Seeking a Perfect Risk-Benefit Balance in Treating VTE
At the dawn of the 21st century, venous thromboembolism (VTE) treatment remained in the dark ages. Backed by an MD and a legacy of paternalistic practice, we convinced patients to do what now seems unthinkable. Unfractionated heparin may come from pigs and cattle, but we infused it like snake oil. Patients spent 5 (or more) days in the hospital chasing partial thromboplastin times and enduring stops and starts with repeated blood draws. Finally, we discharged them on the only drug awful enough to require an eponymous nursing position and clinic.
Our approach to balancing risk-benefit was equally primitive. Patients diagnosed with their first VTE were given the proverbial 'trial of life.' They generally received 3-6 months of anticoagulation before being advised to stop, with guidance as blithe as it was vague: 'If you feel short of breath, go to the emergency room.' It mattered not whether their initial clot was a pulmonary embolism or a deep vein thrombosis. Or whether there was comorbid cardiopulmonary disease. If they had a second VTE, assuming they survived it, the initial treatment regimen (including the hospitalization) was repeated.
By 2008, our guidelines had incorporated data showing that for unprovoked events, fixed courses of anticoagulation provided less mitigation than delay. This pushed risk-benefit analysis to the forefront of all things VTE. Physicians, and patients, were forced to balance VTE recurrence with bleeding risk and decide whether to stop treatment after 3 months or continue it indefinitely. Shortly thereafter, the novel blood thinners hit the market, making indefinite anticoagulation slightly more palatable.
Meanwhile, the field continued to refine risk calculations. D-dimer testing had its moment in the sun before being knocked down a notch by the 2016 CHEST VTE guidelines. Lower-extremity ultrasound also helped, but it wasn't quite clear where and how it fit into overall risk after accounting for other factors. Both have given way to more complicated models that perform well in particular situations. There are even online risk calculators to help battle the viscous time scarcity epidemic afflicting all 21st century medicine clinics.
The latest breakthrough reduces bleeding more than VTE recurrence risk. In 2013, the AMPLIFY-EXT trial showed that after 6 months of full-dose treatment, a half dose of apixaban reduced bleeding without increasing recurrence risk. Not to be outdone, these findings were replicated using rivaroxaban in the EINSTEIN CHOICE study. Taken together, AMPLIFY-EXT and EINSTEIN CHOICE provide strong evidence that for those with a first episode of VTE with clinical equipoise (defined as uncertainty as to whether risk-benefit favored continued treatment) after 6 months of full-dose anticoagulation, reduced doses of apixaban or rivaroxaban are excellent options. The most recent iteration of the CHEST VTE Treatment Guidelines endorses this practice.
Because AMPLIFY-EXT and EINSTEIN CHOICE had the "clinical equipoise" proviso in their inclusion criteria, cancer patients were largely excluded. There's generally not equipoise for them; VTE recurrence risk is expected to remain indefinitely high, requiring indefinite protection. So, the practice of reduced dosing could not be generalized to cancer-related VTE — until now.
The API-CAT investigators very recently published reduced-dose data for cancer patients. Turns out, it works! As the accompanying editorial points out, advances in cancer treatment have led to increased survival times. Longer survival with active cancer translates to more cancer-related VTE. The API-CAT data are a critical addition to the literature. The sooner they're incorporated, the better.
