Podcast: KHN’s ‘What The Health?’ ‘Medicare-For-All’ Debate: Who’s Going To Pay

House Democrats, led by Rep. Pramila Jayapal (D-Wash.), have formally introduced their “Medicare-for-all” legislation. The bill, which would ensure coverage for almost every medical service most people need, did not come with any suggestions for financing. But it will likely reflect the far-left end of the Democratic debate in progress.

Meanwhile, the CEOs of seven of the largest pharmaceutical companies testified before the Senate Finance Committee, where both Democrats and Republicans decried the high cost of drugs but did not specifically say what they plan to do about it.

And the Trump administration has issued final regulations intended to evict Planned Parenthood from the federal Title X family planning program. But advocates and state officials are readying lawsuits to stop the new rules.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Jennifer Haberkorn of the Los Angeles Times.

Among the takeaways from this week’s podcast:

  • In addition to major changes in coverage for Americans, the “Medicare-for-all” bill introduced in the House this week would fundamentally alter how hospitals are paid. The new system would likely give hospitals a set payment for the year to handle all their costs, and administrators would need to make that work.
  • One of the biggest changes for consumers under that House bill would be adding long-term care expenses to the government coverage. Under the current system, Medicare does not pay for most long-term care and Medicaid covers it only if patients have expended most of their resources.
  • The hearing this week with CEOs of major drug manufacturers did not produce many of the anticipated fireworks. Senators seemed to shy away from the tough questioning seen in earlier hearings, as in the 1990s when tobacco executives were called before Congress.
  • Surprisingly, the Trump administration’s proposal to set U.S. drug prices in line with what people pay in foreign countries did not come up at the Finance Committee hearing. That effort puts Republican lawmakers in a difficult position, because they have a long history of opposition to the government being in a position to set prices on goods.
  • If Planned Parenthood clinics are pushed out of Title X, other providers may move in to help meet the needs of women. But that could take years in some cases. In the meantime, women would likely be without services, and unintended pregnancies could increase.
  • Planned Parenthood still gets the bulk of its federal funding through state Medicaid programs, and the changes to Title X would not affect that. Nonetheless, some conservative states are mounting challenges to that funding, too, and those fights are expected to move slowly through the court system.

Also this week, Rovner interviews KHN senior correspondent Julie Appleby, who investigated and wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a wildlife biologist who was bitten by a feral cat — and got a big bill for a rabies shot. You can read the story here.

If you have a medical bill you would like NPR and KHN to investigate, you can submit it here.

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

Julie Rovner: Kaiser Health News’ “Talk About Déjà Vu: Senators Set To Re-Enact Drug Price Hearing Of 60 Years Ago,” by Jay Hancock

Margot Sanger-Katz: The Washington Post’s “Anti-Vaxxers Face Backlash as Measles Cases Surge,” by Lena Sun, and The New York Times’ “After a Debacle, How California Became a Role Model on Measles,” by Emily Oster and Geoffrey Kocks

Paige Winfield Cunningham: Kaiser Health News’ “Cancer’s Complications: Confusing Bills, Maddening Errors And Endless Phone Calls,” by Anna Gorman

Jennifer Haberkorn: The New York Times’ “Build Your Own ‘Medicare for All’ Plan. Beware: There Are Tough Choices,” by Austin Frakt and Aaron E. Carroll

To hear all our podcasts, click here.

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Listening To Older Patients Who Want To Stop Dialysis

Dr. Susan Wong sat down with an 84-year-old patient in the hospital, where he’d been admitted with a flare-up of a serious autoimmune condition and deteriorating kidney function.

The older man told her he wanted to go home; he’d had a good life and was ready for its end. He didn’t want aggressive care — including dialysis — having witnessed his wife and son die painfully in intensive care years ago.

Wong, an assistant professor of nephrology at the University of Washington, was prepared to follow the man’s wishes, but other physicians, eager to pursue tests and treatments, disagreed. For a week, the doctors argued about what to do. Finally, they discharged the patient, who died in hospice care a few weeks later.

Older adults with advanced kidney disease who want to forgo dialysis often encounter similar resistance from physicians, according to a new study in JAMA Internal Medicine by Wong and colleagues at the Veterans Affairs Puget Sound Health Care System in Seattle, where she’s an investigator.

The researchers documented doctors’ reactions by reviewing medical charts of 851 older patients with chronic kidney disease who refused dialysis at the VA health system from 2000 to 2011. In their notes, physicians frequently speculated the patients were incompetent, depressed, suicidal or irrational.

With dialysis, people are hooked up to a machine that removes waste from their blood, usually three times a week for four hours at a stretch. Many older adults find the treatments burdensome, and medical complications are common.

Yet patients who expressed reservations about this treatment were sometimes labeled as difficult or unprepared to confront the reality of their medical condition. “Still in denial about his kidney disease and his need for hemodialysis in the near future — repeat discussions with patient and wife regarding compliance,” one nephrologist wrote. Even when patients were firm about declining dialysis, doctors repeatedly questioned their decisions.

