'US Public Health Agency got it wrong. The cost of their errors is staggering'

 U.S. Agency for Toxic Substances and Disease Registry was established to safeguard the public through the assessment of health risks in America's worst polluted areas. The U.S. Agency for Toxic Substances and Disease Registry (ATSDR) was created to protect the public by assessing health risks at America's most polluted sites.

investigation

It is found to regularly ignore and downplay neighbors' concerns about their health in its reports, and employs practices that even the review board of this company has called "virtually worthless" and "not good."

A review of hundreds agency reports has revealed that in 68% of findings it either declared the communities to be safe or made no determination. At least 20 incidents were found in which the agency disregarded health concerns later confirmed as hazardous by other government researchers or the ATSDR.

Patrick Breysse who headed the agency between 2014 and 2022 said that this is a relatively small number of mistakes.

But the mistakes can be devastating. The ATSDR was responsible for exposing children to high levels of lead, and denying medical benefits to up to one million servicemen and their families after they drank toxic water.

This story was not able to get a response from the ATSDR.

The polluters used faulty agency research to avoid lawsuits, to deny compensation to victims, to criticize opponents and to argue for a delay, reduction or cancellation of cleanups. These are a few examples.

The coal company used an erroneous ATSDR to guide state regulators

Over the years, industrial sites in Birmingham's north have released lead, arsenic, and other pollutants into nearby neighborhoods. The Environmental Protection Agency (EPA) proposed in 2014 to add the area on a list that included the most toxic areas of the United States. Drummond Co., a coal company based in Alabama was one of those affected. Drummond Co., a coal company based in Alabama, was one of the companies affected.

Drummond's attorneys wrote a letter to oppose the recommendation. This letter highlighted a study of industrial areas in the area surrounding Drummond that showed no health risks.

It was then circulated amongst state and federal officials. It was sent by the company to the Governor's Office, who then passed it on to officials from the Alabama Department of Environmental Management. The EPA received it as theirs. According to court documents, the same Drummond attorneys gave state regulators talking point to be used at a state hearing in 2015 about the EPA proposal for the site.

Lance LaFleur was the director at that time. He followed the advice of attorneys while also addressing the health advocate's concerns. LaFleur stated that "we are not prepared to guess what the ATSDR will come up with." LaFleur has not responded to an earlier request for comments.

Charlie Powell, a health activist in the area, stated that the ATSDR's report had angered a majority Black community, which has 20,000 people living near the site. According to the Superfund Center at University of Alabama in Birmingham, the community suffers from high rates of chronic respiratory disease (COPD) and other conditions linked with industrial pollution.

After the report showed that residents yards had dangerously high arsenic levels and lead, two years later the ATSDR reversed its decision. In the new report, it was found that soil contamination in yards close to the site increased cancer risk and lead poisoning for residents. Reports highlighted the dangers to children who are playing in yards.

Drummond won by that time. The neighborhood around the plant of Drummond is entitled to federal funding for the removal of contaminated soil. However, the EPA retracted a proposal which would have held Drummond responsible in part for the cost.

According to the EPA website, it is still negotiating with businesses in order to recover costs for cleanup. The agency stated that protecting the public's health was "mission-critical" in an email statement.

Drummond responded via email to inquiries about the company's actions. The comments were based upon the ATSDR 2013 findings that "soils in the vicinity of the site, with few exceptions did not pose a health hazard for the public." Four years later the corrected ATSDR reports was released.

ATSDR must revisit Marine Base Report after Congressional investigation

According to internal emails that were previously not reported, an environmentalist working for a federal agency offered the opportunity to those who had contaminated the water to change the report.

For years, the Navy and Marines have maintained that residents and workers of Camp Lejeune Marine Corps Base near Jacksonville in North Carolina were not poisoned from drinking chemically-tainted water. Richard Clapp, an epidemiologist, said that a finding of non-hazardous health effects by the federal agency ATSDR would help to clear them from responsibility. Clapp, a former director at Massachusetts Cancer Registry who worked alongside a group former Camp Lejeune workers and residents to promote strong health studies on the base. Clapp stated that any finding of harm caused by water could be detrimental to the reputation of the Navy or Marines, and cost the federal governments billions through compensation claims.

