the equivalent of a monthly cable bill for the satisfaction of having a doctor who knew their histories and cheerfully answered their questions?

Bliss launched an affordable primary-care practice, called Seattle Medical Associates, in 1997–and soon had all the patients he could handle. At last, he was working for them. And he was happy.

Considering the health care model Americans are accustomed to, it can be hard to get your head around the approach Bliss had come to call direct primary care. But here’s how it works: for a flat fee every month, patients have unlimited access to their doctor–in person and by phone or email–for routine things like checkups, cuts and burns, infections, flu shots and skin exams, as well as chronic-condition maintenance like blood tests for diabetes or high cholesterol. Under the law, every American is required to have medical insurance–but direct-primary-care patients can seek less expensive policies, because they require coverage only for hospitalizations, surgeries and other specialized care.

It was working for Bliss, so when he heard that his cousin Erika was miserable after just three years in primary care (“burned out, cooked, feeling like a failure and thinking about getting out,” as she puts it), he shared some of his sunshine with her. “Every time I walk into the examination room, I feel like I’m going to a party!” he sang over the phone. “I think this model I’ve been doing has a lot of potential to change health care for the better. Come help me scale it up.”

Since then, they’ve signed up previously undreamed-of populations: big private employers like Expedia and Comcast, public and industry employee unions like the one for Seattle firefighters and–most radical of all–at least 15,000 Medicaid patients.

The private company’s results so far suggest that the model is scaling up nicely. Qliance now serves some 35,000 patients; the cost of about half of them is paid by the government through traditional and expanded Medicaid programs. Treating a wide variety of patients–young and old, healthy and chronically sick, well-off and poor–Qliance claims to be saving approximately 20% on the average cost of care compared with traditional fee-for-service providers. The company’s staff has tripled over the past year, and Qliance is looking to expand beyond Washington.

Unhappy primary-care docs from across the country are streaming to Seattle to find out if some version of Qliance could be their salvation. The American Academy of Family Physicians, which kept concierge medicine at arm’s length for years, is moving quickly to embrace the direct-care concept. And the promise of greater efficiency and better results has attracted the likes of Amazon’s Jeff Bezos and his fellow billionaire Michael Dell to invest in Qliance.

All of which makes Bliss smile.

A NEW MODEL

Concierge care was originally conceived before Obamacare, and it revved up in response to the Great Recession as an escape hatch for doctors fleeing the status quo. The existing fee-for-service system pays caregivers a certain amount for each test, diagnosis and procedure–which, according to critics, encourages overtreatment instead of preventive wellness care. Qliance, along with a growing number of similar operations, aims to be more than an escape. It seeks to be the answer to the quest of health care reformers: healthier patients at a lower cost. Fix the way primary-care doctors are paid, the Blisses argue, and we can cut unneeded tests, premature procedures and excessive ER visits.

The driving insight here is that primary care and specialized care have two very different missions. Americans need more of the first so they’ll need less of the second. And each requires a different business model. Primary care should be paid for directly, because that’s the easiest and most efficient way to purchase a service that everyone should be buying and using. By contrast, specialty care and hospitalizations–which would be covered by traditional insurance–are expenses we all prefer to avoid. Car insurance doesn’t cover oil changes, and homeowners’ insurance doesn’t cover house paint. So why should insurance pay for your annual checkup or your kid’s strep swab?

When people get good primary care, their maladies are diagnosed more quickly and can be managed before they grow into crises. Fewer patients wind up in expensive hospital beds. Emergency rooms treat genuine emergencies, not routine infections and minor injuries. Patients receive timely advice and encouragement from a trusted physician to shed those pounds, change that diet, drink a little less and exercise more. The fee-for-service insurance model discourages this approach. It pays mainly for treating disease, not preventing it. Worse, it makes the life of a primary caregiver so exhausting that students in medical schools and nursing schools are avoiding the field altogether. According to Colin West, a co-director of the Mayo Clinic’s program on physician well-being, the U.S. faces a shortage of tens of thousands of primary-care doctors–at a moment when we need them more than ever. In a definitive survey of third-year med students published in the Journal of the American Medical Association, he found that only about 20% were headed into primary care.