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CBS News
23 minutes ago
- CBS News
How medical debt impacts your credit (and what you can do about it)
We may receive commissions from some links to products on this page. Promotions are subject to availability and retailer terms. If you're dealing with unpaid medical debt, it could hurt your credit — but there are ways to resolve the today's healthcare landscape, even a brief hospital visit can leave behind a mountain of bills. And with insurance not always covering everything — or in some cases, anything — many Americans are left grappling with medical debts they never expected to face. In 2024, about 20 million Americans, or nearly 1 in 12 adults, owed money for medical debt, according to the Survey of Income and Program Participation (SIPP) survey. The impact of this type of debt can be more than financial, though. Medical debt often hits during a time of personal crisis — after an accident, illness or surgery — leaving people emotionally overwhelmed and financially vulnerable. And when those bills go unpaid, the stress can compound as collections calls start and credit scores begin to slip. For many, this debt is not the result of overspending or poor budgeting, but simply the price of getting necessary care. Luckily, recently updated credit reporting rules and a range of relief programs are starting to ease the burden for many patients. But it's still important to understand exactly how medical debt affects your credit and what steps you can take to protect yourself. Find out how to get help with your debt problems today. How medical debt impacts your credit Medical debt used to be one of the quickest ways to damage your credit score. Even small unpaid bills could end up in collections and drag down your credit for years. But relatively recent changes from the three major credit bureaus — Experian, TransUnion and Equifax — have shifted how this type of debt is handled. Here's what changed: Paid medical collections no longer appear on credit reports. If you settle or pay off your medical debt, it should no longer hurt your credit, even after it goes to collections. If you settle or pay off your medical debt, it should no longer hurt your credit, even after it goes to collections. There's now a one-year waiting period. Medical bills sent to collections won't be added to your credit report for 12 months, giving you time to resolve them or work out a payment plan. Smaller debts are excluded. Medical collections under $500 no longer appear on credit reports at all. These reforms mean that unpaid medical bills might not damage your credit as quickly or as severely as they once did. Still, if a large medical balance goes unresolved for too long, it can eventually show up on your report and lower your credit score, especially if you don't take action during that one-year grace period. It's also important to know that while medical debt is handled differently than credit card or loan debt, lenders don't necessarily make that distinction. A collection is a collection, and any mark on your credit report can impact your ability to get approved for a loan, rent an apartment or even land certain jobs. Explore your debt relief options with the help of an expert now. What you can do about your medical debt If you're struggling with medical debt, you have options. Taking action sooner rather than later can help you avoid collections and limit the potential damage to your credit score. Here are some strategies worth considering: Review and negotiate your bills Start by carefully reviewing every bill for errors or duplicate charges. Medical billing mistakes are surprisingly common. If something doesn't look right, call the provider or hospital's billing department and ask for an itemized statement. Once you verify the charges, see if the provider will negotiate. Many are willing to offer discounts for prompt payment, set up interest-free payment plans or even reduce what you owe if you demonstrate financial hardship. Apply for financial assistance Nonprofit hospitals are legally required to offer financial assistance programs to eligible patients. If you're low-income or facing financial hardship, you may qualify for partial or full forgiveness, even if the bill has already gone to collections. Ask your provider's billing office for an application. Consider a debt relief program If your medical debt is substantial or you're juggling multiple types of unsecured debt, a debt relief program, like debt settlement, may be worth exploring. Debt settlement programs work by negotiating with your creditors to settle your debts for less than the full amount owed. There are also debt relief programs that consolidate your debts into a single monthly payment, which can make them easier to manage. Keep in mind, however, that while debt settlement can help resolve medical collections, it may come with risks, such as fees, tax implications and temporary credit score drops, so it's important to work with a reputable provider and understand the trade-offs. Monitor your credit Your credit report should reflect any paid or settled medical debts accurately, but that may not always be the case. So, be sure to check your credit report regularly to ensure no incorrect medical collections are listed. If you spot an error, dispute it with the credit bureau directly. The bottom line Medical debt can feel uniquely unfair, as it often comes out of nowhere and hits when you're least prepared. But while it has the potential to hurt your credit, changes in how this debt is reported now offer more breathing room. You still need to act quickly and proactively, but there's a path forward even when the bills seem insurmountable. From negotiating with providers to seeking financial aid or working with a debt relief program, there are ways to tackle medical debt without wrecking your financial future. So, know your options and use the time you have before those bills end up on your credit report to tackle the issue before it compounds.
Health Line
28 minutes ago
- Health Line
CHAMPVA and Medicare: Which Is Primary?
