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Medicare Bleeds Billions on Pricey Bandages, and Doctors Get a Cut

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Medicare Bleeds Billions on Pricey Bandages, and Doctors Get a Cut

Companies can set such high prices because of a quirk in Medicare pricing rules, industry experts said. For the first six months of a new bandage product’s life, Medicare will set the reimbursement rate at whatever price a company chooses. After that, the agency adjusts the reimbursement to reflect the actual price paid by doctors after any discounts.

To circumvent the reimbursement drop, some companies simply roll out new products.

In April 2023, Medicare began reimbursing $6,497 for every square inch of a bandage called Zenith, sold by Legacy Medical Consultants, a company in Fort Worth, Texas. Six months later, Zenith’s reimbursement fell to $2,746.

That month, October 2023, Medicare began reimbursing $6,490 for a new Legacy product, a “dual layer” bandage called Impax.

Marketing materials for the two products use identical photographs and similar language. The company describes both products as providing “optimal wound covering and protection during the treatment of wounds.”

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Since 2022, spending on Zenith and Impax has exceeded $2.6 billion, according to Early Read’s analysis.

Legacy Medical Consultants did not answer questions about the marketing and pricing of those products. “Legacy is following the law, not taking advantage of the system,” Dan Childs, a company spokesman, said in a statement.

A cottage industry of doctors and nurses make house calls to treat wounds. Some skin substitute companies pitch themselves to wound care doctors by offering a cut of the rising bandage prices.

Dr. Caroline Fife, a wound care doctor from Texas who often writes about industry excesses, shared on her blog last year an email she received from an undisclosed skin substitute company. The company boasted that other doctors had developed “a healthy revenue stream” from its bandages and that a patch smaller than a credit card “would generate a little over $20,000 for your practice.”

Some companies offer doctors a “bulk discount” of up to 45 percent, according to doctor interviews and contracts reviewed by The Times. But doctors then collect a Medicare reimbursement for the full price of the product.

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Anti-kickback laws prohibit doctors from receiving financial rewards from drug companies or medical suppliers. And although Medicare does allow bulk discounts, experts said that the bandage rebates could have violated federal law because they didn’t actually require high-volume purchases. In some Legacy contracts reviewed by The Times, doctors had to buy only three products to qualify for a 40 or 45 percent discount.

“That is not a volume discount,” said Reuben Guttman, a lawyer in Washington, D.C., who has represented many Medicare whistle-blowers. Mr. Guttman said that such labeling could be used to conceal a kickback.

In 2024, at least nine medical practices billed Medicare more than $50 million for skin substitutes, according to an analysis done for The Times by the National Association of Accountable Care Organizations, which represents medical groups that are incentivized to curb Medicare spending.

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Scientists pinpoint why COVID vaccine may trigger heart inflammation in certain people

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Scientists pinpoint why COVID vaccine may trigger heart inflammation in certain people

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POST-DOSE PATTERN — New research reveals why the COVID vaccine can trigger heart issues, especially in one group

PREVENTION PAYOFF — Simple lifestyle changes could slash heart attack risk for millions

A new study has identified why mRNA COVID-19 vaccines could trigger heart issues, especially in one demographic. (iStock)

SMOKE SCREEN — A major cannabis study finds little proof for popular medical claims and flags big dangers

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HIDDEN LINK — A common dental health issue may hint at a dangerous cardiovascular condition

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SCREENING DEBATE A new study questions whether annual mammograms are necessary for most women

SUPER SPREAD — An “aggressive” new flu variant sweeps the globe as doctors warn of severe symptoms

The flu season has intensified as the new H3N2 variant causes severe illness worldwide. (iStock)

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DANGEROUS DEFICIT — A nutrient deficiency has been linked to heart disease risk for millions

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CORONARY CHRISTMAS — Holiday heart attacks spike as doctors share hidden triggers and prevention tips

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Aging-related joint disorder increasingly affects people under 40, study finds

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Aging-related joint disorder increasingly affects people under 40, study finds

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Cases of gout are rising in younger individuals, according to a global study.

The condition, which is a type of inflammatory arthritis, steadily increased in people aged 15 to 39 between 1990 and 2021, researchers in China announced.

Although rates vary widely between countries, the total number of young people with the condition is expected to continue rising through 2035.

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The study, published in the journal Joint Bone Spine, investigated 2021 data from the Global Burden of Disease (GBD), spanning 204 countries within the 30-year timeframe.

The data measured gout prevalence, incidence and years lived with disability, tracking global trends over time. The results showed a global increase across all three outcomes.

Gout is expected to continue rising in young people through 2035. (iStock)

Prevalence and disability years increased by 66%, and incidence rose by 62%. In 2021, 15- to 39-year-olds accounted for nearly 14% of new gout cases globally, the study found.

Men from 35 to 39 years old and people in high-income regions had the highest burden, but high-income North America topped the list for highest rates.

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‘SKINNY FAT’ WARNING ISSUED AS STUDY FINDS HIDDEN OBESITY BEHIND NORMAL BMI

Men were also found to have lived more years with gout due to high BMI, while women tended to have the condition as a link to kidney dysfunction, the study noted.

The total number of cases is expected to increase globally due to population growth, but the study projected that rates per population would decrease.

The researchers noted that data quality, especially in low-income settings, could have posed a limitation to the broad GBD data.

What is gout?

