From Health and Fitness

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First Edition: October 14, 2019

Patients Eligible For Charity Care Instead Get Big Bills

When Ashley Pintos went to the emergency room of St. Joseph Medical Center in Tacoma, Wash., in 2016, with a sharp pain in her abdomen and no insurance, a representative demanded a $500 deposit before treating her.

“She said, ‘Do you have $200?’ I said no,” recalled Pintos, who then earned less than $30,000 at a company that made holsters for police. “She said, ‘Do you have $100?’ They were not quiet about me not having money.” But Pintos, a single mom with two kids who is now 29, told state officials St. Joseph never gave her a financial aid application form, even after she asked.

Pintos said she was examined and discharged with instructions to buy an over-the-counter pain medication. Then St. Joseph sent her a bill for $839. When she couldn’t pay, the hospital referred the bill to a collection agency, which she said damaged her credit and resulted in a higher interest rate when she applied for a mortgage.

St. Joseph denied erecting barriers to charity care. But the hospital’s owner settled a lawsuit from the state attorney general earlier this year alleging such practices and agreed to pay more than $22 million in refunds and debt forgiveness.

When Ashley Pintos sought emergency care at St. Joseph Medical Center in Tacoma, Wash., in 2016, an employee first demanded a $500 deposit, which Pintos couldn’t cover. After she was examined, Pintos was told by a doctor to buy an over-the-counter pain medication. The hospital later billed her for $839. “They were not quiet about me not having money,” she says.(Dan DeLong for KHN)

Under the Affordable Care Act, nonprofit hospitals like St. Joseph are required to provide free or discounted care to patients of meager incomes — or risk losing their tax-exempt status. These price breaks can help people avoid financial catastrophe.

And yet nearly half — 45% — of nonprofit hospital organizations are routinely sending medical bills to patients whose incomes are low enough to qualify for charity care, according to a Kaiser Health News analysis of reports the nonprofits submit annually to the Internal Revenue Service. Those 1,134 organizations operate 1,651 hospitals.

Together, they estimated they had given up collecting $2.7 billion in bills sent to patients who probably would have qualified for financial assistance under the hospitals’ own policies if they had filled out the applications.

These written-off bills, known as bad debt, represented a tenth of all nonprofit hospital bad debt reported to the IRS in either 2017 or the most recent year for which data is available. That sum may represent an undercount because it is based on self-reported estimates from hospitals and is not independently audited. And it does not include money that financially struggling patients eventually paid.

“People, including me, had the impression that these new protections under the ACA would prevent people who should be getting help from being financially devastated,” said Sayeh Nikpay, an assistant health policy professor at Vanderbilt University School of Medicine. “Clearly, this policy isn’t working, and that’s a major failing.”

About 56% of American community hospitals have nonprofit status, which frees them of paying most taxes and allows them to float tax-exempt bonds. In return, they are supposed to provide community benefits including free or discounted care for patients who can’t afford to pay.

The IRS leaves it up to each hospital to decide the qualifying criteria. A comparatively generous hospital may give free care to people earning less than twice the federal poverty level — around $25,000 for an individual and $50,000 for a family of four — and may provide discounts for people earning up to double that.

For those who do not qualify, hospitals often offer payment plans. But they can turn to aggressive tactics if bills are not resolved. Patients can be pestered by debt collectors, and some hospitals sue them or try to garnish their wages. Medical debt can damage credit ratings — one study calculated Americans had $81 billion in collections in 2016 — and forces some people into bankruptcy.

When hospitals give up on collecting a bill, they categorize it as bad debt and absorb the cost of the care, which is indirectly subsidized by the rates they charge private insurers.

It became this moneymaking system. People would be crying at registration desks, people would be upset, people would walk out.

Rachael Murphy, a former St. Joseph’s Medical Center employee

Charity Options Often Thwarted

In 2017, BJC HealthCare, a large St. Louis-based system, estimated $77 million of its $134 million in bad debt was owed by patients who probably would have qualified for free or discounted care.

Hospitals now owned by Ballad Health, in Tennessee, estimated that $60 million of bad debt in 2016, or 70%, came from patients who might have been eligible for help.

The Hospital of the University of Pennsylvania said $43 million of its bad debt, or 52%, might have involved patients who could have been excused in 2016 from being billed.

While some hospitals say they write off the debt of poor patients without ever resorting to collection measures, several hospitals whose practices were highlighted in news reports this year for aggressively suing patients admitted to the IRS they knew many unpaid bills might have been averted through their financial assistance policies.

A quarter of bad debt at Mary Washington Healthcare, which sued so many patients that a Virginia court convened special sessions to hear the cases, involved candidates for free or discounted care, according to its IRS filing.

So did half of the bad debt at Methodist Le Bonheur Healthcare in Memphis, called out by news organizations for frequently garnishing wages, its filing said.

CHI Franciscan, which owns St. Joseph, said in multiple IRS filings that none of its bad debt arose from billing indigent patients. While Franciscan admitted no wrongdoing in its settlement with the Washington attorney general, the agreement bars the practice of discouraging charity care in the ways alleged in the lawsuit.

