Individuals who submit applications that are missing critical data need to submit the required pieces of data. Once this information is received, their applications will be processed. If the state is unable to provide a timely program determination, temporary coverage will be provided.
This temporary coverage will be available until the state is able to process the application and make a final eligibility determination. 

Notification

The Health Connector and MassHealth will send a letter to all applicants who will be receiving temporary coverage. The letter will explain the temporary coverage, what services are covered, which providers they can see, and how to get more information. The first of these letters will be sent out the week of December 23rd, and most people should receive them by January 1st. Additional letters will be sent out at the end of December and may not be received until early January. Even if an individual does not receive the letter until January, the temporary coverage begins on January 1, 2014.

Using Temporary Coverage

• Individuals with temporary coverage may receive services from providers in the MassHealth network.
• No health insurance ID card will be issued for temporary coverage. The letter that people receive about their temporary coverage will contain their Member ID and will serve as their proof of coverage. Individuals should bring a copy of the letter they received when they go to the doctor, hospital or get prescriptions. 
• There will be no monthly premium for temporary coverage; however, individuals may need to pay a co-pay for some prescriptions and services.
• Providers can verify eligibility for the temporary coverage by using MassHealth’s Eligibility Verification System (EVS). The coverage will display in EVS as MassHealth Standard.
• Coverage/Benefits- Any service that is covered for MassHealth Standard members is covered for individuals receiving this temporary coverage. Temporary coverage uses the same medical necessity and prior-authorization requirements that apply to services provided to MassHealth Standard members.

What Happens Once a Determination is Made?

Applicants should not have a gap in coverage if they take timely action to enroll in a plan after they receive their program determination. Coverage for individuals who are found eligible for MassHealth will begin right away. Applicants who are found eligible for a Health Connector plan will need to select a plan and, if applicable, pay their health insurance premium before their coverage begins. As long as applicants take these steps by the dates specified in the notice they receive from the Connector, they will not have a gap in coverage.

More Information

• Temporary Coverage FAQs:  http://bettermahealthconnector.org/wp-content/uploads/2013/12/Temporary_Coverage_FAQ.pdf
• Temporary Coverage Benefits:  http://bettermahealthconnector.org/wp-content/uploads/2013/12/Summary_of_Benefits_Temporary_Coverage.pdf
• Sample Temporary Coverage Letter: http://origin.library.constantcontact.com/download/get/file/1101674716790-76/Temporary+Coverage+Applicant+Notice+Final+12-20-13.pdf
• Provider Bulletin: http://origin.library.constantcontact.com/download/get/file/1101674716790-78/Temporary+Coverage+Provider+Bulletin+12-20-13.pdf

-Adapted from materials noted above transmitted by Important Update on Temporary Coverage from MassHealth and the Health Connector, MA Health Care Training Forum, December 20, 2013.

ACA: New Report & Lesser Known Provisions

Here’s a visual representation of the Massachusetts Subsidized Coverage landscape under the ACA.

MA ACA Subsidized Health Coverage Landscape

GLOSSARY

QHP= Qualified Health Plan
AWSS= Aliens with Special Status (legally present, but not MassHealth eligible, such as subject to the 5-year bar or “PRUCOL”)

-Adapted from Transitions in Health Care Reform, MLRI: Health Care Access in Changing Times, November 20, 2013.See all handouts at: Health Care Access Programs -- BBT Training.

New Report

A new report from the Blue Cross Blue Shield of Massachusetts Foundation gives a readable, detailed, yet still relatively concise overview of the many Affordable Care Act-related changes to the Massachusetts health coverage landscape.  See the report: Re-Forming Reform Part 2: Implementing the Affordable Care Act in Massachusetts.

Some of the lesser known aspects of implementation, many noted in the report, follow.

