From Health and Fitness

Evaluations Of Medicaid Experiments By States, CMS Are Weak, GAO Says

With federal spending on Medicaid experiments soaring in recent years, a congressional watchdog said state and federal governments fail to adequately evaluate if the efforts improve care and save money.

A study by the Government Accountability Office released Thursday found some states don’t complete evaluation reports for up to seven years after an experiment begins and often fail to answer vital questions to determine effectiveness. The GAO also slammed the federal Centers for Medicare & Medicaid Services for failing to make results from Medicaid evaluation reports public in a timely manner.

“CMS is missing an opportunity to inform federal and state policy discussions,” the GAO report said.

Joan Alker, executive director of the Georgetown University Center for Children and Families, called the report’s findings “troubling but not surprising.”

“It has been clear for some time that evaluations of Section 1115 waivers are not adequate,” she said. “There is some good work going on in this space at the state level, for example in Michigan and Iowa, but as the report makes clear state’s evaluations are often incomplete and not rigorous enough.”

These experiments are often called “demonstration projects” or “1115 demonstration waivers” — based on the section of the law that allows the federal government to authorize them. They allow federal officials to approve states’ requests to test new approaches to providing coverage. They are used for a wide variety of purposes, including efforts to extend Medicaid to people or services not generally covered or to change payment systems to improve care.

Medicaid demonstration programs often run for a decade or more. Several states that expanded Medicaid eligibility under the Affordable Care Act did so through a demonstration program, including Indiana, Iowa, Arkansas and New Hampshire.

Nearly three-quarters of states have Medicaid demonstration programs, such as those testing providing services through private managed-care firms and requiring enrollees to pay monthly premiums. About a third of the federal government’s $300 billion a year in Medicaid spending goes to these test programs, the GAO said.

The study, requested by top GOP lawmakers including Sen. Orrin Hatch (R-Utah), reviewed demonstration programs in eight states — Arizona, Arkansas, California, Indiana, Kansas, Maryland, Massachusetts and New York.

In five of these states, money from their Medicaid demonstration program makes up more than half their total federal Medicaid budgets. Nearly all of Arizona’s funding — 99.7 percent — is through a demonstration program.

The use of Medicaid demonstration programs accelerated during the 1990s. But in recent years the experiments have often reflected the political leanings of state officials or the party controlling the White House. Under a demonstration program, the Trump administration this year approved requests from Indiana and Kentucky to enact work requirements for some adult Medicaid enrollees.

The GAO report noted that states often do not complete their evaluation reports until after the federal government renews their demonstration program. For example, Indiana’s Medicaid expansion demonstration program, which charges premiums and locks some enrollees out of coverage for lack of payment, was renewed in February even though a final evaluation report is not yet complete.

GAO said Indiana’s evaluation of its Medicaid expansion won’t look at the effect of the state’s provision that locks out enrollees for six months if they fail to pay premiums.

“GAO found that selected states’ evaluations of these demonstrations often had significant limitations that affected their usefulness in informing policy decisions,” the report said.

Alker said that “more sunshine and data are needed” to assess waivers, “especially as they are clearly the vehicle the Trump administration is now using to pursue its ideological objectives for Medicaid.”

(Story continues below.)

While states typically contract with independent groups to evaluate Medicaid demonstration programs, the federal government sometimes does its own review.

But the GAO investigators found Indiana’s Medicaid agency wasn’t willing to work with the federal contractor out of privacy concerns. That halted efforts for a federal review.

Joel Cantor, director of the Center for State Health Policy at Rutgers University in New Brunswick, N.J., said the demonstration programs have often shifted from their intended purpose because they are designed by lawmakers pushing an agenda rather than as a scientific experiment to find better ways to deliver care.

“Demonstration programs have been used since the 1990s to advance policy agenda for whoever holds power in Washington and not designed to test an innovative idea,” he said.

The evaluations often take several years to complete, he said, because of the difficulty of getting patient data from states. His center has done evaluations for New Jersey’s Medicaid program.

GAO recommended that CMS require states to submit a final evaluation report after the end of the waiver period, regardless of whether the experiment is being renewed, and that the federal agency publicly release findings from federal evaluations in a timely manner. Federal officials said they agreed with the recommendations.

Matt Salo, executive director of the National Association of Medicaid Directors, said the report highlighted a need to modernize the law dealing with Medicaid so that successful experiments are quickly incorporated into the overall program.

“The underlying problem is that the Medicaid statute has fundamentally failed to keep up with the changing reality of health care in the 21st century,” he said. “There’s no way to update the rules to make these changes” a permanent part of the program.