Charity care requests at St. Joseph’s Medical Center in Tacoma, Wash., required so much documentation that half of the requests were rejected, the state attorney general argued in a lawsuit against the hospital. The hospital agreed this year to provide refunds and debt forgiveness to thousands of patients.(Dan DeLong for KHN)

“We are exceeding the requirements of state law and providing charity care compensation to patients who may be in most need, even if they never applied for charity care or did not actually qualify at the time of service,” Cary Evans, a Franciscan spokesman, said in a statement. Franciscan declined to discuss individual patients.

According to the lawsuit and interviews with former employees, St. Joseph’s workers were told never to voluntarily offer patients a charity care application. If asked for one, they were instructed to insist on a deposit at least three times. Even when submitted, applications required so much documentation that half of the requests were rejected, the lawsuit alleged.

Internal hospital training documents the attorney general submitted as part of the case showed that St. Joseph workers were advised on how to best collect money from patients before they left the hospital. Instead of saying, “Can you pay today?” employees were told to use phrases like “How would you like to pay for that today? Cash, check or credit card?” according to the documents.

“It became this moneymaking system,” Rachael Murphy, a former employee, recalled in an interview. “People would be crying at registration desks, people would be upset, people would walk out.”

Pintos, who signed a written statement for the attorney general and was listed as a potential witness in the case, said the hospital never gave her an application even though she had qualified for charity care the previous year. “They made me feel like I wasn’t good enough to be there,” she said.

St. Joseph recently erased the $839 debt from her credit, but Pintos still owes $1,611 for care from the ER doctors, who have their own practice group and do not have to follow the hospital’s charity care policies, according to Franciscan. That bill remains in collections.

‘A Gap In Trust’

Nonprofit hospitals provide roughly $14 billion worth of charity care a year, about 2% of their operating costs. But their policies can have notable exemptions, such as excluding bills from doctors who are not on the hospital payrolls.

However, information about hospital charity care, often included in the reams of admissions documents or posted on hospital walls, can easily get overlooked by patients and families focused on medical emergencies.

“The signage might be a little hard to find, applications are complicated, documentation is complicated,” said Keith Hearle, a consultant who advised the IRS on collecting hospitals’ charity care data. “You could probably come up with 15 reasons people didn’t apply.”

In their IRS filings explaining the bad debt and in interviews, hospitals said that even when they give applications to patients, some fail to submit them or do not provide complete records of their finances, which can include tax returns and bank statements.

“There is a gap in trust where our patients must not believe that if they are willing to share information, that it will be to their benefit,” said June McAllister Fowler, a spokeswoman for BJC HealthCare.

(Story continues below.)

Shana Tate, senior vice president of revenue cycle at Ballad Health, said Ballad is looking to be more proactive.

“We made the assumption that, ‘We give you the information. What more do you need?’ But we realize a lot of patients don’t read it, don’t pay attention,” Tate said. “They need someone to hold their hand through this process.”

Methodist Le Bonheur, which erased more than 6,000 unpaid bills last month, said it is “increasing access to financial assistance information upfront and throughout the patient care journey” and “enhancing the screening process.”

Penn Medicine said that, as a safety-net hospital system, it has many patients who are poor or coping with other problems. These people, Penn said, face “barriers to completing the process for aid” and their bills are typically “left unpaid.”

Mary Washington did not respond to requests for comment, but after critical news reports last June it announced that it was suspending its lawsuits over unpaid bills and reevaluating its practices.

Laurie Jinkins, a state representative from Tacoma and author of legislation to strengthen Washington’s charity care laws, said, “The drive for dollars in the health care system, and the drive for dollars to expand, causes our nonprofit health systems to lose sight of why they’re actually here.” She said St. Joseph had “really gone off the deep end” in its focus on money.

St. Joseph’s practices hark back years, according to the attorney general’s lawsuit and interviews with employees and patients.

After Alisha Colyer’s husband went to the St. Joseph emergency room with pneumonia in 2007, she said, she tried to apply for help, but the charity care application “was like a book you had to fill out.”

“I remember them asking me what make and model my car was, and I was like, ‘You want me to sell my car to pay my hospital bill?’ ” recalled Colyer, who now works at the hospital as a dietary aide.

When Alisha Colyer applied for St. Joseph Medical Center’s charity care around 2007, she remembers them asking what make and model her car was. “And I was like, ‘You want me to sell my car to pay my hospital bill?’”(Dan DeLong for KHN)

In a statement, Franciscan noted that St. Joseph and its other hospitals now use a simplified two-page application designed by the state hospital association and have agreed to make charity care easier to obtain. It also offers free care for medically necessary services to patients earning up to three times the poverty level, which is more than most hospitals do.

It is too early to assess how the policy changes translate into results. The most recent Washington state analysis, for 2017, found St. Joseph lagged behind the regional average in the amount of charity care it provided.

KHN data editor Elizabeth Lucas contributed to this report.

METHODOLOGY

Bad debt figures were derived from the IRS 990 tax returns filed electronically by nonprofit hospital organizations. That information was downloaded in data form from the IRS website on May 7, 2019, by Jacob Fenton, an independent consultant, and analyzed by Kaiser Health News. Returns that included Schedule H, which only hospital-owning nonprofits must file, were analyzed.

