By Paula Span, for The New York Times.

When Janet Halloran last saw her primary care physician, the doctor asked whether she had undergone her annual mammogram. Yes, she replied, she had.

At 76, Ms. Halloran, a real estate broker in Cambridge, Mass., is past the age that most medical guidelines recommend breast cancer screening for someone with no history of the disease. Even for younger women, the guidelines call for a mammogram every other year, not annually.

So Ms. Halloran could consider stopping mammograms, or at least having them less often. But her doctor has never discussed that prospect. “She says, ‘These are the things you need to do,’” Ms. Halloran said. Besides, she added, it’s an easy test: “Go once a year, hold your breath and you’re done for another year. It’s just routine.”

But for older women, should it be?

“There’s been a lot of uncertainty,” said Dr. Xabier Garcia-Albéniz, an oncologist and epidemiologist at RTI Health Solutions and lead author of a new observational study that tries to answer that question. “This is an area with a complete lack of randomized clinical trials.”

Breast cancer studies, like medical research in general, have often excluded older subjects. So the data on whether mammography improves survival is very limited in women ages 70 to 74, and nonexistent for those 75 and older.

That’s why the independent U.S. Preventive Services Task Force has concluded that while having mammograms every other year improves survival for women ages 50 to 74, there’s “insufficient” evidence to assess their use for those over 75.

The American Geriatrics Society includes screening for breast and other cancers on its Choosing Wisely list of tests that should be questioned. It urges doctors not to recommend it “without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.”

Yet more than half of women over 75 have had a screening mammogram (a test for individuals with no history or symptoms of breast cancer) within the past two years, the Centers for Disease Control and Prevention reported in 2018.

“Whether this investment in breast cancer screening alters survival is a critical question,” said Dr. John Hsu, a health services researcher at Harvard Medical School and senior author of the new study, published in the Annals of Internal Medicine.

3 Medical Routines That Older People May Not Need

The research team used Medicare claims from 2000 to 2008 to follow more than one million women, ages 70 to 84, who had undergone a mammogram.

They had never had breast cancer and had a “high probability,” based on their medical histories, of living at least 10 more years. “That’s the population who will reap the benefit of screening,” Dr. Garcia-Albéniz said, because it takes 10 years for mammography to show reduced mortality.

The researchers divided the subjects into two groups: one that stopped screening, and another that continued having mammograms at least every 15 months. They found that mammograms provided a survival benefit, if a modest one, for women ages 70 to 74. In line with previous research, the study found that annually screening 1,000 women in that age group would result, after 10 years, in one less death from breast cancer.

But among the women who were 75 to 84, annual mammograms did not reduce deaths, although they did, predictably, detect more cancer than in the group that discontinued screening.

“You’re diagnosing more cancer, but that’s not translating to a mortality benefit,” Dr. Garcia-Albéniz said.

Why not? “The cancers themselves might be different at different ages,” Dr. Hsu said. “They might grow faster or slower, or be more likely to spread.”

Treatments may also be less effective at older ages, said Dr. Otis Brawley, an oncologist and epidemiologist at the Johns Hopkins University School of Medicine, who wrote an editorial accompanying the study.

But older people typically are also subject to what researchers call “competing mortality.” Many of the cancers detected by mammography — tiny tumors that earlier technology wouldn’t have spotted — are unlikely to cause any harm if left untreated. But most older people have other diseases that will progress.

“It’s very difficult to tell someone in her 70s or 80s that we’re going to modify your treatment, or not treat you, because of the likelihood that something else will kill you before this cancer will,” Dr. Brawley said.

That reluctance to discuss life expectancy and the limitations of screening also means that many women don’t recognize that, in addition to being inconvenient, expensive and a cause of discomfort or anxiety, mammograms can actually do harm. The tests often prompt unneeded surgery, radiation or drug regimens for cancers that would never have caused symptoms or shortened lives.

Still, because life expectancy varies widely, some very healthy older women may live long enough to benefit and may indeed want screening. Mammograms could lead to treating an aggressive cancer earlier, and with less extensive surgery, for instance.

“I would be very happy if doctors started using our paper to inform the discussion they have with their patients,” Dr. Garcia-Albéniz said.

Yet women remain so committed to regular mammograms that experts doubt they could recruit enough people for a large randomized trial in which half the subjects forgo the tests.

Dr. Mara Schonberg, an internist at Beth Israel Deaconess Hospital in Boston, has worked for years to help women make decisions about breast cancer screening, and has found it tough going.

“These women were told for 40 years to get screened,” Dr. Schonberg said. “They get reassurance from a negative mammogram. And it’s very hard to understand that finding breast cancer early may not help you live longer or better.”

To help explain, Dr. Schonberg developed a decision aid: a brochure, written at a sixth-grade reading level, that uses research findings to explain the pros and cons.

A pilot study showed that, after reading it, women from 75 to 89 were more knowledgeable about mammography, more apt to discuss it with their doctors and less enthusiastic about continuing it.

But they did continue. More than 60 percent, including those with lower life expectancies, had another mammogram within 15 months. A larger study with 546 participants, being readied for publication, will report similar results, Dr. Schonberg said.

Perhaps, as Dr. Brawley said, “the most important thing we can do is get people to understand what the questions are, and to understand that nobody has the exact answers.”

But Dr. Schonberg’s grandmother, who followed her doctor’s recommendation and had a mammogram at age 78, came to a more definitive conclusion.