According to a June 6, 1997 letter from Carole Hossom of the ATSDR to Camp Lejeune’s Environmental Management Department, two months prior to the publication of the report by the ATSDR, Hossom invited Marines and Navy to suggest changes "preferably over the phone." According to a Navy internal memo dated July 1997, after the calls the ATSDR "substantially" changed the report. It does not specify the changes, but it notes that at that time the Navy had concerns that the ATSDR draft report relied upon incomplete or inaccurate data. The Marine Corps technically belongs to the Navy.

The was released in August 1997 and dismissed concerns about adult health. It also failed to mention that fuel benzene was found in drinking water, which is a carcinogen. unable to find out why the ATSDR did not consider benzene or what the Navy had discussed.

The agency. According to a report from the 2010 Congressional session, an agency official told Congress that it had lost a file containing supporting documents. Hossom didn't respond to comments.

The ATSDR report was a great help to the leadership of both the Navy and Marine Corps. The report of the agency was used by the Navy and Marine Corps to refute claims that the water contamination caused health issues. The Department of Veterans Affairs refused to pay medical benefits for ex-servicemen who claimed that the water caused them illness, without the ATSDR finding harm.

Jerry Ensminger is a retired Marine and Mike Partain was born at Camp Lejeune. They searched thousands of Navy records and Environmental Protection Agency files and discovered a report from 1984 that indicated benzene in the drinking water on base. In 2009, after criticism by Congress, the news media reported on this story and admitted that they had missed the contamination of drinking water with benzene.

The ATSDR has agreed to review Camp Lejeune under pressure from Congress. North Carolina Senators Richard Burr & Kay Hagan block two Navy senior appointments until Navy agrees to pay $40M for cleanup.

In 2014, the ATSDR published a report that linked the contaminated water in Camp Lejeune with increased mortality rates, cancer, and other diseases such as Parkinson's among those who lived and/or worked on the Marine base.

According to a Navy spokesperson, the Navy has been working on addressing concerns about past exposure to drinking water contaminated at Camp Lejeune. This includes working with federal agencies conducting health studies.

Terrence Hayes, VA's Press Secretary via email, said that the VA did not have a policy of using the 1997 ATSDR flawed report as a basis to deny medical claims for veterans. Hayes stated that the agency continues to learn more about toxic substances and has, as a result, "dramatically increased health benefits and care for Veterans who have been exposed"

Based on discussions with the ATSDR in 2016, the VA decided to offer free medical care to Camp Lejeune Veterans who had one of the eight conditions that were linked to the contaminated drinking water. These included leukemia and various cancers. Families of veterans were reimbursed for medical expenses not covered by insurance.

The ATSDR declined to answer questions in this article. Patrick Breysse said that the military treated ATSDR like a contractor, often putting pressure on the agency. He claimed that the ATSDR had done excellent work, and found serious health issues at the Marine Base.

Denita McCall was diagnosed in 1997 with parathyroid carcinoma, around the time that the agency released its flawed report.

In an email sent to the ATSDR, she said, "I believe that my diagnosis was delayed because doctors from the VA relied upon the ATSDR Public Health Assessment of 1997." The VA Administration denied my benefits claim citing your 1997 Public Health Assessment.

McCall passed away in July 2009, just three months after the ATSDR acknowledged that its 1997 report had been wrong.

70 Families relocated 16 years after ATSDR declared them safe

Since decades, dust clouds have been rising from an industrial facility owned by Norlite in Cohoes (New York), a manufacturer of construction materials. The dust clogged air conditioners and coated homes. Norlite made 12 residents sick, according to a survey.

The ATSDR was contacted for assistance. Local health advocates wrote to the agency in 2003, saying that 14 houses within one mile of the facility had people with cancer, bronchitis or skin rashes. They also said they were suffering from sinus issues, emphysema, and emphysema. Residents had hoped that the agency would urge state and local authorities to order the incinerator at the site, which burns hazardous waste, to cut down on emissions.

In 2005, the ATSDR released a report that concluded there was no damage to the local community. This report was used by Norlite and the former Cohoes mayor John McDonald to dismiss health concerns raised by neighbors. McDonald said that he initially believed ATSDR’s assessment but now believes the agency should come back to Cohoes and do further research.

