Google has an illegal monopoly on search, US judge finds

 Alphabet's Google broke the law with monopolistic behavior over online search and related advertising, a federal judge ruled on Monday, the first victory for U.S. antitrust authorities who have filed numerous lawsuits challenging Big Tech's market dominance.

The decision is a significant win for the Justice Department, which had sued the search engine giant over its control of about 90% of the online search market, and 95% on smartphones.

"The court reaches the following conclusion: Google is a monopolist, and it has acted as one to maintain its monopoly," U.S. District Judge Amit Mehta wrote.

His ruling against Google paves the way for a second trial to determine potential fixes, such as breaking up the company or requiring the company to stop paying smartphone makers billions of dollars annually to set Google as the default search engine on new phones.

Ultimately, Google will have a chance to appeal the court's rulings to the U.S. District Court of Appeal for the D.C. Circuit.

Shares of Google parent Alphabet fell 4.3% on Monday as part of a broad tech share decline.

Mehta noted that Google had paid $26.3 billion in 2021 alone to ensure that its search engine is the default on smartphones and browsers, and to keep its dominant market share.

"The default is extremely valuable real estate... Even if a new entrant were positioned from a quality standpoint to bid for the default when an agreement expires, such a firm could compete only if it were prepared to pay partners upwards of billions of dollars in revenue share and make them whole for any revenue shortfalls resulting from the change," Mehta wrote.

He noted “Google, of course, recognizes that losing defaults would dramatically impact its bottom line. For instance, Google has projected that losing the Safari default would result in a significant drop in queries and billions of dollars in lost revenues.”

The ruling is the first major decision in a series of cases taking on alleged monopolies in Big Tech.

"A forced divestiture of the search business would sever Alphabet from its largest source of revenue. But even losing its capacity to strike exclusive default agreements could be detrimental for Google," said Emarketer senior analyst Evelyn Mitchell-Wolf, who noted a drawn out legal process will delay any immediate effects for consumers.

In the past four years, federal antitrust regulators have also sued Meta Platforms, Amazon.com, and Apple Inc, claiming the companies have illegally maintained monopolies. Another case against Google over its advertising technology is scheduled to go to trial in September.

https://finance.yahoo.com/news/u-judge-rules-google-broke-185454354.html

'How Good Is Wegovy's Heart Benefit?'

 This story is the first in a series called "Ozempic: Weighing the Risks and Benefits." It was produced in part through a grant from the NIHCM Foundation

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When the final results of the SELECT trialopens in a new tab or window were reported last fall, investigators touted a 20% reduced riskopens in a new tab or window of a major cardiovascular event with semaglutide (Wegovy) compared with placebo -- a figure that sounds impressive on the face of it.

But since then, experts have pointed out that the absolute benefit -- a 1.5 percentage-point difference between the two groups of patients who were overweight and had preexisting cardiovascular disease -- is much smaller.

Indeed, 6.5% of people taking the glucagon-like peptide-1 (GLP-1) receptor agonist had a major cardiovascular event, as did 8% of those on placebo.

While that's a significant difference, it's a small one, several experts told MedPage Today.

"That sounds very impressive, 20%, but it's misleading," said Diana Zuckerman, PhD, president of the National Center for Health Research in Washington, D.C. "I mean, it's still good. But as an individual person making a decision about how much money they're willing to spend for this drug, and all the side effects, whether it's nausea or vomiting or diarrhea ... it just may not be worth it to them."

David Phizackerley, BSc, MRPharmS, deputy editor of The BMJ's Drug & Therapeutics Bulletin, penned an editorialopens in a new tab or window on the absolute cardiovascular benefits in the SELECT trial, noting that the 1.5% absolute risk reduction means that 67 people would need to take the drug for 34 months -- the length of the study -- to prevent just one primary endpoint event (heart attack, stroke, or cardiovascular death). The other 66 people would not see any cardiovascular benefit at all.