For each organization identification number, we selected the return with the most recent tax period end date. In case of duplicates such as amended returns, only the return with the most recent end date and the most recent signature filing date was selected. Because there were still a few duplicates, the one with the largest unique return identifier was selected. The most recent tax returns for 2,508 nonprofits were identified.

Organizations must report their bad debt — bills they have given up on collecting — and, separately, estimate the bad debt “that reasonably is attributable to patients who likely would qualify for financial assistance under the hospital’s financial assistance policy … but for whom insufficient information was obtained to determine their eligibility.” Generally, both figures are greater than the actual cost of providing the services: They are the amount the hospital expected to be paid. For our analysis, we calculated the percentage of bad debt that the organization attributed to patients who might qualify for financial assistance.

A handful of bad debt figures were reported as negative numbers. Those were converted to positives. The amounts were not significant enough to substantially affect aggregates or the analysis’s conclusions.

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California’s New Transparency Law Reveals Steep Rise In Wholesale Drug Prices

Drugmakers fought hard against California’s groundbreaking drug price transparency law, passed in 2017. Now, state health officials have released their first report on the price hikes those drug companies sought to shield.

Pharmaceutical companies raised the “wholesale acquisition cost” of their drugs — the list price for wholesalers without discounts or rebates — by a median of 25.8% from 2017 through the first quarter of 2019, according to the Office of Statewide Health Planning and Development. (The median is a value at the midpoint of data distribution.)

Generic drugs saw the largest median increase of 37.6% during that time. By comparison, the annual inflation rate during the period was 2%.

Several drugs stood out for far heftier price increases: The cost of a generic liquid version of Prozac, for example, rose from $9 to $69 in just the first quarter of 2019, an increase of 667%. Guanfacine, a generic medication for attention deficit hyperactivity disorder (ADHD), on the market since 2010, rose more than 200% in the first quarter of 2019 to $87 for 100 2-milligram pills. Amneal Pharmaceuticals, which makes Guanfacine, cited “manufacturing costs” and “market conditions” as reasons for the price hike.

“Even at a time when there is a microscope on this industry, they’re going ahead with drug price increases for hundreds of drugs well above the rate of inflation,” said Anthony Wright, executive director of the California advocacy group Health Access.

The national debate over exorbitant prescription drug prices — and how to relieve them — was supposed to take center stage in recent weeks, as House Speaker Nancy Pelosi released a plan to negotiate prices for as many as 250 name-brand drugs, including high-priced insulin, for Medicare beneficiaries. Another plan under consideration in the Senate would set a maximum out-of-pocket cost for prescription drugs for Medicare patients and penalize drug companies if prices rose faster than inflation.

President Donald Trump has highlighted drug prices as an issue in his reelection campaign. But lawmakers’ efforts to hammer out legislation are likely to be overshadowed, for now, by presidential impeachment proceedings. In Nevada, health officials in early October fined companies $17 million for failing to comply with the state’s two-year-old transparency law requiring diabetes drug manufacturers to disclose detailed financial and pricing information.

California’s new drug law requires companies to report drug price increases quarterly. Only companies that met certain standards — they raised the price of a drug within the first quarter and the price had risen by at least 16% since January 2017 — had to submit data. The companies that met the standards were required to provide pricing data for the previous five years. In its initial report, the state focused its analysis on drug-pricing trends for about 1,000 products from January 2017 through March 2019.

California’s transparency law also requires drugmakers to state why they are raising prices. Over time, that information, in addition to cost disclosures, could create “one of the more comprehensive and official drug databases on prices that we have nationwide,” Wright said. “That, in itself, is progress, so that we can get better information on the rationale for drug price increases.”

But the data does not reflect discounts and rebates for insurers and pharmacy benefit managers and bears little resemblance to what consumers actually pay, said Priscilla VanderVeer, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America. The group filed a lawsuit seeking to overturn the California legislation that has not yet been resolved.

“If transparency legislation only looks at one part of the pharmaceutical supply chain, without getting into the various middlemen like insurers and pharmacy benefit managers that ultimately determine what patients have to pay at the pharmacy counter, it won’t help patients access or afford their medicines,” VanderVeer said in an email.

State Sen. Richard Pan (D-Sacramento), a pediatrician who chairs the Senate health committee, agrees — up to a point.

“Transparency always has value,” Pan said. But policymakers need more data on how much insurers and consumers are spending on prescription drugs, he said.

And he wonders why the price of generic drugs, including those with plenty of competition, rose at higher rates.

His concerns were echoed by University of Southern California policy researchers, who recently published a study that concluded most state-level drug-transparency laws are “insufficient” to reveal the true transaction prices for prescription drugs, or where in the distribution system excessive profits lie.

“The question is, why are these prices going up? Typically, there are competing stories for that,” said Neeraj Sood, vice dean of the University of Southern California’s School of Public Policy and an author of the study. “Maybe cost of production is going up,” he said. “Maybe there’s a drug shortage, or some competitors got eliminated. This reporting of [wholesale acquisition cost] data doesn’t really tell us which of these stories is true.”