The ATSDR report was not accepted by the neighbors of Norlite, however it stopped the local effort to get Norlite to reduce emissions. Citizens Halting Risks of Norlite’s Industrial Contaminants, a group that led this effort, has disbanded after the ATSDR announced Norlite to be safe.

Kate Tarbay said, "With this report, we wondered what we should do and where we could go from here," as she co-led CHRONIC, in 2005. We're not rich. "We didn't employ chemists."

In a letter sent to a local paper in 2021, Jeff Beswick wrote that Norlite was not a threat to health. In the letter, Jeff Beswick referred to the ATSDR report that concluded there were no concerns about the health of the community. Beswick has not responded to any recent requests for comments.

David Walker from Columbia University, a geologist semi-retired in 2021 and 16 years after ATSDR published its report decided to examine dust coming from the Norlite plant. Walker, who grew up just two miles away from Norlite, was eager to find out what the microscope revealed. The incinerator particles included superheated stones, fragments of silica and jagged pieces of stone that could tear people's lung. The ATSDR had not conducted an analysis of this kind.

Walker's findings prompted the New York Attorney general and Department of Environmental Conservation to act a year later. In the suit, it was alleged that the company failed to maintain dust control and had violated past laws involving metals and chemicals, such as chromium, arsenic, and dioxins.

Tradebe contests the lawsuit. The company responded to New York's lawsuit by stating that the state relied on standards of health in other states, not New York. Rich Bamberger said that the Norlite plant is currently closed while Tradebe inspects, repairs, and evaluates its operation.

Bamberger stated that state air monitors also recorded dust from other sources, including lawnmowers. Norlite's internal air monitoring found that the dust coming from Norlite "

"The community is not negatively affected by the pollution."

A study from the New York Department of Health in 2023, which did not attribute illnesses to Norlite's plant, was also mentioned by the company. This study mentions an elevated rate of lung cancer in the area, but is not conclusive as to the reason.

The Cohoes Housing Authority has announced that it will relocate 70 families in August 2022 from an adjacent public housing complex. Mark Pascal, the chairman of Cohoes Housing Authority said that he was worried about how Norlite emissions could harm families who lived in this complex.

Pascal: "We couldn't believe that this would change. We had to remove those people."

Bamberger said the Tradebe spokesperson that Norlite began operations after the complex of public housing was constructed and there are no signs that residents were in any danger.

Boeing cites disputed ATSDR Report to counter-push for stricter cleaning

After learning in 1959 that a nuclear experiment had partly melted, the neighbors of an ex-rocket testing and research facility north of Los Angeles demanded health studies. The Santa Susana Field Lab attracted little attention from the public until 1979 when University of California Los Angeles (UCLA) students began to dig into its history.

Boeing, the aerospace giant, bought this property in 1996. Scientific studies were published shortly after.

Santa Susana laboratory workers had a higher risk of death from cancers such as lung, lymph, and blood. Members of the community wanted to find out if they too were at risk.

In response to California legislators, the ATSDR sent a team in Southern California during fall 1999. The team's task was to assess whether there was enough data to evaluate the potential impact of the laboratory on health. More than 250 residents of suburban Los Angeles expressed their concerns to the team as they toured site.

It was recommended by the team that further research be conducted to determine if the Santa Susana site is contributing to the cancer rates and other problems of health in the community. The team concluded that, despite the absence of this information, Santa Susana was not a threat to the community.

Boeing has always been adamant about its safety. Cleanup of the wreckage is the responsibility of the company along with NASA and the Department of Energy.

Boeing's spokesperson, quoted by the Associated Press in a report on the ATSDR Report from November 1999: "It offers reassurance for the community there is no evidence that Santa Susana Field Lab activities are a threat to health."

Advocates and legislators pressed for independent studies of health. ATSDR funded the study, while an independent contractor recruited researchers.

Scientists began to release their findings in 2006.

UCLA Researchers

People living in the vicinity of the former laboratory could have a chronic exposure to contaminants. Lead and arsenic could pose a threat to children in the neighborhood south of this site. Children in a neighborhood just south of the site could be at risk from lead and arsenic.

