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Safe Under The ACA, Patients With Preexisting Conditions Now Fear Bias

Cheasanee Huette, a 20-year-old college student in Northern California, is worried. Two years ago, knowing she was protected by the Affordable Care Act’s guarantees of coverage for preexisting conditions, she decided to find out if she carried the same genetic mutation that eventually killed her mother.

She tested positive for one of the cancer-related mutations referred to as Lynch syndrome.

Now, as congressional Republicans advance proposals to overhaul the health law’s consumer protections, she frets that her future health insurance and employment options will be defined by that test — and that the mutation documented in her medical records and related screenings could rule out individual insurance coverage.

“Once I move to my own health care plan, I’m concerned about who is going to be willing to cover me and how much will that cost,” said Huette, who now has coverage under her father’s policy.

This KHN story also ran on NPR. It can be republished for free (details).

With the protections of Obamacare in place, physicians in recent years have urged patients to be screened for a variety of diseases and predisposition to illness, feeling confident it would not affect their future insurability. Being predisposed to an illness — such as carrying BRCA gene mutations associated with breast and ovarian cancer — does not mean a patient will come down with the illness. And it may allow them to take steps to prevent its development.

But the results recorded on patients’ charts could haunt them, experts say.

Dr. Kenneth Lin, associate professor of family medicine at Georgetown University School of Medicine in Washington, D.C., said that doctors might become reluctant to screen for widespread conditions such as prediabetes. The Centers for Disease Control and Prevention and the American Medical Association have urged primary care doctors to screen patients at risk for the condition with a blood test. It is one of the screening tests covered under the ACA at no-cost to those patients.

Lisa Salberg, chief executive officer of the Hypertrophic Cardiomyopathy Association, received a heart transplant in February. She was given her old heart back, frozen and in a plastic bag, so she could use it as a tool to teach people about hypertrophic cardiomyopathy. “We finally got to a place where people understood the value [of genetic testing],” she said. “Now, because we’re turning health care on its head, people are becoming more paranoid again.” (Sarah Vrablik/Speckle Photography)

If the changes being proposed by the GOP become law, Lin wrote in an email, “you can bet that I’ll be even more reluctant to test patients or record the diagnosis of prediabetes in their charts.” Such a notation might mean hundreds of dollars a month more in premiums for individuals in some states under the new bill, according to Lin.

It is a concern expressed by many patient-advocacy groups, who say members could be penalized or face the possible loss of the guarantee of coverage.

Huette is sharing her story publicly, since — come what may — her genetic mutation is already on the record — her medical record.

But genetics experts and patient advocates worry that people are already shying away from testing as the health law’s future becomes more uncertain. Their underlying concern: What if a positive result is added to their medical record, along with related screening and other preventive procedures that might further flag them to future insurers?

There have been “panicked expressions of concern,” said Lisa Schlager, vice president of community affairs and public policy at the nonprofit group Facing Our Risk of Cancer Empowered (FORCE). “Somebody who had cancer even saying, ‘I don’t want my daughter to test now.’ Or ‘I’m going to be dropped from my insurance because I have the BRCA mutation.’ There’s a lot of fear.”

These fears, which come in an era of accelerating genetics-driven medicine, rest upon whether a gap that was closed by the ACA will be reopened.

A law passed in 2008, the Genetic Information Nondiscrimination Act (GINA), bans health insurance discrimination if someone tests positive for a mutation. But that protection stops once the mutation causes “manifest disease,” jargon for a diagnosable health condition.

That means “when you become symptomatic,” although it’s not clear how severe the symptoms must be to constitute having the disease, said Mark Rothstein, an attorney and bioethicist at the University of Louisville School of Medicine in Kentucky, who has written extensively about GINA.

The ACA, passed two years later, closed that gap by barring health insurance discrimination based on preexisting conditions, Rothstein said.