West was particularly dismayed by the number of students who started medical school with primary care as their ideal but gave up by year three. They had figured out, he explains, that the burdens of our health care system “roll downhill to the primary caregivers.” To make up for unpaid time spent filling out forms, docs must see more patients to generate more payment codes.

At the tangled heart of this dysfunction is Medicare, which by its sheer size sets the standards for insurance reimbursements. Specialists dominate the panel that sets its payment rates. Thus the system values surgeries, scans and other procedures more than it values checkups and management of existing conditions. West, a primary-care doc, explains it this way: “If I put in an hour with a patient, I will be reimbursed for one exam–the same payment I would get for seeing that patient for 11 minutes.

“Meanwhile, an ophthalmologist might perform three cataract surgeries in that same hour, and each surgery might be reimbursed at twice the rate of my exam. So that doctor is making six times as much money.”

And if the eye patient has questions after the surgery about her medicine or her recovery, the specialist’s office is likely to suggest that she consult with her primary caregiver. After all, neither doctor gets reimbursed for answering questions on the phone, so the chore is often traded like a hot potato. “We say primary care is critical to a healthier future,” West says, “but in every way we show value, it is at the lowest level.”

DIRECT ACTION, IN ACTION

On a rare crystal day in seattle, i paid a visit to the headquarters of the online travel agent Expedia. For over a year, Expedia has paid Qliance a fixed per-patient fee to provide a direct-primary-care option for HQ workers. Specialists and hospitalization are covered by traditional insurance.

Expedia was motivated to try direct care for reasons that are familiar to business executives everywhere: health care bills were skyrocketing, but employees were not getting healthier. “We had a number of catastrophic illnesses in 2011 and a disturbing number of deaths–12,” vice president for human resources Connie Symes tells me. “We found Qliance and their model of spending quality time with patients addressed our need to get employees involved in their own care.”

Qliance opened a clinic in Expedia’s building. The clinic is staffed by three doctors and includes several exam rooms, a small lab to perform routine tests, an X-ray machine and a stock of commonly prescribed generic medicines. Expedia employees zip from their desks to the doctor’s office with little or no waiting time. New patients spend 45 minutes elaborating their medical histories; after that, most visits can be handled in 15 to 30 minutes. Patients can also reach their doctors by text and email.

At the end of last year, Expedia surveyed the staff, Symes says, and the response was emphatic. More than half the employees had tried Qliance, and of those, more than 95% said they were satisfied. “They love the doctors,” Symes says. “They love the personal relationships they’re forming.” And although Expedia still classifies Qliance as an experiment, Symes says direct primary care, with its emphasis on prevention, “is taking us in the right direction on lowering costs.”

Seems too good to be true, I tell Erika Bliss, and she replies that she hears that a lot–but that’s because we haven’t seen, from the inside, how much waste and inefficiency is larded into the existing system. With enough freedom, she says, a primary caregiver can easily find lots of ways to deliver superior health care at a lower price. Bliss suggests that proper primary care should cost an average of about $1,200 per patient per year and will save significantly more than that in emergency care, specialist visits and treatment of chronic diseases.

“The existing system is built around diagnosing and treating complex cases. It rewards expensive, invasive and complicated solutions. But patients don’t want to be complex cases,” Bliss says. She cites a famous study by the Institute of Medicine that estimated that 30% of each health care dollar is wasted in the U.S. While reformers struggle to “bend the curve” of rising costs by squeezing out the waste, “we just lop it off,” she says.

While the results at Expedia are intriguing, the real test of direct primary care began when Qliance became the first practice of its kind to join the Medicaid system. Medicaid patients can be a challenging population because many of them have untreated medical conditions after years of inadequate health care. Absorbing thousands into the Qliance practice–at a reported cost to the government of about $700 per person per year–had made for a roller-coaster year. Medicaid patients are promised the same care as other Qliance customers.