Evaluations Of Medicaid Experiments By States, CMS Are Weak, GAO Says

With federal spending on Medicaid experiments soaring in recent years, a congressional watchdog said state and federal governments fail to adequately evaluate if the efforts improve care and save money.

A study by the Government Accountability Office released Thursday found some states don’t complete evaluation reports for up to seven years after an experiment begins and often fail to answer vital questions to determine effectiveness. The GAO also slammed the federal Centers for Medicare & Medicaid Services for failing to make results from Medicaid evaluation reports public in a timely manner.

“CMS is missing an opportunity to inform federal and state policy discussions,” the GAO report said.

Joan Alker, executive director of the Georgetown University Center for Children and Families, called the report’s findings “troubling but not surprising.”

“It has been clear for some time that evaluations of Section 1115 waivers are not adequate,” she said. “There is some good work going on in this space at the state level, for example in Michigan and Iowa, but as the report makes clear state’s evaluations are often incomplete and not rigorous enough.”

These experiments are often called “demonstration projects” or “1115 demonstration waivers” — based on the section of the law that allows the federal government to authorize them. They allow federal officials to approve states’ requests to test new approaches to providing coverage. They are used for a wide variety of purposes, including efforts to extend Medicaid to people or services not generally covered or to change payment systems to improve care.

Medicaid demonstration programs often run for a decade or more. Several states that expanded Medicaid eligibility under the Affordable Care Act did so through a demonstration program, including Indiana, Iowa, Arkansas and New Hampshire.

Nearly three-quarters of states have Medicaid demonstration programs, such as those testing providing services through private managed-care firms and requiring enrollees to pay monthly premiums. About a third of the federal government’s $300 billion a year in Medicaid spending goes to these test programs, the GAO said.

The study, requested by top GOP lawmakers including Sen. Orrin Hatch (R-Utah), reviewed demonstration programs in eight states — Arizona, Arkansas, California, Indiana, Kansas, Maryland, Massachusetts and New York.

In five of these states, money from their Medicaid demonstration program makes up more than half their total federal Medicaid budgets. Nearly all of Arizona’s funding — 99.7 percent — is through a demonstration program.

The use of Medicaid demonstration programs accelerated during the 1990s. But in recent years the experiments have often reflected the political leanings of state officials or the party controlling the White House. Under a demonstration program, the Trump administration this year approved requests from Indiana and Kentucky to enact work requirements for some adult Medicaid enrollees.

The GAO report noted that states often do not complete their evaluation reports until after the federal government renews their demonstration program. For example, Indiana’s Medicaid expansion demonstration program, which charges premiums and locks some enrollees out of coverage for lack of payment, was renewed in February even though a final evaluation report is not yet complete.

GAO said Indiana’s evaluation of its Medicaid expansion won’t look at the effect of the state’s provision that locks out enrollees for six months if they fail to pay premiums.

“GAO found that selected states’ evaluations of these demonstrations often had significant limitations that affected their usefulness in informing policy decisions,” the report said.

Alker said that “more sunshine and data are needed” to assess waivers, “especially as they are clearly the vehicle the Trump administration is now using to pursue its ideological objectives for Medicaid.”

(Story continues below.)

While states typically contract with independent groups to evaluate Medicaid demonstration programs, the federal government sometimes does its own review.

But the GAO investigators found Indiana’s Medicaid agency wasn’t willing to work with the federal contractor out of privacy concerns. That halted efforts for a federal review.

Joel Cantor, director of the Center for State Health Policy at Rutgers University in New Brunswick, N.J., said the demonstration programs have often shifted from their intended purpose because they are designed by lawmakers pushing an agenda rather than as a scientific experiment to find better ways to deliver care.

“Demonstration programs have been used since the 1990s to advance policy agenda for whoever holds power in Washington and not designed to test an innovative idea,” he said.

The evaluations often take several years to complete, he said, because of the difficulty of getting patient data from states. His center has done evaluations for New Jersey’s Medicaid program.

GAO recommended that CMS require states to submit a final evaluation report after the end of the waiver period, regardless of whether the experiment is being renewed, and that the federal agency publicly release findings from federal evaluations in a timely manner. Federal officials said they agreed with the recommendations.

Matt Salo, executive director of the National Association of Medicaid Directors, said the report highlighted a need to modernize the law dealing with Medicaid so that successful experiments are quickly incorporated into the overall program.

“The underlying problem is that the Medicaid statute has fundamentally failed to keep up with the changing reality of health care in the 21st century,” he said. “There’s no way to update the rules to make these changes” a permanent part of the program.

Ten ERs In Colorado Tried To Curtail Opioids And Did Better Than Expected

DENVER — One of the most common reasons patients head to an emergency room is pain. In response, doctors may try something simple at first, like ibuprofen or acetaminophen. If that wasn’t effective, the second line of defense has been the big guns.

