Family Medicine

Column: Improve Medicaid payments for primary care in Virginia – The Virginian-Pilot

An ounce of prevention is worth a pound of cure. Despite this, we spend more than $4 trillion a year (18% of our GDP) on health care treatments with less than 6% of that amount going into primary care, which focuses on prevention of illness. Primary care providers include family physicians, internists, pediatricians, OB-GYN doctors, nurse practitioners and physician assistants that are the first stop for most people accessing our health care system.

Primary care in the United States is under tremendous stress. Office overhead expenses run 60-70%. Insurers require increased documentation in electronic health records and prior authorization requirements are frustrating and time consuming. There is an aging workforce and it is difficult to recruit new physicians into this challenging line of work. Many primary care doctors have retired or left private practice and joined large hospital-based systems.

Virginia expanded Medicaid coverage in 2018. Medicaid now insures nearly 1 in 4 Virginians, dramatically increasing the number of Virginians who have health insurance. There is a little discussed problem with Virginias Medicaid payment system however; the payment amount for services is only 72% of that for Medicare and even less than that compared to private insurance payments. Despite this, 76% of primary care providers continue to see Medicaid patients and 58% are taking new Medicaid beneficiaries.

I learned firsthand the financial problems that result from taking low Medicaid payments as the medical director of two large family medicine residency training practices over 17 years. More than a third of our patients had Medicaid and this percentage increased after Virginias 2018 Medicaid expansion. We continued to see more Medicaid patients who needed comprehensive care, but took significant financial losses for doing so. This led to eliminating essential staff positions, making it much more difficult to continue our mission of providing primary preventive care and treating chronic illnesses.

Many Medicaid patients have more severe chronic illnesses than those with private insurance, and thus it takes longer to see them and provide the complex care that they need. This contributes significantly to the stress of primary care doctors, since they are responsible for the many problems these patients have. Other insurance programs have a system for compensating providers with higher reimbursement for treating those with more severe illness and rewarding higher quality care with better payment. Medicaid has no effective system for doing this; payments remain 72% of the average Medicare reimbursement, despite many previous legislative efforts to get these payments to parity with Medicare.

Gov. Glenn Youngkin recently proposed his $84 billion budget for FY 2024 and has proposed tax cuts as noted by The Virginian-Pilot & Daily Press Editorial Board on Dec. 27 (A tax reform opportunity). There was a massive budget surplus in the last two years and much debate about how that money should be spent on many worthy causes. A compromise between tax cuts and spending in important areas was finally reached between Democrats and Republicans this past summer. This debate will go forward in the 2024 legislative session, which begins on Wednesday.

It would be a huge boost to our primary care workforce if the legislature were to act to provide Medicaid payments for primary care that are equal to those of Medicare. Estimates put the cost of this at $178 million dollars annually, which is only 0.2% of the total annual Virginia budget. Doing this would provide health care security to our less fortunate citizens by ensuring continued access to primary care services. Millions of future health care dollars would be saved by providing prevention and early treatment of chronic disease instead of treating much more expensive advanced illnesses. What could be a better investment in the future health of Virginians?

Dr. Bob Newman is a clinical professor of family medicine at Eastern Virginia Medical School in Norfolk. He is the author of Patients Compass, which is a guide to navigating the U.S. health care system, available online at yourpatientcompass.com.

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Column: Improve Medicaid payments for primary care in Virginia - The Virginian-Pilot

Genetics

Mayo Clinic Q&A: Weight loss and genetics – Chicago Tribune

DEAR MAYO CLINIC: It seems like no matter what I do, I cant lose weight. Most of my family members struggle with their weight too. Do our genetics play a part in this?

ANSWER: Its important to understand that we are all unique and gain weight for many different reasons. When trying to understand weight gain and why some of us have difficulty losing weight, there are factors such as gut and brain connections, how we control our sensation of hunger and fullness and how long we stay full. Over a decade of studies at Mayo Clinic have helped identify characteristics that can be associated with groups of people called obesity phenotypes.