“Clinical practice guidelines for advanced kidney disease are geared toward survival, not what would give patients the best quality of life or the greatest functional capacity,” Wong said. Another factor at play: Nephrologists aren’t trained to ask seriously ill patients what’s most important to them and shape treatment recommendations accordingly. Although most patients want to have such conversations with a kidney specialist, few do so, studies have found.

“We don’t really know how to help patients with serious illness make decisions that are right for them or what to do when they don’t really want dialysis,” said Dr. Jane Schell, an assistant professor of palliative care and nephrology at the University of Pittsburgh.

Conversations about the potential benefits and burdens of dialysis, as well as alternatives, are especially important for frail patients 75 and older who have two or more chronic  conditions, such as diabetes and high blood pressure, and difficulty with daily activities such as bathing or walking — a group at risk of experiencing significant complications from dialysis but not achieving longer life.

Healthier older adults have better outcomes on dialysis — a valuable treatment for many people. “We shouldn’t limit access to dialysis based on age, but we should have meaningful conversations about goals of care and make it clear that dialysis is a choice and that patients have alternatives,” said Dr. Bjorg Thorsteinsdottir, an assistant professor of internal medicine and bioethics at the Mayo Clinic.

Options that should be discussed include comprehensive conservative care, which calls for preserving as much kidney function as possible, managing a patient’s health problems, dealing with symptoms such as nausea, swelling, itchiness, pain and breathing difficulties, and preparing for end-of-life care; peritoneal dialysis or hemodialysis at home; and palliative dialysis, a less intensive version of this treatment that keeps people alive for longer but isn’t meant to restore kidney function.

Comprehensive conservative care programs are few and far between (in New York City, Pittsburgh, Seattle, San Francisco and a few other locations), but efforts are underway to change that. With funding from the American Society of Nephrology, Schell and colleagues at the University of Pittsburgh have developed an online conservative care curriculum set to debut in March. Nineteen nephrology training programs for physicians are set to participate.

Also, the Pathways Project, funded by the Gordon and Betty Moore Foundation, is working to make palliative care (also known as supportive care) for patients with advanced kidney disease widely available. (KHN’s coverage of end-of-life and serious illness issues is also supported in part by the Gordon and Betty Moore Foundation.) Dr. Alvin Moss, co-investigator of the project and professor of medicine at West Virginia University School of Medicine, said the project hopes to sign up 10-15 dialysis centers this year.

Sometimes, patients choose a time-limited trial of dialysis with the understanding that they can change their minds down the road.

Cyndy Patton’s 86-year-old mother, Isabel, learned last spring she had advanced kidney disease after going to a Pittsburgh hospital, sickened by repeated bouts of vomiting. Physicians suggested she try dialysis for a few weeks and see if her kidneys might rejuvenate. (The older woman had survived open-heart surgery and a stroke and was living on her own after her husband’s death.)

After a week in the hospital and another week in a rehabilitation center, there was no change: Patton’s mother still needed dialysis. Five weeks later, she confessed to her daughter that the treatment was making her miserable. But giving it up felt like committing suicide, she told Patton — an unacceptable option.

A week later, Isabel had changed her mind. “This is not a life I care to lead, being hooked up to these machines,” she told Patton. “What am I doing this for?” The older woman had consulted with Schell at the University of Pittsburgh about palliative care and hospice care, and she chose hospice.

Dialysis ended and the family gathered at Isabel’s bedside. “She was all ready to die — but she didn’t, and is still living to this day,” Patton said.

It’s an example of how hard it can be to predict what will happen to any given patient with advanced kidney disease. What’s important for the patient to understand is that “it’s not always all or nothing — dialysis or death,” Thorsteinsdottir said.

“Patients have to be very assertive and tell their medical team: This is what I want and what I don’t want,” Moss said. For more information, he suggested people explore the websites of the Coalition for Supportive Care of Kidney Patients (he chairs that organization), the National Kidney Foundation and the American Association of Kidney Patients, and “really spend some time learning about your options.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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Yoga linked to lowered blood pressure with regular practice

(Reuters Health) – Adults who practice yoga with breathing and relaxation exercises at least three times a week may have lower blood pressure than people who don’t, a research review suggests.

FILE PHOTO: Attendees perform yoga during an event called “Yoga por la paz” (Peace through Yoga) before the arrival of Indian Prime Minister Narendra Modi, during a sideline event ahead of the Group 20 summit, in Buenos Aires, Argentina, November 29, 2018. REUTERS/Andres Martinez Casares

For the study, researchers analyzed data from 49 trials with a total of 3,517 participants who were typically middle-aged, overweight women and men who already had high blood pressure or were close to developing the condition. These smaller trials assessed blood pressure before and after participants were randomly assigned either to doing yoga or to a control group without exercise programs.

Overall, the people in the yoga groups experienced average reductions in systolic blood pressure of 5 mmHG (millimeters of mercury) more than those in the control groups, and diastolic blood pressure was reduced by 3.9 mmHG more with yoga.

When people with high blood pressure did yoga three times a week in sessions that also included breathing and relaxation exercises, they experienced average decreases of 11 mmHG more than control groups in systolic blood pressure and 6 mmHG more in diastolic blood pressure.