One of those new patients is Jim Papadem, an out-of-work printing-press operator in his mid-50s from Redmond, Wash., who had long ignored his deteriorating health out of fear that the cost of treatment would ruin him. “I was pretty sure I had diabetes, and it turns out I had atrial fibrillation too,” he says. At his first meeting with his new Qliance physician, Dr. Randy Leggett, Papadem detailed his many symptoms. Leggett dispatched him to an eye specialist for treatment of a diabetes-related condition. She also prescribed two generic drugs to manage his blood sugar. Next came a referral to a cardiologist to treat the heart malfunction, which Leggett now monitors routinely. “She calls me now and then to check up on me at the end of the day, and when I have questions, she is available to help me connect the dots,” Papadem said.

So where are the cost savings? For Papadem, proper primary care reduces the likelihood of blindness, stroke and heart failure. More immediately, the Qliance patients now have an alternative to getting their care at the local emergency room. According to a 2010 survey of ERs in Washington State, the vast majority of emergency-room complaints are not actual emergencies. Instead, they involve common maladies that are easily handled by primary caregivers. With the average cost of a child’s ER visit running almost $2,000–and the average adult ER visit more than $4,500–Qliance more than pays for itself every time it keeps a client out of the ER.

Qliance’s large, diverse patient group makes it the first direct-care firm in a position to compile compelling statistics on the promise of direct care. “What will tip the scales for us is when we can produce hard data on savings and outcomes,” Bliss says hopefully. That takes some time, but the numbers are firming up. “If we can show that we are getting 15% to 30% of the costs out by using a model that doctors like and patients want, the whole system is going to flip pretty quickly.”

Centene Corp. is a Fortune 500 company hired by Washington State to manage its Medicaid plans. Jay Fathi, CEO of Centene’s Washington affiliate, tells me that “we already have evidence to show us that they are doing a good job.” Confident that the direct-primary-care model has legs, Centene has joined the growing roster of Qliance investors.

SO WHAT’S THE CATCH?

Of course, there’s a catch–at least in the short term. Docs on the treadmill are often responsible for 2,000, 2,500 or even 3,000 patients each. Direct-primary-care doctors serve far fewer patients. In a nation where there is already a shortage of primary caregivers, this would seem to disqualify direct care as a mass solution.

“It’s a trend that will probably grow a bit, but I think there is probably some ceiling to it,” says Ceci Connolly, managing director of the Health Research Institute at consulting giant PwC. Connolly foresees direct care as one part of a wider mix of patient-directed primary-care options, from drugstore clinics and Weight Watchers outlets to wearable monitors and digital apps.

But leaders of the direct-care movement argue that in the longer term, their model can solve the shortage of frontline doctors. By giving primary caregivers a good living doing work they can love, direct care encourages young physicians to follow their heart.

On a recent visit to Wichita, Kans., I met a young doctor who is doing that. Josh Umbehr, 33, was an aspiring primary-care doctor at the University of Kansas when, like many others, he grew horrified by the fee-for-service system. “It was crazy,” he said. “Insurance paid more for a prostate exam if it was done on a separate visit from a checkup. So the patient would have to come in twice. Medicare would pay for cleaning out earwax–but only one ear per visit. You had to schedule a second appointment for the other ear.”

Then he discovered direct care. As the son of a garbage collector, he understood the idea of one price for unlimited service. With classmate Doug Nunamaker, 34, Umbehr launched a moderately priced clinic called Atlas MD. The idea caught on enough that they recently hired a third doctor. Now they care for about 1,800 patients at an average monthly price of about $50 each.

An entrepreneurial dynamo, Umbehr paints a sky’s-the-limit future in which primary care is transformed into medicine’s most valuable role. To hear him tell it, he’s already living that dream, seeing an average of five patients per day–with other interactions by phone, text and email–while earning $200,000 to $240,000 per year. (The national average for primary-care physicians is well below $200,000.)