Gout is a common form of arthritis involving sudden and severe attacks of pain, swelling, redness and tenderness in the joints, according to Mayo Clinic. It most often occurs in the big toe.

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The condition occurs when urate crystals accumulate in the joint. These form when there are high levels of uric acid in the blood, which the body produces when it breaks down a natural substance called purines.

A gout flare-up can happen at any time, often at night, causing the affected joint to feel hot, swollen, tender and sensitive to the touch.

Urate crystals, described as sharp and needle-like, build up in the joint, causing intense pain and swelling. (iStock)

Purines can also be found in certain foods, like red meat or organ meats like liver and some seafood, including anchovies, sardines, mussels, scallops, trout and tuna, according to the Mayo Clinic. Alcoholic drinks, especially beer, and drinks sweetened with fruit sugar can also lead to higher uric acid levels.

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Uric acid will typically dissolve in the blood and pass through the kidneys into urine, but when the body produces too much or too little uric acid, it can cause a build-up of urate crystals. These are described by the Mayo Clinic as sharp and needle-like, causing pain, inflammation and swelling in the joint or surrounding tissue.

Risk factors for gout include a diet rich in high-purine foods and being overweight, which causes the body to produce more uric acid and the kidneys to have trouble eliminating it.

Experts urge patients to seek medical attention for gout flare-ups. (iStock)

Certain conditions like untreated high blood pressure, diabetes, obesity, metabolic syndrome and heart and kidney diseases can increase the risk of gout, as well as certain medications.

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A family history of gout can also increase risk. Men are more likely to develop the condition, as women tend to have lower uric acid levels, although symptoms generally develop after menopause.

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Untreated gout can cause worsening pain and joint damage, experts caution. It may also lead to more severe conditions, such as recurrent gout, advanced gout and kidney stones.

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The Mayo Clinic advises patients to seek immediate medical care if a fever occurs or if a joint becomes hot and inflamed, which is a sign of infection. Certain anti-inflammatory medications can help treat gout flares and complications.

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Fox News Digital reached out to the researchers for comment.

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New study questions whether annual mammograms are necessary for most women

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New study questions whether annual mammograms are necessary for most women

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A new study suggests that annual mammograms may not be the only effective approach for preventing breast cancer.

The research, published in the Journal of the American Medical Association (JAMA), tested a risk-based breast cancer screening approach against standard annual mammography.

The WISDOM randomized clinical trial, led by study authors from universities and healthcare systems across the U.S., considered more than 28,000 women aged 40 to 74 years old, splitting them into a risk-based screening group and an annual mammography group.

ERIN ANDREWS HAD ‘NO SYMPTOMS’ BEFORE CANCER DIAGNOSIS, PUSHES FOR EARLY SCREENINGS

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Researchers calculated each woman’s individual risk based on genetics (sequencing of nine breast cancer genes) and other health factors. 

A new study suggests that annual mammograms may not be the only effective approach for preventing breast cancer. (iStock)

Those who were at the highest risk were advised to alternate between a mammogram and an MRI scan every six months. Patients with elevated risk were told to get an annual mammography and counseling.

Average-risk women were guided to get mammograms every two years, while low-risk individuals were advised to have no screening until they became higher risk or reached age 50.

HIDDEN TYPE OF BREAST CANCER COULD BE EXPOSED BY NEW BREAKTHROUGH TECH

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The researchers found that risk-based screening did not lead to more advanced cancer diagnoses (stage 2B or higher) compared with annual screening, indicating that it is just as safe as traditional methods. The risk-based approach, however, did not reduce the number of biopsies overall, as researchers had hoped.

Among the risk-based group of women, those with higher risk had more screening, biopsies and detected cancers. Women at lower risk had fewer procedures.

The research, published in the Journal of the American Medical Association (JAMA), tested a risk-based breast cancer screening approach against standard annual mammography. (iStock)

“[The] findings suggest that risk-based breast cancer screening is a safe alternative to annual screening for women aged 40 to 74 years,” the researchers noted in the research summary. “Screening intensity matched individual risk, potentially reducing unnecessary imaging.”

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Fox News medical contributor Dr. Nicole Saphier, associate professor of radiology at Memorial Sloan Kettering Cancer Center in New Jersey, commented that while these findings are important, the study “completely sidelines” what screenings are designed to do — detect cancer early.

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“If you don’t measure stage 0, stage 1 or stage 2A cancers, you can’t tell whether personalized screening delays diagnosis in a way that matters for survival and treatment intensity,” Saphier, who was not involved in the study, told Fox News Digital in an interview.

Those who were at the highest risk were advised to alternate between a mammogram and an MRI scan every six months. (iStock)

More than 60% of breast cancers in the U.S. are diagnosed at stage 1 or 2A, where cure rates exceed 90%, the doctor noted.

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The trial doesn’t “fully evaluate” whether risk-based screening changes detection at the earliest and most treatable stages, where screening “delivers its greatest benefit,” according to Saphier.

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“Mammography is not without risk — radiation exposure, false positives, anxiety and potential over-diagnosis are real and should be acknowledged,” she said. “But it remains the most effective, evidence-based tool for detecting breast cancer early, when treatment is most successful.”

The expert added that labeling women under 50 as “low risk” is “outdated,” as breast cancer diagnoses are on the rise in younger females.

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“Until long-term mortality data support alternative approaches, annual screening beginning at 40 for average risk women should continue,” Saphier added. “Women should be assessed for breast cancer risk by 25 years old to determine if screening should begin earlier.”

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