Ann Schonberg was a Detroit homemaker and a lifelong smoker with mild emphysema. When her mammogram found a small Stage 1 cancer, she underwent a lumpectomy and began endocrine therapy, taking drugs that might lower the risk of recurrence. “She didn’t like how she felt, so she stopped everything after three years,” Dr. Schonberg said.

When Ann Schonberg reached her mid 80s, a mammogram picked up another small cancer, prompting another lumpectomy. At the same time, although she had stopped smoking at 80, her emphysema worsened steadily. That is what caused her death at 88, not breast cancer.

“All the doctors’ appointments, the surgeries, the worry — for her, it was all for naught,” Dr. Schonberg said. Shortly before Ann Schonberg’s death, she told her granddaughter, “I wish I’d never had that mammogram.”

By Rebecca Torrence, Fierce Healthcare, Feb 08, 2022.

Machine learning has numerous potential applications for health insurers, including in predicting disease onset, future hospitalizations and medication adherence.

But when bias creeps into the development or use of machine learning models, technologies that intend to improve health outcomes can create barriers for certain patients.

In an analysis published in Health Affairs, researchers from Independence Blue Cross, the Massachusetts Institute of Technology and the University of California Berkeley identified several areas where bias can arise in machine learning tools used by health insurers and outlined recommendations for tackling those issues.

Predictive modeling is among the most well-known culprits of bias built into healthcare algorithms. Payers don’t rely solely on risk-based predictive modeling to identify potentially at-risk members, but typically use a combination of predictive modeling, risk scores from commercial vendors, and “if-then” business rules to allocate healthcare resources to those members, the authors wrote.

Disease onset predictive models are less likely to be developed for diseases that impact a smaller segment of the population, or for diseases that don’t have easily scalable interventions, which may leave marginalized communities unaccounted for.

Because these models rely on utilization data to generate predictions, patients who seek care less frequently will contribute less data to the models.

Any data used as the foundation of the model could also be skewed if the provider collecting those data exhibited explicit or implicit biases.

Implicit bias in patient-provider interactions has been heavily studied in recent years. Just last month, a study conducted by the University of Chicago found that Black patients were two-and-a-half times as likely as white patients to be given negative descriptors like “aggressive” or “non-compliant” in their electronic health records.

Similar issues arise with machine learning models that predict the likelihood of avoidable hospitalizations, as barriers to access and use can influence the model’s target population and reinforce existing inequities.

The researchers suggest integrating data that account for social determinants of health, including socioeconomic status, education level, housing and access to transportation, food, and healthcare, into the disease onset and likelihood of hospitalization models to reduce reliance on utilization patterns.

Predictive models for medication adherence run into disparities in diagnosis—racial and ethnic minorities are less likely to be prescribed medications like antidepressants, anticoagulants, diabetes medication and opioids, even when the evidence would call for the prescription of those medications. Access to pharmacies and prescription drugs can also obscure the data.

Indirectly predicting medication adherence through contextual information could allow data scientists to find members that might benefit from lower-cost medication alternatives, the researchers suggest, and thus make them more likely to take those medications.

The analysis suggests health insurers audit their predictive models and business processes to identify potential sources of bias using a variety of strategies.

To ensure each racial and ethnic group is accurately represented in the data, rates of outreach and engagement in care management programs should reflect the proportions of each group in the population at large. Insurers should also examine their rates of false negatives and false positives for predictions and conduct analyses to determine whether those rates differ significantly on the basis of race, ethnicity or gender.

Counterfactual reasoning, the researchers posit, can also be used to consider if a person would’ve received a different prediction if they were a member of a different subpopulation despite their health profile.

Addressing biases in machine learning models can determine whether members receive high-quality care. The analysis notes the importance of payers collecting data on social determinants of health and using those data ethically, as well as working across the industry to reduce barriers to care to ensure these technologies aim to tackle health disparities rather than exacerbate them.

Article link

Americans will most likely pay significantly more for Covid medical care during this new wave of cases — whether that’s a routine coronavirus test or a lengthy hospitalization.

Earlier in the pandemic, most major health insurers voluntarily waived costs associated with a Covid treatment. Patients didn’t have to pay their normal co-payments or deductibles for emergency room visits or hospital stays.

Most Covid tests were free, too.

The landscape has since changed, as the pandemic persists into its second year. Federal law still requires insurers to cover testing at no cost to the patient when there is a medical reason for seeking care, such as exposure to the disease or a display of symptoms. But more of the tests sought now don’t meet the definition of “medical reason” and are instead for monitoring.

And insurers are now treating Covid more like any other disease, no longer fully covering the costs of care. Some businesses, like Delta Air Lines, are planning to charge unvaccinated employees higher rates for insurance, citing in part the high hospitalization costs for Covid cases.

“Insurers are confronting the question about whether the costs of Covid treatment should fall on everyone, or just the individuals who have chosen not to get a vaccine,” said Cynthia Cox, a vice president at the Kaiser Family Foundation who has researched how insurers are covering Covid treatment.

The federal rules that make coronavirus testing free include exemptions for routine workplace and school testing, which has become more common as students head back to the classroom and as companies mandate regular testing for unvaccinated workers.

Because insurers are not required to cover that regular testing, some patients have already received testing bills as high as $200 for routine screenings, according to documents that patients have submitted to a New York Times project tracking the costs of Covid testing and treatment. If you’ve received a bill, you can submit it here.

Some of the highest bills, however, will probably involve Covid patients who need extensive hospital care now that most insurers no longer fully cover those bills. Seventy-two percent of large health plans are no longer making Covid treatment free for patients, a recent study from the Kaiser Family Foundation found.