Researchers at the University of Michigan found that people who lived within two miles of a lab had higher rates of cancers such as thyroid, bladder, and blood than those farther away.

Burt Cooper who worked on the ATSDR team in 1999 said he was not surprised that the ATSDR preliminary studies came to different conclusions. Cooper stated that "the science isn't exact."

Boeing has continued to cite the 1999 ATSDR report. Boeing used its earlier study to contest the UCLA 2006 report. Boeing questioned the UCLA study's use of "essentially" the same information and the ATSDR, but how they "reached different conclusions," as per a

Letter

The company sent the UCLA author's study.

A group of industry advocates cited the ATSDR report from 1999 in 2011 to refute the claims made by an environmental group that a cluster thyroid and bladder tumors surrounded the old lab.

Boeing also referenced the 1999 report when answering questions about a

Story about Santa Susana

In 2022, and an email sent to a health official from the county who had spoken at a 2023 public meeting about the importance of cleaning up the area.

Boeing stated in a press release for this article that, taken together, numerous studies "does not support any linkage between cancer incidences and previous operations at the Santa Susana Field Laboratory."

Questions about Boeing or the Santa Susana Lab were not answered by ATSDR.

https://www.marinelink.com/blogs/blog/the-us-public-health-agency-got-it-wrong-the-cost-of-their-101561

Bristol Myers cited by FDA for misleading claims on Krazati website

 FDA issues untitled letter to Bristol Myers Squibb over misleading claims on cancer drug website for cancer drug Krazati.

https://seekingalpha.com/news/4136316-bristol-myers-cited-fda-misleading-claims-krazati-website

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Cancer Screening Costs Over $43B a Year in US — Colorectal cancer screening 64%

 The cost of initial cancer screening in the U.S. was estimated to be over $43 billion in 2021, which was less than the reported annual cost of cancer treatment in the first year after diagnosis, according to a modeling study.

Using national healthcare survey and cost resources data, the total healthcare system costs for initial breast, cervical, colorectal, lung, and prostate cancer screening were estimated at $43.2 billion in 2021, reported Michael T. Halpern, MD, PhD, of the National Cancer Institute, and colleagues.

Of note, colorectal cancer screening accounted for 63.6% of the total amount, at $27.5 billion, with screening colonoscopy representing about 55% of the total, they noted in the Annals of Internal Medicineopens in a new tab or window.

Patients with private insurance accounted for more than 88% of all screening costs, while Medicare beneficiaries accounted for 8.5%, and Medicaid beneficiaries, those with coverage from another government program, and uninsured patients accounted for 3.2%.

"The annual cost of cancer screening represents a notable portion of overall U.S. healthcare system costs related to cancer," Halpern and colleagues wrote. "Identification of these costs and the drivers for cancer screening costs are critical to help inform policy and develop programmatic priorities, particularly for enhancing access to recommended cancer screening services."

While the costs of screening are substantial, the authors noted that "it is important to consider the value resulting from cancer screening."

They pointed out that previous research supports the cost-effectiveness of screening for breast, cervical, colorectal, and lung cancer, and clinical trials have shown that recommended cancer screening can reduce cancer-specific mortality.

However, in an editorial accompanying the studyopens in a new tab or window, H. Gilbert Welch, MD, MPH, of Brigham and Women's Hospital in Boston, noted that whether the cost of screening is "$43 billion or $100 billion, questions remain about the value of the expenditure."

He argued that the effect of cancer screening "is so small that randomized trials must enroll tens of thousands of participants to reliably detect a change in cancer-specific mortality -- not all-cause mortality," adding that "exaggeration of benefits and minimization of harms cause real problems."

"Resources devoted to cancer screening would be better directed toward ensuring widespread access to effective cancer treatment," Gilbert wrote. "And addressing the social determinants of cancer risk -- smoking, obesity, poverty, and unhealthy living conditions -- would reduce death from multiple causes, not just cancer."

For this study, Halpern and team estimated the number of people screened for breast, cervical, colorectal, lung, and prostate cancer in the past year using data from the 2021 National Health Interview Survey. To estimate the total cost of cancer screening, they multiplied the number of people screened for those cancers and associated healthcare system costs by typical insurance cost per screen in 2021 dollars.