On paper, the legislation unveiled by Senate Majority Leader Mitch McConnell (R-Ky.) last week wouldn’t permit higher rates to be charged to people with preexisting conditions, but health policy analysts said it could effectively exclude such patients from coverage because it allows states to offer insurance that carved out coverage for certain maladies. The bill that passed the House last month has a provision that allows states to waive preexisting protections for people buying their own insurance if they have a gap in coverage of 63 days or longer during the prior year.

A genetic predilection for a certain disease is “not black-and-white,” said Dr. Robert Green, a medical geneticist who directs the Genomes2People (G2P) Research Program at Brigham and Women’s Hospital and Harvard Medical School in Boston. Once someone tests positive for a mutation, the recommended screening to catch disease at an earlier point could over time identify clinical or laboratory data “that are suggestive, but not definitive,” he said.

Green was involved with a study published this week in the Annals of Internal Medicine, which found that even seemingly healthy individuals can carry — unbeknownst to them — mutations for rare diseases. Of the 50 healthy patients who agreed to undergo whole-genome sequencing, 11 tested positive. Subsequently, two of the 11 were found to have related symptoms; the rest showed no signs of disease.

Lisa Salberg, chief executive officer of the Hypertrophic Cardiomyopathy Association, has cardiomyopathy, a condition that can make the walls of the heart thick and rigid. She was recovering from a heart transplant earlier this year when her phone and social media accounts blew up over the preexisting waivers in the House bill. “We finally got to a place where people understood the value [of genetic testing],” she said. “Now, because we’re turning health care on its head, people are becoming more paranoid again.”

When members of a Lynch syndrome-related social media group were asked about their views on testing, with assurance of no direct attribution without prior consent, slightly more than two dozen men and women responded.

Nearly all of those who posted said they were delaying action for themselves or suggesting that family members, and particularly children, should hold off. (Lynch syndrome refers to a cluster of mutations that can boost the risk of a wide range of cancers, particularly colon and rectal.)

Huette was the only one who agreed to speak for attribution.

She had witnessed the impact that worries about insurance coverage before the ACA had on patients. Her mother, a veterinarian, had wanted to run her own practice but instead took a federal government job for the guarantee of health insurance. She died at age 57 in 2011 of pancreatic cancer, one of six malignancies she had been diagnosed with over the years.

Huette said she doesn’t regret getting tested. Without that result, Huette pointed out, how was she going to persuade a doctor to give her a colonoscopy in her 20s? She added: “Ultimately, my health is more important than my bank account.”

Drop In Sudden Cardiac Arrests Linked To Obamacare

If 22 million Americans lose their health care coverage by 2026 under the GOP Senate’s plan to repeal and replace the Affordable Care Act, how many people could die? The question is at the heart of the debate raging in Washington, D.C., but has been difficult to answer.

“Show me the data on lives saved by Obamacare, please,” conservative political scientist Charles Murray requested in a recent tweet.

A pilot study published Wednesday in the Journal of the American Heart Association may provide an answer: Researchers found that the rate of sudden cardiac arrest outside of a hospital dropped by 17 percent among people ages 45-64 in Multnomah County, Ore., after the Affordable Care Act expanded insurance coverage.

The study analyzed sudden cardiac arrest data from the emergency medical system in 2011-12 before the ACA, and compared the data from 2014-15, after insurance coverage expanded. During that time, the percentage of people in Multnomah County with Medicaid coverage nearly doubled, from 7 percent to 13.5 percent.

Cardiac arrest can serve as an early indicator to show how an increase in health insurance coverage under the ACA might affect mortality.

Use Our ContentThis KHN story can be republished for free (details).

Each year, about 350,000 people in the United States have a sudden cardiac arrest, in which the heart unexpectedly stops beating. It is one of the most deadly types of heart attacks — only 1 in 10 patients survive it. “It speaks to the importance of predicting and preventing [cardiac arrest], because once it happens, it’s much too late,” said Dr. Sumeet Chugh, medical director of the Heart Rhythm Center of the Cedars-Sinai Heart Institute in California and one of the authors of the study.