MassHealth

The big provisions include eligibility expansion to those who do not fall into one of the previous eligibility categories.  But lesser-known provisions include:

19- and 20-Year-Olds Eligible for MassHealth Standard

Beginning in 2014, 19- and 20-year-olds with incomes up to 150 percent FPL will be considered children under MassHealth, will receive MassHealth Standard benefits (including Early and Periodic Screening, Diagnosis and Treatment), and will be exempt from co-payments. Previously, MassHealth defined children as ages zero to 18. (Parents are still defined as parents living with children under age 19, and 19- and 20-year-olds with income over 150 percent FPL will not be able to qualify for Family Assistance as children.)

Former Foster Care Children’s Group to be Eligible for MassHealth Standard

Currently, Independent Foster Care Adolescents up to age 21 are eligible for MassHealth. Beginning in 2014, in addition to the 21 and younger population, former foster care children up to age 26 will be eligible for MassHealth Standard regardless of income.

Males Now Eligible for Breast and Cervical Cancer Treatment Program

Beginning in 2014, the Breast and Cervical Cancer Treatment Program will allow men with breast cancer to enroll in the program. Applicants for this program will no longer have to go through a clinic supported by the Women’s Health Network but will be able to apply directly and later will be asked to submit medical verification of their cancer screening and diagnosis.

Increased Benefits for Certain MassHealth Members with HIV

Previously, HIV-positive individuals with incomes at or below 200 percent FPL received MassHealth Family Assistance. As a result of the ACA Medicaid expansion, individuals in the HIV Family Assistance Program with incomes of 133 percent FPL or less will be eligible for MassHealth Standard. Individuals between 133.1 and 200 percent FPL will continue to receive MassHealth Family Assistance.

Automatic MassHealth Eligibility for TANF, SSI, and EAEDC Beneficiaries

The state will continue to provide automatic MassHealth Standard eligibility for those receiving Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), or Emergency Aid to Elders, Disabled and Children (EAEDC) without making a separate income determination using MAGI methodology.

Those with Access to Employer Sponsored Insurance May Be Able to Shop for
ConnectorCare

People with access to employer-sponsored insurance (ESI) that is “unaffordable” will be eligible for ConnectorCare (up to 300% FPL). Most people with access to ESI, even if unaffordable, were not eligible for the Commonwealth Care program. According to federal rules, employer-based coverage is affordable if a worker's share of the monthly premium for an individual plan is not greater than 9.5% of the worker's income. The cost of a family plan, which is much higher than the cost of an individual plan, is not taken into account.
 
Massachusetts may offer state subsidies to help families who do not qualify for federal assistance based on the cost of an individual plan, but cannot afford the higher cost of employer-based family coverage.
(Affordability definitions from:  http://www.massresources.org/health-care-2014.html#qhps [As of March 2015 website no longer operational].)

Non-Group Coverage

Previously in Massachusetts, an individual could only purchase non-group coverage (inside or outside the Health Connector) if he or she did not have access to employer-sponsored insurance that met the state’s Minimum Creditable Coverage standards. However, in order to comply with the ACA, the state has changed its laws to allow any resident of Massachusetts to purchase non-group coverage, and anyone who meets Health Insurance Marketplace requirements (must be a U.S. citizen or lawful resident, not incarcerated, and a resident of the state in which the Health Insurance Marketplace is operating) to purchase coverage through the Health Connector for these non-subsidized plans.

Hospital Determined Presumptive Eligibility

“Presumptive eligibility” allows for providing temporary health coverage to an individual so that he or she can receive covered health services immediately, while the MassHealth application is processed. Massachusetts will allow hospitals to make presumptive eligibility determinations — based on preliminary information provided by the individual — that provide benefits until the end of the following month or until an application is completed and an eligibility determination is made for the following Medicaid populations:

• Children and Young Adults (19 & 20) up to 150 percent FPL;
• Pregnant women up to 200 percent FPL;
• Parents and caretaker relatives and other adults up to 133 percent FPL;
• Individuals who need treatment for breast or cervical cancer up to 250 percent FPL;
• Individuals who are HIV positive up to 200 percent FPL; and
• Former foster care adolescents with no income limit (up to age 26).

The state will provide pregnant women who are determined presumptively eligible with full MassHealth Standard benefits.