"For all screening tests, only medical care costs associated with the initial screening were included," they noted. "Due to limitations of available data, costs of follow-up imaging and procedures after initial abnormal or positive screening results were not included, although these are critical components of the screening process."

Halpern and colleagues determined that mammography (32.8 million) and cervical cancer screening (33.0 million) accounted for the largest total number of tests performed in 2021, while an estimated 22.3 million colorectal cancer screening tests were performed, mainly comprising fecal immunochemical testing (9.8 million) and colonoscopy (9.2 million). In addition, there were 8.3 million prostate-specific antigen tests performed, as well as 2.4 million lung screening tests.

Of the estimated cost of $43.2 billion:

• Colonoscopy was the largest component, accounting for an estimated $23.7 billion
• All other colorectal cancer screening tests combined accounted for an additional $3.8 billion
• Breast cancer screening accounted for $8.8 billion, cervical cancer screening for $5.5 billion, and prostate and lung cancer screening each cost an estimated $700 million

The authors also observed that the cost of cancer screening is dependent on facility costs, particularly in the cases of colonoscopy, sigmoidoscopy, CT colonography, and CT lung cancer screening, for which the facility costs are much higher than the physician costs.

"Policies that affect facility costs or sites where screening tests are done (hospital outpatient facilities vs ambulatory surgery centers) may have substantial effects on the cost of cancer screening," Halpern and colleagues wrote. "In addition, changes in rates of receipt of facility- versus home-based colorectal cancer screening tests could have substantial effects on cost estimates."

Disclosures

Halpern reported receiving funding to his institution for travel to the American Association for Cancer Research annual meeting, and being a chair of the American Public Health Association Cancer Forum.

Co-authors reported relationships with industry, government entities, and universities.

Welch reported receiving royalties from books, and honoraria for speaking at the University of Pennsylvania, University of Michigan, and University of Maryland.

Primary Source

Annals of Internal Medicine

Source Reference: opens in a new tab or windowHalpern MT, et al "The annual cost of cancer screening in the United States" Ann Intern Med 2024; DOI: 10.7326/M24-0375.

Secondary Source

Annals of Internal Medicine

Source Reference: opens in a new tab or windowWelch HG "Dollars and sense: The cost of cancer screening in the United States" Ann Intern Med 2024; DOI: 10.7326/M24-0887.

https://www.medpagetoday.com/hematologyoncology/othercancers/111379

'Intermittent Fasting May Improve Memory, Executive Function, Early Trial Suggests'

 Intermittent calorie restriction improved executive function and memory measures in cognitively intact older adults, an exploratory pilot study suggested.

The 8-week randomized clinical trialopens in a new tab or window of 40 overweight, cognitively normal older adults with insulin resistance examined the effect of two interventions -- a 5:2 intermittent fasting plan versus a "healthy living" diet based on portion control and calorie reduction guidelinesopens in a new tab or window from the U.S. Department of Agriculture -- on brain health. The 5:2 intermittent fasting group had 2 days of food intake of 480 calories/day (two meal replacement shakes), and 5 days of a healthy living diet.

Both interventions improved executive function and memory, with intermittent fasting showing better results on certain cognitive measures, said Dimitrios Kapogiannis, MD, of the National Institute on Aging (NIA) and the Johns Hopkins University School of Medicine in Baltimore, in a poster presented at the Alzheimer's Association International Conferenceopens in a new tab or window.

The findings also were published in Cell Metabolismopens in a new tab or window.

The study aimed to determine whether intermittent calorie restriction could lower insulin resistance, improve cognitive performance, brain metabolism and function, and normalize Alzheimer's-associated biomarkers in adults ages 55 to 70.

"Many people think that eating a healthy diet or following an intermittent fasting regimen are good ways to stave off cognitive decline during aging, but our study actually provided supporting evidence," Kapogiannis told MedPage Today.

"Our study lays the groundwork for larger clinical trials that will examine a variety of dietary interventions that will help people have good brain health and live healthier, longer lives," he said.