This includes Blue Cross Blue Shield of Florida, the largest health plan in a state experiencing one of the country’s worst outbreaks. On Wednesday, Florida Blue began requiring patients to pay their normal deductibles and co-payments for Covid treatment. Toni Woods, a spokeswoman, said the plan was now focused on encouraging vaccinations.

“When the Covid-19 pandemic began last year, we implemented several emergency provisions to temporarily help our members,” she said in a statement. “Medical diagnostic testing for Covid-19 as well as vaccinations continue to be available to members at $0 cost share.”

Oscar Health, which sells coverage in Florida and 14 other states, also ended free Covid treatment this week. It cited the widespread availability of the vaccine as a key reason.

“We started waiving cost sharing for Covid-19 treatment at the peak of the pandemic in 2020, when there were few options available for those who fell ill with the virus,” said Jackie Khan, an Oscar spokeswoman. “We believe that the Covid vaccine is our best way to beat this pandemic, and we are committed to covering it and testing at $0 for our members.”

The new policies generally apply to all patients, including the vaccinated; people who get sick with a breakthrough infection; and children under 12, who are not yet eligible for the vaccine.

“If you have a small kid who gets Covid at school and ends up at the I.C.U., that family is going to now be stuck with the bill even though that patient did not have the ability to get vaccinated,” said Dr. Kao-Ping Chua, a pediatrician at the University of Michigan who researches Covid care costs.

The average Covid hospitalization costs approximately $40,000, researchers have found. A lengthy hospital stay — one that requires time in the intensive care unit, or a transfer by air ambulance — can cost many multiples more. Most insured patients won’t pay that entire bill; they will face whatever share they owe through deductibles and co-payments.

Dr. Chua and his colleagues published research this summer finding that, among patients who had to pay a share of their Covid hospitalization, the average costs were $3,800.

“There were some patients where it was $10,000 and others where it was $500,” he said. “It gives you some semblance of what things will now look like without the waivers.”

Surprise bills for routine Covid testing could be smaller but more common, as schools and workplaces increasingly rely on regular screening to prevent coronavirus from spreading.

At many workplaces, unvaccinated workers must submit to monitoring at least weekly. Some employers, including the federal government, plan to fully cover the costs of those tests. But others, including some hotels and universities, will ask unvaccinated workers to bear some or all of the testing costs.

Rebecca Riley recently received a $200 bill from a laboratory with an unfamiliar name. When she called to inquire about the charge, she learned it was a fee for a Covid test. Her son, a high school student, is regularly tested at his Los Angeles-area high school.

“I didn’t expect to get any bills,” she said. “I feel stupid, but I’d heard the tests were free.”

Ms. Riley contacted her insurer about the charge, and it agreed to pay the full amount. But she now worries about future surprise testing bills. “I really feel for the families that won’t be able to pay,” she said.

Article link: https://www.nytimes.com/2021/09/02/upshot/covid-medical-bills.html

MARCS-CMS 607133 — FEBRUARY 18, 2021

Recipient:

Dr. Joseph M. Mercola, DO

Mercola.com, LLC

Issuing Office:

Center for Food Safety and Applied Nutrition (CFSAN)

United States

WARNING LETTER

Date: February 18, 2021

RE: Unapproved and Misbranded Products Related to Coronavirus Disease 2019 (COVID-19)

This is to advise you that the United States Food and Drug Administration (FDA) reviewed your websites at the Internet addresses https://www.mercola.com and https://www.mercolamarket.com on February 8, 2021. We also reviewed your social media site at https://www.twitter.com/mercola, where you direct consumers to your website https://www.mercolamarket.com to purchase your products. The FDA has observed that your website offers “Liposomal Vitamin C,” “Liposomal Vitamin D3,” and “Quercetin and Pterostilbene Advanced” products for sale in the United States and that these products are intended to mitigate, prevent, treat, diagnose, or cure COVID-191 in people. Based on our review, these products are unapproved new drugs sold in violation of section 505(a) of the Federal Food, Drug, and Cosmetic Act (FD&C Act), 2pt1 U.S.C. § 355(a). Furthermore, these products are misbranded drugs under section 502 of the FD&C Act, 21 U.S.C. § 352. The introduction or delivery for introduction of these products into interstate commerce is prohibited under sections 301(a) and (d) of the FD&C Act, 21 U.S.C. § 331(a) and (d).

There is currently a global outbreak of respiratory disease caused by a novel coronavirus that has been named “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2). The disease caused by the virus has been named “Coronavirus Disease 2019” (COVID-19). On January 31, 2020, the Department of Health and Human Services (HHS) issued a declaration of a public health emergency related to COVID-19 and mobilized the Operating Divisions of HHS.2 In addition, on March 13, 2020, there was a Presidential declaration of a national emergency in response to COVID-19.3 Therefore, FDA is taking urgent measures to protect consumers from certain products that, without approval or authorization by FDA, claim to mitigate, prevent, treat, diagnose, or cure COVID-19 in people. As described below, you sell products that are intended to mitigate, prevent, treat, diagnose, or cure COVID-19 in people. We request that you take immediate action to cease the sale of such unapproved and unauthorized products for the mitigation, prevention, treatment, diagnosis, or cure of COVID-19.