Editor's note: this provision is not yet in effect at MGH as of 1/15/14. This will be subject to a contracting process. If we sign a contract it would allow us to determine presumptive eligibility for our outpatients as well as inpatients.

One Must File Taxes to Receive Tax Credits

The new federal subsidies are provided in the form of tax credits.  This applies to Connector Care plans (for those under 300% FPL and not eligible for MassHealth) and Qualified Health Plans with Tax Credits (for those between 300 and 400% FPL). To qualify for tax credits one must file taxes. If an applicant says they will not file taxes for the benefit year, they cannot receive a tax credit.  Applicants to applicable programs must attest that they will file taxes to receive a tax credit.  If someone has never filed taxes before that will not be a block to getting tax credits as long as the person attests that he or she will file taxes for the year in which tax credits are given.  Married applicants must file a joint return for the year in which they receive these tax credits.

-This section adapted from Information on Tax Credit Eligibility. (Distributed at MLRI: Health Care Access in Changing Times, November 20, 2013. See all handouts at: Health Care Access Programs -- BBT Training.)

Reconciliation

All receiving subsidized health coverage should report any changes in income, household configuration and filing status promptly. Tax credits are determined based on projected estimates of income, household composition and tax filing status for the year in which one will be receiving benefits. Those receiving tax credits will be subject to reconciliation after filing their taxes for a year in which they received tax credits.  The federal government will compare the projected income/household composition/tax filing status  provided at application to the actual figures once the year is over.  After this determination, individuals may be entitled to a higher refund than expected, or may be required to pay back any tax credits they received that they were not entitled to.

-This section adapted from Transitioning to Connector Care, part of MLRI: Health Care Access in Changing Times, November 20, 2013. See all handouts at: Health Care Access Programs -- BBT Training.

-Article adapted (unless otherwise noted) from Re-Forming Reform Part 2: Implementing the Affordable Care Act in Massachusetts,  Blue Cross Blue Shield of Massachusetts Foundation, December 2013.Linked from Health Care for All Massachusetts’ A Healthy Blog.

CMS Releases 2014 Medicaid Spousal Impoverishment Limits

The expense of nursing home care - which ranges from $5,000 to $8,000 a month or more - can rapidly deplete the lifetime savings of elderly couples. In 1988, Congress enacted "spousal impoverishment" provisions to protect the spouse who is still living at home. These provisions help ensure that the community spouse had adequate resources.
 
Medicaid Spousal Impoverishment Figures for 2014

• The new minimum community spouse resource allowance (CSRA) is $23,448 and the new maximum CSRA is $117,240. 
• The new maximum monthly maintenance needs allowance is $2,931. The minimum monthly maintenance needs allowance remains $1,891.25 ($2,365 for Alaska and $2,176.25 for Hawaii) until July 1, 2014.

Medicaid Home Equity Limits

• Minimum: $543,000; Maximum: $814,000

-See the original CMS announcement. 
-Adapted from: http://attorney.elderlawanswers.com/2014-spousal-impoverishment-and-home-equity-figures-released-14399

Opinion: How Failed Massachusetts Housing Policies are Threatening the State’s Neediest Families

Motels are the Commonwealth’s answer to the severe shortage of beds in homeless shelters. Overall, more than 4,100 families are in shelters and motels in the state, an all-time high — and a number that could rise through next summer.

The motels are woefully inadequate for keeping children healthy. There is often no place to play safely, no way to cook nutritious food, and a lack of nearby social supports. So, while homeless families technically have a roof over their heads, their bodies and brains

I work at Boston Medical Center, where the pediatric emergency room sees 28,000 children a year. A survey of 6,000 Boston-area families by the pediatric research center Children’s HealthWatch estimated that more than half of the children younger than 4 were housing insecure, moving frequently or otherwise living in unsafe or inappropriate housing. Such children are more likely than their housing-secure peers to get hospitalized, be hungry, and have developmental delays. As Dr. Megan Sandel, a BMC pediatrician and longtime housing advocate, often says, housing is a vaccine; it protects our children from hunger, disease, and violence, just as a shot protects them from measles.