Each phenotype has a single genetic predisposition (an increased likelihood of developing obesity based on a persons genetic makeup) and interacts differently with their environment. In many environments we see today, there is an excess of food, and were less active than before. Some people may feel hungry between meals, while others only have one big meal a day our genetics drives this. Your genetic makeup determines which phenotype youre going to have. These phenotypes can help guide treatment for weight loss. Each of these genetic phenotypes, or genotypes, identifies the type of obesity and which medication would work best.

The first phenotype is what we call hungry brain. These patients start eating and dont feel full even after consuming large meals with second and third helpings. Usually, this runs in families. The other phenotype is what we call hungry gut. These patients start eating and feel full after their usual portion, but the gut does not send those signals to the brain. Because of that, they feel hungry between meals. Signals from the gut to the brain are hormones, such as glucagon-like peptide-1 (GLP-1). Semaglutide medications such as Wegovy, Ozempic and Rybelsus work on behalf of the GLP-1 hormone. They connect between the gut and the brain, and they signal to the brain that youre full.

Patients who have emotional hunger are another group. Whether having a good or bad day, these patients look to cope with life by eating food. The fourth group is patients with a slow burn or abnormal metabolism where the body does not burn all the calories they consume.

Looking at these four phenotypes can help individualize obesity therapy. How genes correlate with an obesity phenotype can help determine which medications should be prescribed. Each of us also should have a unique diet approach based on our genotype and phenotype. Many diets have mainly focused on obesity-related complications, such as managing Type 2 diabetes or preventing heart risk, but none have been customized to phenotypes. The concept of the phenotype-tailored diet came from multiple studies that showed metabolic benefits during and after the diet plan began. These findings were then matched to each phenotype to define recommended diets.

At Mayo Clinic, we work closely with our colleagues in bariatric surgery through endoscopic procedures to find out, based on our genetics, how we can identify who will be the most responsive to each course of action. We want to bring precision medicine as we have for any other disease, and I think its time we do the same for obesity. Andres Acosta, M.D., Ph.D., Bariatrician, Gastroenterologist, Mayo Clinic, Rochester, Minnesota

(Mayo Clinic Q & A is an educational resource and doesnt replace regular medical care. For more information, visit http://www.mayoclinic.org.)

2024 Mayo Foundation for Medical Education and Research. All rights reserved. Distributed by Tribune Content Agency, LLC.

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Genetics

Controversial New Research Find That Bisexuals Are a Bunch of Rascals – Futurism

Image by Getty / Futurism

It turns out that there may be some genetic and evolutionary factors afoot when it comes to bisexuality but naturally, there are ethical concerns about such bold statements.

AsScience magazine reports, this new research looking into the genetics of bisexuality suggests more of a propensity for risk-taking and is distinct from the genes that may underly homosexual behavior. If that sentence raises alarm bells, you're not alone.

Published in the journalScience Advances, even the name of the paper itself, "Genetic variants underlying human bisexual behavior are reproductively advantageous," harkens back to the old nature-versus-nurture arguments that most people, queer or otherwise, would rather forget.

Despite the face-value implications, however, the content of the study is pretty fascinating.

Jianzhi Zhang and Siliang Song, the evolutionary geneticist duo out of the University of Michigan who coauthored the paper together, insist that their findings need not be painted with the brush of morality because, as Zhang put it, the association they found between bisexuality and risk-taking behavior "is an empirical observation."

"We hold no moral judgement on risk-taking and believe [it] has pros and cons (depending on the situation), as almost any trait," Zhang toldScience. "This is partly a biological question, so we should understand it."

Zhang and Song examined data from the UK Biobank, the giant genetic database compiled with the help of 23andMe, and deviated in one key way from a groundbreaking 2019 study about the genetics of same-sex behaviors: they decoupled self-reported homosexual and bisexual behaviors, which until now had been lumped together under the "same-sex sex" umbrella.

Using some statistical and algorithmic magic, the UM team found that although the genetic variants between bisexual behavior and homosexual behavior are related, they're still distinct from one another.