Some examples of the claims on your websites that establish the intended use of your products, based on statements about the purported effects of their ingredients, and misleadingly represent them as safe and/or effective for the treatment or prevention of COVID-19 include:

• “Vitamins C and D are finally being adopted in the conventional treatment of novel coronavirus, SARS-CoV2. This fortunate turn of events is likely to save thousands of lives ….” [from an April 7, 2020 post on your Twitter page, https://twitter.com/mercola/status/1247540121919827970]

From your article titled “Vitamin C and D Finally Adopted as Coronavirus Treatment” (https://articles.mercola.com/sites/articles/archive/2020/04/07/coronavirus-treatment.aspx):

• “Vitamins C and D are finally being adopted in the conventional treatment of novel coronavirus, SARS-CoV-2.”
• “Vitamin C at extremely high doses acts as an antiviral drug, actually killing viruses.”
• “Vitamin C Is a Vastly Underutilized Antiviral ‘Drug’”
• “Another powerful component in the prevention and treatment of influenza is vitamin D. Although vitamin D does not appear to have a direct effect on the virus itself, it does strengthen immune function, thus allowing the host body to combat the virus more effectively. It also suppresses inflammatory processes. Taken together, this might make vitamin D useful against SARS-CoV-2 infection.”
• “In my view, optimizing your vitamin D levels is one of the absolute best strategies available to prevent respiratory illness of all kinds.”
• “Based on the available scientific evidence, there’s no reason to ignore vitamins C and D for the prevention and treatment of COVID-19 and other respiratory infections.”
• “Vitamin C is also a crucial aid, both for the prevention and treatment of viral illnesses. You can find pertinent reports and research about vitamin C against COVID-19 on the Orthomolecular Medicine News Service website. I recommend using liposomal vitamin C, as it allows you to take far higher dosages than regular vitamin C ….”

From your article titled “Nutrition and Natural Strategies Offer Hope Against COVID-19” (https://articles.mercola.com/sites/articles/archive/2020/03/29/andrew-saul-vitamin-c.aspx):

• “Vitamin C . . . kills pathogens, including viruses, when taken in high doses.”
• “[T]he government of Shanghai has issued official recommendations that vitamin C should be used for treating COVID-19.”
• “High-Dose Vitamin C Kills Viruses”

From your article titled “Quercetin and Vitamin C: Synergistic Therapy for COVID-19” (https://articles.mercola.com/sites/articles/archive/2020/08/24/quercetin-and-vitamin-csynergistic-effect.aspx):

• “Vitamin C and quercetin have synergistic effects that make them useful in the prevention and early at-home treatment of COVID-19.”
• “[V]itamin C at extremely high doses acts as an antiviral drug, effectively inactivating viruses.”
• “While high-dose vitamin C is new for COVID-19 treatment, it’s been used as a treatment for sepsis since about 2017. The vitamin C-based sepsis treatment was developed by Dr. Paul Marik …. In the interview above, Marik explains how the COVID-19 critical care protocol grew out of his sepsis treatment, as he and other doctors noticed there were many similarities between sepsis and severe COVID-19 infection ….”
• “Quercetin was initially found to provide protection against SARS coronavirus in the aftermath of the SARS epidemic … Now, some doctors are advocating its use against SARS-CoV-2, in combination with vitamin C, noting that the two have synergistic effects.”
• “There is evidence that vitamin C and quercetin co-administration exerts a synergistic antiviral action due to overlapping antiviral and immunomodulatory properties and the capacity of ascorbate to recycle quercetin, increasing its efficacy.”

You should take immediate action to address the violations cited in this letter. This letter is not meant to be an all-inclusive list of violations that exist in connection with your products or operations. It is your responsibility to ensure that the products you sell are in compliance with the FD&C Act and FDA’s implementing regulations. We advise you to review your websites, product labels, and other labeling and promotional materials to ensure that you are not misleadingly representing your products as safe and effective for a COVID-19-related use for which they have not been approved by FDA and that you do not make claims that misbrand the products in violation of the FD&C Act. Within 48 hours, please send an email to (REMOVED) describing the specific steps you have taken to address these violations. Include an explanation of each step being taken to prevent the recurrence of violations, as well as copies of related documentation. Failure to adequately correct any violations may result in legal action, including, without limitation, seizure and injunction.

FDA is advising consumers not to purchase or use certain products that have not been approved, cleared, or authorized by FDA and that are being misleadingly represented as safe and/or effective for the treatment or prevention of COVID-19. Your firm will be added to a published list on FDA’s website of firms and websites that have received warning letters from FDA concerning the sale or distribution of COVID-19 related products in violation of the FD&C Act. This list can be found at http://www.fda.gov/consumers/health-fraud-scams/fraudulent-coronavirus-disease-covid-19-products. Once you have taken actions to address the sale of your unapproved and unauthorized products for the mitigation, prevention, treatment, diagnosis, or cure of COVID-19, and any appropriate corrective actions have been confirmed by the FDA, the published list will be updated to indicate that your firm has taken such corrective actions.

This letter notifies you of our concerns and provides you with an opportunity to address them. If you cannot take action to address this matter completely within 48 hours, state the reason for the delay and the time within which you will do so. If you believe that your products are not in violation of the FD&C Act, include your reasoning and any supporting information for our consideration.

If you are not located in the United States, please note that products that appear to be misbranded or unapproved new drugs may be detained or refused admission if they are offered for importation into the United States. We may advise the appropriate regulatory officials in the country from which you operate that FDA considers your products referenced above to be unapproved and misbranded products that cannot be legally sold to consumers in the United States.

Sincerely,

/S/

William A. Correll

Director

Office of Compliance

Center for Food Safety and Applied Nutrition

Food and Drug Administration

GO AHEAD – BE A HERO

Start a Gofundme Fundraiser for our life-saving programs.