The good news is that nearly half of patients experience warning symptoms, offering an opportunity for intervention, said Chugh. Cholesterol and blood pressure medication, diet and exercise, and surgical interventions can all help stave off sudden cardiac arrest. But patients without health insurance might ignore their symptoms and avoid seeing a doctor.

“Imagine that you’re someone with a warning symptom. If you had insurance or access to health care that was relatively easy, you might be more inclined to see a provider. If you didn’t,you might let it go for a while,” said Chugh.

Chugh cautions that the study population was small and did not examine other factors that could have led to a decline in cardiac arrests. Still, it is consistent with other studies that found a link between Medicaid expansion and a decline in mortality. Chugh and fellow author Eric Stecker of the Oregon Health & Science University plan follow-up studies to narrow in on the causes in Multnomah County.

J. Michael McWilliams of the Department of Health Care Policy at Harvard Medical School, who was not involved in the study, questioned the large reduction in cardiac arrests seen in the study, saying it “seems too good to be true.”

Still, he said assessing the effects of health insurance on clinical outcomes like cardiac arrest is notoriously difficult, and there is good evidence that health insurance improves access to care and diagnosis of important conditions.

“I think when we focus on the lack of consensus evidence on the effects of coverage on hard outcomes like mortality, and use that as an argument against covering the uninsured, I think we let perfect be the enemy of good,” McWilliams said.

James Frank (Courtesy of James Frank)

Take James Frank, 64, of Lancaster, Calif., who was uninsured several years ago when he first started experiencing the symptoms of heart disease.

“I couldn’t catch my breath, I was wheezing,” Frank recalled. “I felt like I had like a chest cold. My feet were tingling. I was getting the sweats.” In 2013, Frank had a heart attack and was taken to the emergency room.

He signed up for coverage under Covered California, the state’s health insurance exchange, which opened in 2013 for coverage that began in January 2014. His doctor put him on a statin and blood pressure medication to prevent another heart attack, and he started watching his weight religiously.

Frank was quick to add that the coverage he gained under the ACA has not been perfect — his premium and deductibles are high, and he thinks that Congress should repair it. Still, he believes the health law saved his life. “I had the same heart attack that killed my mother,” he said. “Had it not been for Obamacare, I probably would have had another one.”

Calif. Officials Sound Alarm, Envisioning $114B Hit To Medi-Cal Under U.S. Senate Bill

California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday.

The reductions in the nation’s largest Medicaid program would start at $3 billion in 2020 and would escalate to $30.3 billion annually by 2027, according to an analysis released by the state departments of finance and health care services.

“It is not Medicaid reform,” Jennifer Kent, director of the state Department of Health Care Services, said in an interview. “It is not entitlement reform. It is simply a huge funding reduction in the Medicaid program. We are deeply concerned what that means for the long-term viability of the program as it stands today.”

Medicaid covers a staggering 13.5 million low-income Californians — children, people with disabilities, nursing home residents and others. About 3.8 million of them, many of whom are chronically ill, became eligible for coverage under the Affordable Care Act, informally known as Obamacare.

Use Our ContentThis story can be republished for free (details).

California would face the biggest losses of any state, according to a report issued Wednesday by the consulting firm Avalere Health. Federal funding would drop by 26 percent over 10 years, the report said. Many states, including Alabama, Georgia, Texas and Florida, would face a drop of less than 10 percent.

The Senate bill to repeal and replace the ACA would be a “massive and significant fiscal shift” of responsibility from the federal government to states, according to the analysis. It would force difficult decisions about who and what to cover and how much to pay doctors, hospitals and clinics, the report said.

In addition to expanding its Medicaid population early and vigorously under Obamacare, the state began covering undocumented immigrant children last year. California’s program, known as Medi-Cal, also provides dental care and other services that are optional under federal Medicaid rules.

The state’s Medicaid director, Mari Cantwell, said Republican proposals present a fundamental problem that can’t be solved by making cuts around the edges.

“Nothing is safe — no population, no services,” Cantwell said. “It is really disheartening and honestly horrifying to think about the world under this Senate bill and what it would mean.”