“Our results not only showed that yoga can be just as, or even more effective than aerobic exercise to reduce blood pressure; but also quantitatively showed the importance of emphasizing yoga breathing techniques and mental relaxation/meditation along with physical forms during practice,” said lead study author Yin Wu, a researcher in kinesiology at the University of Connecticut in Storrs.

“So, yoga, among other lifestyle interventions (such as diet and smoking cessation) should be adopted early on even when the blood pressure is still relatively low, and should be continued along with medication when blood pressure is relatively high,” Wu said by email.

Yoga appeared beneficial, but less so, when people practiced regularly but didn’t focus on breathing and relaxation or meditation. Under these circumstances, yoga was associated with average drops of 6 mmHG more in systolic blood pressure and 3 mmHG more in diastolic blood pressure compared to the groups doing no exercise.

In adults, a normal or healthy blood pressure reading is considered to be 120/80 mmHG or lower.

People in the study started out with average blood pressure readings of 129.3/80.7 mmHG. This suggests the reductions associated with yoga might be enough to return some people to the normal range.

The first number in the reading, known as systolic blood pressure, is the pressure blood exerts against artery walls when the heart beats. The second number, known as diastolic blood pressure, represents the pressure between beats when the heart is at rest.

One limitation of the study is that researchers lacked data on the intensity of yoga practices, including how long people held poses and how rapidly participants transitioned from one position to the next, the study authors note in Mayo Clinic Proceedings.

And while yoga with relaxation techniques appears to be beneficial, a separate study in the same journal offers a reminder of the potential risks for some in a review of records from 89 patients with injuries caused primarily by yoga.

The study looked at the types of injuries that occurred and found that 66 people had soft tissue injuries including pain from overuse, and six had discomfort or mobility limitations around a rotator cuff in the shoulder. In addition, 46 people experienced aggravation of pain from degenerative joint disease, while 13 had compression fractures.

These observations only included injured people, researchers note. The study wasn’t designed to determine whether or how yoga might directly cause injuries.

“In general, yoga improves balance, strength and flexibility, but trying to be extremely flexible with fragile joints can cause problems,” said senior study author Dr. Mehrsheed Sinaki, a rehabilitation specialist at the Mayo Clinic in Rochester, Minnesota.

“Also, if a person is 70 or 80 and does too many hip-opening movements or hyper extensions, they may develop hip pain,” Sinaki said by email.

While most people can practice yoga safely, older people with osteoporosis (thinning, brittle bones) should be careful, agreed Dr. Edward Laskowski, coauthor of an accompanying editorial and co-director of Mayo Clinic Sports Medicine.

“Rather than a one-size-fits-all approach, an individualized exercise prescription which takes into account a person’s unique medical history and personal goals should be considered,” Laskowski said by email.

SOURCE: bit.ly/2BUUSXO , bit.ly/2Ejzkof and bit.ly/2BYnRtJ Mayo Clinic Proceedings, online February 18, 2019.

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U.S. Senator Sanders urges FDA to allow older versions of $375,000 drug

(Reuters) – U.S. Senator Bernie Sanders this week urged regulators to allow pharmacies and manufacturers to resume distributing unbranded, lower-cost versions of a drug used to treat a rare neuromuscular disorder, according to a letter provided by his office to Reuters.

FILE PHOTO: U.S. Senator Bernie Sanders speaks during a news conference on Yemen resolution on Capitol Hill in Washington, U.S., January 30, 2019. REUTERS/Yuri Gripas

The drug is now sold at a list price of $375,000 a year by Catalyst Pharmaceuticals Inc under the brand name Firdapse. It is used to treat Lambert-Eaton Myasthenic Syndrome (LEMS), which affects about one in 100,000 people in the United States.

Shares of Florida-based Catalyst were down nearly 10 percent at $2.79 on Thursday.

The company received Food and Drug Administration approval for Firdapse in November, along with rights to sell it exclusively for several years under a designation granted to developers of treatments for rare diseases.

The drugmaker, in response to a recent query from Sanders, said its prices are in line with similar products in the industry.

Catalyst on Thursday declined to comment on the senator’s request to the FDA.

Before the launch of Firdapse, patients were able to get the same drug for free from Jacobus Pharmaceuticals, a small New Jersey-based drug company, which offered it through an FDA program called “compassionate use.”

The program allows patients with rare diseases and conditions access to experimental drugs outside of a clinical trial when there is no viable alternative.

In his Feb. 26 letter Sanders, citing the Catalyst drug’s “shocking price,” called on FDA Commissioner Scott Gottlieb to announce that the agency will not take enforcement action against pharmacies and manufacturers that were previously providing the drug to patients. Sanders also gave the letter to U.S. Health and Human Services Secretary Alex Azar in a private meeting on Tuesday.

FDA spokeswoman Jennifer Rodriguez, in an emailed statement, said the FDA has received the letter and will respond directly to the senator. HHS also said it has received the letter and will respond.

In 2012, a federal judge dismissed a lawsuit brought by K-V Pharmaceutical Co against the U.S. government seeking to ban sales by pharmacies of cheaper, unapproved versions of its drug Makena to prevent premature birth. The FDA had allowed such sales after public outcry over the high price of the newer drug.

FDA approval of Makena came years after pharmacies had already been compounding such a drug at far lower prices than Makena, using an active ingredient, hydroxyprogesterone, available without formal FDA approval.