You can use CHAMPVA and Medicare at the same time. When you use Medicare together with CHAMPVA, Medicare is the primary payer. CHAMPVA is a cost-sharing health coverage program for some military families who don't qualify for TRICARE. You can use CHAMPVA with Medicare when you're eligible for both programs. CHAMPA will be the secondary payer to Medicare and will pay most of your out-of-pocket costs. Since there are no additional premiums if you qualify for CHAMPVA, using it alongside Medicare can significantly lower your healthcare costs. Glossary of common Medicare terms Out-of-pocket cost: This is the amount you pay for care when Medicare doesn't pay the full cost or offer coverage. It includes premiums, deductibles, coinsurance, and copayments. Premium: This is the monthly amount you pay for Medicare coverage. Deductible: This is the annual amount you must spend out of pocket before Medicare begins to cover services and treatments. Coinsurance: This is the percentage of treatment costs you're responsible for paying out of pocket. With Medicare Part B, you typically pay 20%. Copayment: This is a fixed dollar amount you pay when receiving certain treatments or services. With Medicare, this often applies to prescription medications. What is CHAMPVA? The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a healthcare plan for certain dependents of veterans. CHAMPVA is a different program from TRICARE, which also services military members, veterans, and their families. TRICARE eligibility is open to people who are: active or retired uniformed service members spouses or children of active or retired uniformed service members members of the Army National Guard or Reserve spouses or children of Army National Guard or Reserve members spouses or children of deceased military members certain former spouses of military members Medal of Honor recipients spouses and children of Medal of Honor recipients You can't use CHAMPVA if you have or are eligible for TRICARE. CHAMPVA helps cover certain dependents who aren't eligible for TRICARE. For example, service members who leave active duty under certain conditions might not qualify for TRICARE. However, if they have a disability caused by their service, their family may be able to enroll in CHAMPVA. How does CHAMPVA work with Medicare? Since 2001, CHAMPVA beneficiaries have been able to use their coverage after turning 65 years old. This means CHAMPVA can be used alongside Medicare. You'll need to be enrolled in Medicare to keep your CHAMPVA coverage. Here are the rules for how that works: If you turned age 65 before June 5, 2001, and did not have Medicare Part B at the time, you only need to be enrolled in Medicare Part A to keep your CHAMPVA coverage. If you turned age 65 before June 5, 2001, and were already enrolled in Part B at that time, you need to be enrolled in both Part A and Part B to keep your CHAMPVA coverage. If you turned 65 years old after June 5, 2001, you need to be enrolled in parts A and B to keep your CHAMPVA coverage. Example For example, let's say you turned 65 years old in 1999 and enrolled in Medicare parts A and B. You won't be able to drop your Part B coverage and keep your CHAMPVA coverage. However, if you turned age 65 in 1999 and enrolled in only Part A, you wouldn't need to sign up for Part B to keep your CHAMPVA coverage. You can use CHAMPVA alongside: Original Medicare (parts A and B) Medicare Advantage (Part C) Medicare Part D, which is prescription drug coverage It's important to note that CHAMPVA won't pay for the cost of your Part B premium. You should also know that you can no longer use VA healthcare facilities or healthcare professionals once you're enrolled in Medicare. What services does CHAMPVA cover? CHAMPVA is a cost-sharing health insurance program. This means it will pay a portion of the cost of health services you receive, and you'll pay the remaining amount. You won't pay a premium for CHAMPVA, but there is a $50 deductible before coverage kicks in. After you pay your deductible, CHAMPVA will pay what's known as the 'allowable amount' for all covered services. Generally, CHAMPVA will pay 75% of the allowable amount, and you'll pay the other 25%. Covered services include: hospital stays primary care doctor visits specialist visits lab work skilled nursing care home care ambulance transportation mental health services prescription drugs There are two other completely covered benefits: Hospice care from any provider is 100% covered under CHAMPVA. You can also get prescription coverage at no cost to you if you use the Department of Veterans Affairs (VA) Meds by Mail program, if you have no other prescription drug coverage. Coverage works differently if you use CHAMPVA alongside another health insurance plan, including Medicare. When you use CHAMPVA with another insurance plan, CHAMPVA becomes what's called a