It’s so easy!

1. Register at gofundme.com  
2. Start a fundraiser and select fundraising for a charity. When you are asked for the name of the charity, enter American Patient Rights Association and select it when it shows on the screen.
3. When asked how much you wish to raise, enter $1,000. 
4. Upload a picture of yourself, your family, or someone you wish to commemorate by fundraising.
5. Pick a title for your fundraiser.  Maybe something like Dave’s Fundraiser to Save Lives      
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7. Start sharing your fundraiser. 

Start a Gofundme fundraiser for APRA now.  100% of all donations go to support our life-saving programs, such as:

PATIENT SAFETY REPORTING SYSTEM. An incident reporting system for patients, their families, and advocates to assist patients when they are harmed by their healthcare and to assist medical facilities in improving their patient safety. Reports will be available to the public.

SAVING PATIENTS’ HOMES. A program to help people who are threatened with bankruptcy because of predatory medical bills. Many COVID patients who are hospitalized will have extraordinary bills to pay. Some hospitals that are offering COVID tests have billed people over $2000 for a single test!  

ABOUT APRA – We are an independent nonprofit organization founded and run by patients for patients, with an extraordinary mission: to fight for fair, safe, transparent healthcare. We are fighting for you and your rights to fair and safe healthcare!

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Unless specifically requested, we do not solicit nor do we wish to receive any confidential, secret, or proprietary information or other material from you through the Web Site, by e-mail or in any other way. Any information, creative works, demos, ideas, suggestions, concepts, methods, systems, designs, plans, techniques or other materials submitted or sent to us (including, for example and without limitation, that which you submit or post to our chat rooms, message boards, survey responses, and/or our blogs, or send to us via e-mail) (“Submitted Materials”) will be deemed not to be confidential or secret, and may be used by us in any manner consistent with the Web Site’s Privacy Policy. By submitting or sending Submitted Materials to us, you: (i) represent and warrant that the Submitted Materials are original to you, that no other party has any rights thereto, and that any “moral rights” in Submitted Materials have been waived, and (ii) you grant us and our affiliates a royalty-free, unrestricted, worldwide, perpetual, irrevocable, non-exclusive and fully transferable, assignable and sublicensable right and license to use, copy, reproduce, modify, adapt, publish, translate, create derivative works from, distribute, perform, display and incorporate in other works any Submitted Materials (in whole or part) in any form, media, or technology now known or later developed, including for promotional and/or commercial purposes. We cannot be responsible for maintaining any Submitted Material that you provide to us, and we may delete or destroy any such Submitted Material at any time.

Prohibited User Conduct.
You warrant and agree that, while using the Web Site and the various services and features offered on or through the Website, you shall not: (a) impersonate any person or entity or misrepresent your affiliation with any other person or entity; (b) insert your own or a third party’s advertising, branding or other promotional content into any of the Web Site’s content, materials or services (for example, without limitation, in an RSS feed or a podcast received from American Patient Rights Association or otherwise through the Website), or use, redistribute, republish or exploit such content or service for any further commercial or promotional purposes; or (c) attempt to gain unauthorized access to other computer systems through the Website. You shall not: (i) engage in spidering, “screen scraping,” “database scraping,” harvesting of e-mail addresses, wireless addresses or other contact or personal information, or any other automatic means of obtaining lists of users or other information from or through the Website or the services offered on or through the Website, including without limitation any information residing on any server or database connected to the Website or the services offered on or through the Website; (ii) obtain or attempt to obtain unauthorized access to computer systems, materials or information through any means; (iii) use the Website or the services made available on or through the Website in any manner with the intent to interrupt, damage, disable, overburden, or impair the Website or such services, including, without limitation, sending mass unsolicited messages or “flooding” servers with requests; (iv) use the Website or the Website’s services or features in violation of American Patient Rights Association’s or any third party’s intellectual property or other proprietary or legal rights; or (v) use the Website or the Website’s services in violation of any applicable law. You further agree that you shall not attempt (or encourage or support anyone else’s attempt) to circumvent, reverse engineer, decrypt, or otherwise alter or interfere with the Website or the Website’s services, or any content thereof, or make any unauthorized use thereof. You agree that you shall not use the Website in any manner that could damage, disable, overburden, or impair the Website or interfere with any other party’s use and enjoyment of the Website or any of its services. You shall not obtain or attempt to obtain any materials or information through any means not intentionally made publicly available or provided for through the Website.

Public Forums.
American Patient Rights Association may, from time to time, make messaging services, chat services, bulletin boards, message boards, blogs, other forums and other such services available on or through the Website. The public forum posts and comments to such public forum posts are not monitored for accuracy, completeness, thoroughness or timeliness, and do not constitute medical advice or recommendation of any kind. You should not rely on any information contained in such posts or comments and you should consult with your qualified health care professionals to meet your individual needs or advise you as to any treatment. In addition to any other rules or regulations that we may post in connection with a particular service, you agree that you shall not upload, post, transmit, distribute or otherwise publish through the Website or any service or feature made available on or through the Website, any materials which (i) restrict or inhibit any other user from using and enjoying the Website or the Website’s services, (ii) are fraudulent, unlawful, threatening, abusive, harassing, libelous, defamatory, obscene, vulgar, offensive, pornographic, profane, sexually explicit or indecent, (iii) constitute or encourage conduct that would constitute a criminal offense, give rise to civil liability or otherwise violate any local, state, national or international law, (iv) violate, plagiarize or infringe the rights of third parties including, without limitation, copyright, trademark, trade secret, confidentiality, contract, patent, rights of privacy or publicity or any other proprietary right, (v) contain a virus, spyware, or other harmful component, (vi) contain embedded links, advertising, chain letters or pyramid schemes of any kind, or (vii) constitute or contain false or misleading indications of origin, endorsement or statements of fact. You further agree not to impersonate any other person or entity, whether actual or fictitious, including anyone from American Patient Rights Association You also may not offer to buy or sell any product or service on or through your comments submitted to our forums. You alone are responsible for the content and consequences of any of your activities.