“Catalyst may be the most recent company to exploit their monopoly after receiving FDA approval for an inexpensive old drug, but they were certainly not the first,” Sanders said in the letter.

He noted that the prices of very old and inexpensive drugs such as colchicine, vasopressin, neostigmine, and others have been raised substantially by drugmakers following FDA approval, causing needless suffering and adding to the cost of health care.

The government has intensified its scrutiny of the pharmaceutical industry and rising U.S. prescription drug prices, a top voter concern and a priority of President Donald Trump’s administration.

Both the Democratic-led House of Representatives and the Senate, controlled by Trump’s fellow Republicans, have begun holding hearings this year on the rising costs of medicines. Sanders is an independent who usually votes with Democrats.

Reporting by Yasmeen Abutaleb in Washington and Deena Beasley in Los Angeles; editing by Michael Perry and Bill Berkrot

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Cancer’s Complications: Confusing Bills, Maddening Errors And Endless Phone Calls

Carol Marley wants everyone to know what a life-threatening cancer diagnosis looks like in America today.

Yes, it’s the chemotherapy that leaves you weak and unable to walk across the room. Yes, it’s the litany of tests and treatments — the CT scans and MRIs and biopsies and endoscopies and surgeries and blood draws and radiation and doctor visits. Yes, it’s envisioning your funeral that torments you day and night.

But none of these is her most gnawing, ever-present concern.

That would be the convoluted medical bills that fill multiple binders, depleted savings accounts that destroy early retirement plans, and so, so many phone calls with insurers and medical providers.

“I have faith in God that that my cancer is not going to kill me,” said Marley, who lives in Round Rock, Texas. “I have a harder time believing that this is gonna get straightened out and isn’t gonna harm us financially. That’s the leap of faith that I’m struggling with.”

Coping with the financial fallout of cancer is exhausting. And nerve-wracking. But the worst part, Marley said, is that it’s unexpected. When she was diagnosed with pancreatic cancer last summer, she didn’t anticipate so many bills, or so many billing mistakes. After all, she is a hospital nurse with good, private insurance that allowed her access to high-quality doctors and medical centers.

Randall Marley, a computer systems engineer, said he frequently comes home from work to find his wife not feeling well and frustrated having spent a precious day of her recovery making phone calls to understand and dispute medical bills. One recent night she was in tears and “emotionally at a breaking point,” he said. “The hardest part of this is seeing the toll it’s taken on my wife.”

Randall Marley says he frequently comes home from work to find his wife not feeling well and frustrated about the medical bills.(Anna Gorman/KHN)

Piling On The Pain

More than 42 percent of the 9.5 million people diagnosed with cancer from 2000 to 2012 drained their life’s assets within two years, according to a study published last year in the American Journal of Medicine. Cancer patients are 2.65 times more likely to file for bankruptcy than those without cancer, and that puts them at a higher risk for early death, according to research.

But those statistics don’t convey the daily misery of a patient with a life-threatening disease trying to navigate the convoluted finances of U.S. health care, while simultaneously facing a roller coaster of treatment and healing.

Stephanie Wheeler, a professor at the University of North Carolina at Chapel Hill, said the number of bills coming from different providers can be overwhelming.

“It’s oftentimes multiple different bills that are rolling in over a period of several months and sometimes years,” said Wheeler, who has conducted survey research with metastatic cancer patients. “As those bills start to accumulate it can be very stress-inducing.”

Given many patients cannot work during treatment, these bills may force even relatively well-to-do cancer patients to take out second mortgages, spend college savings or worry about leaving debt behind for their families, Wheeler said.

Carol Marley is a slight woman who dotes on her two dogs and is involved in her church. Her 88-year-old father, who has dementia, had moved in. She and Randall pride themselves on living frugally. They pay their credit card off every month and don’t have car payments.

After Carol Marley was diagnosed with pancreatic cancer last July, she says, she worried what it would mean for her family, including her 88-year-old father with dementia.(Anna Gorman/KHN)

Marley and her daughter, June Marley — a second-year college student — have health insurance through her employer, Ascension Health, a large, faith-based health care system with facilities across the nation. Her husband has separate insurance through his job.

They were hoping to retire early, buy an RV and drive around the country. Instead, they see their meticulous plans disappearing, even if Carol recovers. Their high-deductible insurance policy meant they had to spend $6,000 before their insurance started covering her treatment expenses. They hit their annual out-of-pocket maximum of $10,000 well before the year was over. But Carol Marley said she was prepared for that. “What I didn’t anticipate is the knock-down, drag-out fight that I would have to engage in to get people to see there were errors and address it.”

Since she’s unable to work, the family lost her nursing salary.

“Money is not coming in, and it’s going out by the thousands,” she said.

Coming To Terms With Diagnosis

Marley had treated cancer patients before. She had seen them come in with unexplained aches and leave with devastating diagnoses. Now it was her turn. Though she didn’t recognize it at the time, her symptoms were textbook. Fatigue. Back pain. Weight loss. In July, doctors told her she had pancreatic cancer.