secondary payer. This means your other insurance plan will be billed first, and CHAMPVA will then pay the remaining cost. This can save you a lot of money on out-of-pocket medical expenses like copayments or coinsurance amounts. Who pays first for healthcare costs? Medicare is the primary payer when you use it with CHAMPVA. This means Medicare will be the first to pay the cost of any service you receive, and then CHAMPVA will pay the rest. You'll have very few out-of-pocket costs using CHAMPVA and Medicare together since CHAMPVA will generally pay any copayments or coinsurance amounts. You can expect to pay: nothing out of pocket for any service that both Medicare and CHAMPVA cover your Medicare coinsurance cost of 20% for a service Medicare covers, but CHAMPVA doesn't your CHAMPVA cost sharing of 25% for anything CHAMPVA covers, but Medicare doesn't The same rules apply to Medicare Part D. CHAMPVA will pick up your copayments on all covered prescriptions. It will also pay 75% of the cost of prescriptions that your Medicare Part D plan doesn't cover. Present both your Medicare Part D plan card and your CHAMPVA ID card at your in-network pharmacy for coverage. Getting your coverage questions answered If you're not sure who will pay for a service, you can check ahead of time by: calling Medicare's Benefits Coordination & Recovery Center at 855-798-2627 (TTY: 855-797-2627) calling CHAMPVA customer care at 800-733-8387, Monday through Friday from 8:05 a.m. to 7:30 p.m. Eastern Standard Time What about Medicare Advantage? You can use your CHAMPVA coverage with a Medicare Advantage plan. Since Medicare Advantage plans replace Original Medicare, having an Advantage plan still meets the requirement to be enrolled in Medicare to keep CHAMPVA once you're age 65. Your Medicare Advantage plan will be the primary payer, just like when you have Original Medicare. CHAMPVA will pay your copayments and other out-of-pocket costs. Your bill will go to your Medicare Advantage plan first and then to CHAMPVA. In most cases, you won't have any out-of-pocket costs. Many Medicare Advantage plans also include Part D coverage. When you use a Medicare Advantage plan that includes Part D along with CHAMPVA, your CHAMPVA benefits will pick up the cost of your prescription copayments. Medicare Advantage plans often have networks. The network includes all the providers that your Medicare Advantage plan will cover healthcare services. In many cases, you'll need to pay out of pocket for any services you receive from an out-of-network provider. However, when you use CHAMPVA along with your Medicare Advantage plan, you can often get 75% of the cost of out-of-network services covered. How do I choose the right coverage options for me? You need to enroll in Original Medicare (parts A and B) to keep your CHAMPVA coverage. You can also choose to enroll in additional Medicare parts, such as: Medicare Advantage Medigap Medicare Part D The best option for you will depend on your personal needs and budget. Medicare Advantage, Medigap, and Medicare Part D plans have their own premiums, deductibles, and other costs. CHAMPVA can cover some of these costs, but not your premiums. You might not even need additional Medicare parts if you're using CHAMPVA. For example, Medigap plans are designed to cover the out-of-pocket costs of Medicare parts A and B. However, since CHAMPVA already does this when you use it alongside Medicare, you might not need a Medigap plan. Here are some other common scenarios to consider: Original Medicare + CHAMPVA Let's say you have CHAMPVA and Medicare parts A and B, and you choose not to enroll in any other Medicare plans. You'd pay the Medicare Part B premium, and Medicare would be your primary payer for all covered services. You could get prescriptions for 25% of the allowable amount at a pharmacy or completely covered if you use the Meds by Mail program using only CHAMPVA. Original Medicare + Part D + CHAMPVA You have CHAMPVA, Medicare parts A and B, and a Part D plan. You'd pay the Medicare Part B premium and the premium for your Part D plan. Medicare would be the primary payer for services and prescriptions. CHAMPVA would pick up your copayments and coinsurance amounts. Medicare Advantage + CHAMPVA You have CHAMPVA and a Medicare Advantage plan that includes Part D coverage. You'd pay the Medicare Part B premium plus the premium for your Medicare Advantage plan. Medicare would be the primary payer for your services and prescriptions. CHAMPVA would pay your copayments and coinsurance. Ways to save on Medicare coverage It's worth noting that you may be able to find Medicare Advantage or Medigap plans in your area with $0 premiums. You can shop for plans in your area on the Medicare website and compare prices, networks, and covered services before you commit to a plan. You can also look for savings on your Medicare