Previous studies have tied insulin metabolism with Alzheimer's riskopens in a new tab or window. Animal studies have suggested that insulin contributes to normal memory functionopens in a new tab or window and intermittent fasting may have benefitopens in a new tab or window in neurodegenerative diseases.

Excessive weight is implicated in peripheral insulin resistance and faster brain aging, Kapogiannis noted. In this study, both diets decreased BMI and waist conference, but results were better with intermittent fasting. The intermittent fasting group had markers suggesting increased ketogenesis and high compliance; the healthy living diet group did not.

At 8 weeks, the two diets had comparable effects in improving insulin signaling biomarkers in neuron-derived extracellular vesicles. Brain glucose on magnetic resonance spectroscopy was reduced with both diets, more so with intermittent fasting, the researchers noted. BrainAGE, an MRI measure of the pace of brain agingopens in a new tab or window, decreased with both diets.

Within the groups, executive function composite scores improved significantly with the intermittent fasting diet, but not with the healthy living diet. Learning and memory assessed with the long-delay cued recall task on the California Verbal Learning Testopens in a new tab or window also improved significantly with the intermittent fasting diet, while the healthy living diet showed no effect. Logical memory improved across both groups.

Actigraphy data showed that sedentary bouts decreased with intermittent fasting and increased with the healthy living diet.

Despite the decrease in brain aging measures, levels of amyloid-beta 42 and phosphorylated-tau (p-tau) 181 did not change in cerebrospinal fluid with either diet during the 8-week timeframe. Neurofilament light chain (NfL) increased in both groups.

Kapogiannis and co-authors enrolled 40 older adults with a BMI of 27.5 or higher from 2015 to 2022 at the NIA Clinical Research Unit. Twenty people in the intermittent fasting group and 20 in the healthy living diet group completed the study. Mean age of all participants was 63.2; 60% were women, 62.5% were Caucasian, and mean BMI was 34.4.

The trial duration was short and effects that may have occurred beyond week 8 may have been missed, the researchers said. The study had sufficient power to detect only large or moderate effects over time and between the two interventions. Cognitive performance improvements may partly reflect practice effects, they acknowledged.

Disclosures

The study was supported by NIA.

Kapogiannis reported no competing interests.

Primary Source

Alzheimer's Association International Conference

Source Reference: opens in a new tab or windowKapogiannis D, et al "Brain effects of 5:2 intermittent fasting and the healthy living diet in a randomized clinical trial" AAIC 2024; Poster Sunday-776.

https://www.medpagetoday.com/meetingcoverage/aaic/111363

One-Hour Nurse Visits That Let Insurers Collect $15 Billion From Medicare

 Millions of times each year, insurers send nurses into the homes of Medicare recipients to look them over, run tests and ask dozens of questions.

The nurses aren’t there to treat anyone. They are gathering new diagnoses that entitle private Medicare Advantage insurers to collect extra money from the federal government.

A Wall Street Journal investigation of insurer home visits found the companies pushed nurses to run screening tests and add unusual diagnoses, turning the roughly hourlong stops in patients’ homes into an extra $1,818 per visit, on average, from 2019 to 2021. Those payments added up to about $15 billion during that period, according to a Journal analysis of Medicare data.

Nurse practitioner Shelley Manke, who used to work for the HouseCalls unit of UnitedHealth Group, was part of that small army making home visits. She made a half-dozen or so visits a day, she said in a recent interview.

Part of her routine, she said, was to warm up the big toes of her patients and use a portable testing device to measure how well blood was flowing to their extremities. The insurers were checking for cases of peripheral artery disease, a narrowing of blood vessels. Each new case entitled them to collect an extra $2,500 or so a year at that time.

But Manke didn’t trust the device. She had tried it on herself and had gotten an array of results. When she and other nurses raised concerns with managers, she said, they were told the company believed that data supported the tests and that they needed to keep using the device.

“It made me cringe,” said Manke, who stopped working for HouseCalls in 2022. “I didn’t think the diagnosis should come from us, period, because I didn’t feel we had an adequate test.”

Other nurses interviewed by the Journal said many of the diagnoses that home-visit companies encouraged them to make wouldn’t otherwise have occurred to them, and in many cases were unwarranted.