“Percocet or Vicodin,” explained ER doctor Peter Bakes of Swedish Medical Center, “medications that certainly have contributed to the rising opioid epidemic.”

Now, though, physicians are looking for alternatives to help cut opioid use and curtail potential abuse. Ten Colorado hospitals, including Swedish in Englewood, Colo., participated in a six-month pilot project designed to cut opioid use, the Colorado Opioid Safety Collaborative. Launched by the Colorado Hospital Association, it is billed as the first of its kind in the nation to include this number of hospitals in the effort.

The goal was for the group of hospitals to reduce opioids by 15 percent. Instead, Dr. Don Stader, an ER physician at Swedish who helped develop and lead the study, said the hospitals did much better: down 36 percent on average.

“It’s really a revolution in how we approach patients and approach pain, and I think it’s a revolution in pain management that’s going to help us end the opioid epidemic,” Stader says.

The decrease amounted to 35,000 fewer opioid doses than during the same period in 2016.

The overall effort to limit opioid use in emergency departments is called the Colorado ALTO Project; ALTO is short for “alternatives to opioids.”

The method calls for coordination across providers, pharmacies, clinical staff and administrators. It introduces new procedures, for example, like using non-opioid patches for pain. Another innovation, Stader said, is using ultrasound to “look into the body” and help guide targeted injections of non-opioid pain medicines.

Rather than opioids like oxycodone, hydrocodone or fentanyl, Stader said, doctors used safer and less addictive alternatives, like ketamine and lidocaine, an anesthetic commonly used by dentists.

Lidocaine was by far the leading alternative; its use in the project’s ERs rose 451 percent. Ketamine use was up 144 percent. Other well-known painkillers were used much less, like methadone (down 51 percent), oxycodone (down 43 percent), hydrocodone (down 39 percent), codeine (down 35 percent) and fentanyl (down 11 percent).

Lidocaine was the most commonly used alternative in the Colorado Opioid Safety Collaborative pilot project. Hospitals used a multifaceted approach to reduce reliance on opioid painkillers. (John Daley/CPR News)

Claire Duncan is a clinical nurse coordinator in the Swedish Medical Center’s emergency department. (John Daley/CPR News)

“We all see the carnage that this opioid epidemic has brought,” Stader said. “We all see how dangerous it’s been for patients, and how damaging it’s been for our communities. And we know that we have to do something radically different.”

Claire Duncan, a clinical nurse coordinator in the Swedish emergency department, said the new approach has required intensive training. And there was some pushback, more from patients than from medical staff.

“They say ‘only narcotics work for me, only narcotics work for me.’ Because they haven’t had the experience of that multifaceted care, they don’t expect that ibuprofen is going to work or that ibuprofen plus Tylenol, plus a heating pad, plus stretching measures, they don’t expect that to work,” she said.

The program requires a big culture change, encouraging staff to change the conversation from pain medication alone to ways to “treat your pain to help you cope with your pain to help you understand your pain,” Duncan said.

Emergency medical staff are all too familiar with the ravages of the opioid epidemic.

They see patients struggling with the consequences every day. But Bakes, the ER doctor at Swedish, said this project has changed minds and allowed health care professionals to help combat the opioid crisis they unwittingly helped to create.

“I think that any thinking person or any thinking physician, or provider of patient care, really felt to some extent guilty, but … powerless to enact meaningful change,” Bakes said.

Patient Ashley Copeland talks to her mother, Sue Iverson, in the Swedish Medical Center emergency department. Copeland was treated for a severe headache with a nerve blocking anesthetic, but no opioid painkillers. She was discharged and advised to use over-the-counter meds for pain. (John Daley/CPR News)

Dr. Peter Bakes is an emergency medicine doctor at Swedish Medical Center. (John Daley/CPR News)

The pilot project has proven so successful that Swedish and the other emergency departments involved will continue the new protocols and share what they learned. Stader said the Colorado Hospital Association will help spread the word about opioid safety and work toward its adoption statewide by year’s end.

“And I think if we did put this in practice in Colorado and showed our success that this would spread like wildfire across the country,” Stader said.

The 10 hospitals that collaborated on the project include Boulder Community Health, Gunnison Valley Health, Sedgwick County Health Center, Sky Ridge Medical Center, Swedish Medical Center, UCHealth Greeley Emergency and Surgical Center, UCHealth Harmony Campus, UCHealth Medical Center of the Rockies, UCHealth Poudre Valley Hospital and UCHealth Yampa Valley Medical Center.

This story is part of a partnership that includes Colorado Public Radio, NPR and Kaiser Health News.