"If it was over a year, you'd have to treat three times as many people" to have one person benefit, Phizackerley added.

On top of that, Phizackerley pointed out that only one of the three components of the composite endpoint was significant.

There was a significant benefit for non-fatal myocardial infarction (HR 0.72, 95% CI 0.61-0.85), but "even that was quite small" at a 1% absolute risk reduction (2.7% for semaglutide vs 3.7% for placebo), he said.

"You do the math on that, and it's a number needed to treat of 100, so you'd have to treat 100 people to prevent one event," Phizackerley told MedPage Today. "Say you're sitting with a patient who wants a realistic explanation of what this drug might do for them. If I said, 'We have a room of 100 people, and if I give it to all 100, one of you will walk out with a benefit. The other 99 won't.' That's redressing the balance."

The other two parts of the composite endpoint were death from cardiovascular causes (2.5% vs 3%) and non-fatal stroke (1.7% vs 1.9%), neither of which was significant (HR 0.85, 95% CI 0.71-1.01, P=0.07; and HR 0.93, 95% CI 0.74-1.15).

Michael Lincoff, MD, of the Cleveland Clinic, the lead author on the SELECT study, disagreed with Phizackerley's and Zuckerman's interpretations of the trial results, arguing that a 20% relative risk reduction is "a big deal in cardiovascular medicine."

"We consider a successful trial a 15% reduction, some are 20% or 25%," Lincoff told MedPage Today. "That's a significant reduction in terms of being clinically relevant."

As for the non-significant components of the composite endpoint, Lincoff said trialists "never expect components to be significant unless we do a trial powered for that. We powered the trial for the composite endpoint."

The fact that there was no effect on non-fatal stroke was interesting, Lincoff said, because "other trials of GLP-1s in patients with [type 2] diabetes actually showed very big effects on stroke," including the SUSTAIN-6 trialopens in a new tab or window of semaglutide in type 2 diabetes (HR 0.61, 95% CI 0.38-0.99, P=0.04).

"Whether or not that's real, or just a play of chance in these patients, we don't know," he said about the SELECT findings, adding that there was a "strong trend" in the reduction in cardiovascular death and in overall mortality, "so all things were moving in approximately the same direction."

Less is known about cardiovascular outcomes for tirzepatide as a weight-loss agent (Zepbound), which has a slightly different mechanism of action from semaglutide, as it's a combined GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) agonist.

While a cardiovascular outcomes studyopens in a new tab or window for tirzepatide is ongoing, a pre-specified cardiovascular meta-analysisopens in a new tab or window of seven randomized controlled trials from the SURPASS program focused on patients with type 2 diabetes found a lower risk of a primary composite cardiovascular endpoint (cardiovascular death, myocardial infarction, stroke, and hospitalized unstable angina), but it wasn't significant.

Despite questions about the true benefit of GLP-1 agonists in cardiovascular disease, Medicare will now payopens in a new tab or window for semaglutide in adults with cardiovascular disease and either obesity or overweight, an indication the FDA approved in Marchopens in a new tab or window. (The federal insurer is still not allowed to cover weight loss drugs for shedding pounds, but that could change in part if Congress passes the Treat and Reduce Obesity Actopens in a new tab or window.)

At a cost of more than $1,000 per month, some question whether the potential cardiovascular benefit is worth it -- not just because of the small absolute risk reduction in the SELECT trial, but also because patients don't stay on the drug, for both tolerance and cost reasons, Zuckerman said.

In that trial, people in the semaglutide group were twice as likely to drop out as those in the placebo group (about 17% vs 8%).

"Everyone picked up on the 20% relative reduction [in cardiovascular risk], but no one picked up on the 100% increase in the dropout rate," Phizackerley told MedPage Today. "If you were on the drug, you were twice as likely, if I'm going to use a relative risk, to stop taking the drug and drop out of the trial."