Alarmingly, being housing insecure in Massachusetts does not necessarily qualify a family for shelter. In 2012, the eligibility requirements were sharply restricted, and as of April 2013, up to 75 percent of applicants were being denied placement, sometimes because they couldn’t prove they had slept somewhere unfit for human habitation, like a car or a bus station.

When BMC social worker Nikki Hinckley talks about these families, her voice is tense. She talks about a child with sickle cell disease, a condition where cold weather can bring on intense pain, strokes, and life-threatening lung problems. The family was sleeping in a cold church basement, which disqualified them for shelter but landed the child in the hospital. She talks about autistic children living in crowded conditions, causing them severe emotional distress, and families who come to the ER over and over, trying to find a way to get housed. “It’s just awful, sitting in front of families day after day saying we have nothing to offer them,” she says.

HomeBASE, a temporary housing subsidy program put in place in 2011, was supposed to be an answer to the combined crisis of housing insecurity and unsuitable motels. It was originally intended to provide three years of assistance to homeless families, supplementing their income so that they could afford apartments, get on their feet, and ideally start paying their own rent. It expired this summer, after the Legislature voted to shorten the program by a year.

More than half of the state’s approximately 5,000 HomeBASE families will have lost their subsidies by the end of this month, according to the Metropolitan Boston Housing Partnership, or MBHP. The rest will lose them by the end of July. Although new stipends from the state have helped keep many of those families off the street so far, the funds top out at $8,000, which doesn’t go far around here. “All bets are off once that assistance is gone,” says MBHP executive director Chris Norris.

According to a May 2013 report from MBHP, which administers the HomeBASE program in the Boston area, program families had an average monthly income of $845, with an average monthly housing cost of $1,283. In one of the nation’s most expensive housing markets, it was unrealistic to expect that these families could get to the point where they could afford their rent without the support. Ironically, those in motels end up costing the state roughly $2,400 a month, significantly more than paying their full rent would be.

Norris, Sandel, and others believe the answer is permanent income-adjusted housing subsidies. These would require a significant initial investment, and we would need to maintain a shelter safety net as long as it’s needed.

But we know that temporary subsidies don’t work and that the motel system is unhealthy and expensive — the rooms now cost the state $46 million a year. And data from a program for homeless adults indicate that subsidies would likely be cheaper than health care and other services currently used by housing-insecure families.

Permanent subsidies introduced without further restricting access to the shelter system would be a real, cost-effective investment, and our legislators need to know that’s an investment we want them to make.

-See Dr. Alexandria Coria’s full Boston Globe Magazine perspective...

Low Social Service Spending Linked to Poor US Health Care Outcomes

A new book, The American Health Care Paradox, by Elizabeth Bradley and Lauren Taylor (previously reviewed in the Globe), puts forth a novel central argument about the dilemma of U.S. health care spending.

We all know the dilemma:

The U.S. pays so much more for medical care than does any other advanced nation, and from that societal investment, we get mediocre to poor results on life expectancy (26th place), infant mortality (31st), low birth weight (28th), maternal mortality (25th), you name it. It's been true since the early 1980s, and we keep looking for solutions from within the health care sector itself.

Bradley's research over the past several years examines spending on social services as well as spending on health care services in the equation.  She finds an important result. Though the U.S. spends the most on medical care among advanced (OECD) nations, we spend the absolute least (Mexico and Korea are our runners up) on non-health social services. When you put both together, we're not number one in spending, we're number ten. What kinds of social service spending are included:

"Social services expenditures included public and private spending on old-age pensions and support services for older adults, survivor benefits, disability and sickness cash benefits, family support, employment programmes (e.g., public employment services and employment training), unemployment benefits, housing support (e.g., rent subsidies) and other social policy areas excluding health expenditures."

Something compelling is going on here. Bradley and Taylor write: "Inadequate attention to and investment in services that address the broader determinants of health is the unnamed culprit behind why the United States spends so much on health care but continues to lag behind in health outcomes."