The losses are more than what was predicted under the House bill. The analysis said that’s because the cost shift increases over time under the Senate proposal.

Ken Bascom, 62, was diagnosed with kidney cancer after becoming eligible for Medi-Cal in 2014. Bascom is now cancer-free but said that without insurance, “more likely than not, I would’ve been dead.” (Anna Gorman/KHN)

GOP leaders in Congress have been trying to repeal the ACA for seven years, deeming it disastrous public policy that costs too much and leaves consumers with rising premiums and too few choices for care.

The Senate bill would overhaul Obamacare in several ways. Besides revamping the Medicaid program, it would dramatically change the system of tax credits used to help low-income Americans get health coverage. The Congressional Budget Office concluded that the bill would cut the federal deficit by $321 billion over the next decade while leaving 22 million more Americans without health insurance.

Unable to lock down the support he needs in the Senate, Majority Leader Mitch McConnell on Tuesday postponed a vote on the bill until after the July Fourth holiday. Its fate remains uncertain as senators head back to their districts for a weeklong recess.

Under the legislation, the federal government would pay a fixed amount to states for Medicaid expenditures, a per capita rate, instead of paying for a share of all expenses incurred.

State health leaders predict that the state’s costs would outpace the federal government’s allocation, meaning California would have to come up with an additional $37.3 billion between 2020 and 2027.

“Whether it’s drugs or cost of living going up or new technologies in health care, there are costs we can’t control,” Cantwell said. “And if you have a trend factor that doesn’t really reflect the reality of what health care looks like, the state is always going to be in a place of not being able to bring the costs within that target.”

The proposed financial caps would have a “devastating and chilling effect” on spending in the Medicaid program and would pinch providers further, the analysis said. California already ranks near the bottom for how much it pays Medicaid providers.

The Senate’s overhaul of Obamacare would also force hospitals and clinics serving the poor and uninsured to live within the new financial limits, leading to “uncompensated care in the hundreds of millions, if not billions annually,” according to the analysis.

In addition, the Senate bill would phase out funding for the expansion of Medicaid, which enabled 3.8 million single, childless adults and others in the state to qualify. Under the Affordable Care Act, the federal government pledged to pay for 90 percent of their costs. But the Senate bill would reduce that to 50 percent beginning in 2024.

Without the promised federal funds, California would have to spend five times more than previously estimated to continue covering those newly eligible. By 2027, the cumulative cost to California would be $74.1 billion, according to the analysis.

California leaders vowed Tuesday to fight the bill, known as the Better Care Reconciliation Act. “Simply stated, this is a terrible bill and we must defeat it,” said Democratic Sen. Dianne Feinstein in a call with reporters.

Sen. Kamala Harris, also a Democrat, added that the most vulnerable populations are the ones who have most to lose: children, people with disabilities, seniors. “This bill is nothing short of a disaster, and it’s no wonder they did it in secret because they have nothing to be proud of,” said Harris, who aims to kill the bill before it hits the Senate floor.

The fallout would be particularly bad in Los Angeles County, home to 1 of every 20 Medicaid recipients in the nation, county officials said Tuesday.

“L.A. County will be ground zero for the plan’s deadly consequences,” said county Supervisor Sheila Kuehl during a press conference. “This is not just about money. … This is about the people who count on us for health care.”

During the conference, several Los Angeles County residents and union members held up signs that read “Healthcare is a Human Right” and, in Spanish, “SALUD para todos,” or “Health for everyone.”

Ken Bascom, 62, who lives in Venice, Calif., and attended the gathering, said he lost his job and his employer-based insurance during the recession. Soon after Bascom became eligible for Medi-Cal in 2014, he was diagnosed with kidney cancer. Now cancer-free, Bascom said he often thinks about what would have happened if he hadn’t been able to get health care.

“More likely than not, I would’ve been dead,” said Bascom, who gets care at Venice Family Clinic. “It’s very scary.”