In this case, the number needed to harm would be 12, Phizackerley added. "For every 12 people treated, one would drop out," he said. "It was part of the story that was missed."

Zuckerman said other researchopens in a new tab or window has shown that about 44% of people stopped taking semaglutide within 6 months, and 60% had dropped it by the end of a year. While that study is a retrospective claims analysis, it may better reflect real-world use than a clinical trial, she said.

"Talking about these [drugs] as a way to make people healthier, therefore, Medicare and Medicaid should pay for it, is very misleading, because the vast majority of people don't take it long enough to benefit," Zuckerman said. "If you've got millions of people trying it for a few months, that's an enormous amount of money with zero benefit."

Lincoff acknowledged that the costs of treating patients with cardiovascular disease and obesity "can appear staggering," even if patients only stay on the drug for 4 or 6 months.

"We're having this discussion because these drugs are so expensive," he said, noting that people frequently abandon other cardiovascular drugs, like statins, but that's less controversial because they cost far less.

"We know that the natural evolution of this is that more drugs will come on the market and prices will change," Lincoff added. "But that doesn't change the fact that we have to grapple with it now."

Indeed, rates of overweight and obesity are "exploding around the world, despite 20 or 30 years or more of people trying to address the root causes," Lincoff said. "The traditional approaches of diet, exercise, counseling, whatever we've been doing, aren't working."

"I think we all worry about medicalizing a large proportion of the world's population," Lincoff said. "But the reality is that overweight and obesity are associated with increased risk -- not just cardiovascular risk, but a variety of other metabolic and orthopedic [conditions] and cancer. ... No one would suggest [semaglutide] takes the place of public health efforts to help control the explosion. But as it stands now, we don't have other good therapies."

https://www.medpagetoday.com/special-reports/exclusives/111335

Harris' Cal. Healthcare Battles Signal Fights Ahead for Hospitals if She Wins

 When Kamala Harris was California's top prosecutor, she was concerned that mergers among hospitals, physician groups, and health insurers could thwart competition and lead to higher prices for patients. If she wins the presidency in November, she'll have a wide range of options to blunt monopolistic behavior nationwide.

The Democratic vice president could influence the Federal Trade Commission (FTC) and instruct the departments of Justice (DOJ) and HHS to prioritize enforcement of antitrust laws and channel resources accordingly. Already, the Biden administration has taken an aggressive stance against mergers and acquisitions. In his first year in office, President Joe Biden issued an executive orderopens in a new tab or window intended to intensify antitrust enforcement across multiple industries, including healthcare.

Under Biden, the FTC and DOJ have fought more mergersopens in a new tab or window than they have in decades, often targeting healthcare deals.

"What Harris could do is set the tone that she is going to continue this laser focus on competition and healthcare prices," said Katie Gudiksen, PhD, a senior health policy researcher at University of California College of the Law San Francisco.

The Harris campaign didn't respond to a request for comment.

For decades, the health industry has undergone consolidation despite government efforts to maintain competition. When health systems expand, adding hospitals and doctor practices to their portfolios, they often gain a large enough share of regional healthcare resources to command higher prices from insurers. That results in higher premiumsopens in a new tab or window and other healthcare costs for consumers and employers, according to numerous studies.

Health insurers have also consolidated in recent decades, leaving only a handful controlling most markets.

Healthcare analysts say it's possible for Harris to slow the momentum of consolidation by blocking future mergers that could lead to higher prices and lower-quality care. But many of them agree the consolidation that has already taken place is an inescapable feature of the U.S. healthcare landscape.

"It's hard to unscramble the eggs," said Bob Town, PhD, an economics professor at the University of Texas.

There were nearly 1,600 hospital mergers in the U.S. from 1998 to 2017 and 428 hospital and health system mergers from 2018 to 2023, according to a KFF studyopens in a new tab or window. The percentage of community hospitals that belong to a larger health system rose from 53 in 2005 to 68 in 2022. And in another sign of market concentration, as of January, well over three-quarters of the nation's physicians were employed by hospitals or corporations, according to a report produced by Avalere Healthopens in a new tab or window.