Ten ERs In Colorado Tried To Curtail Opioids And Did Better Than Expected

DENVER — One of the most common reasons patients head to an emergency room is pain. In response, doctors may try something simple at first, like ibuprofen or acetaminophen. If that wasn’t effective, the second line of defense has been the big guns.

“Percocet or Vicodin,” explained ER doctor Peter Bakes of Swedish Medical Center, “medications that certainly have contributed to the rising opioid epidemic.”

Now, though, physicians are looking for alternatives to help cut opioid use and curtail potential abuse. Ten Colorado hospitals, including Swedish in Englewood, Colo., participated in a six-month pilot project designed to cut opioid use, the Colorado Opioid Safety Collaborative. Launched by the Colorado Hospital Association, it is billed as the first of its kind in the nation to include this number of hospitals in the effort.

The goal was for the group of hospitals to reduce opioids by 15 percent. Instead, Dr. Don Stader, an ER physician at Swedish who helped develop and lead the study, said the hospitals did much better: down 36 percent on average.

“It’s really a revolution in how we approach patients and approach pain, and I think it’s a revolution in pain management that’s going to help us end the opioid epidemic,” Stader says.

The decrease amounted to 35,000 fewer opioid doses than during the same period in 2016.

The overall effort to limit opioid use in emergency departments is called the Colorado ALTO Project; ALTO is short for “alternatives to opioids.”

The method calls for coordination across providers, pharmacies, clinical staff and administrators. It introduces new procedures, for example, like using non-opioid patches for pain. Another innovation, Stader said, is using ultrasound to “look into the body” and help guide targeted injections of non-opioid pain medicines.

Rather than opioids like oxycodone, hydrocodone or fentanyl, Stader said, doctors used safer and less addictive alternatives, like ketamine and lidocaine, an anesthetic commonly used by dentists.

Lidocaine was by far the leading alternative; its use in the project’s ERs rose 451 percent. Ketamine use was up 144 percent. Other well-known painkillers were used much less, like methadone (down 51 percent), oxycodone (down 43 percent), hydrocodone (down 39 percent), codeine (down 35 percent) and fentanyl (down 11 percent).

Lidocaine was the most commonly used alternative in the Colorado Opioid Safety Collaborative pilot project. Hospitals used a multifaceted approach to reduce reliance on opioid painkillers. (John Daley/CPR News)

Claire Duncan is a clinical nurse coordinator in the Swedish Medical Center’s emergency department. (John Daley/CPR News)

“We all see the carnage that this opioid epidemic has brought,” Stader said. “We all see how dangerous it’s been for patients, and how damaging it’s been for our communities. And we know that we have to do something radically different.”

Claire Duncan, a clinical nurse coordinator in the Swedish emergency department, said the new approach has required intensive training. And there was some pushback, more from patients than from medical staff.

“They say ‘only narcotics work for me, only narcotics work for me.’ Because they haven’t had the experience of that multifaceted care, they don’t expect that ibuprofen is going to work or that ibuprofen plus Tylenol, plus a heating pad, plus stretching measures, they don’t expect that to work,” she said.

The program requires a big culture change, encouraging staff to change the conversation from pain medication alone to ways to “treat your pain to help you cope with your pain to help you understand your pain,” Duncan said.

Emergency medical staff are all too familiar with the ravages of the opioid epidemic.

They see patients struggling with the consequences every day. But Bakes, the ER doctor at Swedish, said this project has changed minds and allowed health care professionals to help combat the opioid crisis they unwittingly helped to create.

“I think that any thinking person or any thinking physician, or provider of patient care, really felt to some extent guilty, but … powerless to enact meaningful change,” Bakes said.

Patient Ashley Copeland talks to her mother, Sue Iverson, in the Swedish Medical Center emergency department. Copeland was treated for a severe headache with a nerve blocking anesthetic, but no opioid painkillers. She was discharged and advised to use over-the-counter meds for pain. (John Daley/CPR News)

Dr. Peter Bakes is an emergency medicine doctor at Swedish Medical Center. (John Daley/CPR News)

The pilot project has proven so successful that Swedish and the other emergency departments involved will continue the new protocols and share what they learned. Stader said the Colorado Hospital Association will help spread the word about opioid safety and work toward its adoption statewide by year’s end.

“And I think if we did put this in practice in Colorado and showed our success that this would spread like wildfire across the country,” Stader said.

The 10 hospitals that collaborated on the project include Boulder Community Health, Gunnison Valley Health, Sedgwick County Health Center, Sky Ridge Medical Center, Swedish Medical Center, UCHealth Greeley Emergency and Surgical Center, UCHealth Harmony Campus, UCHealth Medical Center of the Rockies, UCHealth Poudre Valley Hospital and UCHealth Yampa Valley Medical Center.