Her first thought was that she was going to die. A nurse friend asked if she had her affairs in order. That’s because pancreatic cancer is usually discovered too late. Just 9 percent of patients are alive five years after diagnosis, compared with 90 percent of breast cancer patients. Marley knew she was lucky. Hers hadn’t spread. She might be able to undergo surgery. But first, four months of chemotherapy and five weeks of radiation.

The chemotherapy — seven or eight rounds, she can’t quite remember — drained her. “I couldn’t put words together in my head,” she said. She had muscle spasms and developed fevers that landed her in the emergency room.

As she became weaker, Marley realized she could no longer care for her father at home. On a recent morning in early January, Marley sat down with nurse from a memory care facility where a space had become available. Holding back tears, Marley told the nurse she knew this day would come. “I didn’t think it would be so soon, and I didn’t know under these circumstances.”

Becoming Her Own Patient Advocate

Later that same day, Marley’s energy was up. She adjusted the colorful scarf on her head, turned on her computer and pulled out a pen. Some days, Marley said, she spends hours trying to clarify and fix medical bills. “But I don’t do that frequently because it is so fruitless and it is stressful,” she said.

Often, she is just trying to figure out what different bills mean. “Even as a nurse, I feel like it’s impossible to understand,” she said. “I can’t make heads or tails of it.”

Sometimes there are errors.

Part of the problem, she contends, is that one insurance company covers visits with Ascension providers and hospitals and another company covers pharmacy claims and specialty drugs and providers outside of the Ascension network. Some of the bills, including one for $1,400 from an ER visit — were sent to the wrong insurer, she said.

Marley cited other issues. An $18,400 chemotherapy bill submitted with missing information and then denied because it arrived late. A $870 MRI bill denied because the provider said there had been no preauthorization.

“It’s not any one individual. It’s not any one system or provider,” she said. “The whole system is messed up. … There’s no recourse for me except to just keep making phone calls.”

Carol Marley says often, she is just trying to figure out what different bills mean. “Even as a nurse, I feel like it’s impossible to understand,” she said. “I can’t make heads or tails of it.”(Anna Gorman/KHN)

On this particular afternoon, Marley has a long list of calls to make. One to figure out why she couldn’t access her insurance claims online. Another to a medical provider that urged her to pay $380, even though they acknowledged they owed her about $80 of that total.

Someone who answered the phone again suggested Marley pay the entire amount. “Once it’s posted to your account and it goes through,” the woman said, “we would send you a check.”

Marley shook her head. “I’m sure y’all are fine people over there, but I’m not trusting a refund to come,” she responded, reflecting on her experience as a consumer of cancer care. “The problem is, they want their money and they are going to get it one way or the other.”

As for her hospital bills, Ascension declined to comment, citing protected health information. But spokesman Nick Ragone said, “The matter at issue was favorably resolved.”

He did not say which issue was resolved.

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Diabetes tied to risk for more advanced, aggressive breast cancer

(Reuters Health) – Women with diabetes are more likely than those without the disease to be diagnosed with a more advanced and difficult to treat form of breast cancer, a Dutch study suggests.

The researchers examined data on 6,267 women diagnosed with breast cancer from 2002 to 2014, including 1,567 patients with type 2 diabetes.

Overall, women with diabetes were 28 percent more likely to be diagnosed with more advanced and aggressive types of tumors than women without diabetes, the study found. Whether women with diabetes used insulin didn’t appear to influence the characteristics of their breast cancers.

“This finding matters for patients with type 2 diabetes who may be concerned about how insulin treatment may affect breast cancer risk,” said Christina Dieli-Conwright, a researcher at the University of Southern California in Los Angeles who wasn’t involved in the study.

Type 2 diabetes, the most common form, is linked to obesity and aging and happens when the body can’t properly use or make enough of the hormone insulin to convert blood sugar into energy. Failure to manage the condition can result in complications like blindness, kidney failure, nerve damage and amputations.

Many people with type 2 diabetes can control their symptoms with prescription drugs designed to help lower blood sugar and with lifestyle modifications like eating healthier food and exercising more often. Some of these patients also need to inject insulin to help regulate their blood sugar.

Some previous research has linked insulin use to an increased risk of breast cancer in women with type 2 diabetes, but results have been mixed and often lacked detailed information about the exact types of tumors women developed, researchers note in Diabetes Care.

In the current study, women with diabetes were more likely to have more advanced tumors, that were larger and had spread to more lymph nodes surrounding the breast. With diabetes, women were also more likely to have tumors that were “graded” as more aggressive and more likely to grow and spread rapidly in the body.

Half of the 388 women taking insulin for diabetes had been on insulin for at least 3.4 years.

Researchers didn’t find any connection between the duration of insulin use and breast cancer characteristics.

The study wasn’t designed to prove whether or how diabetes or insulin use might directly impact the risk of developing breast cancer or getting more aggressive or hard to treat tumors.

Beyond its small size, another limitation of the study is that it lacked data on a range of individual patient characteristics including obesity and any history of abnormal mammogram findings, note the authors, Jetty Overbeek of VU University Medical Center in Amsterdam and colleagues. Overbeek didn’t respond to requests for comment.

The results are surprising because of previous research suggesting that more insulin in the body might trigger processes that lead to tumor growth, Dieli-Conwright said by email.