Also in attendance was Steven Martin, 27, who said he depends on insurance he got through Obamacare to pay for his leukemia treatment. Martin, who has private insurance through Covered California, the state’s exchange, said his medication costs tens of thousands of dollars each year.

“Without insurance, I’m not going to have access to my medication,” he said.

Los Angeles County Health Agency Director Mitch Katz said the ACA made a “huge difference” in the county — dramatically cutting the uninsured rate, reducing wait times at emergency rooms and helping connect patients to primary care doctors.

“The emergency rooms themselves often had two- and three-day waits,” he said. “Because of the ACA, that is no longer the case. … The emergency room now is back to what is should be — for emergencies.”

Katz said he feared all of that would change if the Republicans succeed in overhauling the health law.

Ana Ibarra contributed to this report.

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

For Millennials, Both Good And Bad News In Senate’s GOP Health Bill

Darlin Kpangbah receives free health insurance through Medicaid and is grateful for the coverage in case of accidents, such as when she tore a ligament in her leg a few years ago. “I feel like I’m injury-prone,” said Kpangbah, 20, who lives in Sacramento, Calif. Without insurance, she said, the injury “would’ve been huge to pay for.”

Young adults like Kpangbah were among the biggest beneficiaries of Obamacare, which helped reduce the rates of uninsured millennials to record lows and provided millions of Americans with access to free or low-cost insurance as well as maternity care, mental health treatment and other services.

Now, Senate Republicans have proposed overhauling the Affordable Care Act — a move that could help some young adults by lowering the cost of their premiums in the private insurance marketplaces but could hurt others who gained insurance through a massive expansion to Medicaid. A Congressional Budget Office analysis of the bill released Monday estimated that 22 million Americans could lose coverage under the Senate bill, which could change significantly before an expected vote before July 4.

The proposed legislation also would retain a popular Obamacare provision that allowed young adults up to age 26 to stay on their parents’ insurance. But the bill in its current form also could dramatically reduce health coverage and care for other young adults, according to the bill’s many critics, which include the American Medical Association and the American Hospital Association.

This story also ran in the Teen Vogue. It can be republished for free (details).

“Don’t be fooled,” said Jen Mishory, executive director of the advocacy organization Young Invincibles. “This is going to be a bad deal, particularly for the most vulnerable young people.”

Mishory said one of the biggest concerns is that states could opt out of requiring insurers to provide benefits such as maternity care, mental health care and prescription drugs — all commonly used among young adults. “You will see a lot of young people not getting the kind of coverage they need,” she said.

The proposed changes in the marketplaces, however, could make coverage more attractive to young people. The Congressional Budget Office reports that the Senate bill would result in a larger number of younger people paying lower premiums to buy private plans. The proposal would allow insurers to charge older people up to five times more than others, which could mean lower premiums for younger people.

At the same time, the Senate bill shifts the amount people who qualify for subsidies must pay toward their own premiums, meaning that people under age 40 might pay a smaller portion of their income toward coverage than they do under Obamacare.

But young adults could face other cost increases because of larger deductibles and less help with out-of-pocket expenses. Some no longer would qualify for subsidies at all, because the bill would reduce the income threshold for eligibility.

Millions of young adults have enrolled in coverage through the insurance exchanges, in part because of a coordinated push to get as many healthy, young people into the marketplace to balance out older, sicker consumers who were eager to sign up right away.

About 27 percent of the 12.2 million consumers who enrolled in health insurance through the exchanges across the nation in 2017, were 18 to 34 years old. In California, 37 percent of 2017 enrollees were in that age group, according to Covered California, the state’s insurance exchange.

Steven Orozco, who lives in Los Angeles, is among them. He, his wife and 2-year-old daughter have a plan through Covered California. Orozco, who is a real estate agent, said they are all healthy so they don’t use it often, but he has it just in case of broken arms or other unexpected health needs.

Orozco, 32, said that he is concerned about what could happen in Washington and how that might affect his coverage, which currently costs about $450 a month.