coverage. You might qualify for programs to help lower your costs if you have a limited income. These programs include: Extra Help, which lowers your prescription drug costs Medicare savings programs, which can lower your costs for parts A and B Ultimately, the right plan for you depends on your needs and your budget. You'll want to select a plan that includes: the doctors you want to see any prescriptions you take any services you need You can also search for premiums in your price range, and those with out-of-pocket costs you can manage. How do I know if I'm eligible for CHAMPVA? You're eligible for CHAMPVA if you're the dependent child or the current or widowed spouse of a veteran who meets one of these conditions: is permanently and totally disabled from a service-related injury or disability was permanently and totally disabled from a service-related injury or disability at the time of their death died from service-related injury or disability died during active duty is not eligible for TRICARE There is no premium cost for CHAMPVA coverage. You can apply for CHAMPVA at any time. You'll need to send in an application along with documents that prove your eligibility. Depending on your circumstances, these might include: service records marriage records birth certificates You'll also need to send in information about any other insurance plan you currently have. Your application will generally be processed in 3 to 6 weeks. If your application is approved, you will receive a CHAMPVA card in the mail. As soon as your card arrives, you can start using CHAMPVA coverage. The takeaway When you use CHAMPVA with Medicare, CHAMPVA acts as the secondary payer. CHAMPVA doesn't cover Medicare premiums but will cover most of your other out-of-pocket healthcare expenses. CHAMPVA pays 75% of the cost of most services. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
CNN
43 minutes ago
- CNN
How Trump's pick for surgeon general uses her big online following to make money
Trump appointments Social media Donald Trump MediaFacebookTweetLink Follow President Donald Trump's pick to be the next U.S. surgeon general has repeatedly said the nation's medical, health and food systems are corrupted by special interests and people out to make a profit at the expense of Americans' health. Yet as Dr. Casey Means has criticized scientists, medical schools and regulators for taking money from the food and pharmaceutical industries, she has promoted dozens of health and wellness products — including specialty basil seed supplements, a blood testing service and a prepared meal delivery service — in ways that put money in her own pocket. A review by The Associated Press found Means, who has carved out a niche in the wellness industry, set up deals with an array of businesses. In her newsletter, on her social media accounts, on her website, in her book and during podcast appearances, the entrepreneur and influencer has at times failed to disclose that she could profit or benefit in other ways from sales of products she recommends. In some cases, she promoted companies in which she was an investor or adviser without consistently disclosing the connection, the AP found. Means, 37, has said she recommends products that she has personally vetted and uses herself. She is far from the only online creator who doesn't always follow federal transparency rules that require influencers to disclose when they have a 'material connection' to a product they promote. Still, legal and ethics experts said those business entanglements raise concerns about conflicting interests for an aspiring surgeon general, a role responsible for giving Americans the best scientific information on how to improve their health. 'I fear that she will be cultivating her next employers and her next sponsors or business partners while in office,' said Jeff Hauser, executive director of the Revolving Door Project, a progressive ethics watchdog monitoring executive branch appointees. The nomination, which comes amid a whirlwind of Trump administration actions to dismantle the government's public integrity guardrails, also has raised questions about whether Levels, a company Means co-founded that sells subscriptions for devices that continuously monitor users' glucose levels, could benefit from this administration's health guidance and policy. Though scientists debate whether continuous glucose monitors are beneficial for people without diabetes, U.S. Health Secretary Robert F. Kennedy Jr. has promoted their use as a precursor to making certain weight-loss drugs available to patients. The aspiring presidential appointee has built her own brand in part by criticizing doctors, scientists and government officials for being 'bought off' or 'corrupt' because of ties to industry. Means' use of affiliate marketing and other methods of making money from her recommendations for supplements, medical tests and other health and dietary products raise questions about the extent to which she is influenced by a different set of special interests: those of the wellness industry. Means earned her medical degree from Stanford University, but she dropped out of her residency program in Oregon in 2018, and her license to practice is inactive. She has grown her public profile in part with a compelling origin story that seeks to explain why she left her residency and conventional medicine. 