Last month, the Journal reported that insurers received nearly $50 billion in payments from 2019 to 2021 due to diagnoses they added themselves for conditions that no doctor or hospital treated. Many of the insurer-driven diagnoses were outright wrong or highly questionable, the Journal found.

The diagnoses added after home visits accounted for about 30% of that total. More than 700,000 peripheral artery disease cases diagnosed only during home visits added $1.8 billion in payments during that period.

In the Medicare Advantage system—conceived as a lower-cost alternative to traditional Medicare—private insurers get paid a lump sum to provide health benefits to about half of the 67 million seniors and disabled people in the federal program. The payments go up when people have certain diseases, giving insurers an incentive to diagnose those conditions.

To find out how insurers use home visits to add diagnoses, the Journal interviewed nurses, patients, home-visit managers and industry executives and reviewed hundreds of pages of internal documents from home-visit companies. They described a system that used nurses, software and audits to generate diagnoses.

“They do the job with a purpose, and it pays off for the Medicare Advantage plans,” said Francois de Brantes, a former executive at Signify Health, a company that does home visits for insurers. “Identifying the diagnoses, that’s the job.”

Insurers, including UnitedHealth and CVS Health, owner of both Signify and Aetna, said the house calls help patients by, among other things, catching diseases early and making sure people are taking their medicine properly. The insurers said they relay home-visit findings to primary-care doctors.

Nurses who made visits said they felt they were helping some patients with advice about medications, performing needed tests and sometimes reporting health emergencies.

For UnitedHealth, the parent company of the largest Medicare insurer, each home visit was worth about $2,735 in extra Medicare payments during the three years covered by the data, the Journal analysis found. That’s nearly three times the average for all other Medicare Advantage insurers.

UnitedHealth’s chief physician, Dr. Wyatt Decker, attributed the disparity to what he said was UnitedHealth’s sicker patient population and its nurse practitioners being so effective at their jobs.

Sixty percent of UnitedHealth home visits generated at least one new revenue-producing diagnosis of a condition no doctor was treating, the analysis showed. Home visits by Humana, the No. 2 Medicare insurer, did so 39% of the time.

The Journal reviewed Medicare data covering the home visits under a research agreement with the federal government. The data doesn’t include patients’ names, but covers details of doctor visits, hospital stays, prescriptions and other care.

The home-visit industry has grown in recent years. UnitedHealth’s HouseCalls sent nurse practitioners to the homes of more than 2.7 million people last year. CVS’s Signify performed about 2.6 million home visits in 2023.

Step one is getting Medicare Advantage recipients to agree to a visit, especially patients whom insurers deem most likely to have undiagnosed conditions that would garner extra payments.

Two former managers who oversaw home visits for Humana, and a third who worked for both Humana and Signify, said insurers used an internal scoring system to identify prospects. Under the Medicare Advantage system, diagnoses have to be documented every year to trigger the extra payments, so people who had an earlier home visit that produced extra payments were particularly valued, the managers said.

Insurers also considered other factors, including how likely patients were to agree to a visit, some home-visit executives said.

Call centers bombard Medicare recipients with offers of home visits—in the case of Humana, autodialing them as many as 10 times, according to the former managers. Agents sometimes offered the Medicare recipients incentives such as Walmart gift cards.

A Humana spokesman said the company is committed to accurately identifying patients’ health conditions.

Dave Sherwood, a 68-year-old retired accounting executive in Williamsburg, Va., joined a UnitedHealth Medicare Advantage plan last year. Earlier this year, he got a flurry of calls from representatives of the insurer. When he finally answered one, he told them he didn’t want a home visit.

Months later, he started getting the calls again. Finally, he said, he picked one up and told the agent to stop calling.

When patients agree to a visit, home-visit companies send nurse practitioners or, less frequently, doctors or physician assistants. Some are full-time employees, others contractors who get paid around $100 or more per visit.

At each home, the nurses run through a series of questions covering medical history and medications, as well as doing a physical assessment and some basic testing.

In the HouseCalls system, nurses feed the information into a laptop or tablet, and the software suggests diagnoses. They automatically appear in a “diagnosis cart” on the side of the screen, according to training documents from last year that were viewed by the Journal.