What's more, the risk-taking aspect of bisexual behavior was apparent in men, but not in women and, strangely enough, the risk-taking genetic variants also seemed to account for a higher chance of having offspring, too.

The conclusion drawn here is that bisexuality has evolutionary benefits. But as behavioral geneticist Andrea Camperio Ciani of the University of Padova in Italy pointed out to Science, it still doesn't do much to explain what evolutionary purpose, if any, same-sex behavior might carry.

"[Gay people] have been everywhere in every nation," he explained. "Always at a low frequency, but everywhere."

Beyond the murkiness on the evolutionary side of things, there's also the data itself. The paper's results are based on self-reported sexual behaviors rather than orientation or identity. And as Yale geneticist Steven Reilly cautioned Science, the UK Biobank's respondents skew older and may have been describing encounters or behaviors that took place when homosexuality was still illegal and stigma-laden.

Lastly, of course, is the stigma such research could bring about in today's world, where bisexuality is much more accepted than it was in the past but is still very misunderstood and maligned, even in queer communities.

Purdue sociogenomicist Robbee Wedow, who coauthored the 2019 study finding genetic variants associated with homosexuality, went so far as to say that the new research's focus on bisexuality and evolutionary fitness "is not only incorrect, but I would say dangerous."

Zhang, on his end, rejects that characterization outright.

"Many studies that were once considered dangerous propelled the progress of science, technology, and society," the researcher toldScience.

More on queer procreation:Scientists Find Kids With Gay Dads Are Doing Better Than Kids With Straight Dads

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Controversial New Research Find That Bisexuals Are a Bunch of Rascals - Futurism

Genetics

The DNA of privacy and the privacy of DNA – Federal Trade Commission News

Companies selling genetic testing products tout the benefits of DNA-based insights learning more about health, lineage, family tree so that consumers can seek medical attention, customize their diet or exercise regimen, find long-lost relatives, or understand more about their background. But for consumers to realize benefits from DNA-based products or services, consumers need to be able to trust their accuracy and trust that the companys practices related to the DNA of privacy (data minimization, purpose limitations, retention limits, etc.) will protect the privacy of their DNA. Here are some lessons on privacy, data security, truth in advertising, and artificial intelligence (AI) drawn from a trio of FTC enforcement actions involving sellers of genetic testing products: CRI Genetics, 1Health/Vitagene, and Genelink.

Protecting biometric information including genetic data is a top FTC priority. Since announcing itsBiometric Policy Statementin May 2023, the FTC has settled actions against two sellers of direct-to-consumer DNA testing kits. Why are these cases so important? Genetic data reveals sensitive information not only about consumers health, characteristics, and ancestry, but also about their families. While some other data types can be stripped of identifying characteristics, thats not necessarily the case when it comes to genetic information. Where the sensitivity of the data is high, so too is the risk of harm, particularly in this era of increasing biometric surveillance. The FTCs actions in Amazon/Alexa and Ring to protect voice recordings and videos further illustrate this point. To stay on the right side of the law, heed the lessons from these cases.

Secure genetic data. In both 1Health/Vitagene (consumers may know the company as Vitagene) and Genelink, the FTC charged that sellers of genetic-based products had subpar data security. The FTCs Vitagene complaint alleges that the company didnt inventory its genetic data, so it wasnt even aware that it had stored some of it in a cloud storage bucket accessible to the public. In addition, the company allegedly didnt use access controls, didnt encrypt that publicly accessible data, didnt log or monitor access to it, and didnt remedy the problem even after receiving credible warnings. Genelink preceded Vitagene by about nine years and yet there are eerie similarities. According to the Genelink complaint,the company maintained sensitive data in clear text, failed to limit employee and contractor access to sensitive data, failed to assess the risks to that data, and didnt include terms in the contract to require contractors to use safeguards and to allow Genelink to oversee their practices. The data practices described in both complaints are shoddy for any data, but especially for sensitive genetic information, where the risk of harm to consumers from exposure of that data is high. If you collect or store genetic data, youre on notice that the FTC expects security in line with the sensitivity of the data.