His in-house pharmacy, run out of a closet, saves patients hundreds of dollars per year on meds–a major selling point for those who blanch at his monthly fee. Take the uninsured mother who could not imagine paying $120 each month to cover herself, her husband and their two kids. Umbehr asked if she was taking any medications, and she said that was the problem: her prescriptions cost $138 per month. Umbehr buys the generic version wholesale for $1.55. “I told her her membership would cover the drugs. We eat the buck and a half as a cost of doing business, and she gets primary care for her family. At the end of each month, she’s 18 bucks ahead.”

When people say this is going to worsen the physician shortage, Umbehr says, “No. The current system is worsening the physician shortage. The ship is already sinking. We probably talk to 10 doctors per week who are burned out, going bankrupt, ready to retire years before they ought to. And when they see they can take better care of their patients and never deal with insurance companies again, and earn $210,000, $220,000, $250,000 per year, you’re going to see physicians flocking.”

Wouldn’t that be something? After so many years of dire forecasts, of blue-ribbon panels and expert commissions, of alphabet agencies and battles on Capitol Hill–wouldn’t it be amazing if the health care revolution finally arrived in the form of simple family doctors offering better care in exchange for a happier life? It’s worth a try, because if it works, an awful lot of people will be wearing that blissful smile.

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TIME Veterans

Rising VA Disability Payments Linked to Veteran Unemployment

Last US Military Convoy Departs Iraq
A U.S. soldier waves as the final American convoy pulls out of Iraq in 2011 at the end of the second Iraq war. Mario Tama / Getty Images

Stanford study suggests a seesaw relationship between the two

Unemployment persists among military veterans as a sharply growing number of them are receiving disability payments from the Department of Veterans Affairs, according to a new study by a Stanford economist. The steep increase in such payments, Mark Duggan suggests, could be acting as a brake on their employment prospects.

Veterans receiving disability compensation from the VA rose from 8.9% in 2001 to 18% this year, Duggan’s study says. Even as the number of veterans shrank from 26.1 million in 2001 to 22 million this year, those receiving federal money for wounds linked to military service have climbed from 2.3 million to 3.9 million.

 

Stanford Institute for Economic Policy Research

“The substantial rise in Disability Compensation enrollment in recent years suggests that this program may be affecting labor market outcomes for military veterans,” Duggan writes. He cites two possible reasons:

– It can reduce a veteran’s “propensity to work because—with the additional income—he may now prefer additional leisure to work.”

– Additional work may also “prevent a veteran from qualifying for a higher level of Disability Compensation benefits—and thus increase the effective tax rate on work.”

The jobless rate among post-9/11 vets was 7.2% in October, compared to the nation’s 5.8% rate—and a 4.5% rate among all veterans.

The study “is important because it shows how the good intentions of the disability system can sabotage the well-being of veterans,” says Sally Satel, a one-time VA psychiatrist who now works at the conservative American Enterprise Institute think tank. But the report, she adds, could boomerang: “Talking about reforming the veterans’ disability system is a third-rail topic because, on superficial glance, it appears as if reformers want to deny veterans help.”

But Satel, a reform advocate, denies that. “Reformers urge that assistance be given in the most constructive way possible,” she says. “This means that the VA should go all-out in terms of treatment and rehabilitation, to maximize entry into the workforce and minimize exit from it.”

Some vets believe the report misses the point. Repeated deployments and the lack of a formal, uniformed and organized enemy, ground down the Americans who fought the post-9/11 wars, says Alex Lemons, a Marine sergeant who pulled three tours in Iraq, “A number of my friends were blown into many pieces and they never quite reassembled them,” he says. “You might look at this person and think they look fine despite scars, but then you find out they can’t stand for more than an hour a day, they have shrapnel that works its way out of their dermis and have to pry it out, they are near deaf without hearing aids, or they can’t pick up things as a result of nerve damage in a hand. It means they will never be qualified for many jobs.”