This story is part of a partnership that includes Colorado Public Radio, NPR and Kaiser Health News.

Podcast: KHN’s ‘What The Health?’ The Long Wait Ends For Short-Term Plan Rules

The Trump administration finally released a long-awaited rule that would allow significant expansion of health insurance policies that do not meet all the requirements of the Affordable Care Act, both in terms of what they cover and how much they charge.

The administration says it wants to broaden the availability of so-called short-term insurance plans to give people who buy their own insurance more choices of lower-cost coverage. Critics say that the plans would draw the healthiest people out of the plans that meet the ACA’s requirements, driving up premiums for those who remain in that market.

And in the wake of last week’s tragic school shooting in Florida, attention is once again turning to the issue of a long-standing federal funding ban on most gun-related public health research.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Margot Sanger-Katz of The New York Times and Julie Appleby of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • The Trump administration’s proposal for short-term insurance plans may offer some less expensive coverage options, but those plans have a history of leaving patients on the hook if they develop health problems.
  • Federal health officials estimated that as many as 200,000 people now buying ACA plans might instead move to buy the short-term plans being proposed. But many analysts suspect the number could be much higher — and that will mean the prices could rise dramatically in the ACA marketplace plans and cost the federal government more money for the premiums it subsidizes.
  • Idaho’s proposal to allow plans that don’t meet ACA requirements is being watched closely, but federal officials have not yet tipped their hands about how they will react.
  • Although Congress has restricted funding for federal research into gun violence, studies are going forward by other academic researchers.
  • A growing divide among consumers is raising concerns. People who buy their own insurance are more frustrated as their costs continue to go up while they see others getting coverage paid for by the ACA subsidies or the expansion of Medicaid.
  • Democrats are seizing on the growing concerns over price among people who buy their own insurance to propel talks about establishing a way for more people to be covered by Medicare or Medicaid.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: The New York Times’ “As Some Got Free Health Care, Gwen Got Squeezed: An Obamacare Dilemma,” by Abby Goodnough.

Margot Sanger-Katz: HuffPost’s “The Liberal Establishment Suddenly Sounds Very Ambitious On Health Care,” by Jonathan Cohn.

Julie Appleby: Vox.com’s “Idaho’s Brazen Plan To Unravel Obamacare, Explained,” by Dylan Scott.

Stephanie Armour: The Washington Post’s “Bad Beside Manner: Bank Loans Signed In The Hospital Leave Patients Vulnerable,” by Shefali Luthra of Kaiser Health News.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

 

Podcast: KHN’s ‘What The Health?’ The Long Wait Ends For Short-Term Plan Rules

The Trump administration finally released a long-awaited rule that would allow significant expansion of health insurance policies that do not meet all the requirements of the Affordable Care Act, both in terms of what they cover and how much they charge.

The administration says it wants to broaden the availability of so-called short-term insurance plans to give people who buy their own insurance more choices of lower-cost coverage. Critics say that the plans would draw the healthiest people out of the plans that meet the ACA’s requirements, driving up premiums for those who remain in that market.

And in the wake of last week’s tragic school shooting in Florida, attention is once again turning to the issue of a long-standing federal funding ban on most gun-related public health research.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Margot Sanger-Katz of The New York Times and Julie Appleby of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • The Trump administration’s proposal for short-term insurance plans may offer some less expensive coverage options, but those plans have a history of leaving patients on the hook if they develop health problems.
  • Federal health officials estimated that as many as 200,000 people now buying ACA plans might instead move to buy the short-term plans being proposed. But many analysts suspect the number could be much higher — and that will mean the prices could rise dramatically in the ACA marketplace plans and cost the federal government more money for the premiums it subsidizes.
  • Idaho’s proposal to allow plans that don’t meet ACA requirements is being watched closely, but federal officials have not yet tipped their hands about how they will react.
  • Although Congress has restricted funding for federal research into gun violence, studies are going forward by other academic researchers.
  • A growing divide among consumers is raising concerns. People who buy their own insurance are more frustrated as their costs continue to go up while they see others getting coverage paid for by the ACA subsidies or the expansion of Medicaid.
  • Democrats are seizing on the growing concerns over price among people who buy their own insurance to propel talks about establishing a way for more people to be covered by Medicare or Medicaid.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: The New York Times’ “As Some Got Free Health Care, Gwen Got Squeezed: An Obamacare Dilemma,” by Abby Goodnough.

Margot Sanger-Katz: HuffPost’s “The Liberal Establishment Suddenly Sounds Very Ambitious On Health Care,” by Jonathan Cohn.