“Perhaps this study did not find insulin to play a role in breast cancer progression because of the small sample size,” she added. “This is an understudied area within diabetes and cancer risk, thus further larger studies are warranted to examine the impact of insulin treatment on cancer risk.”

Patients should still understand that diabetes itself can pose a cancer risk, said Dr. Tahseen Chowdhury, a diabetes consultant at Royal London Hospital in the UK, who wasn’t involved in the study.

“Women with diabetes appear to have not only a higher risk of breast cancer, but also a higher risk of poorer types of breast cancer,” Chowdhury said by email.

In addition to taking prescribed medications and making lifestyle changes to lose weight, diabetics should also make sure to get regular screening mammograms and seek immediate medical attention when they detect pain or lumps in their breasts, Chowdhury advised.

SOURCE: bit.ly/2tDGD5d Diabetes Care, online January 24, 2019.

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Congo Ebola center in flames after another armed attack

GOMA, Democratic Republic of Congo (Reuters) – Armed assailants attacked an Ebola center in eastern Democratic Republic of Congo on Wednesday, setting off a fire and becoming embroiled in an extended gunbattle with security forces that has yet to end, the local mayer said.

The identity and motive of the assailants were unclear. Aid workers have faced mistrust fueled by widespread rumors in some areas as they work to contain the Ebola outbreak.

Dozens of armed militia also regularly attack civilians and security forces in eastern Congo’s borderlands with Uganda and Rwanda, which has significantly hampered the response to the disease.

Wednesday’s attack in the city of Butembo was the second in Congo’s Ebola-hit east. On Sunday unidentified assailants set fire to another treatment center in the nearby town of Katwa, killing a nurse.

“After the attack… in Katwa, we decided to reinforce the security of these structures. That is why there is an exchange of fire between the police and the assailants,” Butembo mayor Sylvain Mbusa Kanyamanda told Reuters.

“Elements from the Congolese army have been deployed to contain the situation. As the operations continue, I do not have a casualty toll for the moment,” he said.

The current Ebola outbreak, first declared last August, is the second deadliest of the haemorrhagic fever since it was discovered in Congo in 1976. It is believed to have killed at least 551 people so far and infected over 300 more.

Reporting By Fiston Mahamba; Additional reporting by Giulia Paravicini; Writing by Aaron Ross; Editing by Gareth Jones

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Pharma execs dig in for a fight against outraged senators

Senators got their first opportunity Tuesday to prod drugmakers about the wallet-emptying prices they charge for prescription drugs.

Almost in unison, the executives expressed support for eliminating rebates that flow to industry middlemen instead of patients; for increasing transparency about how they set prices; for shifting to a more value-based pricing system, in which outcomes are rewarded. Together they demurred when asked to commit to lowering list prices on drugs like insulin and the blockbuster rheumatoid arthritis drug Humira.

The drugmakers — AbbVie, AstraZeneca, Bristol-Myers Squibb, Johnson & Johnson, Merck, Pfizer and Sanofi — appeared before the Senate Finance Committee as lawmakers mull how to best control rising drug prices. Several declined the committee’s first invitation to testify last month, agreeing to appear after committee leaders publicly named them prior to Tuesday’s hearing.

Outlining the problem, Sen. Ron Wyden of Oregon, the committee’s top Democrat, said that last fall 10 companies accounted for half of all profits in the health care sector, nine of them drugmakers. He pointed out that all but one of the drugmakers represented Tuesday were among the top 10 profit-makers.

“Your profits are outsized compared to others in the industry, you get a massive portion of your revenue from American taxpayers, and you bear none of the consequences of high drug prices,” Wyden said.

Sen. Chuck Grassley of Iowa, the committee’s Republican chairman, emphasized the seriousness of the hearing, opening with an unusual reminder to the executives that it is a crime to lie to Congress and pressing them to commit to lowering prices.

Even Sen. Johnny Isakson of Georgia, a Republican who praised the industry for discovering lifesaving drugs — like the ones that help him live with Parkinson’s disease — expressed reservations. “When I can’t explain it, it’s tough, and I can’t explain the cost increases,” he said.

Congress has spent decades trying to contain rising drug prices, leaving some skeptical that even broad bipartisan support and the backing of the Trump administration is enough to wrangle the deep pockets of the pharmaceutical industry.

But Tuesday’s hearing offered some sense of what drugmaker opposition — or support — might look like.

Here are five key takeaways:

Targeting Rebates And PBMS

Each of the seven executives said they support eliminating rebates, or discounts negotiated by pharmacy benefit managers that lower the cost of drugs for those footing the bill — generally, insurance companies or larger employers. PBMs keep a portion of the rebate as payment, but patients are often the only ones who don’t benefit.

Yet, when asked about the Trump administration’s recent proposal to strip PBMs of their ability to claim rebates for brand-name drugs covered by government programs, not a single executive would commit to lowering list prices should the proposal be realized.

Drugmakers have long blamed PBMs for driving up costs, and — though they seemed to tone down their accusations after senators made it clear they would not tolerate finger-pointing — these executives were no exception.