Right to Monitor and Editorial Control.
American Patient Rights Association reserves the right, but does not have an obligation, to monitor and/or review all materials posted to the Website or through the Website’s services or features by users, and American Patient Rights Association is not responsible for any such materials posted by users. However, American Patient Rights Association reserves the right at all times to disclose any information as necessary to satisfy any law, regulation or government request, or to edit, refuse to post or to remove any information or materials, in whole or in part, that in American Patient Rights Association’s sole discretion are objectionable or in violation of this Terms of Use, American Patient Rights Association’s policies or applicable law. We may also impose limits on certain features of the forums or restrict your access to part or all of the forums without notice or penalty if we believe you are in breach of the guidelines set forth in this paragraph, our terms and conditions or applicable law, or for any other reason without notice of liability.

Private or Sensitive Information on Public Forums.
It is important to remember that comments submitted to a forum may be recorded and stored in multiple places, both on our Website and elsewhere on the Internet, which are likely to be accessible for a long time and you have no control over who will read them eventually. It is therefore important that you are careful and selective about the personal information that you disclose about yourself and others, and in particular, you should not disclose sensitive, proprietary or confidential information in your comments to our public forums.

Linking to the Website.
You agree that if you include a link from any other website to the Website, such link shall open in a new browser window and shall link to the full version of an HTML formatted page of this Website. You are not permitted to link directly to any image hosted on the Web Site or our services, such as using an “in-line” linking method to cause the image hosted by us to be displayed on another website. You agree not to download or use images hosted on this Website on another website, for any purpose, including, without limitation, posting such images on another site. You agree not to link from any other website to this Website in any manner such that the Web Site, or any page of the Website, is “framed,” surrounded or obfuscated by any third-party content, materials or branding. We reserve all of our rights under the law to insist that any link to the Website be discontinued, and to revoke your right to link to the Website from any other website at any time upon written notice to you.

Indemnification.
You agree to defend, indemnify and hold American Patient Rights Association and its’ affiliates, directors, officers, employees and agents harmless from any and all claims, damages, liabilities, costs, and expenses, including reasonable attorneys’ fees, and INCLUDING WITHOUT LIMITATION CLAIMS BASED UPON THE NEGLIGENCE OF AMERICAN PATIENT RIGHTS ASSOCIATION, its affiliates, directors, officers, employees, and agents, arising in any way from your use of the Website, THE MATERIALS IT CONTAINS, AND ANY SITES LINKED TO THIS SITE, your placement or transmission of any message, content, information, software or other materials through the Website, your breach or violation of the law or of these Terms and Conditions, American Patient Rights Association reserves the right, at its own expense, to assume the exclusive defense and control of any matter otherwise subject to indemnification by you, and in such case, you agree to cooperate with the American Patient Rights Association’s defense of such claim.

Orders for Products and Services.
We may make certain products available to visitors and registrants of the Website. If you order any products, you hereby represent and warrant that you are 18 years old or older. You agree to pay in full the prices for any purchases you make either by credit/debit card concurrent with your online order or by other payment means acceptable to American Patient Rights Association You agree to pay all applicable taxes. If payment is not received by us from your credit or debit card issuer or its agents, you agree to pay all amounts due upon demand by us. Certain products that you purchase and/or download on or through the Website may be subject to additional terms and conditions presented to you at the time of such purchase or download.

Third Party Websites.
You may be able to link from the Website to third-party websites and third-party websites may link to the Website (“Linked Sites”). You acknowledge and agree that we have no responsibility for the information, content, products, services, advertising, code or other materials which may or may not be provided by or through Linked Sites, even if they are owned or run by affiliates of ours. Links to Linked Sites do not constitute an endorsement or sponsorship by us of such websites or the information, content, products, services, advertising, code or other materials presented on or through such websites. The inclusion of any link to such sites on our Site does not imply the American Patient Rights Association’s endorsement, sponsorship, or recommendation of that site. American Patient Rights Association disclaims any liability for links (1) from another website to this Website and (2) to another website from this Website. American Patient Rights Association cannot guarantee the standards of any website to which links are provided on this Website nor shall American Patient Rights Association be held responsible for the contents of such sites, or any subsequent links. American Patient Rights Association does not represent or warrant that the contents of any third party website is accurate, compliant with state or federal law, or compliant with copyright or other intellectual property laws. Also, American Patient Rights Association is not responsible for or any form of transmission received from any linked website. Any reliance on the contents of a third-party website is done at your own risk and you assume all responsibilities and consequences resulting from such reliance.

Copyright Agent.
We respect the intellectual property rights of others and require that the people who use the Website, or the services or features made available on or through the Website, do the same. If you believe that your work has been copied in a way that constitutes copyright infringement, please forward the following information to American Patient Rights Association’s Copyright Agent, designated as such pursuant to the Digital Millennium Copyright Act, 17 U.S.C. § 512(c)(2), named below:

Your address, telephone number, and email address;
A description of the copyrighted work that you claim has been infringed;
A description of where the alleged infringing material is located;
A statement by you that you have a good faith belief that the disputed use is not authorized by the copyright owner, its agent, or the law;

An electronic or physical signature of the person authorized to act on behalf of the owner of the copyright interest; and
A statement by you, made under penalty of perjury, that the above information in your notice is accurate and that you are the copyright owner or are authorized to act on the copyright owner’s behalf.