Kristen Bell, a nurse practitioner who left HouseCalls in May after doing home visits for seven years, said the prompts were one way to prod nurses to add diagnoses. They also got regular training about conditions they could record, she said. She characterized the message from management as: “I’m not going to beat you up about this, but I want you to go in this direction.”

Secondary hyperaldosteronism, a condition in which levels of the hormone aldosterone rise, is rarely diagnosed in traditional Medicare patients. HouseCalls documents show that its software would suggest the diagnosis if a patient had a history of heart failure or cirrhosis, and either took certain drugs, such as diuretics, or had swelling due to fluid retention. Nurses weren’t required to confirm the diagnosis with a lab test.

“In a million years, I wouldn’t have come up with a diagnosis of secondary hyperaldosteronism,” said Bell, the former HouseCalls nurse.

UnitedHealth diagnosed it 246,000 times after home visits, leading to $450 million in payments over the three years of the Journal’s analysis. All other Medicare insurers combined collected $42 million from making that diagnosis after home visits.

“It is a vastly underdiagnosed condition that is super valuable to call out,” said UnitedHealth’s Decker.

To find more cases of peripheral artery disease, both HouseCalls and Signify used the testing device that nurse Manke said she distrusted, company manuals show.

The Food & Drug Administration said the device, called the QuantaFlo, “is not indicated for use as a stand-alone diagnostic device but as an adjunct to the diagnostic process.” Medical guidelines recommend against widespread screening for the condition.

A HouseCalls training manual advised nurses to diagnose peripheral artery disease based on results from the device. Managers at Signify told nurses they were required to use the device to test the patients of most insurers, a 2020 email shows.

Nurses diagnosed the condition after 568,000 home visits to UnitedHealth patients in the period analyzed by the Journal, adding up to nearly $1.4 billion in additional payments.

UnitedHealth’s Decker said the company expected clinicians to use their judgment in making peripheral artery disease diagnoses. A spokesman for Signify-owner CVS said medical providers decide when the test is appropriate on a case-by-case basis, and that the 2020 email was “not clearly worded” and didn’t reflect company policy.

Renae Cormier, chief financial officer of QuantaFlo maker Semler Scientific, said the device assesses risk for the disease.

Dr. Amy Chappell, a 73-year-old neurologist in Naples, Fla., was surprised when a nurse sent to her house earlier this year by UnitedHealth pulled out a QuantaFlo device. “She had no reason to think I had peripheral artery disease,” said Chappell, who says she has had no symptoms of the condition and is an avid runner and tennis player.

Chappell tested positive, although the nurse didn’t do any other standard exam to check for symptoms of the disease, Chappell said. Her primary-care doctor, Dr. Rebekah Bernard, said in an email that the diagnosis was inaccurate.

“From what I do know of the case, it’s an example of where we could have done better, and we need to own that,” said UnitedHealth’s Decker. The company later confirmed the diagnosis was a mistake and said it corrects such errors.

The Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress, has recommended that diagnoses from home visits shouldn’t count toward extra payments to Medicare insurers. The inspector general that oversees the Medicare agency has said it should reconsider the use of such diagnoses.

A spokeswoman for the Centers for Medicare and Medicaid Services, said the agency recently ramped up audits to verify diagnoses. The agency also is eliminating some diagnoses from those that qualify for extra payments, including peripheral artery disease.

Nathanael Lacaria, a nurse practitioner who did home visits in Colorado for CVS’s Signify unit in 2019 and 2020, said he didn’t feel it was appropriate to make definitive diagnoses based on one visit.

He said he didn’t realize insurers were submitting some of his tentative diagnoses to Medicare for billing purposes until a woman he had visited called the company to complain. “What’s this depression diagnosis in my chart?” she asked, according to Lacaria.

When he visited the woman, whose husband had died, Lacaria said, he recorded her answers to a standard depression screening tool, but he hadn’t actually diagnosed depression. “These visits were definitely used to jump to conclusions I wouldn’t have arrived at,” he said.

The CVS spokesman said Signify’s clinicians independently determine which conditions a patient has.

https://www.msn.com/en-us/money/companies/the-one-hour-nurse-visits-that-let-insurers-collect-15-billion-from-medicare/ar-AA1oekCQ