For now, California’s new data is not likely to be of much help to consumers, Pan said. But he said it might help state officials in their bid to overhaul the way the state purchases drugs for 13 million people served by Medi-Cal, the state’s Medicaid program for low-income residents. Gov. Gavin Newsom’s controversial plan to have the state, rather than individual Medi-Cal managed-care plans, negotiate directly with drugmakers would save the state an estimated $393 million a year by 2023, according to the administration.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Helping Teenagers Quit Vaping

For many years, my lead-in question with adolescents, after I asked the parent to leave the room at pediatric appointments, was whether the kid had ever tried smoking cigarettes. It made a reasonable lead-in because it felt less highly charged than asking about marijuana or other substances, and in recent decades, the answer was very often no. Youth tobacco smoking in the United States was on the decline.

And then came vaping, e-cigarettes and Juuls. And like many parents, many pediatricians are flying a little bit blind here, not sure what questions to ask or how to respond to the answers we get. This was brought home to me vividly when an adolescent patient told me that he was vaping pretty regularly — even in school, keeping it hidden.

He told me he had tried to stop a couple of times and he couldn’t do it — high school, he said, was just too stressful.

There are frightening numbers about e-cigarette use in the young, and increasing reports of serious illness, lung damage and death related to vaping. What can we do to help an adolescent or a young adult shake a nicotine habit?

The announcement last week of the death of a 17-year-old, the first teenager known to die from a vaping-related illness, may help shift young people’s thinking about the risk.

“There’s a perception it’s safe, safer than cigarettes; youth in general agree cigarettes are not safe,” said Dr. Sarah M. Bagley, an addiction specialist who is assistant professor of medicine and pediatrics at Boston Medical Center/Boston University School of Medicine.

“Everybody who comes in smoking cigarettes knows it’s going to kill them,” said Dr. Sharon Levy, the director of the adolescent substance use and addiction program at Boston Children’s Hospital. “Till very recently, people thought vapes were the healthy alternative.” Those sobering messages are not necessarily turning up on the news sources that her adolescent patients follow, she said. “There are kids who come to our clinic thinking we’re making a big deal about nothing.”

“How do we help kids quit vaping, the million-dollar question,” Dr. Levy said. There is not a research literature yet, and understanding vaping habits is more complicated than counting the number of cigarettes a day.

Dr. Scott Hadland, a pediatrician and adolescent addiction specialist at the Grayken Center for Addiction at Boston Medical Center, said, “Before you can have these conversations with young people, you need to understand what a vaping device is, what some of the brands are, the types of cartridges.” Are they buying it from a “legitimate” source or buying it illegally? For some, vaping is about marijuana, not nicotine.

And when there is secretive vaping going on all day in school, he said, young people may be more likely to develop a physiological dependence on nicotine than they were with traditional cigarettes.

Someone who is using a high-concentration nicotine cartridge every day or two, Dr. Hadland said, is probably taking in the equivalent of about a pack of cigarettes a day, much more than adolescents typically smoke.

Nicotine is a stimulant, and like other stimulants, at low doses it can make people feel more alert and attentive; higher doses, Dr. Levy said, do just the opposite, making people jittery, revved up and unable to concentrate. The high-concentration cartridges deliver a bigger, faster hit of nicotine than was possible with traditional cigarettes. “What Juul did was it perfected nicotine delivery,” Dr. Levy said.

“My sense, and there are not data to guide this yet, is that the more severe the nicotine use disorder, the more necessary to give medication,” Dr. Hadland said. That includes nicotine replacement, with patches, and then lozenges or gum to deal with breakthrough cravings. It can also include a medication called Chantix, which can help with cravings, but has not been found to be effective for those 16 and under, and is generally used cautiously in older adolescents and younger adults. The antidepressant medication Wellbutrin is also sometimes used.

“Nicotine replacement doesn’t work as well as it does in adults, but it does increase the quit rate,” Dr. Levy said. “We do a lot of coaching of our pediatric colleagues, we tell them go ahead and be generous,” that is, for example, helping parents understand that because vaping can mean an adolescent is accustomed to a very high dose of nicotine, that kid may go through a lot of lozenges.

All of these medications are more effective with cognitive behavioral therapy to help you deal with your emotions and manage cravings, Dr. Levy said. Counseling is an important part of treatment, and one reason I try hard to refer my patients to specialty clinics is that I want them to have experienced counselors. And treatment is much more likely to be successful when there is support from a parent.

Because of the high nicotine concentrations and the physiological dependence, Dr. Hadland said, young people who are trying to quit vaping may experience symptoms that go well beyond the cravings that those who smoke traditional cigarettes experience when they try to quit. In addition to those very strong cravings, there may be general irritability, headaches or a sense of feeling sick to your stomach.

“For some, this withdrawal is almost paralyzing,” Dr. Hadland said. “They can’t go about their day, can’t go to school — it’s not something I had ever seen with regular cigarettes, it feels different to me as a clinician.” For the first time, he said, he has to write school letters asking that patients can wear the patch and chew gum when necessary.