Despite former President Donald Trump's hostility to regulation as a candidate, his administration was active on antitrust efforts -- though it did allow one of the largest healthcare mergers in U.S. history, between drugstore chain CVS Health and the insurer Aetna. Overall, Trump's Justice Department was more aggressive on mergersopens in a new tab or window than past Republican administrations.

Harris, as California's attorney general from 2011 to 2017, jump-started healthcare investigations and enforcement.

"She pushed back against anticompetitive pricing," said Rob Bonta, California's current attorney general, who is a Democrat.

One of Harris' most impactful decisions was a 2012 investigationopens in a new tab or window into whether consolidation among hospitals and physician practices gave health systems the clout to demand higher prices. That probe bore fruit 6 years later after Harris' successor, Xavier Becerra, filed a landmark lawsuitopens in a new tab or window against Sutter Health, the giant Northern California hospital operator, for anticompetitive behavior. Sutter settled with the stateopens in a new tab or window for $575 million.

In 2014, Harris was among 16 state attorneys generalopens in a new tab or window who joined the FTC in a lawsuit to dismantle a merger between one of Idaho's largest hospital chains and its biggest physician group. In 2016, Harris joinedopens in a new tab or window the U.S. Department of Justice and 11 other states in a successful lawsuitopens in a new tab or window to block a proposed $48.3 billion merger between two of the nation's largest health insurers, Cigna and Anthem.

Attempts to give the state attorney general the power to nix or impose conditions on a wide range of healthcare mergers have been fiercely, and successfully, opposed by California's hospital industryopens in a new tab or window. Most recently, the hospital industry persuaded state lawmakers to exempt for-profit hospitals from pending legislationopens in a new tab or window that would subject private equity-backed healthcare transactions to review by the attorney general.

A spokesperson for the California Hospital Association declined to comment.

As attorney general of California, Harris' work was eased by the state's deep-blue political hue. Were she to be elected president, she could face a less hospitable political environment, especially if Republicans control one or both houses of Congress. In addition, she could face opposition from powerful healthcare lobbyists.

Though it often gets a bad rap, consolidation in healthcare also confers benefits. Many doctors choose to join large organizations because it relieves them of the administrative headaches and financial burdens of running their own practices. And being absorbed into a large health system can be a lifeline for financially troubled hospitals.

Still, a major reason health systems choose to expand through acquisition is to accumulate market clout so they can match consolidation among insurers and bargain with them for higher payments. It's an understandable reaction to the financial pressures hospitals are under, said James Robinson, PhD, MPH, a professor of health economics at the University of California Berkeley.

Robinson noted that hospitals are required to treat anyone who shows up at the emergency room, including uninsured people. Many hospitals have a large number of patients on Medicaid, which pays poorlyopens in a new tab or window. And in California, they face a series of regulatory requirements, including seismic retrofitting and nurse staffing minimums, that are expensive. "How are they going to pay for that?" Robinson said.

At the federal level, any effort to blunt anticompetitive mergers would depend in part on how aggressive the FTC is in pursuing the most egregious cases. FTC Chair Lina Khan has made the FTC more proactive in this regard.

Last year, the FTC and DOJ jointly issuedopens in a new tab or window new merger guidelines, which suggested the federal government would scrutinize deals more closely and take a broader view of which ones violate antitrust laws. In September, the FTC filed a lawsuitopens in a new tab or window against an anesthesiology group and its private equity backer, alleging they had engaged in anticompetitive practices in Texas to drive up prices.

In January, the agency sued to stop a $320 million hospital acquisitionopens in a new tab or window in North Carolina.

Still, many transactions don't come to the attention of the FTC because their value is below its $119.5 million reporting threshold. And even if it heard about more deals, "it is very underresourced and needing to be very selective in which mergers they challenge," said Paul Ginsburg, PhD, a professor of the practice of health policy at the University of Southern California's Sol Price School of Public Policy.

