Health
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.”
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.
Doctor Discounts
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.
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.
Health
Judge rules West Virginia parents can use religious beliefs to opt out of school vaccine requirements
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A West Virginia judge ruled on Wednesday that parents can use religious beliefs to opt out of school vaccine requirements for their children.
Raleigh County Circuit Judge Michael Froble on Wednesday issued a permanent injunction, saying children of families who object to the state’s compulsory vaccination law on religious grounds will be permitted to attend school and participate in extracurricular sports.
Froble found that a state policy prohibiting parents from seeking religious exemptions violates the Equal Protection for Religion Act signed into law in 2023 by then-Gov. Jim Justice.
West Virginia was among just a handful of states to offer only medical exemptions from school vaccinations when Gov. Patrick Morrisey issued an executive order earlier this year allowing religious exemptions.
ALABAMA, KANSAS TOP LIST OF MOST ‘FAITH-FRIENDLY’ STATES; MICHIGAN, WASHINGTON RANK LOWEST: REPORT
West Virginia Gov. Patrick Morrisey said that the ruling “is a win for every family forced from school over their faith.” (Andrew Harnik/Getty Images)
However, the state Board of Education voted in June to instruct public schools to ignore the governor’s order and follow long-standing school vaccine requirements outlined in state law.
The board said following Wednesday’s ruling that it “hereby suspends the policy on compulsory vaccination requirements” pending an appeal before the state Supreme Court.
Morrisey said in a statement that the ruling “is a win for every family forced from school over their faith.”
Two groups had sued to stop Morrisey’s order, arguing that the legislature has the authority to make these decisions instead of the governor.
Legislation that would have allowed the religious exemptions was approved by the state Senate and rejected by the House of Delegates earlier this year.
The judge found that a state policy prohibiting parents from seeking religious exemptions violates the Equal Protection for Religion Act signed into law in 2023. (Julian Stratenschulte/dpa (Photo by Julian Stratenschulte/picture alliance via Getty Images))
The judge ruled that the failure to pass the legislation did not determine the application of the 2023 law. He rejected the defendants’ argument that religious exemptions can only be established by legislative moves.
“Legislative intent is not absolute nor controlling in interpreting a statute or determining its application; at most, it is a factor,” Froble said.
A group of parents had sued the state and local boards of education and the Raleigh County schools superintendent. One parent had obtained a religious exemption to the vaccine mandate from the state health department and enrolled her child in elementary school for the current school year before receiving an email in June from the local school superintendent rescinding the certificate, according to the lawsuit.
In July, Froble issued a preliminary injunction allowing the children of the three plaintiffs’ families in Raleigh County to attend school this year.
FEDERAL JUDGE RULES PUBLIC CHARTER SCHOOL VIOLATED CHURCH’S FIRST AMENDMENT RIGHTS
State law requires children to receive vaccines for chickenpox, hepatitis B, measles, meningitis, mumps, diphtheria, polio, rubella, tetanus and whooping cough before attending school. (iStock)
Last month, Froble certified the case as a class action involving 570 families who had received religious exemptions in other parts of the state. He said the class action also applies to parents who seek religious exemptions in the future.
Froble said the total number of exemptions so far involved a small portion of the statewide student population and “would not meaningfully reduce vaccination rates or increase health risks.”
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State law requires children to receive vaccines for chickenpox, hepatitis B, measles, meningitis, mumps, diphtheria, polio, rubella, tetanus and whooping cough before attending school.
At least 30 states have religious freedom laws. The laws are modeled after the federal Religious Freedom Restoration Act, which was signed into law in 1993 by then-President Bill Clinton, allowing federal regulations that interfere with religious beliefs to be challenged.
The Associated Press contributed to this report.
Health
12 High-Fiber Foods That Burn Belly Fat Fast for Women Over 50
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Health
The deadly cancer hiding in plain sight — and why most patients never get screened
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A new study from Northwestern Medicine suggests that current lung cancer screening guidelines may be missing most Americans who develop the disease — and researchers say it’s time for a major change.