Jennifer Taubert, the executive vice president and worldwide chairman of pharmaceuticals for Johnson & Johnson, called PBMs “extraordinarily effective negotiators.” Albert Bourla, who became the chief executive of Pfizer last month, said the company sets its prices “through negotiations with PBMs, and they are very powerful.” And Pascal Soriot, the chief executive of AstraZeneca, said the rebate system is “not sustainable.”

They were met with some notable skepticism. Wyden pointed out that about 40 percent of drugs covered under Medicare Part D don’t have a rebate, challenging the idea that rebates are at the heart of the problem. And PBMs, who weren’t in the room, pushed back against the blame.

“Drugmakers alone have the power to set prices,” JC Scott, the president and chief executive of the Pharmaceutical Care Management Association, the national trade organization for PBMs, said in a statement.

Debating List Prices

Wyden had little patience for the executives’ emphasis on rebates, which he dismissed as “window-dressing.” He was unequivocal: List prices set by the drugmakers are the real problem.

“I just want you all to know that the No. 1 reason consumers are getting hammered is because these list prices … are unaffordable,” Wyden said.

While the pharmaceutical industry is prone to dismissing list prices due to the fact that relatively few pay them after rebates and other discounts are applied, those prices are used to calculate copayments for some — such as seniors using Medicare Part D.

Kenneth Frazier, the chairman and chief executive of Merck, called the system “regressive,” lamenting that it is typically those without insurance who pay list prices.

“The biggest problem we have as a country is we have a system where the sickest and the poorest are subsidizing the others,” Frazier said.

Grassley and Wyden each pressed executives to commit to lowering list prices, especially if the Trump administration passes its proposal to eliminate rebates in government programs like Medicare and Medicaid.

Executives balked, with some saying rebates would first need to be eliminated from the entire system, not just government programs.

“If the rebates were removed from the commercial sector as well, we would definitely reduce our list prices,” said Soriot of AstraZeneca.

The pharma executives did express support for both the vague notion of increasing transparency about how drugmakers set prices, as well as for shifting to a more value-based pricing system. “Imagine a system in which Pfizer gets paid based on the number of heart attacks we prevent” rather than the number of pills sold, said Bourla of Pfizer.

Applauding The CREATES Act

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All seven executives pledged support for the CREATES Act, which is designed to stop what Food and Drug Administration chief Scott Gottlieb calls “shenanigans” perpetrated by brand-name companies to block competition. Pharma firms often refuse to supply makers of generics with needed samples to develop rival, less expensive products or abuse safety rules as another way of hindering competition.

Alleged culprits include companies represented Tuesday. The FDA’s “name and shame” list of those withholding samples, a list originally published last year, included AstraZeneca, Pfizer, Johnson & Johnson’s Actelion division and Celgene, which has agreed to be bought by Bristol-Myers.

The unanimous support for CREATES seems to put the executives opposite their own trade group, the Pharmaceutical Research and Manufacturers of America, which has staunchly opposed the bill and spent millions of dollars last year lobbying on it.

On Tuesday, PhRMA CEO Stephen Ubl said the group is working with generics manufacturers “to jointly develop a modified version” of CREATES and would “work with policymakers on a bipartisan basis to advance this legislation.”

Flap Over Prices Overseas

Senators hammered executives on price disparities between the United States and elsewhere, extracting admissions that the companies make money even in markets where prices are much lower.

“How is that not gouging the American consumer with high prices even though you’re giving other people, Western, industrialized countries, a better deal?” Wyden asked Richard Gonzalez, AbbVie’s CEO.

“I think that you charge more here because you can, and American taxpayers are subsidizing all of you to be able to have incredibly high profits,” said Sen. Debbie Stabenow, a Michigan Democrat.

Pharma bosses responded by saying that terms vary by market. Research and patient access could be threatened by over-regulation of U.S. prices, they said.

The result of lower prices in Europe is that “these medicines are available many years later than they are here,” Frazier said. “They actually provide very few of these medicines early on to their populations.”

Friction Over Patents

AbbVie, the maker of the top-selling rheumatoid arthritis drug Humira, came under especially intense — and notably bipartisan — scrutiny for its use of patents to thwart competition.

Wyden accused AbbVie of clinging to its exclusivity “like Gollum with his ring,” preventing lower-cost generics from coming to market and easing the burden on patients’ wallets.

Gonzalez said Humira’s multiple patents covered its different uses as they were identified. “Remember, Humira is like nine different drugs, 10 different drugs,” he said, referring to the fact that the drug is used to treat other diseases, such as Crohn’s disease.

Sen. John Cornyn, Republican of Texas, was incredulous, pointing to the decades-long grip AbbVie has on Humira since it secured multiple patents on the drug without making changes to it, as well as the drugmaker’s lawsuit to block another company, Amgen, from creating a cheaper, biosimilar version. (AbbVie ultimately settled, agreeing Amgen could release its version in 2023.)

Perhaps the Senate Judiciary Committee should also investigate AbbVie as a matter of anti-competitive behavior, Cornyn said, turning to Grassley, who is also on that committee. Grassley agreed.