Khan's term ends in September 2024, and Harris, if elected, could try to reappoint her, though her ability to do so may depend on which party controls the Senate.

Harris could also promote regulations that discourage monopolistic behaviors such as all-or-nothing contractingopens in a new tab or window, in which large health systems refuse to do business with insurance companies unless they agree to include all their facilities in their networks, whether needed or not. That behavior was one of the core allegations in the Sutter case.

She could also seek policies at the HHS, which runs Medicare and Medicaid, that encourage competition.

Bonta, California's current attorney general, said that, while there are bad mergers, there are also good ones. "We approve them all the time," he said. "And we approve them with conditions that address cost and that address access and that address quality."

He expects Harris to bring similar concerns to the presidency if she wins.

https://www.medpagetoday.com/washington-watch/electioncoverage/111368

Microplastics Are Everywhere, but Are They Harming Us?

 Microplastics have been found in the ocean and the air, in our food and water. They have been found in a wide range of body tissues, including the heart, liver, kidneys, and even testicles.

But are they actually harming you?

Evidence suggests they might, but it's limited in scope. Some researchers are worried, but acknowledge there are lots of unanswered questions.

Marya Zlatnik, MD, an obstetrician at the University of California San Francisco who has studied environmental toxins and pregnancy, has seen studies raising concerns about microplastics' impact on the health of babies and adults.

But it's a young research field, and it's not something she generally discusses with patients.

"I'm not entirely sure what to say yet," Zlatnik said.

Here's a look at what's known so far:

What Are Microplastics?

Plastics are man-made materials -- many of them derived from oil or other petroleum products. They can break down into smaller particles, through exposure to heat and weather and even animal digestion.

Researchers have increasingly been interested in microplastics, which can be as wide as a pencil eraser or as small as a fraction of the width of a human hair. Nanoplastics, another area of study, are even smaller.

These miniscule plastics have been detected in air, water and soil, in milk, and in bottled and tap drinking water. They also have been found in a variety of foods, including salt, sugar, honey, rice, and seafood.

Are There Microplastics in You?

Most likely yes.

There is scientific debate about how much people inhale and ingest, and it can vary depending on what they eat and drink and where they live, researchers say.

Some Australian researchers, on behalf of the World Wildlife Fund, calculated in 2019 that many people each week consume roughly 5 g of plastic from common food and beverages -- the equivalent of a credit card. That estimate is not universally embraced by researchers, but is commonly mentioned in news articles.

Researchers are still trying to understand exposure levels, but study after study is finding signs of plastics in body tissues.

"Microplastics have been measured in pretty much all of the body tissues that have been evaluated," said Tracey Woodruff, PhD, MPH, a University of California San Francisco researcher. Scientists have even reported finding them in the penisopens in a new tab or window, in ovariesopens in a new tab or window, and in placentas.

Will Microplastics Hurt You?

That's still being sorted out.

A 2022 World Health Organization reportopens in a new tab or window concluded there was no clear risk to human health, based on the available evidence.

There's also not an obvious signal of widespread public health impact, at least in terms of mortality. Cancer, heart disease, and stroke death rates have been falling, not rising.

But researchers only started measuring plastics in the human body -- and trying to assess the health effects -- in recent years. Some of that work is only coming to fruition now.

It makes sense that microplastics are harmful because they contain toxic chemicals, said Woodruff, who was part of a team that reviewed nearly 2,000 studies about microplastics at the request of California legislators. It may be, for example, that microplastics play a role in rising occurrences of some cancers in younger people, she said.

Available information indicates plastics can spark inflammation and cause other problematic changes in the body that can, for example, raise the risk of heart attack and stroke.

A small studyopens in a new tab or window in the New England Journal of Medicine earlier this year suggested, but did not prove, that patients with evidence of plastics in their arteries were at greater risk of death from heart attacks and strokes. But an expert not involved in the research suggested the study may have overstated any effects.