Despite potential benefits to young adults in the private marketplace, the most damaging changes under the Senate proposal would be for young adults covered by Medicaid, said Walter Zelman, chairman of the public health department at Cal State-Los Angeles.

In addition to phasing out the expansion of Medicaid, the Senate bill also would result in reduced funding for the program, he said.

“The biggest impact on young people is the dismantling of Medicaid,” Zelman said.

Since the Affordable Care Act took effect, about 3.8 million young adults have gained coverage through the expansion of Medicaid, according to Young Invincibles.

In California alone, Zelman said, hundreds of thousands of young people won’t be able to access Medi-Cal, California’s version of Medicaid, if the expansion is phased out. Zelman, who worked to enroll California State University students into health coverage under Obamacare, said that historically the highest percentages of uninsured people have been young adults, low-income residents, part-time workers and Latinos.

“Those are my students,” he said. “And, more generally, those are young people overall. … Anything that threatens [their] access to health is bad for them,” he said.

It’s unclear whether the proposed Republican overhaul would result in more or fewer young enrollees.

Uninsured Sacramento resident Sydney Muns, 27, works at a nonprofit that doesn’t offer health coverage, and she earned too much money to qualify for Medi-Cal or receive Obamacare subsidies. Muns said she hopes premiums and out-of-pocket costs will decline in the future so she can get coverage.

“It’s just not affordable,” said Muns, who faces $50,000 in college loan debt. “I don’t know anyone my age who has insurance.”

Carly Carpenter, left, and Chyneise Dailey are each on their parents’ health insurance plans, but say they will purchase their own when they have to. (Kellen Browning/California Healthline)

But Chyneise Dailey, 24, said she plans to purchase health care whether or not she is required to do so. Dailey, who works at Sacramento State, remains on her parents’ Blue Cross health insurance plan, but knows she has only a couple of years before she has to buy her own coverage.

“You never know what can happen. You get into a car accident, you’re in the ER — do you want to pay full rate or do you want to pay your copay?” Dailey said. “I’d just rather be safe than sorry.”

Under both the Senate and House plans to overhaul Obamacare, young women who go to Planned Parenthood for reproductive health and other medical services could be hurt because of a provision to ban federal funding of the organization for a year.

That concerns Niki Kangas, 35, who frequently visits Planned Parenthood clinics even though she has job-based coverage from Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.) Kangas, of Sacramento, said she is “pissed off” that the Senate’s proposed bill would impose a one-year ban on federal funding to the organization, which is a frequent target for conservatives.

“I’ve used Planned Parenthood a lot, either in between jobs or sometimes it’s just more convenient than going out to Kaiser, like if I just need birth control,” said Kangas, a project manager at a design agency. “I think for people who don’t have insurance through their work that it’s a resource they depend on.”

Mary Agnes Carey, Julie Appleby and Barbara Feder Ostrov contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Hospitals Ramp Up Hyperbaric Therapy For Diabetics, Despite Concerns

The Villages Regional Hospital did not sweat its decision to add hyperbaric oxygen therapy in 2013.

Hyperbaric treatment, increasingly given to diabetics — many of them elderly with persistent wounds — involves breathing pure oxygen inside a pressurized air chamber typically for two hours each weekday, often for more than a month. Twenty outpatient sessions can bring a hospital $9,000 in revenue.

Villages serves a central Florida retirement community that supplied nearly half of the hyperbaric patients at another hospital 30 minutes away. Hospital officials knew their clientele preferred their medical appointments only a golf-cart’s ride from home.

“Wound care was a service line we saw as low-hanging fruit,” said Todd Powell, who oversees hyperbaric therapy at Villages hospital.

This KHN story also ran in The Washington Post. It can be republished for free (details).

Many hospitals seem to agree. Enticed by healthy Medicare payments — about $450 for a two-hour session — and for-profit management companies that do much of the work, nearly 1,300 U.S. hospitals have installed hyperbaric facilities. That’s triple the number that an industry group says offered the service in 2002, when Medicare first decided to pay for the therapy for certain diabetic wounds.