Lemons says it’s good that troops are coming forward seeking help for post-traumatic stress disorder, which has gone from the 10th most-common condition among vets on disability in 2000, to third in 2013. “In my infantry battalion the number of Marines who are on PTSD disability is not more than 35%,” he says, “even though I believe everyone who deployed with us has it.”

The average monthly disability payment grew 46%—from $747 to $1,094—between 2001 and 2013, Duggan reports. While that’s not much per veteran, the nation paid out a total of $54 billion in such benefits in 2013.

Congressional Budget Office

Not only are more veterans receiving disability compensation, Duggan’s report says, but they’re receiving more than earlier veterans did. That’s because the VA has ruled that the impact of their military service on their health is greater than for earlier generations of vets. Disability payments are pegged to a VA-determined rating, which is expressed in 10 percentage-point increments. Between 2001 and 2013, the number of vets deemed 10% disabled—generating an average monthly payment of $131 last year—dropped by 1%. Over the same period, the more than 800,000 vets rated 80% or more disabled—receiving an average monthly payment of $2,700—rose by 221%.

Military service also may have “become more demanding over time,” accounting for less veteran participating in the labor force, Duggan’s report says. “Consistent with this explanation,” he adds, “veterans have become more likely than non-veteran males to report that their health is poor or just fair rather than excellent, very good, or good.”

Elspeth Ritchie, a retired colonel who served as the Army’s top psychiatrist before retiring in 2010, believes the report slights what troops experienced in the nation’s post-9/11 wars. “It does not seem to factor in the high rate of physical injuries, traumatic brain injury and PTSD in the veterans from these conflicts,” she says.

Since turning its back on its veterans following the unpopular war in Vietnam, American society has sung the praises of its veterans, and has been footing the bills for those hurt to prove it. “Spending on veterans’ disability benefits has almost tripled since fiscal year 2000, from $20 billion in 2000 to $54 billion in 2013—an average annual increase of nearly 8%, after adjusting for inflation,” the Congressional Budget Office reported in August. “VA projects that such spending will total $60 billion in 2014 and $64 billion in 2015, a 19% increase from two years earlier.”

Duggan reports that a “key driver” in the growth of such benefits has been the VA’s decision to make veterans who served in southeast Asia during the Vietnam war eligible for benefits if they have Type 2 diabetes, ischemic heart disease, Parkinson’s disease, or B-cell leukemia. The agency took the action when it decided to “presume” the ailments were linked to military service in the theater and possible exposure there to the defoliant Agent Orange.

Today’s veterans, the study says, are more likely than their fathers to seek and gain VA disability benefits. Nearly one in four vets since 1990 are being compensated, compared to one in seven veterans prior to 1990. “This higher rate of enrollment may be primarily driven by the VA’s approval of presumptive conditions for Gulf War veterans who served in the Southwest Asia theater from 1990 to the present (including Iraq and Afghanistan),” Duggan found.

 

Congressional Budget Office

He also reports that while veterans between 1980 and 1999 were more like to be employed than non-veterans, that has flipped since 2000. “This significant reduction in labor force participation among veterans,” he adds, “closely coincides with their increase in Disability Compensation enrollment during this same period.”

Duggan notes that a 2010 change in VA regulations no longer required veterans with a diagnosis of PTSD to document their exposure to wartime trauma such as firefights or IED blasts. The number of veterans being compensated for PTSD rose from 133,789 in 2000 to 648,992 last year. “The percentage of all veterans on the Disability Compensation program with a diagnosis of PTSD has increased by a factor of six during this period,” Duggan writes, “from 0.5% in 2000 to 3.0% in 2013.”

The jump doesn’t surprise William Treseder, who deployed to Afghanistan and Iraq as a Marine sergeant. “Many post-9/11 vets can tell you stories about the inflation of VA claims,” he says. “We are often told to file for certain conditions—especially post-traumatic stress—whether or not we think it’s actually an issue. It’s the chicken-soup principle in action: can’t hurt; might help.”

Like Duggan, Treseder believes more study is needed examining the impact of disability payments on veterans. “This is much-needed research,” he says. “I’m glad to see someone out there looking into this.”