"Even though there's a lot we still don't know about microplastic particles and the harm they cause to humans, the information that is available today is, in my mind, very concerning," said Philip Landrigan, MD, of Boston College.

What Can You Do About Microplastics?

There are ways to reduce potential microplastics exposure, researchers say.

Take your shoes off before you go in the house, to avoid tracking in plastics-laden dust (not to mention germs, dirt, and other debris) throughout your home.

Eat foods -- especially fresh fruits and vegetables -- that you prepare in the home.

Don't microwave a meal in a plastic tray, no matter what TV dinner instructions might say, Woodruff said.

And opt for reusable stainless steel or glass water bottles, rather than disposable plastic ones, she added.

Zlatnik, the obstetrician, noted that families with limited incomes may have bigger things to worry about.

"If someone is worried about where their next meal is going to come from, I'm not going to give them advice to keep their leftovers in glass containers and to not microwave in plastic," she said.

https://www.medpagetoday.com/publichealthpolicy/environmentalhealth/111367

'Millions of Americans Use Potentially Hepatotoxic Botanical Products'

 An estimated 15.6 million adults in the U.S. reported use of at least one potentially hepatotoxic botanical supplement within the past 30 days, according to a survey study using nationally representative data.

In the cohort of over 9,600 participants in the National Health and Nutrition Examination Survey (NHANES), the overall prevalence of herbal and dietary supplement use was 57.6%, and the prevalence of using six potentially hepatotoxic botanicals of interest was 4.7%, reported Alisa Likhitsup, MD, MPH, of the University of Michigan in Ann Arbor, and colleagues in JAMA Network Openopens in a new tab or window.

The six potentially hepatotoxic botanicals in question were turmeric/curcumin (n=236), green tea extract (n=92), ashwagandha (n=28), Garcinia cambogia (n=20), red yeast rice (n=20), and black cohosh (n=19).

The estimate of 15.6 million is comparable to the estimated numbers of U.S. patients who are prescribed the potentially hepatotoxic medications simvastatin and nonsteroidal anti-inflammatory drugs, Likhitsup and team noted.

However, "the safety and efficacy of herbal and dietary supplements are not well established due to the lack of regulatory requirements by the [FDA] for human pharmacokinetic or prospective clinical trials prior to marketing," they added.

They pointed out that the number of cases of liver injuries due to herbal and dietary supplements jumped from 7% in 2004-2005 to 20% in 2013-2014, according to the Drug-Induced Liver Injury Networkopens in a new tab or window, a multicenter, observational program that collects data from U.S. patients with hepatotoxic effects attributed to various drugs and herbal and dietary supplements. A similar increase in liver injuries due to herbal and dietary supplements was observed by the Acute Liver Failure Study Groupopens in a new tab or window: 12.4% in 1998-2007 to 21.1% in 2007-2015.

"In light of the lack of regulatory oversight on the manufacturing and testing of botanical products, it is recommended that clinicians obtain a full medication and herbal and dietary supplement use history when evaluating patients with unexplained symptoms or liver test abnormalities," Likhitsup and colleagues concluded.

Of note, the most common reasons for using the botanicals among the survey respondents were to "improve or maintain health or to prevent health problems or boost immunity."

Maya Balakrishnan, MD, MPH, of Baylor College of Medicine in Houston, told MedPage Today that "most people are using the products intentionally to treat or to prevent a specific medical condition, most commonly osteoarthritis, fatigue, or hot flashes associated with menopause."

"I was also struck that most users are learning about and making the decision to take these botanicals on their own, without input from their physicians," noted Balakrishnan, who was not involved in the study.

"It is important for the public to know that most botanicals taken as supplements are packaged at much higher concentrations than found in their natural forms," she said, adding that clinicians should discuss botanical products and engage in conversations about their pros and cons with patients.