Medicare — the largest payer of hyperbaric services — has flagged evidence of overuse in at least some parts of the country. Medicare officials declined to comment for this story, but they have retained coverage for more than 15 years, even as studies have questioned the therapy’s effectiveness.

The American Diabetes Association does not recommend the treatment. After an ADA committee of experts in diabetes care reviewed the available research last year, it concluded there was “not enough supporting data on the efficacy of this treatment to recommend its use,” said William Cefalu, the association’s chief medical officer.

Some experts say hyperbaric therapy’s increased use for diabetic wounds owes more to hospitals’ pursuit of Medicare revenue than to the treatment’s proven value.

“The science remains poor to support its use, but it is being widely used [in the United States], and one possible explanation to this may be related to reimbursement,” explained Dr. Andrew Boulton, an internationally recognized expert on hyperbaric therapy, and a professor of medicine at University of Manchester medical school in Great Britain.

“Some folks are chasing the money. It’s seen as a money grab because reimbursement has been favorable,” acknowledged John Peters, executive director of the Undersea & Hyperbaric Medical Society, which accredits 200 hyperbaric oxygen facilities nationally and has inspected 500 for accreditation in the past 15 years.

Offered at a handful of hospitals in the last decades of the 20th century, hyperbaric chambers were a niche treatment for deep-sea divers suffering with the bends — a painful and potentially fatal condition where gas bubbles accumulate in the bloodstream during too-rapid ascents from depth. In 2002 — after industry lobbying and some suggestive research — Medicare approved hyperbaric therapy for certain diabetic wounds that did not respond to conventional treatments.

That decision drove a building boom in outpatient wound care centers over the next half-decade, featuring hyperbaric therapy. Medicare covers the treatment for more than a dozen conditions in which skin fails to heal, such as failing grafts and tissue damage from anti-cancer from radiation, but the USA’s rising diabetic population supplies much of the demand.

It costs about $500,000 to install a hyperbaric unit with two chambers. With Medicare’s lucrative reimbursement policies, “hospitals can generate cash almost immediately,” Peters said. During hyperbaric sessions, patients merely lie on a bed in a glass-enclosed tube containing high-pressure oxygen under a physician’s supervision.

The business model is so compelling that management companies typically pay for the equipment and staff. Hospitals provide space for the chamber, make patient referrals and handle billing. The companies and the hospitals split revenue from insurers.

Because of poor blood circulation, diabetics are susceptible to developing ulcers in their lower legs and feet that heal poorly and can sometimes lead to amputations. Hyperbaric oxygen therapy, in theory, works by stimulating the body’s creation of new blood vessels and aiding the formation of new skin around a wound. Side effects are uncommon but include ear and sinus pressure, paralysis and air embolisms, according to the Food and Drug Administration.

In 2015, Medicare imposed stricter billing procedures in three states where its expenses for hyperbaric services were 21 percent above the national average — possible evidence of overuse or overbilling. Providers in Illinois, Michigan and New Jersey must get regulators’ preauthorization of expenses before treating Medicare patients for the most commonly approved conditions in non-emergency cases. Elsewhere, Medicare requires documentation supporting hyperbaric therapy’s need only after services begin.

Signs of abusive industry practices predate the 2015 action. A critical report by the Health and Human Services Department’s inspector general in 2000 disclosed that Medicare was billed millions of dollars for non-diabetic wound care treatments that were inappropriate or excessive. The office has promised a follow-up report before Oct. 1 — its first since 2000.

The Justice Department alleged fraud or other wrongdoing involving hyperbaric therapy in at least five cases from 2008 to 2014. It has won more than $11 million in penalties and restitution — along with some jail sentences — in court rulings and settlements.

(The FDA warned in 2013 about some treatment centers’ falsely promoting the therapy for unapproved uses, including as a cure for cancer, autism and diabetes.)