Secure customer accounts. Securing genetic data doesnt just mean good network security (although thats a must). It also means securing customer accounts through which a bad actor could access genetic data or other personal information. The more sensitive the data, the more valuable it may be to bad actors which means customer accounts are likely targets for hackers. The Ring matter illustrates that point. According to the complaint, the home security camera company failed to take reasonable steps to secure customer accounts against common hacking techniques, including credential-stuffing attacks. (Credential stuffing involves the use of credentials, such as usernames and passwords, obtained from one breached account to gain access to a consumers other accounts.) The complaint alleges that Ring only used half-measures to prevent these attacks. For example, Ring made multi-factor authentication available to consumers, but didnt require them to use it even though customer accounts were the gateway to highly sensitive information like stored videos and live streams of consumers in private spaces of their homes. If your customer accounts offer data thieves a similar gateway to sensitive data (for example, results from genetic testing), learn from the Ring case and properly secure those accounts.

Dont oversell: Can you support your accuracy claims about genetic testing? Be careful not to exaggerate your claims about your genetic testing product. Theres a line between puffery and deception that you dont want to cross. According to the CRI Genetics complaint, the company among other things overstated the accuracy of their test results (accuracy greater than 99.9%) and falsified reviews. Heres the truth about DNA testing for ancestry: Companies estimate consumers ancestry by comparing consumers DNA with the companies proprietary DNA reference data. Their algorithms predict consumers ancestry, with varying margins of error. DNA testing for ancestry is, therefore at best an estimation of ancestry, not a precise science. The Genelink complaint alleges that the company claimed their genetically customized nutritional supplements could treat diabetes, heart disease, arthritis, insomnia, and other health conditions all without scientific support. When making claims about the accuracy of genetic testing or the purported benefits of DNA-related products, stick with reliable science. If you dont have a reasonable basis to support your claim, dont make it in the first place.

The FTC is watching how companies use and claim to use Artificial Intelligence. DNA algorithms are no exception. Its no secret that the FTC is focused on making sure that consumers can enjoy the benefits of AI without suffering substantial harms like bias, privacy invasions (Amazon/Alexa and Ring), or questionable accuracy (WealthPress, DK Automation, Automators AI). That holds true when it comes to DNA algorithms. In the CRI Genetics matter, the FTC alleged that the patented DNA algorithm the company touted in its ads was not in fact patented and didnt generate the highly accurate results the company claimed. In this age of AI, some companies may be tempted to use loose talk about AI and algorithms, perhaps as a means of conveying technological sophistication. Watch out. If youre promoting your AI or algorithm, make sure your claims dont deceive or otherwise harm consumers.

The FTC has a strong track record of challenging deceptive or unfair dark patterns, including when it comes to obtaining consent for the use and disclosure of genetic data. Recent enforcement actions like Amazon/Prime, Publishers Clearinghouse, and Vonage demonstrate the high priority the FTC places on challenging allegedly illegal dark patterns manipulative designs that coerce consumers into decisions they wouldnt knowingly agree to make. The CRI Genetics matter reinforces this point. According to the complaint, the company used dark patterns confusing pop-ups and directions, bogus rewards, claimed urgency to push consumers into buying more. In the ongoing battle against illegal dark patterns, the orders in both CRI Genetics and Vitagene require the companies to obtain affirmative express consent consent that precludes the use of dark patterns for future uses or disclosures of genetic data. Companies are on notice that they shouldnt be using dark patterns to get consent.

Dont commit a foul when changing the rules of the game. The Vitagene order includes that affirmative express consent requirement because the company had allegedly changed its terms on a key issue but the company didnt get real consent from consumers for this material retroactive change. According to the complaint, changing the rules of the game in the privacy policy was unfair, even though the company hadnt yet implemented the change. The bottom line is that consumers should know what to expect from your data practices. A bait-and-switch approach to collecting personal information (especially genetic data) doesnt fit with the FTC Acts requirements.