I can never consider U.S. macro-health spending again and ignore this piece of the puzzle. While many in the U.S. public health and social services sectors have recognized the chasm between the vast financial resources in the medical care sector versus the comparatively puny resources in the social services sector, Bradley's analysis puts it in a new and far more compelling light.

Our American tendency to medicalize everything we can get our hands on, while sometimes helpful for short-term problems, has accomplished far more harm than we realize. Our assumption that we can solve the U.S. health care dilemma from within the "house of health care" itself may be one of our saddest delusions.

This is not to belittle the efforts of those many, many men and women dedicated to the continuous and transformational improvement of medical care. Bradley's analysis, though, puts it in a different light. Fundamentally, the solution to the health care paradox cannot come from within health care itself.  It must come from outside, from public and political leadership at all levels, to get this straight.  Not just government, though very much from government.

-See John McDonough’s full opinion piece with relevant graphs at Boston.com...

Cited in/Linked from: HEALTH CARE WEEKLY UPDATE, Barbara Roop & John Goodson, Health Care for Massachusetts, December 20, 2013.

The Massachusetts Prevention and Wellness Trust

The Massachusetts Prevention and Wellness Trust is a four-year, $60 million project designed to support prevention and health-promotion activities in the state. The first project of its kind in the United States will fund six to 12 collaborative initiatives, and partners on the initiative will include municipalities, community-based organizations, health care providers, regional agencies and health plans. Information on the Trust is detailed in a new report prepared by the Institute on Urban Health Research and Practice at Northeastern University and funded by the Robert Wood Johnson Foundation.

The vision behind the creation of the project is to give all Massachusetts residents the opportunity to live in communities that promote health, as well as seamless access to all community and clinical services needed to prevent and control chronic diseases. It was created because while there is access to health insurance and health care in Massachusetts, health costs continue to rise. The goals of the project include:

• Reducing the rate of the state’s most costly preventable health conditions
• Reducing health disparities
• Increasing healthy behaviors
• Increasing the adoption of workplace wellness programs
• Developing a strong evidence base of effective prevention programs

To implement these goals, the Massachusetts Department of Public Health identified four priority areas: tobacco use, childhood asthma, hypertension and elder falls prevention.

A new infographic created for the Prevention and Wellness Trust’s inauguration illustrates how community links work together to improve health under the principles of the Trust. For example, a diagnosis of hypertension would need a provider to prescribe medications, but the obesity and exercise needs that would also improve the condition for many patients requires input from other community entities, including:

• Classes in exercise, medication and stress reduction by community agencies
• Chronic disease self management classes and home visits for medication use instruction by a community agency
• A neighborhood policy that provides support for transportation changes to encourage walking or biking and zoning for healthy food stores
• A neighborhood policy that provides support for more accessible recreation options in parks and city centers for increased stress reduction
• Workplace policies that provide support for workplace wellness programs that help provide and encourage exercise, healthy foods and stress reduction

NewPublicHealth recently spoke with John Auerbach, a Professor at Northeastern University and the primary author of a report on the Trust, and Cheryl Bartlett, public health commissioner of Massachusetts and the lead person charged with its implementation.

-Read the full NewPublicHealth interview...
(Linked from HCFA MA Healthy Blog http://blog.hcfama.org/)

Health Policy Commissioner Paul Hattis Reflects After First Year Of Cost Control

This month marks one year since the inaugural meeting of the state’s Health Policy Commission .  Health Care for All  invited board member Dr. Paul Hattis, a long-time friend of HCFA, through his leadership in GBIO (the Greater Boston Interfaith Organization), to write his own reflections on the role of HPC in efforts to control costs and reform our health care system, and his role as the consumer voice in its governance.

With just one year in, I would say that the 2012 health care cost law (Chapter 224) has covered some significant ground in a short period of time. That said, though, this law doesn’t rely on quick fixes. It’s designed to be for the long-term and, as such, health care reform is a work in progress with many moving parts to be developed in the coming months and years.  The same is true for the HPC.  Containing the growth in health care spending is no easy task; the attendant issues are often complex and the details matter. 