Copyright Agent:
Copyright Agent
American Patient Rights Association
P. O. Box 2073
Mount Dora FL 32756
e-mail: copyrightdmca@americanpatient.org

For Customer Service do not contact the Copyright Agent, please contact:
APRA Customer Service
P. O. Box 2073
Mount Dora FL 32756
e-mail: service@americanpatient.org

DISCLAIMER OF WARRANTIES.
THE WEBSITE, INCLUDING, WITHOUT LIMITATION, ALL SERVICES, CONTENT, FUNCTIONS, AND MATERIALS PROVIDED THROUGH THE WEBSITE, ARE PROVIDED “AS IS,” “AS AVAILABLE,” WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING, WITHOUT LIMITATION, ANY WARRANTY FOR INFORMATION, DATA, DATA PROCESSING SERVICES, UPTIME OR UNINTERRUPTED ACCESS, ANY WARRANTIES CONCERNING THE AVAILABILITY, PLAYABILITY, DISPLAYABILITY, ACCURACY, PRECISION, CORRECTNESS, THOROUGHNESS, COMPLETENESS, USEFULNESS, OR CONTENT OF INFORMATION, AND ANY WARRANTIES OF TITLE, NON-INFRINGEMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, AND WE HEREBY DISCLAIM ANY AND ALL SUCH WARRANTIES, EXPRESS AND IMPLIED. WE DO NOT WARRANT THAT THE WEBSITE OR THE SERVICES, CONTENT, FUNCTIONS OR MATERIALS PROVIDED THROUGH THE WEBSITE WILL BE TIMELY, SECURE, UNINTERRUPTED, OR ERROR-FREE, OR THAT DEFECTS WILL BE CORRECTED. WE MAKE NO WARRANTY THAT THE WEBSITE OR THE PROVIDED SERVICES WILL MEET USERS’ REQUIREMENTS. NO ADVICE, RESULTS OR INFORMATION, WHETHER ORAL OR WRITTEN, OBTAINED BY YOU FROM US OR THROUGH THE WEBSITE SHALL CREATE ANY WARRANTY NOT EXPRESSLY MADE HEREIN. AMERICAN PATIENT RIGHTS ASSOCIATION ALSO ASSUMES NO RESPONSIBILITY, AND SHALL NOT BE LIABLE FOR, ANY DAMAGES TO, OR VIRUSES THAT MAY INFECT, YOUR EQUIPMENT ON ACCOUNT OF YOUR ACCESS TO, USE OF, OR BROWSING IN THE WEBSITE OR YOUR DOWNLOADING OF ANY MATERIALS, DATA, TEXT, IMAGES, VIDEO CONTENT, OR AUDIO CONTENT FROM THE WEBSITE. IF YOU ARE DISSATISFIED WITH THE WEBSITE, YOUR SOLE REMEDY IS TO DISCONTINUE USING THE WEBSITE.

WE TRY TO ENSURE THAT THE INFORMATION POSTED ON THE WEBSITE IS CORRECT AND UP-TO-DATE. WE RESERVE THE RIGHT TO CHANGE OR MAKE CORRECTIONS TO ANY OF THE INFORMATION PROVIDED ON THE WEBSITE AT ANY TIME AND WITHOUT ANY PRIOR WARNING. American Patient Rights Association NEITHER ENDORSES NOR IS RESPONSIBLE FOR THE ACCURACY OR RELIABILITY OF ANY OPINION, ADVICE OR STATEMENT ON THE WEB SITE, NOR FOR ANY OFFENSIVE, DEFAMATORY, OBSCENE, INDECENT, UNLAWFUL OR INFRINGING POSTING MADE THEREON BY ANYONE OTHER THAN AUTHORIZED AMERICAN PATIENT RIGHTS ASSOCIATION EMPLOYEE SPOKESPERSONS WHILE ACTING IN THEIR OFFICIAL CAPACITIES (INCLUDING, WITHOUT LIMITATION, OTHER USERS OF THE WEB SITE). IT IS YOUR RESPONSIBILITY TO EVALUATE THE ACCURACY, COMPLETENESS OR USEFULNESS OF ANY INFORMATION, OPINION, ADVICE OR OTHER CONTENT AVAILABLE THROUGH THE WEBSITE. PLEASE SEEK THE ADVICE OF PROFESSIONALS, AS APPROPRIATE, REGARDING THE EVALUATION OF ANY SPECIFIC INFORMATION, OPINION, ADVICE OR OTHER CONTENT, INCLUDING BUT NOT LIMITED TO FINANCIAL, HEALTH, OR LIFESTYLE INFORMATION, OPINION, ADVICE OR OTHER CONTENT.

PRIOR TO THE EXECUTION OF A PURCHASE OR SALE OF ANY SECURITY OR INVESTMENT, YOU ARE ADVISED TO CONSULT WITH YOUR BROKER OR OTHER FINANCIAL ADVISOR TO VERIFY PRICING AND OTHER INFORMATION. WE SHALL HAVE NO LIABILITY FOR INVESTMENT DECISIONS BASED UPON, OR THE RESULTS OBTAINED FROM, THE CONTENT PROVIDED HEREIN. NOTHING CONTAINED IN THE WEBSITE SHALL BE CONSTRUED AS INVESTMENT ADVICE. AMERICAN PATIENT RIGHTS ASSOCIATION IS NOT A REGISTERED BROKER-DEALER OR INVESTMENT ADVISOR AND DOES NOT GIVE INVESTMENT ADVICE OR RECOMMEND ONE PRODUCT OVER ANOTHER.