Nothing but the truth. According to the FTCs complaint in Vitagene, the company made detailed privacy promises for example, about how it stored genetic data and destroyed genetic samples but didnt deliver on those promises. The company made these promises prominently (a good thing!), including on a page dedicated to genetic privacy. But, according to the complaint, rather than storing genetic data without identifying information, it stored results with names and other personal information. When the time came to delete genetic data, the company couldnt delete it because they didnt even know where some of it was stored meaning that they broke that promise, too. And the company failed to have a process in place through contractual obligations, in particular to ensure that third-party labs destroyed genetic samples after testing. The upshot: If youre selling genetic testing products (or any product, for that matter), you owe consumers nothing less than the truth.

The consequences for ignoring these warnings can be significant. In both recent genetic testing matters, the companies ended up paying substantial financial settlements, either as civil penalties under California state law (CRI Genetics) or for consumers redress (Vitagene). Furthermore, the orders in both cases required the companies to delete or destroy certain valuable biometric data or materials. These remedies were on top of other order provisions, such as prohibitions on misrepresentations, required notice to consumers of the FTCs action, mandates to obtain affirmative express consent for the future use or disclosure of genetic data, and a mandated security program with independent assessments. Its clear that the consequences of non-compliance with the FTC Act and other laws can be significant. Your best bet is to stay on the right side of the law by following these lessons.

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The DNA of privacy and the privacy of DNA - Federal Trade Commission News

Genetics

Development of a human genetics-guided priority score for 19365 genes and 399 drug indications – Nature.com

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Genetics

Educational attainment of East Asians are linked to genetics – KBR

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Educational attainment of East Asians are linked to genetics - KBR

Genetics

MESuSiE enables scalable and powerful multi-ancestry fine-mapping of causal variants in genome-wide association … – Nature.com

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MESuSiE enables scalable and powerful multi-ancestry fine-mapping of causal variants in genome-wide association ... - Nature.com

Genetics

Novel Genetic Priority Score Unveiled to Enhance Target Prioritization in Drug Development – Mount Sinai

Driven by the need for a better way to prioritize targets for drug development, the Icahn School of Medicine at Mount Sinai has led the development of a novel genetic priority score (GPS) that will integrate various types of human genetic data into a single easy-to-interpret score.

The findings were described in the January 3 online issue of Nature Genetics [DOI: 10.1038/s41588-023-01609-2].

Studies have shown that drugs have an increased likelihood of success in clinical trials when the genes they target have been demonstrated to have genetic support. The new tool integrates multiple lines of genetic evidence to prioritize these drug targets.

The score measures the general ability of a gene to be targeted by drugs; genes with a high score in the new tool are more likely to succeed as a drug target. The score identifies both known drug gene targets as well as potential novel therapeutic targets.

We built a genetic priority score that was inspired by the realization that diverse human genetic data provides insights into drug targets, yet there was an absence of a cohesive strategy for integrating these various data types into an easily interpretable score. So we developed a computational score to prioritize drug targets for enhanced drug discovery," says Ron Do, PhD, senior study author and the Charles Bronfman Professor in Personalized Medicine at Icahn Mount Sinai. Remarkably, several genes with high GPS were already known to be targeted by approved drugs, providing validation for the new tool.

The GPS, with its potential to streamline target prioritization, is positioned to have a significant impact on drug development. It offers a valuable resource for researchers seeking to optimize the selection of drug gene targets for enhanced efficiency in the drug development process, say the investigators.

The rising cost of developing therapeutics, in the billions, is primarily due to high clinical trial failures, underscoring inefficiencies in drug development pipelines. Improving early-stage target prioritization is critical. Studies consistently show that drug indications with human genetic support are more likely to succeed in trials and gain approval, says study first author Aine Duffy, a PhD candidate in the lab of Dr. Do.

The researchers are encouraged by the developments but emphasize this represents only a first step for prioritization and the need for careful follow-up and further investigation of gene targets with high scores. Next, the investigators plan to refine the model by incorporating additional genetic features and evaluating more sophisticated algorithms for constructing the GPS.

