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.
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The American Cancer Society (ACS) has updated its guidelines for colorectal cancer screening.
The organization released the update in its flagship journal on Wednesday, noting that the new recommendations “re-affirm” that adults at average risk should be screened for colorectal cancer at age 45 and continue through 75, for those with a life expectancy greater than 10 years.
In addition to the standard colonoscopy, the ACS also recommends that patients receive a blood-based screening test in a doctor’s office, which is designed to detect tumor DNA in the blood.
COMMON CANCER TYPE COULD BE DETECTED WITH NEW BLOOD TEST
The ACS also suggested an at-home screening option that looks for hidden blood and molecular markers in stool samples.
These new guidelines reflect recent advancements in disease detection, as well as a “critical shift in public health strategy to expand screening options and lower barriers to access,” the ACS stated in a press release.
The ACS recommends blood-based testing and at-home stool sampling as options for colorectal cancer screening. (iStock)
Dr. Robert Smith, senior vice president of early cancer detection science at the American Cancer Society and senior author of the report, wrote in a statement that colorectal cancer should be emphasized as a “highly preventable disease as much as a treatable one.”
“By offering more screening tools in our guideline update, more eligible adults will be able to participate in lifesaving colorectal cancer testing, helping to close the screening gap and catch more cancers at an earlier, treatable stage,” he added.
JAMES VAN DER BEEK MISTOOK CANCER SYMPTOMS FOR PROBLEMS WITH HIS DIET
According to the ACS, colorectal screening “dramatically improves survival,” as studies show early-stage detection yields a five-year survival rate of more than 90% in the U.S.
About one in three American adults are eligible for colorectal cancer screening but have not been tested, although ACS research marks colorectal cancer as the top cancer killer of adults under 50.
Colorectal cancer is the top cancer killer of adults under the age of 50, according to the ACS. (iStock)
People at a high risk of colorectal cancer may need to begin screening before age 45 or be screened more often, the ACS added. Those over 85 years old should no longer be screened for colorectal cancer, per the guidelines.
Dr. William Dahut, chief scientific officer at the ACS, commented that “no matter which test you choose, what’s most important is to get screened, and that includes underserved, rural and minority populations.”
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These guideline changes follow a surge in colorectal cancer diagnoses in younger individuals. Recent ACS research revealed a 50% relative increase in diagnoses in adults aged 45 to 49 from 2021 to 2022.
Dr. Aparna Parikh, medical director of the Center for Young Adult Colorectal Cancer at the Mass General Cancer Center, who is not affiliated with the ACS, shared that experts don’t “entirely understand why” cases are on the rise.
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“But it seems to be an interplay of a person’s risk factors, overall makeup and early exposures,” she previously told Fox News Digital. “[Those] include dietary exposures, environmental exposures and possible antibiotic exposures, as well as lifestyle factors in the right host.”
Changes in bowel habits are the primary red flag that should raise the suspicion of colorectal cancer. (iStock)
Another recent ACS study found that drinking heavily and consistently over an adult’s lifetime could lead to a higher risk of colorectal cancer.
Other known risk factors include family history, obesity, smoking, a diet high in red and processed meats, inflammatory bowel disease, and a personal history or family history of polyps.
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While there may be no symptoms of colorectal cancer before diagnosis, especially in the early stages, certain symptoms should not be overlooked, experts say.
Dr. Eitan Friedman, PhD, an oncologist and founder of The Suzanne Levy-Gertner Oncogenetics Unit at the Sheba Medical Center in Israel, confirmed to Fox News Digital that changes in bowel habits are the primary red flag that should raise the suspicion of colorectal cancer.
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Other symptoms include fatigue as a result of anemia, stomach pain or abdominal discomfort, rectal bleeding or blood in the stool, weakness and unexplained weight loss.
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The sudden death of Kyle Busch has drawn attention to a rare but devastating medical progression: when pneumonia escalates into fatal sepsis.
An ER doctor spoke with Fox News Digital about how sepsis can trigger a rapid health decline.
“Sepsis is actually not a specific disease or diagnosis, but rather the syndrome that occurs when the body has certain abnormal findings and a presumed infection,” said Dr. Kenneth J. Perry, a South Carolina-based emergency medicine physician.
HOW PNEUMONIA PROGRESSES TO SEPSIS: DOCTORS EXPLAIN AFTER KYLE BUSCH’S DEATH
The markers of sepsis include elevated white blood cell counts, a high or low temperature, and elevated heart and respiratory rates, according to Perry. Because of this, a patient with pneumonia is often already technically septic by definition.
In the wake of Kyle Busch’s sudden passing, there is a focus on the rapid decline from pneumonia to fatal sepsis. (Getty; iStock)
While many people assume a worsening infection means bacteria are multiplying uncontrollably, it often has more to do with the body’s internal environment.
“It is often not the bacteria itself that is causing the specific decline,” Perry said. “In most cases, it is a cascade of inflammatory processes that are set in motion by the infection.”
When this inflammation spirals out of control, the body moves from having a manageable infection into severe sepsis. This is when otherwise healthy people can rapidly deteriorate.
SURGE IN WALKING PNEUMONIA AFFECTS THESE HIGH-RISK GROUPS, SAYS DR. MARC SIEGEL
“The concerning thing that can happen with any individual … is that sepsis can then lead to low blood pressure, worsening vital signs and organ damage,” Perry said.
“As multiple organs fail, it becomes very difficult for the medical team to treat and can sometimes lead ultimately to death.”
“The medical evaluation provided to the Busch Family concluded that severe pneumonia progressed into sepsis, resulting in rapid and overwhelming associated complications,” the family shared in a statement. (James Gilbert/Getty Images)
It is very unlikely to have pneumonia and not have any symptoms, according to Perry. Early signs can mimic a severe flu, including fevers, chills, a productive cough, and chest or back pain in cases where the lung is infected.
When sepsis begins to take hold, time becomes the most critical factor. “We have known for a number of years that early antibiotic therapy is beneficial in the treatment of sepsis,” Perry said.
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If you or a loved one are managing an infection at home, the doctor says the following red flags mean you should bypass the clinic and head straight to the emergency room.
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- Shortness of breath or difficulty breathing
- A racing heart rate or fever that continues to worsen even after starting treatment
- Severe chest pain associated with a productive cough
The slide into sepsis is, in most cases, a cascade of inflammatory processes that are set in motion by the infection, the doctor said. (iStock)
While cases like Busch’s are tragic, Perry stressed that this shouldn’t cause widespread panic. Most patients with pneumonia do very well with standard oral antibiotics.
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The NASCAR star’s rapid decline underscores the importance of medical vigilance and “having a primary care physician with whom you have a good relationship,” according to the ER doctor.
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“Monitoring symptoms while having easy access to primary care is a very beneficial and appropriate plan for most patients,” he added.
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