Julie Appleby: Vox.com’s “Idaho’s Brazen Plan To Unravel Obamacare, Explained,” by Dylan Scott.

Stephanie Armour: The Washington Post’s “Bad Beside Manner: Bank Loans Signed In The Hospital Leave Patients Vulnerable,” by Shefali Luthra of Kaiser Health News.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

 

5 Ways to Torch Your Core in Every Workout

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This article originally appeared on DailyBurn.com. Check out the rest of the exercises at Daily Burn.

At the core of every movement is just that: your core. And while lots of times “core” and “abs” become synonymous, it’s not 100% correct to use them interchangeably. Your rectus abdominus, transverse abdominus and obliques do comprise your midsection, but those aren’t the only muscles involved. Your back, hips and glutes also provide that stable base you need for stepping forward and backward, jumping side-to-side or turning all about. So to get a serious core workout you need to work them all.

“Core strength and stability not only enhances physical and athletic performance, but also helps maintain and correct posture and form, and prevent injury,” says Andia Winslow, a Daily Burn Audio Workouts trainer. “Those who have an awareness of their core and ability to engage it properly also have enhanced proprioception — or a sense of the positions of their extremities, without actually seeing them.”

Just picture elite athlete’s movement, Winslow explains, and how rhythmic and easy they travel through space, often in several planes of motion at the same time. They can thank strong trunk muscles for that. “Core should be a focus in every workout,” Winslow says. “Workouts won’t be as effective without proper core engagement.”

That’s not to say crunches need a permanent place in your sweat sessions. You can easily sneak in added core challenges during other common exercises. “When folks elect to add difficulty to workouts, they often increase weight, repetition or duration. Another — and often more effective — way to increase the intensity is by altering stance, ground contact, and/or dynamic variance equipment [think: sand or water],” Winslow says. Shifting your weight, testing your balance, or focusing on sticking a landing, all engage your middle more.

Learn how to get a solid core workout in every strength session with these sneaky midsection-scorching strategies from Winslow.

RELATED: 50 Ab Exercises to Score a Stronger Core

Strength Tips: How to Work Your Core in Every Workout

Photo: Twenty20

1. Add weight overhead. 

Whether you’re doing squats or lunges, Winslow suggests pushing or holding a weight overhead — or even just keeping your arms straight up — to activate your abs and shoulders. These muscle groups have to work harder to keep your spine in a neutral position so you don’t over-arch, straining your low back. Translation: Put your hands in the air like you really care (about your core workout).

2. Hold your step-ups and pull-ups.

Stepping up onto a bench, chair or box requires you to use one leg, driving off your heel to reach the top. While balancing on one limb already works your core to keep you upright, Winslow explains that pausing at the top (with knee raised) will incorporate your midsection more. When you stand up, simply hold for a two- to five-second count, then go back down.

Same strategy holds (literally!) for chin-ups and pull-ups. By pausing with your chin at the bar, your core fires to keep you steady and in one solid line. Leg or arm day turned core workout.

RELATED: 6 Exercises for the Ultimate Back and Chest Workout

Photo: Twenty20

3. Stick a single-leg landing on box jumps.

To crank up the core work in a box jump, start by bringing the hop height down. Then, keep the explosive leap to one leg and really stick the landing. (Hold it at the top for one to three seconds before standing up and stepping off.) One full-body exercise at its finest.

4. Do a single-arm dumbbell press or fly.

Make your arm and ab routine go hand-in-hand. Moving one arm at a time in exercises like a dumbbell press or fly, drives your midsection to work against the rotation to keep your hips square and your back straight. This will work whether you’re standing or lying on your back. Lift your hips into a bridge and you target your glutes, too. So many muscles; so much less time.

RELATED: 5 Planks, 10 Minutes: Your Ultimate Abs Workout

Photo: Daily Burn 365

5. Go for a twist. 

We tend to rotate in multiple directions all day, from turning to give a fellow studio mate a high five to twisting around to chat with a co-worker. But to keep that movement safe, your core needs enough strength to prop you upright and protect the spine. Enter: rotational exercises to build stability. Try twisting your torso at the top of a step-up or the bottom of a front or side lunge, so your body learns to better handle those turns you take throughout the day.

Después del tiroteo “hay que respetar cómo los jóvenes lidian con sus sentimientos”

Estudiantes, profesores, familiares, están luchando por sobrellevar los terribles días posteriores a la masacre en la escuela secundaria Marjory Stoneman Douglas, en Parkland, Florida. Y una psicóloga de Maryland dice entenderlos especialmente.