"This means inquiring about herbal, botanical, and supplement use, just as we review all other medications," she said.

For this study, Likhitsup and team used nationally representative data from NHANES, a national cross-sectional survey of the U.S. population, from January 2017 to March 2020. They also used information from the 2020 U.S. Census for population estimates.

Of the 9,685 adults enrolled in this cohort, mean age was 47.5, 51.8% were women, 62.2% were white, 11.5% were Black, and 16.3% were Mexican or non-Mexican Hispanic.

Those who used the six herbal and dietary supplements were significantly older (adjusted OR 2.36, 95% CI 1.06-5.25, P=0.04 for ages 40-59 and aOR 3.96, 95% CI 1.93-8.11, P=0.001 for ages ≥60), had a higher educational level (aOR 4.78, 95% CI 2.62-8.75, P<0.001), and were more likely to have arthritis (aOR 2.27, 95% CI 1.62-3.29, P<0.001) compared with those who did not use them.

Of the turmeric users, 26.8% said they consumed these products for joint health or arthritis, and 27.2% of green tea users said they were trying to improve their energy level. Seventy percent of Garcinia cambogia users reported that they were trying to lose weight, while 84.2% of black cohosh users said they were taking these products to treat hot flashes. The most commonly stated reason to consume red yeast rice was for heart health (90%).

Disclosures

Likhitsup reported no conflicts of interest.

Co-authors reported relationships with Kowa, AstraZeneca, Ipsen, Takeda, and Kezar Life Sciences.

Primary Source

JAMA Network Open

Source Reference: opens in a new tab or windowLikhitsup A, et al "Estimated exposure to 6 potentially hepatotoxic botanicals in US adults" JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.25822.

https://www.medpagetoday.com/gastroenterology/generalhepatology/111370

PA Group Asks AMA for Policy Truce

 The American Academy of Physician Associates (AAPA) released an open letter

opens in a new tab or window to the president of the American Medical Association (AMA) last week, calling for an end to the AMA's opposition of legislative measures and public policies that would allow PAs to have broader clinical practice rights.

"We urge the AMA to cease its divisive campaign against PAs and other healthcare providers and engage in constructive dialogue about how to strengthen our healthcare workforce, promote health equity, and address the evolving needs of our patients," wrote AAPA President Jason Prevelige, DMSc, MBA, PA-C, and CEO Lisa Gables, CPA, in the letter to AMA President Bruce Scott, MD.

"Collaboration, rather than competition, must guide our efforts to build a robust and effective healthcare system," they noted. "We extend our hand in collaboration and urge the AMA to join us in this critical endeavor."

However, the AMA declined to comment on the letter at this time.

"Their opposition to us at the state level, [and] the whole background of their campaign is based on false information," Gables told MedPage Today during a phone interview with a press person present. "We think patients deserve better."

The AMA has spent a lot of time and money to fight the AAPA in legislative efforts to change state practice laws for PAs, she said. While the AMA claims those legislative efforts amount to scope expansion, Gables said efforts are focused on breaking down practice barriers to increase overall access to care, especially in states with a shortage of healthcare professionals.

In their letter, Prevelige and Gables noted that there are 178,000 PAs who deliver "high-quality, patient-centered care across America," and play "an indispensable role in addressing healthcare disparities and ensuring equitable access to care."

They also claimed that the AMA has been "spreading misinformation and using fear-mongering tactics" to discredit the care provided by PAs in clinical practice. These tactics only serve the AMA's "dangerous agenda above the interest of patients," they added.

To illustrate this point, Prevelige and Gables pointed out that the AMA obstructed roughly 100 bills in 2023 that were "aimed at expanding access to care and modernizing healthcare laws."

They further explained that claims made about PAs, including allegations of "scope creep," are misleading and damaging. In refuting these claims, they cited a medical malpractice payment report published in the Journal of Medical Regulationopens in a new tab or window, which showed that states with more permissive PA practice policies did not have an increase in malpractice payments.