Published in JAMA Network Open, the study analyzed nearly 1,000 lung cancer patients who were treated at Northwestern Medicine between 2018 and 2023.
The goal was to see how many of those patients would have qualified for screening under existing guidance from the U.S. Preventive Services Task Force (USPSTF).
STEALTH BREAST CANCER THAT HIDES FROM SCANS TARGETED IN BREAKTHROUGH TECH
USPSTF currently recommends annual CT scans for adults ages 50 to 80 who have a 20 pack-year smoking history (the equivalent of one pack of cigarettes per day for 20 years) and either still smoke or quit within the last 15 years.
Only about 35% of those diagnosed with lung cancer met the current criteria to undergo screenings.
Current lung cancer screening guidelines may be missing most people who develop the disease, a new study shows. (iStock)
That means roughly two-thirds of patients would not have been flagged for testing before their diagnosis.
“Not only does that approach miss many patients who had quit smoking in the past or did not quite meet the high-risk criteria, it also misses other patients at risk of lung cancer, such as non-smokers,” Luis Herrera, M.D., a thoracic surgeon at Orlando Health, told Fox News Digital.
The study noted that these patients tended to have adenocarcinoma, the most common type of lung cancer among never-smokers.
Missed patients tended to have adenocarcinoma, the most common type of lung cancer among never-smokers. (iStock)
Those missed by the guidelines were more often women, people of Asian descent and individuals who had never smoked, the study found.
The research team also compared survival outcomes. Patients who didn’t meet the screening criteria had better survival, living a median of 9.5 years compared with 4.4 years for those who did qualify.
ERIN ANDREWS HAD ‘NO SYMPTOMS’ BEFORE CANCER DIAGNOSIS, PUSHES FOR EARLY SCREENINGS
While this difference partly reflects tumor biology and earlier detection, it also highlights how current screening rules fail to catch a broad range of cases that could be treated sooner, according to researchers.
“The current participation in lung cancer screening for patients who do qualify based on smoking history is quite low,” said Herrera, who was not involved in the study. This is likely due to the complexity of the risk-based criteria and stigma associated with smoking and lung cancer, he added.
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To test an alternative, the researchers modeled a different approach: screening everyone between the ages of 40 and 85, regardless of smoking history.
Under that universal, age-based model, about 94% of the cancers in their cohort would have been detected.
Universal screening procedures could save lives and hundreds of thousands of dollars, according to the researchers. (iStock)
Such a change could prevent roughly 26,000 U.S. deaths each year, at a cost of about $101,000 per life saved, according to their estimates.
The study emphasized that this would be far more cost-effective than current screening programs for breast or colorectal cancer, which cost between $890,000 and $920,000 per life saved.
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Herrera noted the many challenges in the adoption of lung cancer screening, from lack of awareness to some providers not recommending the screening test.
However, he added, “The cost of screening is covered by most health insurance plans and many institutions also offer discounts for patients who don’t have insurance.”
“The current participation in lung cancer screening for patients who do qualify based on smoking history is quite low.”
Lung cancer remains the deadliest cancer in the country, killing more people each year than colon, prostate and breast cancer combined. But because of the narrow eligibility criteria based on smoking history, millions at risk never get screened.
Northwestern Medicine researchers argue that expanding screening to include all adults within an age range could help close those gaps, especially for groups often underdiagnosed.
Researchers argue that expanding screening to include all adults could help catch the missing cases. (iStock)
The study was conducted at a single academic center, which means the patient population may not represent the wider U.S. population. It also looked back at existing data, so it can’t prove how the new model would perform in real-world screening programs, the researchers acknowledged.
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The cost and mortality projections rely on assumptions that could shift depending on how screening is implemented.
The researchers also didn’t fully account for the potential downsides of broader screening, such as false positives or unnecessary follow-ups, they noted.
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For patients who don’t qualify for lung cancer screening, there are other opportunities for lung evaluations, including “heart calcium scores, CT scans and other imaging modalities that can at least evaluate the lungs for any suspicious nodules,” Herrera added.
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