[The site smokefree.gov offers specific advice for helping teenagers quit vaping. Other resources include the Great American Smokeout, the American Lung Association, the National Cancer Institute.]

Assessing the degree of nicotine dependency or addiction means not only looking for withdrawal symptoms, Dr. Hadland said, but also at whether someone has tried to cut back without success, and at whether there is a general sense of being out of control — spending more and more money on the habit, finding it is causing conflict with family members, getting in the way of participation in sports.

With 14-year-old patients, he said, sometimes the approach is: “Are you willing to give your Juul and your cartridges to your parents so they can get rid of them — they say yes — you can almost cut the supply off by getting rid of the access.” But for older people, he said, it becomes a lot more difficult, and it can be really hard for them to give up their devices.

Even with medications and counseling, many young people will struggle hard to quit their nicotine habits. Many will face daily temptations in high school, where vaping may be common and normalized, Dr. Bagley said. They need family support and understanding, and may do better with rewards and positive reinforcement.

To fix that high school environment, we should be thinking about what was so effective in communicating the message that cigarettes were dangerous, Dr. Bagley said, and formulating a better public health response to vaping.

But in the meantime, parents need to have those conversations, even if your child insists that the vape pen in his backpack belongs to someone else. “That’s an opportunity to say, these things are dangerous, get rid of this,” Dr. Levy said. “The sense you want to give is, your child does not have your permission to do this.” If kids say they can quit, she said, take them to a health care provider and make sure they get help — if they say they aren’t willing, if they say vaping is safe, consider taking them to talk to a pediatrician.

Staying on Guard Against Skin Cancer

“If you see something, say something,” a catchy warning from the Department of Homeland Security about possible terrorist threats, applies as well to skin lesions that, if ignored, could become fatal.

Susan Manber, now a 55-year-old from Cortlandt Manor, N.Y., knows this well. She credits her astute daughter with having saved her life nearly six years ago when Sarina, then 13, remarked, “Mom, what’s that thing on your nose?”

That “thing” was a tiny white nodule on the rim of one nostril, a weird place, Ms. Manber thought, for a pimple.

In a few weeks this seemingly innocent pimple had developed a tiny purple center, prompting her to see a dermatologist, who thought it wasn’t anything to worry about but sent her to a specialist to have it removed and biopsied.

The report that came back on New Year’s Eve 2013 could not have been more shocking: a very rare and aggressive form of skin cancer called Merkel cell carcinoma. It’s a diagnosis made only 2,500 times a year in the United States, and until recently had a life expectancy of five months from diagnosis.

Ms. Manber endured seven surgeries, including removal of the left side of her nose (which was rebuilt using ear cartilage) and cancer-containing lymph nodes in her neck, combined with radiation and chemotherapy.

Treatment with immunological agents available since 2016 has improved the prognosis for this cancer, though it is still three times more deadly than melanoma.

Ms. Manber, who was finally able to return to work as a health communications specialist two years ago, now advocates for the Skin Cancer Foundation’s new, simplified campaign to get people to take skin cancer more seriously. In honor of the foundation’s 40th anniversary, it has a new alert message: “The Big See” — “see” as in look, and “C” as in cancer. If you see something anywhere on your skin that is new, changing, not healing or doesn’t seem right to you, Dr. Deborah S. Sarnoff, the foundation’s president, urges you to get it checked out as soon as possible.

While all forms of skin cancer, including basal cell carcinoma, can be fatal if ignored long enough, the most common life-threatening form is melanoma, which is diagnosed 192,000 times a year in the United States and claims 9,000 lives. For many years, the “ABCDE” test for worrisome lesions was used to alert people to this dangerous disease: A for asymmetry, B for irregular border, C for color (tan, brown or black), D for diameter (usually larger than ¼-inch) and E for evolving.

Perhaps, the foundation realized, the alphabet warning was too complex and limiting. “Many melanomas and most nonmelanoma skin cancers don’t fall under the ABCDE pattern,” the foundation reported recently in its journal. “When we educate people about the warning signs of skin cancer, we often hear from them, ‘Mine didn’t look like that.’”

The Big See message can alert people to all forms of skin cancer, often unnoticed for many months or years and dismissed as “no big deal.” Last year, for example, I had a small sore on my leg that never healed, but waited six months to find out it was a basal cell carcinoma that required surgical removal.

More than five million nonmelanoma skin cancers are diagnosed annually in America, and every hour more than two people die from skin cancer even though it is the cancer everyone can see. No scans or special or invasive detection tests are required, just your eyes or those of a friend or companion who, if they see something, should say something.

Complementing the foundation’s new The Big See message is a “What’s that?” alert and a talking mirror being placed in retail locations nationwide in which a lively comedian tells people about skin cancer.

As Ms. Manber said in an interview, “Most people don’t realize that just five sunburns can double your chances of developing melanoma. They don’t know that one person in five will get skin cancer.” Now determined to raise awareness about detecting this disease, she joins skin cancer specialists in urging people to install a full-length mirror in their home to facilitate frequent skin checks. By standing with your back to the full-length mirror and holding a hand mirror, I’ve found that even a person who lives alone can do a full body self-exam.