'During my training as a surgeon, I saw how broken and exploitative the healthcare system is and left to focus on how to keep people out of the operating room,' she wrote on her website. Means turned to alternative approaches to address what she has described as widespread metabolic dysfunction driven largely by poor nutrition and an overabundance of ultra-processed foods. She co-founded Levels, a nutrition, sleep and exercise-tracking app that can also give users insights from blood tests and continuous glucose monitors. The company charges $199 per year for an app subscription and an additional $184 per month for glucose monitors. Means has argued that the medical system is incentivized not to look at the root causes of illness but instead to maintain profits by keeping patients sick and coming back for more prescription drugs and procedures. 'At the highest level of our medical institutions, there are conflicts of interest and corruption that are actually making the science that we're getting not as accurate and not as clean as we'd want it,' she said on Megyn Kelly's podcast last year. But even as Means decries the influence of money on science and medicine, she has made her own deals with business interests. During the same Megyn Kelly podcast, Means mentioned a frozen prepared food brand, Daily Harvest. She promoted that brand in a book she published last year. What she didn't mention in either instance: Means had a business relationship with Daily Harvest. Influencer marketing has expanded beyond the beauty, fashion and travel sectors to 'encompass more and more of our lives,' said Emily Hund, author of 'The Influencer Industry: The Quest for Authenticity on Social Media.' With more than 825,000 followers on Instagram and a newsletter that she has said reached 200,000 subscribers, Means has a direct line into the social media feeds and inboxes of an audience interested in health, nutrition and wellness. Affiliate marketing, brand partnerships and similar business arrangements are growing more popular as social media becomes increasingly lucrative for influencers, especially among younger generations. Companies might provide a payment, free or discounted products or other benefits to the influencer in exchange for a post or a mention. But most consumers still don't realize that a personality recommending a product might make money if people click through and buy, said University of Minnesota professor Christopher Terry. 'A lot of people watch those influencers, and they take what those influencers say as gospel,' said Terry, who teaches media advertising and internet law. Even his own students don't understand that influencers might stand to benefit from sales of the products they endorse, he added. Many companies, including Amazon, have affiliate marketing programs in which people with substantial social media followings can sign up to receive a percentage of sales or some other benefit when someone clicks through and buys a product using a special individualized link or code shared by the influencer. Means has used such links to promote various products sold on Amazon. Among them are books, including the one she co-wrote, 'Good Energy'; a walking pad; soap; body oil; hair products; cardamom-flavored dental floss; organic jojoba oil; a razor set; reusable kitchen products; sunglasses; a sleep mask; a silk pillowcase; fitness and sleep trackers; protein powder and supplements. She also has shared links to products sold by other companies that included 'affiliate' or 'partner' coding, indicating she has a business relationship with the companies. The products include an AI-powered sleep system and Daily Harvest, for which she curated a 'metabolic health collection.' On a 'My Faves' page that was taken down from her website shortly after Trump picked her, Means wrote that some links 'are affiliate links and I make a small percentage if you buy something after clicking them.' It's not clear how much money Means has earned from her affiliate marketing, partnerships and other agreements. Daily Harvest did not return messages seeking comment, and Means said she could not comment on the record during the confirmation process. Means has raised concerns that scientists, regulators and doctors are swayed by the influence of industry, oftentimes pointing to public disclosures of their connections. In January, she told the Kristin Cavallari podcast 'Let's Be Honest' that 'relationships are influential.' 