It is hard to briefly summarize the broad charge given to the HPC under the 2012 law.  Suffice it to say, the Legislature created our Board and asked us to use a combination of some regulatory authority, moral suasion,  and good critical thinking to help move the health care system and its actors towards higher-value.  Specifically, the HPC from my vantage point has been asked to frame, name, tame, acclaim, shame and blame our way to a more affordable and higher quality health care system.  When I teach students at Tufts Medical School about Chapter 224, and talk about the HPC’s role, I tell them:

We are trying to navigate our way to reducing the growth in health care spending using “GPS:”

G—Global Payment:  Promoting and evaluating the evolution of the health care payment system away from fee-for-service toward value-based payment that incentivizes less wasteful care and improved quality.   Payment system reforms should also help to create a framework for improved care integration among providers with a special focus on improving behavioral health care from an access, cost and quality perspective.

P—Prices and Provider Transformation:   It is important to recognize that there are higher-priced and lower-priced providers in our state, with the challenge that some amount of this price variation is unwarranted.   This reality suggests that there are important societal gains from helping to promote a payment system that pays fairly to all for high value care, and encourages  all providers to become more efficient.  Promoting high value care also necessitates our making smart investments in challenged community hospitals to help them transform and thrive for the long-term.  The HPC is also charged with completing Cost and Market Impact Reviews of transactions which may have significant cost, quality, access or market implications.  Prices also relate to the consumer side, where, in the non-urgent care context, a goal is to make price and quality information more transparent and readily available to consumers so that they can “choose wisely.”

S—Spending Target:  The HPC is responsible for overseeing the efforts of all stakeholders  to reduce the overall growth in health care spending by creating a per-person “cost growth target”  which is tied to the overall growth rate of the economy.
Let me try to name some of the key areas of focus and concern which will likely occupy the attention of the HPC over the next 12 months and may be of special interest to HCFA blog readers.  I will try to categorize them under the GPS framing:

G—Global Payment

1. Development of a Patient Centered Medical Home certification program
2. Development of an Accountable Care Organization certification program
3. Examination of issues tied to improved care integration with a special focus on the challenges of behavioral health care from an access, cost and quality perspective.

P – Prices and Provider Transformation

1. Development of regulations regarding notices of “Material Change” and the Cost and Market Review process
2. Completing Cost and Market Impact Reviews of  transactions which may have significant cost/quality/access or market implications
3. Selection and monitoring of grantees for Phases I and II of the Community Hospital Acceleration, Revitalization, Transformation (CHART) Investment Program

S – Spending Target

1.  Cost Trend analysis and reporting, including initial Cost Trend Report in late 2013
2.  Later in 2014—review and commentary of initial reporting by the Center for Health Information and Analysis (CHIA) of state cost growth target data for 2013
3. Understanding resource allocation and needs through the Health Resource Planning Council and the Registration of Provider Organizations

-See the full blog post:  http://blog.hcfama.org/2013/11/20/health-policy-commissioner-paul-hattis-reflects-after-first-year-of-cost-control/  

Partners-South Shore Deal May Increase Costs

Plans to meld South Shore Hospital and Harbor Medical Associates into Partners HealthCare System would boost the state’s three largest health insurers’ spending by a projected $23 million to $26 million annually, overwhelming potential savings from more efficient operations, according to a summary of a report released this month by the Massachusetts Health Policy Commission.

The watchdog agency, created last year to help bring health cost increases in line with the state’s economic growth, will refer its report on Partners’ proposed South Shore expansion to Attorney General Martha Coakley’s office for further review, the summary said. The Health Policy Commission does not have authority to block any of the deals, but state and federal antitrust regulators could sue to prevent the acquisitions.

 “We find the proposed transactions between Partners, South Shore Hospital [in Weymouth], and Harbor will increase health care spending, likely reduce market competition, and result in increased premiums for employers and consumers,” the summary concluded.

“We find the projected benefits from care delivery efficiencies and quality improvement to be limited in comparison to known spending increases.”