Christine Sylvest, terapeuta infantil de Rockville, Maryland, tiene una perspectiva única. Creció en Coral Springs, Florida, y fue alumna de la escuela en donde murieron 17 estudiantes y profesores. Se mudó con su familia a Ashburn, Virginia, antes de su último año, en 1995.

“Para mí, esa fue mi escuela secundaria”, dijo en una entrevista con Kaiser Health News el miércoles 21 de febrero. “Puedo imaginarme en ese pasillo, y puedo imaginarme el horror”.

Sylvest habló sobre cómo los adolescentes en Stoneman Douglas y en otros lugares pueden lidiar con sus sentimientos y cómo los padres y educadores deberían responder.

Hemos visto estudiantes de Stoneman Douglas, y otros en todo el país, marchando, participando de protestas. ¿Es algo terapéutico para ellos?

Si, absolutamente. Es realmente una forma saludable para estos adolescentes que han vivido un episodio muy traumático de hacer algo con la reacción inicial de enojo, incredulidad y conmoción. Y esta también es una forma con la que otros adolescentes pueden lidiar con sus sentimientos de enojo y desesperanza.

La psicóloga de Maryland, Christine Sylvest, quien fue estudiante de Stoneman Douglas High School, en Parkland, por tres años, dijo, “para mí esa fue mi escuela. Puedo imaginarme en el pasillo y puedo imaginarme el terror”. (Aiste Ray/Bee Me Photo)

¿Cómo pueden los padres ayudar a sus hijos adolescentes a lidiar con sus sentimientos después del tiroteo?

Los padres no deben tener miedo de abordar el tema con sus hijos y preguntarles qué saben al respecto. Los niños han visto mucha información en los medios tradicionales y en las redes sociales sobre el tiroteo. Los padres deben simplemente escuchar y luego validar el sentimiento de su hijo diciéndoles que es comprensible sentir enojo, miedo y ansiedad.

¿Qué deberían decirle los padres a los niños que están preocupados por ir a la escuela?

Los padres deben enfatizar que las escuelas son en realidad lugares bastante seguros. El tiroteo en la escuela está recibiendo mucha cobertura porque sucede muy raramente. Hay que enfatizar las cosas específicas que la escuela de su hijo hace para mantenerlos a salvo, como simulacros de incendio o si entra un intruso. Y decirles que si ven algo [sospechoso], pueden decírselo a un profesor, administrador o consejero. Pueden decirles a los niños que todo es posible, pero que hechos como este ataque son poco probables. Hay que darle al hijo información concreta sobre lo que está haciendo su escuela para mantenerlos a salvo.

¿Cuáles son las implicaciones a largo plazo para la salud mental y el bienestar de los niños de Stoneman Douglas?

Preocupa que desarrollen síntomas de trastorno de estrés postraumático. No les pasará a todos los que vivieron esta tragedia, pero algunos pueden tener síntomas. Esto incluye pesadillas y escenas retrospectivas, y revivir del trauma. Alarmas de incendio o ruidos fuertes pueden desencadenar que recuerden los disparos. El procesamiento de esta experiencia es más como una maratón para algunas personas, y, definitivamente, podría requerir apoyo de la familia y la comunidad, y terapia.

¿Los niños de Parkland, una comunidad relativamente privilegiada, se ven afectados de manera diferente ante un tiroteo que, por ejemplo, los adolescentes que crecen en Chicago u otros lugares donde pueden estar más expuestos a la violencia por armas de fuego?

Estos eventos pueden ser aún más traumáticos en otras áreas del país donde la violencia con armas de fuego es más común y en donde los niños tienen más experiencia con estos eventos. Niños que no han pasado por un trauma antes y generalmente no temen por su seguridad: estos son factores que los protegen. Entonces, en ese sentido, los niños en Parkland están más protegidos de desarrollar síntomas de trauma que los niños que no viven en áreas seguras.

¿Cómo pueden los padres y las escuelas ayudar a los adolescentes de Parkland a recuperarse?

Las rutinas son muy importantes para ayudar a los niños a sentir normalidad, pero es importante respetar la forma en que los niños quieren lidiar con sus sentimientos, y se debe respaldar cualquier cosa dentro de lo razonable. Es importante que los niños vuelvan a la escuela, pero cada uno puede estar listo en distintos momentos. En Stoneman Douglas, los maestros y los administradores realmente van a tener que prestar atención al estado emocional de los niños y facilitar su regreso. Ningún niño puede saber cuándo sus sentimientos intensos se vayan a interponer en el camino.

Después del tiroteo “hay que respetar cómo los jóvenes lidian con sus sentimientos”

Estudiantes, profesores, familiares, están luchando por sobrellevar los terribles días posteriores a la masacre en la escuela secundaria Marjory Stoneman Douglas, en Parkland, Florida. Y una psicóloga de Maryland dice entenderlos especialmente.