Ms. Manber is equally passionate about the importance of protecting one’s skin from the damaging rays of sunlight, which can penetrate all windows (except windshield glass in cars), pass through cloud cover and be reflected by water, sand and concrete. Thus, shade is not completely protective. The damage to DNA caused by ultraviolet A (UVA) and ultraviolet B (UVB) rays starts within minutes of sun exposure, and the body’s immune defenses do not repair all of it, which can result in cancer-causing mutations over time.

UVB causes sunburn, and UVA, in addition to causing sunburn and tanning, ages and wrinkles the skin, creating what my husband called elephant hide.

People with fair complexions, blue eyes, freckles or a family history of skin cancer are especially susceptible to the cancer-inducing rays of sunlight. They and anyone spending many hours outdoors in daylight are advised to always use a broad-spectrum sunscreen with an SPF of at least 30 and reapply it every two hours and after swimming. They are also urged to wear protective clothing and a hat when out during the day, and be particularly careful about avoiding sun exposure when it is most intense — between 10 a.m. and 4 p.m.

Protecting babies and children is especially important. Before 6 months of age, they should be kept out of the sun by using clothing, hats, blankets and stroller shades; after 6 months, add sunscreen to the mix. And don’t forget sunglasses for toddlers on up.

Needless to say, tanning beds are a major no-no for everyone; their use before the age of 35 can increase the risk of melanoma by 75 percent, the foundation reported.

But as you might guess, extreme sun avoidance can have its own risks: a decrease in the body’s ability to form biologically active vitamin D, which is critical to bone health and, according to a Swedish study that followed nearly 30,000 women for 20 years, is tied to a small but significant increase in deaths from cardiovascular disease and other noncancer-related disorders. Compared to the women in the study who were most exposed to sun, the life expectancy of sun avoiders was 0.6 to 2.1 years shorter. Also, as you might expect, not every expert endorses this finding.

Your Paycheck May Impact Your Heart Health

Fluctuations in earnings may affect your heart health.

Previous research has found that higher income is associated with lower rates of cardiovascular disease. Now a new study reports that changes in income also have a significant effect.

The report, in JAMA Cardiology, prospectively followed 8,989 people, recording changes in income between two interviews that were taken an average of six years apart. They followed their health for the next 17 years.

Compared with people whose income remained relatively stable, those whose income dropped by 50 percent or more were 17 percent more likely to have heart failure, fatal coronary heart disease, a heart attack or a stroke. Those whose income went up by 50 percent were 14 percent less likely to have a cardiovascular event.

The association of cardiovascular health with income change was significant even after controlling for many health and behavioral characteristics. But it is also possible that getting sick itself causes the decline in income.

“Incomes going down can be an enormous life stress,” said the senior author, Dr. Scott D. Solomon, a professor of medicine at Brigham and Women’s Hospital in Boston. “We don’t often think about the social factors that can contribute to cardiovascular health. It’s a different way of thinking that we as cardiologists are not used to.”

No Drop in Vaping Cases, C.D.C. Says

As illnesses and deaths linked to vaping continue to rise, health experts on Friday updated their advice to doctors on how best to recognize symptoms and treat patients, and warned that the start of the flu season would make it harder to arrive at the right diagnosis.

“I can’t stress enough the seriousness of these lung injuries associated with e-cigarettes or vaping products,” Dr. Anne Schuchat, principal deputy director of the federal Centers for Disease Control and Prevention, said at a news briefing. “We are not seeing a meaningful drop-off in new cases, and unfortunately many more people have been hospitalized with lung injury each week.”

A new concern has come to light. She said a handful of patients, fewer than five, were hospitalized for vaping illness, recovered and went home, and then wound up back in the hospital again, from five to 55 days later. The reason is not yet known, she said. One possibility is that the patients may have started vaping again.

Dr. Schuchat said those cases highlight the importance of follow-up for patients who have been treated for vaping-related illnesses. The C.D.C. says they should see doctors no later than a week or two after leaving the hospital, and some may need referrals for counseling for marijuana use disorder, a form of dependence.

Vaping Illnesses

As of Oct. 11, there have been 1,299 vaping illnesses and 29 deaths. More maps and charts.


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By The New York Times | Source: Centers for Disease Control and Prevention and state agencies

Of the 1,299 cases reported to the C.D.C. since mid-August, 70 percent of the patients are male, and 80 percent are under 35 years old. The majority, 76 percent, have vaped THC, the psychoactive ingredient in marijuana, and many have also used nicotine. Twenty-nine deaths have been reported. Only Alaska has no reported cases.

The cause of the illnesses is not known, and the C.D.C. says no vaping products can be considered safe. Dr. Schuchat said there might turn out to be more than one cause, and it might take months to find the answer.

Health officials have given the illness a formal name, “e-cigarette, or vaping, product use associated lung injury,” or Evali.

The start of the flu season may make it harder to diagnose cases, because some symptoms of lung damage from vaping — cough, shortness of breath, fever — can mimic those of influenza. The C.D.C. recommends testing patients with those symptoms for flu and other respiratory infections, but it is possible for patients to have both a lung injury from vaping and the flu or some other viral or bacterial ailment affecting their lungs.