But the commission’s findings on Partners’ expansion push on the South Shore are being called preliminary. That means Partners will be given 30 days to respond before a final report is published. The commission is also pressing forward with a review of Partners’ plans to take over a pair of community hospitals north of Boston.

A Partners vice president, Rich Copp, said he hoped the report would be the springboard to a “meaningful dialogue” on the system’s efforts to strengthen health care delivery and rein in costs.

“Our proposed acquisition will improve the care that patients in Southeastern Massachusetts receive as we invest in primary care and health information technology, resulting in more coordinated and cost-efficient care,” he said.

Separately, the Health Policy Commission will issue a cost trends report Wednesday that shows Massachusetts continued to have the highest per-capital medical care spending in the nation as of 2009, when the state spent $9,278 per resident, compared with $6,815 for the nation as a whole. Among the drivers of high prices, that report said, was the greater use of hospitals in Massachusetts than nationally, especially for outpatient services that are more often performed in doctors’ offices elsewhere.

-See the full Boston Globe article...

Cancer and the Power of Placebo

Editor's Note:
In his book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine, Paul A. Offit, MD, explains why these unregulated industries continue to tempt millions of patients who are desperate for a cure, and who believe that anything that is "natural" must be good for them. Lidia Schapira, MD, spoke with Dr. Offit about his book and the use of alternative therapies for patients with cancer.

Chemo Is More Efficacious Than Emu Oil and Prayer

Dr. Schapira: Your book is a wonderful reminder of the power of stories that people tell themselves to explain illness and bring order to chaotic or terrifying experiences. You say that Steve Jobs "was seduced by bogus cancer cures." What is the seduction of alternative therapies for patients diagnosed with a serious illness, such as cancer?

Dr. Offit: These alternative therapies -- in Jobs' case, acupuncture, bowel cleansings, and fruit and vegetable juices -- are seductive because they exist under an untouchable halo. They can only help; they can't possibly hurt and are far less frightening than chemotherapy, radiation, or surgery. The notion that such therapies can help without the harms associated with conventional cancer treatments is very seductive -- wrong, but seductive.

Placebo Effect: More Something Than Nothing

Dr. Schapira: Let's talk about some of the treatments that might work through a placebo effect. Whether it is real or sham, if acupuncture relieves arthralgia from breast cancer treatment, what should we recommend? Should we say, "That's great, Mrs. Jones. I'm glad you found something that works," and leave it there? Should we tell the next patient that many patients say that acupuncture relieved their symptoms? Or should we not express an opinion at all?

Dr. Offit: Studies have shown that at least some people experience a positive effect from acupuncture. But let me take a step back.

The word "placebo" is unfortunate. When people hear placebo, they hear something dismissive -- that it's all in their minds. We know that you can learn to release endogenous endorphins. You can learn to upregulate your own immune system by releasing gamma-interferon, and downregulate your immune system with cortisol. By making your own cortisol, you can learn to release your own dopamine.

We need to find out how such therapies as acupuncture work so that we can figure out how to do them with the lowest risk, burden, and cost. I would argue that acupuncture has nothing to do with putting the needles under the skin. You probably could use retractable needles and achieve the same effect, as shown in studies by Ed Ernst. If retractable needles work just as well, then using them would eliminate the problem of needles breaking off or of inadvertently introducing viruses, such as hepatitis B, hepatitis C, or HIV.

I worry that these therapies evoke a kind of magical thinking, prompting proponents to explain their effectiveness by saying, "There are just some things we can't understand." Although this is true in the realm of religion, it isn't true in medicine. We may not understand it yet, but it can be analyzed.

For the most part, acupuncture doesn't hurt. However, it hurt Steve Jobs when he chose acupuncture over conventional therapy for a neuroendocrine pancreatic tumor. Complementary therapies, such as yoga, meditation, and prayer, are all fine to practice because they reduce stress, but not instead of antibiotics for meningitis.

-See the full Medscape interview: Cancer and the Power of Placebo. Medscape. Dec 13, 2013.