Christine Sylvest, terapeuta infantil de Rockville, Maryland, tiene una perspectiva única. Creció en Coral Springs, Florida, y fue alumna de la escuela en donde murieron 17 estudiantes y profesores. Se mudó con su familia a Ashburn, Virginia, antes de su último año, en 1995.

“Para mí, esa fue mi escuela secundaria”, dijo en una entrevista con Kaiser Health News el miércoles 21 de febrero. “Puedo imaginarme en ese pasillo, y puedo imaginarme el horror”.

Sylvest habló sobre cómo los adolescentes en Stoneman Douglas y en otros lugares pueden lidiar con sus sentimientos y cómo los padres y educadores deberían responder.

Hemos visto estudiantes de Stoneman Douglas, y otros en todo el país, marchando, participando de protestas. ¿Es algo terapéutico para ellos?

Si, absolutamente. Es realmente una forma saludable para estos adolescentes que han vivido un episodio muy traumático de hacer algo con la reacción inicial de enojo, incredulidad y conmoción. Y esta también es una forma con la que otros adolescentes pueden lidiar con sus sentimientos de enojo y desesperanza.

La psicóloga de Maryland, Christine Sylvest, quien fue estudiante de Stoneman Douglas High School, en Parkland, por tres años, dijo, “para mí esa fue mi escuela. Puedo imaginarme en el pasillo y puedo imaginarme el terror”. (Aiste Ray/Bee Me Photo)

¿Cómo pueden los padres ayudar a sus hijos adolescentes a lidiar con sus sentimientos después del tiroteo?

Los padres no deben tener miedo de abordar el tema con sus hijos y preguntarles qué saben al respecto. Los niños han visto mucha información en los medios tradicionales y en las redes sociales sobre el tiroteo. Los padres deben simplemente escuchar y luego validar el sentimiento de su hijo diciéndoles que es comprensible sentir enojo, miedo y ansiedad.

¿Qué deberían decirle los padres a los niños que están preocupados por ir a la escuela?

Los padres deben enfatizar que las escuelas son en realidad lugares bastante seguros. El tiroteo en la escuela está recibiendo mucha cobertura porque sucede muy raramente. Hay que enfatizar las cosas específicas que la escuela de su hijo hace para mantenerlos a salvo, como simulacros de incendio o si entra un intruso. Y decirles que si ven algo [sospechoso], pueden decírselo a un profesor, administrador o consejero. Pueden decirles a los niños que todo es posible, pero que hechos como este ataque son poco probables. Hay que darle al hijo información concreta sobre lo que está haciendo su escuela para mantenerlos a salvo.

¿Cuáles son las implicaciones a largo plazo para la salud mental y el bienestar de los niños de Stoneman Douglas?

Preocupa que desarrollen síntomas de trastorno de estrés postraumático. No les pasará a todos los que vivieron esta tragedia, pero algunos pueden tener síntomas. Esto incluye pesadillas y escenas retrospectivas, y revivir del trauma. Alarmas de incendio o ruidos fuertes pueden desencadenar que recuerden los disparos. El procesamiento de esta experiencia es más como una maratón para algunas personas, y, definitivamente, podría requerir apoyo de la familia y la comunidad, y terapia.

¿Los niños de Parkland, una comunidad relativamente privilegiada, se ven afectados de manera diferente ante un tiroteo que, por ejemplo, los adolescentes que crecen en Chicago u otros lugares donde pueden estar más expuestos a la violencia por armas de fuego?

Estos eventos pueden ser aún más traumáticos en otras áreas del país donde la violencia con armas de fuego es más común y en donde los niños tienen más experiencia con estos eventos. Niños que no han pasado por un trauma antes y generalmente no temen por su seguridad: estos son factores que los protegen. Entonces, en ese sentido, los niños en Parkland están más protegidos de desarrollar síntomas de trauma que los niños que no viven en áreas seguras.

¿Cómo pueden los padres y las escuelas ayudar a los adolescentes de Parkland a recuperarse?

Las rutinas son muy importantes para ayudar a los niños a sentir normalidad, pero es importante respetar la forma en que los niños quieren lidiar con sus sentimientos, y se debe respaldar cualquier cosa dentro de lo razonable. Es importante que los niños vuelvan a la escuela, pero cada uno puede estar listo en distintos momentos. En Stoneman Douglas, los maestros y los administradores realmente van a tener que prestar atención al estado emocional de los niños y facilitar su regreso. Ningún niño puede saber cuándo sus sentimientos intensos se vayan a interponer en el camino.