'There's huge money, huge money going to fund scientists from industry,' Means said. 'We know that when industry funds papers, it does skew outcomes.' In November, on a podcast run by a beauty products brand, Primally Pure, she said it was 'insanity' to have people connected to the processed food industry involved in writing food guidelines, adding, 'We need unbiased people writing our guidelines that aren't getting their mortgage paid by a food company.' On the same podcast, she acknowledged supplement companies sponsor her newsletter, adding, 'I do understand how it's messy.' Influencers who endorse or promote products in exchange for payment or something else of value are required by the Federal Trade Commission to make a clear and conspicuous disclosure of any business, family or personal relationship. While Means did provide disclosures about newsletter sponsors, the AP found in other cases Means did not always tell her audience when she had a connection to the companies she promoted. For example, a 'Clean Personal & Home Care Product Recommendations' guide she links to from her website contains two dozen affiliate or partner links and no disclosure that she could profit from any sales. Means has said she invested in Function Health, which provides subscription-based lab testing for $500 annually. Of the more than a dozen online posts the AP found in which Means mentioned Function Health, more than half did not disclose she had any affiliation with the company. Means also listed the supplement company Zen Basil as a company for which she was an 'Investor and/or Advisor.' The AP found posts on Instagram, X and on Facebook where Means promoted its products without disclosing the relationship. Though the 'About' page on her website discloses an affiliation with both companies, that's not enough, experts said. She is required to disclose any material connection she has to a company anytime she promotes it. Representatives for Function Health did not return messages seeking comment through their website and executives' LinkedIn profiles. Zen Basil's founder, Shakira Niazi, did not answer questions about Means' business relationship with the company or her disclosures of it. She said the two had known each other for about four years and called Means' advice 'transformational,' saying her teachings reversed Niazi's prediabetes and other ailments. 'I am proud to sponsor her newsletter through my company,' Niazi said in an email. While the disclosure requirements are rarely enforced by the FTC, Means should have been informing her readers of any connections regardless of whether she was violating any laws, said Olivier Sylvain, a Fordham Law School professor who was previously a senior adviser to the FTC chair. 'What you want in a surgeon general, presumably, is someone who you trust to talk about tobacco, about social media, about caffeinated alcoholic beverages, things that present problems in public health,' Sylvain said, adding, 'Should there be any doubt about claims you make about products?' Means isn't the first surgeon general nominee whose financial entanglements have raised eyebrows. Jerome Adams, who served as surgeon general from 2017 to 2021, filed federal disclosure forms that showed he invested in several health technology, insurance and pharmaceutical companies before taking the job — among them Pfizer, Mylan and UnitedHealth Group. He also invested in the food and drink giant Nestle. He divested those stocks when he was confirmed for the role and pledged that he and his immediate family would not acquire financial interest in certain industries regulated by the Food and Drug Administration. Vivek Murthy, who served as surgeon general twice, under Presidents Barack Obama and Joe Biden, made more than $2 million in COVID-19-related speaking and consulting fees from Carnival, Netflix, Estee Lauder and Airbnb between holding those positions. He pledged to recuse himself from matters involving those parties for a period of time. Means has not yet gone through a Senate confirmation hearing and has not yet announced the ethical commitments she will make for the role. Hund said that as influencer marketing becomes more common, it is raising more ethical questions, such as what past influencers who enter government should do to avoid the appearance of a conflict. Other administration officials, including Homeland Security Secretary Kristi Noem and Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz, have also promoted companies on social media without disclosing their financial ties. 'This is like a learning moment in the evolution of our democracy,' Hund said. 'Is this a runaway train that we just have to get on and ride, or is this something that we want to go differently?'