Many patients with vaping illness also have stomach pain, nausea, vomiting and diarrhea, and it is important to ask people with those symptoms about vaping.

Doctors should “strongly consider” admitting patients to the hospital if they have become ill after vaping and are short of breath, have underlying illnesses that could affect their lungs or their blood oxygen level is less than 95 percent, the C.D.C. said. That level, called oxygen saturation, can be measured with a device clipped to the fingertip, the agency said in its Morbidity and Mortality Weekly Report, published on Friday.

The report also said that some patients who initially had mild symptoms then deteriorated rapidly within 48 hours. And many patients who ended up in the hospital had previously been sent home after seeking help at emergency rooms or clinics.

Because the vaping illnesses often involve severe inflammation in the lungs, many patients have been treated with corticosteroid drugs. But the report said it was not known whether the drugs really helped or whether the patients might have recovered on their own. And corticosteroids can increase the risk of infection.

The report says that “in some circumstances,” it might be best to avoid corticosteroids in patients who are being tested for illnesses like fungal pneumonia, which could worsen with the drugs. But the report also says that in patients who are severely ill, it may be necessary to give them corticosteroids along with other drugs to fight infection.

Patients who have had high doses of corticosteroids may need to see a specialist in endocrinology to help minimize or manage the side effects.

Patients older than 50 who become ill after vaping tend to be sicker than younger ones: more likely to need ventilators and to stay longer in the hospital. These older patients may need special consideration, the report said, adding that a quick diagnosis, treatment with steroids and consultation with specialists in pulmonary and critical care “might be lifesaving in this patient population.”

Dr. Ned Sharpless, acting commissioner of the Food and Drug Administration, said his agency had received more than 700 samples of vaping products for testing. So far, the cause of the outbreak has not been identified. The tests have found varying levels of THC and nicotine in different products, and some of the THC products also contain vitamin E acetate, which some sellers use to dilute the THC.

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Yours truly is back from beautiful Vietnam and it seems I missed one or two … ahem … minor news events while traipsing around.

I come bearing no souvenirs but rather two health reminders (one via Sen. Bernie Sanders). Firstly, don’t forget your flu shot — Australia has had an unusually early and severe season, which rarely bodes well for our own. The second comes in the form of a hard-earned lesson from a 2020 candidate: Don’t ignore those heart attack warning signs! (This is especially directed at women, who are dying unnecessarily from cardiac events.)

Now enough mother-henning. (You missed me, didn’t you?) On to the news of the week!

The Supremes are back in action, and a look at the high court’s docket reveals a potentially doozy of a politically charged term (with rulings expected to land as the general election heats up in 2020).

In the health care sphere, a big case to watch is the Louisiana abortion suit. An essentially identical Texas law — which requires doctors performing abortions to have admitting privileges at nearby hospitals — was ruled unconstitutional by the court in 2016, but that means little with two new justices appointed by President Donald Trump weighing in.

The New York Times: As the Supreme Court Gets Back to Work, Five Big Cases to Watch

Oral arguments in two other health-related cases were held this week. The justices grappled with the moral and legal complexities of the insanity defense. The case prompted questions such as this one from Justice Stephen Breyer: One defendant kills a victim he thinks is a dog. “The second defendant knows it’s a person but thinks the dog told him to do it,” Breyer said. “They are both crazy. And why does Kansas say one is guilty, the other is not guilty?”

The New York Times: Supreme Court Opens New Term With Argument on Insanity Defense

Tuesday was all about LGBTQ rights. Although most of the justices were divided along ideological lines on whether federal civil rights legislation applies to sexual orientation and gender identification, Justice Neil Gorsuch hinted his vote might be in play. As an avowed believer in textualism, he suggested that the words of Title VII are “really close, really close” to barring employment discrimination for those workers. But don’t go placing bets on the outcome yet. He also noted that he was worried about “the massive social upheaval” that would follow such a Supreme Court ruling.

The New York Times: Supreme Court Considers Whether Civil Rights Act Protects L.G.B.T. Workers


On that note, the 2020 Democratic candidates participated in an LGBTQ forum on the eve of National Coming Out Day. There were a handful of notable moments through the night (including a zinger from Sen. Elizabeth Warren that was met with loud applause), but much of the spotlight was on protesters who demanded the candidates pay attention to violence against black transgender women. “We are hunted,” said one member of the audience.

CNN: Protesters Interrupt CNN LGBTQ Town Hall to Highlight Plight of Black Transgender Women

Elsewhere on the campaign trail this week, controversy over a pregnancy discrimination talking point from Warren’s stump speech prompted women — including Warren rival Sen. Amy Klobuchar — to speak out on social media about their own and their mothers’ experiences.

NBC News: Women Rally in Support of Elizabeth Warren by Sharing Their Own Pregnancy Discrimination Stories

Sanders’ campaign confirmed that the health scare from last week was indeed a heart attack. The 2020 candidate — who promised to return “full blast” to the race — said he hopes people learn from his “dumb” mistake of ignoring the warning signs. In true politician-running-for-office style, he also was able to use the scare as a way to emphasize the importance of his signature policy proposal, “Medicare for All.”