The paper is titled Development of a human genetics-guided priority score for 19,365 genes and 399 drug indications. Please see [DOI:10.1038/s41588-023-01609-2] to view competing interests.

The remainingauthors, all with Icahn Mount Sinai except where indicated, are Ben Omega Petrazzini (Associate Bioinformatician); David Stein (PhD candidate); Joshua K. Park (MD/PhD candidate); Iain S. Forrest, PhD (and MD candidate); Kyle Gibson (MD candidate); Ha My Vy, PhD; Robert Chen Park (MD/PhD candidate); Carla Marquez-Luna, PhD; Matthew Mort, PhD (Cardiff University, UK); Marie Verbanck, PhD (Universite Paris Cite and Icahn Mount Sinai); Avner Schlessinger, PhD; Yuval Itan, PhD; David N. Cooper, PhD (Cardiff University, UK), Ghislain Rocheleau, PhD; and Daniel M. Jordan, PhD.

The study was funded by the following: the NIH T32 Postdoctoral Research Award (5T32HL00782424); the National Institute of General Medical Sciences of the NIH (R35-GM124836); the National Heart, Lung and Blood Institute of the NIH (R01-HL139865) and (R01-HL155915); the French National Research Agency (ANR) (ANR-21-CE45-0023-01); the Leducq Foundation (21CVD01); The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai; and the Helmsley Foundation Award (2209-05535).

About the Icahn School of Medicine at Mount Sinai

The Icahn School of Medicine at Mount Sinai is internationally renowned for its outstanding research, educational, and clinical care programs. It is the sole academic partner for the eight- member hospitals* of the Mount Sinai Health System, one of the largest academic health systems in the United States, providing care to a large and diverse patient population.

Ranked 14th nationwide in National Institutes of Health (NIH) funding and among the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges, Icahn Mount Sinai has a talented, productive, and successful faculty.More than 3,000 full-time scientists, educators, and clinicians work within and across 44 academic departments and 36 multidisciplinary institutes, a structure that facilitates tremendous collaboration and synergy.Our emphasis on translational research and therapeutics is evident in such diverse areas as genomics/big data, virology, neuroscience, cardiology, geriatrics, as well as gastrointestinal and liver diseases.

Icahn Mount Sinai offers highly competitive MD, PhD, and Masters degree programs, with current enrollment of approximately 1,300 students.It has the largest graduate medical education program in the country, with more than 2,000 clinical residents and fellows training throughout the Health System.In addition, more than 550 postdoctoral research fellows are in training within the Health System.

A culture of innovation and discovery permeates every Icahn Mount Sinai program.Mount Sinais technology transfer office, one of the largest in the country, partners with faculty and trainees to pursue optimal commercialization of intellectual property to ensure that Mount Sinai discoveries and innovations translate into healthcare products and services that benefit the public.

Icahn Mount Sinais commitment to breakthrough science and clinical care is enhanced by academic affiliations that supplement and complement the Schools programs.

Through the Mount Sinai Innovation Partners (MSIP), the Health System facilitates the real-world application and commercialization of medical breakthroughs made at Mount Sinai. Additionally, MSIP develops research partnerships with industry leaders such as Merck & Co., AstraZeneca, Novo Nordisk, and others.

The Icahn School of Medicine at Mount Sinai is located in New York City on the border between the Upper East Side and East Harlem, and classroom teaching takes place on a campus facing Central Park. Icahn Mount Sinais location offers many opportunities to interact with and care for diverse communities.Learning extends well beyond the borders of our physical campus, to the eight hospitals of the Mount Sinai Health System, our academic affiliates, and globally.

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*Mount Sinai Health System member hospitals: The Mount Sinai Hospital; Mount Sinai Beth Israel; Mount Sinai Brooklyn; Mount Sinai Morningside; Mount Sinai Queens; Mount Sinai South Nassau; Mount Sinai West; and New York Eye and Ear Infirmary of Mount Sinai.

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Novel Genetic Priority Score Unveiled to Enhance Target Prioritization in Drug Development - Mount Sinai