Kaiser Health NewsThis article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Machine learning algorithm was able to sort children with arthritis into seven distinct types of disease according to the location of painful joints in the body in a way that was predictive of disease outcome. This will help physicians to better tailor treatment so that patients who are more likely to develop milder form of disease can be spared medications that can have serious side effects.
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A Parent-To-Parent Campaign To Get Vaccine Rates Up

In 2017, Kim Nelson had just moved her family back to her hometown in South Carolina. Boxes were still scattered around the apartment, and while her two young daughters played, Nelson scrolled through a newspaper article on her phone. It said religious exemptions for vaccines had jumped nearly 70 percent in recent years in the Greenville area — where they had just moved from Florida.

She remembers yelling to her husband in the other room, “David, you have to get in here! I can’t believe this.”

Nelson didn’t know any mom friends that didn’t vaccinate their kids.

“It was really eye-opening that this was a big problem,” she said.

Nelson’s dad is a doctor; she had her immunizations, and so did her kids. But this news scared her. She knew that infants were vulnerable — they couldn’t get started on most vaccines until they were 2 months old. And some kids and adults have diseases that compromise their immune systems, which means they can’t get vaccines and rely on herd immunity. Nelson was already thinking about public health a lot back then, and was even considering a career switch, from banking to public health. She decided she had to do something.

“I very much believe if you have the ability to advocate then you have to,” she said. “The onus is on us if we want change.”

Like a lot of moms, Nelson had spent hours online. She knew how easy it was to fall down internet rabbit holes, into a world of fake studies and scary stories.

“As somebody who just cannot stand wrong things being on the internet,” Nelson said, “if I saw something with vaccines, I was very quick to chime in ‘That’s not true’ or ‘No, that’s not how that works.’ … I usually got banned.”

Nelson started her own group, South Carolina Parents for Vaccines. She began posting scientific articles online. She started responding to private messages from concerned parents with specific questions. She also found positive reinforcement was important and would roam around the mom groups, sprinkling affirmations.

“If someone posts ‘My child got their 2 months shots today,’” Nelson said, she’d quickly post a follow-up comment, “Great job, mom!”

Nelson, 33, was inspired by peer-focused groups around the country doing similar work. Groups with national reach like Voices for Vaccines, and regional groups like Vax Northwest in Washington, take a similar approach, encouraging parents to get educated and share facts about vaccines with other parents.

Nationally, 91 percent of children under 3 years old are vaccinated for measles. But in some communities the rate is much lower. In Clark County, Wash., where a measles outbreak is up to 62 cases, about 76 percent of kindergartners come to school without all their vaccines. Public health specialists, concerned about weakened herd immunity, are increasingly raising the alarm about the need to improve vaccination rates.

But efforts to reach vaccine-hesitant parents often fail. And some parents remain entrenched in a decision not to vaccinate even when presented with the facts.

Pediatricians could play a role — and many do — but they’re not compensated to have lengthy discussions with parents, and some of them find it a frustrating task. That’s left a huge opening for alternative approaches. Nelson thought it would be best to zero in on moms who were still on the fence about vaccines.

“It’s easier to pull a hesitant parent over than it is somebody who is firmly anti-vax,” Nelson said. She explained that parents who oppose vaccination often feel so strongly about it that they won’t engage in a discussion. “They feel validated by that choice — it’s part of community, it’s part of their identity.”

The most important thing is timing: People may need information about vaccines before they become parents. A first pregnancy — when men and women start transitioning into their parental roles — is often when the issue first crops up. Nelson points to one survey study from the Centers for Disease Control and Prevention that showed 90 percent of expectant women have made up their minds on vaccines by the time they are six months pregnant.

“They’re not going to a pediatrician [yet],” Nelson said. “Their OB-GYN is probably not speaking to the pediatric vaccine schedule. … So where are they going? They’re going online.”

Nelson tries to counter bad information online with facts. But she also understands the value of in-person dialogue. She organized a class at a public library and advertised the event on mom forums. Nelson was nervous that people hostile to vaccines might show up.

“Are they here to rip me a new one? Or are they here to learn about vaccines?” Nelson wondered. “I just decided, if they’re here, I’m going to give them good information.”

Amy Morris was pregnant, but she drove an hour and a half to attend the class. Morris wasn’t the typical first-time mom Nelson was trying to reach. She already had three kids. But during this pregnancy, she was getting increasingly nervous about vaccines. She had recently had a miscarriage, and it was right around the time she got a flu shot. Morris had been reading pro- and anti-vaccine posts in the mom forums, and was starting to have some doubts. In Nelson’s class, she learned the risks of not vaccinating.

“That spoke to me more than anything,” said Morris.

Now, holding her healthy 8-month-old son, Thorin, on her lap, she said she’s glad she went, because she was feeling vulnerable.

“I always knew it was the right thing to do,” Morris said. “I was listening to that fear monster in the back of my head.”

Nelson said that fear is what the anti-vaccine community feeds on. She’s learned to ask questions to help parents get at the root of their anxiety.

“I do think they appreciate it when you meet them sympathetically and you don’t just try and blast facts down their throat,” Nelson said.

Nelson is now trying to get local hospitals to integrate that vaccine talk into their birthing classes. She’s studying for a master’s degree in public health at the University of South Carolina, and also works with the Bradshaw Institute for Community Child Health and Advocacy. She’s even considering a run for public office.

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

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