Reuters: Democratic Presidential Hopeful Sanders Says He Was ‘Dumb’ to Ignore Health Warnings

In a sign of what’s to come for Big Pharma, South Bend Mayor Pete Buttigieg, one of the field’s more moderate candidates, released a drug pricing plan that is decidedly not moderate. The move falls in line with a broader sense that there’s an ever-growing appetite among even middle-ground Dems for action to rein in drugmakers.

Stat: Buttigieg Unveils an Aggressive Plan for Lowering Drug Prices

And for you political wonks out there, this was an interesting read on the shifting political dynamics of doctors, who once used to be a sure thing for the GOP.

The Wall Street Journal: Doctors, Once GOP Stalwarts, Now More Likely to Be Democrats


A key ruling on the health law is expected in the next few weeks, but officials (on condition of anonymity,  mind you) said that if the ruling is against the ACA, the Trump administration will ask the court to put any changes on hold — possibly until after the election. The reports further support the idea that the law, which has been, uh, politically fraught (to say the very least) over its entire life span, is at the moment viewed as an Achilles’ heel for Republicans.

The Washington Post: Trump Administration Plans to Delay Any Changes If the ACA Loses in Court

Two other major news items out of the administration this week to pay attention to:

The Associated Press: Trump Signs Proclamation Restricting Visas for Uninsured

The Associated Press: Overhaul Is Proposed for Decades-Old Medicare Fraud Rules


The first teenager’s death in the outbreak of vaping-related lung illnesses drove home this week public health officials’ message that young people are “playing with their lives” when they partake. The number of cases jumped to 1,299 as of Oct. 8, with the number of deaths rising to 26.

The Wall Street Journal: New York City’s First Vaping-Related Death Is a Bronx Teen

Reuters: U.S. Vaping-Related Deaths Rise to 26, Illnesses to 1,299

Although Juul is facing a barrage of lawsuits, one filed this week was notable. It was believed to be the first from school districts, which claim that fighting the vaping epidemic has been a drag on their resources. While some legal experts are dubious about whether the school districts can establish their standing, others aren’t ruling it out.

The New York Times: Juul Is Sued by School Districts That Say Vaping Is a Dangerous Drain on Their Resources

And the ripple effect of the crisis is spreading to life insurance prices.

Bloomberg: Prudential Plans to Boost Life Insurance Prices for Vapers


Time for you to flex your ethical muscles for the week: Should there be boundaries to highly personalized medicine? A pricey drug designed — and named for! — just one patient sparked questions this week about how far researchers should go in the name of curing a single person. Especially when there are thousands of patients out there with rare diseases. Would only the wealthiest subset be given cures? Who would decide which patients deserve limited research hours over others?

The New York Times: Scientists Designed a Drug for Just One Patient. Her Name Is Mila.

And ProPublica shines a light on the practice of drug companies using flashy Facebook ads, cash incentives and other marketing techniques to woo Mexican residents over the border to donate plasma. It’s not as innocuous as it might seem — donating too much plasma can compromise the immune system. (Selling plasma has been banned in Mexico since 1987.)

ProPublica: Pharmaceutical Companies Are Luring Mexicans Across the U.S. Border to Donate Blood Plasma


In the miscellaneous file for the week:

  • An Ohio doctor is being charged in 25 fentanyl-related deaths. How on earth was such a lapse allowed to occur? The New York Times peels back the curtain on years of lapses and missed warnings in one Columbus intensive care unit.

The New York Times: One Doctor. 25 Deaths. How Could It Have Happened?

  • During the week of World Mental Health Day, research finds that Americans are starting to internalize all the political rhetoric (and myths) about the connection between mental health and violence. “People want simple solutions: They want to be able to neatly explain things,” said one expert.

Los Angeles Times: Americans Increasingly Fear Violence From People Who Are Mentally Ill

  • There’s more than one way to keep a community healthy, and that goes beyond doctor’s offices, clinics and hospitals. A growing number of medical professionals are embracing the notion that steady paychecks, stable housing and good food are crucial to supporting their patients before they get sick.

The New York Times: When a Steady Paycheck Is Good Medicine for Communities

  • In a sad sign of the times, a muppet on “Sesame Street” is going to have a mother struggling with addiction. The storyline is meant to help an ever-increasing number of children affected by the opioid crisis.

Stat: ‘Sesame Street’ Launches Initiative to Help Explain Parental Addiction to Kids

  • High levels of uranium were found in the blood of Navajo women and babies in a study that underscored the real costs of America’s atomic development. Lawmakers are pushing for legislation that would compensate those who have been exposed.

The Associated Press: US Official: Research Finds Uranium in Navajo Women, Babies

  • And the Nobel Prizes are given out this week: In medicine, scientists who worked with oxygen and cells were honored. Their work has the potential to be the building blocks for things like cancer treatments.

The Washington Post: Nobel Prize in Medicine Awarded for Discovery of How Cells Sense Oxygen


That’s it from me! It’s good to be back with you guys, and I hope you have a great weekend!

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