Medicare’s crackdown on billing in three states saved $5.3 million in its first 13 months, the government said in November. Medicare’s total spending on hyperbaric therapy — including all approved conditions — in 2015 fell about 10 percent to $230 million. That was the first annual decline in a decade.

Debates about the utility of the treatment continue despite decades of use.

In fact, few large, controlled studies have explored hyperbaric oxygen therapy for diabetic wounds — and nearly all were done outside the United States.

Some studies have found the treatment benefits certain patients while others have concluded it neither increases a wound’s chances of healing nor prevents amputations. The problem is knowing which wounds would have healed over time on their own.

Businesses and individuals invested in the facilities remain unalloyed boosters. The treatment “used to be considered voodoo medicine. But today more doctors have been swayed, and it’s now seen as mainstream therapy,” said Marc Kaiser, owner of Precision Health Care, which manages hyperbaric centers at five hospitals in New York and Connecticut.

Based on studies and anecdotal experience, Dr. Geoffrey Gurtner, a plastic surgeon who helped establish the Stanford University Wound Care Center in 2014, believes the therapy has some merit. But he said that research is needed to understand how the treatment works, which patients need it and the right number of sessions for each wound.

And, critics say, companies are profiting from and abusing the current state of uncertainty. Medicare pays for hyperbaric therapy for diabetic wounds that have not healed after 30 days of standard treatments. If hospitals provide more than 30 treatments, they must document that patients’ wounds are improving.

Twenty to 30 sessions of hyperbaric therapy should heal diabetic wounds, but radiation-damaged skin might require 40 treatments, said Dr. Phi-Nga Jeannie Le, a Houston physician.

“The problem is, we see these financially motivated centers keep doing the treatment into the hundreds of visits,” she said.

Also, Medicare pays nearly double the standard rate when the treatment is performed at hospital-affiliated facilities, which can add on a “facility fee.” Because of this quirk in the rules, hyperbaric management companies tend to court hospitals to install their devices.

April Hall underwent 50 sessions of hyperbaric oxygen therapy at MedStar Good Samaritan Hospital in Baltimore last summer.

April Hall receives hyperbaric oxygen therapy at MedStar Good Samaritan Hospital in Baltimore in 2016. (Phil Galewitz/Kaiser Health News)

Stretched out in one of the hospital’s four hyperbaric chambers, wrapped in blankets with her head propped up to watch television, Hall breathed pure oxygen for two hours at a time.

One wound on the bottom of her left foot healed. The other did not.

“I did what I had to do to save my foot,” said Hall, 50, who is on Medicare disability.

Sometimes even dozens of treatments do not avert amputations, as diabetic William Padgett Jr., 65, of Culpeper, Va., can attest. He lost his right leg in 2013 after nearly 90 hyperbaric sessions failed to heal a wound.

Last year, he tried hyperbaric oxygen again to close a wound on his left leg, taking about 80 sessions over four months at a hospital in Arlington, Va. The wound healed. “It’s been a slow process … but well worth the time,” he said.

William Padgett Jr. of Culpeper, Va., received dozens of hyperbaric oxygen therapy sessions in 2013 and again in 2016 for diabetic wounds on his lower legs. Part of his right leg still had to be amputated, but the left one was saved. (Phil Galewitz/Kaiser Health News)

In any one case, it is hard to say whether the treatment was key to success.

A 2014 federal whistleblower lawsuit against Healogics, which manages about half — 750 — of the nation’s hospital-owned wound-care and hyperbaric centers, raised other concerns. Two doctors and a third employee who worked for Healogics alleged a company conspiracy to defraud the federal government by billing it for unnecessary wound care and hyperbaric services.

Healogics denied the claims in its court-filed responses, and a judge dismissed the case for lack of detail. It is under appeal.

The lawsuit alleged Healogics “actively targeted each and every [wound care] patient for conversion” to hyperbaric therapy and set benchmarks for each center on the amount of hyperbaric care that would be provided.

According to Healogics, 5 percent of its 326,000 patients last year had hyperbaric treatment. Only 2 percent of those received more than 50 sessions.

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