Prevelige and Gables also wrote that the AMA's "clear pattern of opposing legislative measures and public policies" hinders progress in underserved communities, which have been hit hardest by the growing physician shortage.

Gables added that PAs can be part of the solution to those shortages, if the AMA would work with the AAPA to address legislative barriers to practices for the profession.

"We have this massive supply and demand problem going on," Gables said. "And [the AMA] fighting us at the legislative level and the state [level] is exacerbating that problem."

https://www.medpagetoday.com/special-reports/features/111374

'US Power Producers Binge On Ultra-Cheap Gas'

 By John Kemp, Senior Energy Analyst, Reuters

U.S. electricity generators consumed a record amount of gas in the first four months of the year as prices slumped to the lowest level in real terms for more than half a century. Ultra-low prices encouraged more power production from some of the least-efficient single-cycle gas and steam turbines at the expense of coal.

But record combustion by generators made little impact on swollen gas inventories amid continued growth in gas production and sluggish exports.

Generators produced a record 1,334 billion kilowatt-hours (kWh) between January and April, according to the latest data from the U.S. Energy Information Administration.

Generation was up by 47 billion kWh (4%) compared with the same period a year earlier and by about the same compared with the prior 10-year average.

Two-thirds of the extra output came from gas-fired units (30 billion kWh) with most of the rest from solar farms (13 billion kWh).

As a result, generators boosted their gas consumption by 213 billion cubic feet (6%) compared with a year earlier to a record 3,941 bcf.

BLOATED STOCKS

Despite record power burn, gas stocks remained abnormally high, with inventories 671 bcf (+36% or +1.46 standard deviations) above the prior 10-year seasonal average at the end of April.

The surplus had swelled from 261 bcf (+14% or +0.58 standard deviations) a year previously thanks to a mild winter in 2023/24.

By April, the actual cost of gas received by electricity generators had slumped to an average of just $2.05 per million British thermal units.

After adjusting for inflation, power generators' gas acquisition costs had fallen to the lowest level on record in data going back to 1973.

MAXIMIZING RUNS

Exceptionally cheap fuel encouraged gas-fired generators to run their units for more hours, including the least-efficient, most fuel-hungry plants that normally operate mostly during the summer and winter peak periods.

Single-cycle gas turbines and gas-fuelled steam generators are much less efficient than combined-cycle units and usually operate only in peak periods of electricity demand.

With fuel so cheap, however, gas turbines operated with a record seasonal capacity factor of more than 14% in April 2024 up from 12% in April 2023 and 10% in April 2022.

Gas-fired steam turbines generated more than 15% of their maximum theoretical output, up from 13% in 2023 and 10% in 2022, and the highest for more than a decade.

PERSISTENT SURPLUS

Record gas-fired generation has helped prevent surplus inventories swelling even further but has not yet reduced bloated stocks to more normal levels.

Recurrent problems with the operation of the Freeport LNG export terminal have also delayed the normalisation of stocks.

Gas generation spiked to an all-time record early in July 2024, owing to high temperatures across much of the Lower 48 states, slow wind speeds, and the impact of low gas prices themselves.

Even so, inventories were still the second-highest on record for the time of year on July 19 and 479 bcf (+17% or +1.35 standard deviations) above the prior ten-year seasonal average.

After bouncing a little in May and June, futures prices have slumped in July towards the trough earlier this year, returning near to multi-decade lows in real terms.

Such extraordinarily low prices are sending the strongest possible signal to gas producers on the need to cut drilling and output even further after an initial round of cuts announced in February.

They are also sending a signal to generators to offer their units to the grid as much as possible, with gas generation records likely to be smashed this summer.

Prices will remain lower for longer until the inventories start to converge with the long-term seasonal average, most likely by the end of winter 2024/25.

https://www.zerohedge.com/markets/us-power-producers-binge-ultra-cheap-gas