TIME Research

11 Remarkable Health Advances From 2014

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And what to look forward to in 2015

From groundbreaking new drugs to doctor-assisted suicide, 2o14 was full of historic moments that are bound to play on in a big way throughout 2015 and beyond.

1. 3D Mammography is proven to be effective
Multiple studies in 2014 showed 3-D mammography to be a highly accurate screening tool for detecting breast cancer with fewer false positive results. It’s not widely available yet, but the growing evidence suggests we’ll see more adoption in 2015. Hologic, one of two U.S. companies selling 3-D mammography machines, told TIME there’s growing interest, with at least one of their machines in all 50 states.

2. The number of uninsured Americans nears record low
Federal data released Dec. 18 revealed that the percentage of uninsured Americans neared historic lows in 2014 at 11.3%. As TIME reported, it appears certain to fall to record lows next year.

3. Brittany Maynard wins support for “death with dignity”
After she discovered she had terminal brain cancer, Maynard, 29, chose to end her own life in the company of her family and friends by taking prescribed barbiturates on Nov. 1. Maynard moved from California to Oregon for the state’s death with dignity law that allows doctors to prescribe lethal medications for the terminally ill. A video of Maynard explaining her choice went viral, and a recent poll showed most U.S. doctors now support death with dignity.

MORE: TIME’s Person of the Year: The Ebola Fighters

4. CVS stops selling cigarettes
In February, CVS announced it would stop sales of cigarettes and tobacco products in its 7,600 U.S. stores by Oct. 1. Tobacco products made up about 3% of the company’s annual revenue. Anti-smoking advocates were pleased by the move.

5. Way more calorie counts are coming
The FDA rolled out new rules in November that require chains—including restaurants, movie theaters, vending machines and amusement parts—with 20 or more locations to list their calories for all their food and drinks. Companies have a year to comply.

6. The FDA unveils new nutrition labels
In a similar move, the FDA revealed in February proposed changes to nutritional labels that will put greater emphasis on calories, added sugars and have more realistic serving sizes. Calories will be listed in bigger and bolder type, and may be listed on the front of food packaging.

MORE: 3D Mammograms Are Better For Dense Breasts

7. The Sunscreen Innovation Act becomes law
In December, President Obama signed into law the much-anticipated Sunscreen Innovation Act, which requires the FDA to quickly respond to pending sunscreen-ingredient applications that have been awaiting a response for over a decade. There’s a good chance that in summer 2015, we could have a batch of new, up-to-date sunscreens to try.

8. New drugs show promise for heart failure
Novartis is anticipating approval for its new heart failure drug, LCZ696, in the second half of 2015. The drug could replace the current treatment of care: ACE inhibitors. The company’s most recent human clinical trial was forced to end when it apparent LCZ696 saved more lives than standard of care.

9. PillPack offers a new kind of pharmacy
For people on multiple medications, remembering what to take and when can be a medical nightmare. That’s why pharmacist T.J. Parker launched PillPack in 2014. Instead of sending customers bottles, every two weeks the company sends a dispenser that has all the customers’ individual pills sorted and organized by day on a ticker tape sheet of tearable pouches. TIME named it one of the best inventions of 2014.

MORE: New Heart Drug Saves More Lives Than Standard of Care

10. A device literally filters Ebola from blood of a sick patient
One of the most novel treatments during the Ebola outbreak is a device that can suck the Ebola virus out of the blood. Developed by Aethlon Medical, the Hemopurifier is a specially developed cartridge that can be attached to a standard dialysis machine and uses proteins that bind to the Ebola viruses and pull them out of patients’ blood. It’s still experimental, but appears to have worked in at least one patient with Ebola in Germany.

11. The Ebola vaccine shows promise
In August, two vaccines to prevent the deadly Ebola virus went onto human clinical trials. The vaccines are being tested with the hope that it could be deemed effective, and safe enough to be distributed widely in West Africa, where the Ebola crisis rages on.

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