WITHOUT LIMITATION OF THE ABOVE IN THIS SECTION, AMERICAN PATIENT RIGHTS ASSOCIATION AND ITS AFFILIATES, SUPPLIERS AND LICENSORS MAKE NO WARRANTIES OR REPRESENTATIONS REGARDING ANY PRODUCTS OR SERVICES ORDERED OR PROVIDED VIA THE WEBSITE, AND HEREBY DISCLAIM, AND YOU HEREBY WAIVE, ANY AND ALL WARRANTIES AND REPRESENTATIONS MADE IN PRODUCT OR SERVICES LITERATURE, FREQUENTLY ASKED QUESTIONS DOCUMENTS AND OTHERWISE ON THE WEBSITE OR IN CORRESPONDENCE WITH American Patient Rights Association OR ITS AGENTS. ANY PRODUCTS AND SERVICES ORDERED OR PROVIDED VIA THE WEBSITE ARE PROVIDED BY American Patient Rights Association “AS IS,” EXCEPT TO THE EXTENT, IF AT ALL, OTHERWISE SET FORTH IN A LICENSE OR SALE AGREEMENT SEPARATELY ENTERED INTO IN WRITING BETWEEN YOU AND American Patient Rights Association OR ITS LICENSOR OR SUPPLIER.

LIMITATION OF LIABILITY.
IN NO EVENT, INCLUDING BUT NOT LIMITED TO NEGLIGENCE, SHALL AMERICAN PATIENT RIGHTS ASSOCIATION, OR ANY OF ITS DIRECTORS, OFFICERS, EMPLOYEES, AGENTS OR CONTENT OR SERVICE PROVIDERS (COLLECTIVELY, THE “PROTECTED ENTITIES”) BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL, EXEMPLARY OR PUNITIVE DAMAGES ARISING FROM, OR DIRECTLY OR INDIRECTLY RELATED TO, THE USE OF, OR THE INABILITY TO USE, THE WEBSITE OR THE CONTENT, MATERIALS AND FUNCTIONS RELATED THERETO, YOUR PROVISION OF INFORMATION VIA THE WEBSITE, LOST BUSINESS OR LOST SALES, EVEN IF SUCH PROTECTED ENTITY HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE LIMITATION OR EXCLUSION OF LIABILITY FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES SO SOME OF THE ABOVE LIMITATIONS MAY NOT APPLY TO CERTAIN USERS. IN NO EVENT SHALL THE PROTECTED ENTITIES BE LIABLE FOR OR IN CONNECTION WITH ANY CONTENT POSTED, TRANSMITTED, EXCHANGED OR RECEIVED BY OR ON BEHALF OF ANY USER OR OTHER PERSON ON OR THROUGH THE WEBSITE. IN NO EVENT SHALL THE TOTAL AGGREGATE LIABILITY OF THE PROTECTED ENTITIES TO YOU FOR ALL DAMAGES, LOSSES, AND CAUSES OF ACTION (WHETHER IN CONTRACT OR TORT, INCLUDING, BUT NOT LIMITED TO, NEGLIGENCE OR OTHERWISE) ARISING FROM THE TERMS AND CONDITIONS OR YOUR USE OF THE WEB SITE EXCEED, IN THE AGGREGATE, THE AMOUNT, IF ANY, PAID BY YOU TO American Patient Rights Association FOR YOUR USE OF THE WEBSITE OR PURCHASE OF PRODUCTS VIA THE WEBSITE.

Photosensitive Seizures.
A very small percentage of people may experience a seizure when exposed to certain visual images, such as flashing lights or patterns that may appear in video games or other electronic or online content. Even people who have no history of seizures or epilepsy may have an undiagnosed condition that can cause these “photosensitive epileptic seizures” while watching video games or other electronic content. These seizures have a variety of symptoms, including lightheadedness, disorientation, confusion, momentary loss of awareness, eye or face twitching, altered vision or jerking or shaking of arms or legs. If you experience any of the foregoing symptoms, or if you or your family has a history of seizures or epilepsy, you should immediately stop using the Website and consult a doctor.

Applicable Laws.
We control and operate the Website from our offices in the United States of America. We do not represent that materials on the Website are appropriate or available for use in other locations. Persons who choose to access the Website from other locations do so on their own initiative, and are responsible for compliance with local laws, if and to the extent local laws are applicable. All parties to these terms and conditions waive their respective rights to a trial by jury.

Governing Law and Venue
This Agreement, the entire relationship between you and AMERICAN PATIENT RIGHTS ASSOCIATION, and any litigation or other legal proceeding between you and AMERICAN PATIENT RIGHTS ASSOCIATION (whether grounded in tort, contract, law or equity) shall be governed by and construed in accordance with the laws of the State of Florida, without giving effect to its choice of law rules.

This contract is fully performable in Lake County, Florida. Any litigation arising between the parties hereto shall be brought only in the state or federal courts having subject matter jurisdiction in Lake County, Florida. You hereby irrevocably and unconditionally consent to the jurisdiction of any such courts and hereby irrevocably and unconditionally waive any defense of an inconvenient forum for the maintenance of any action or proceeding in any such court, any objection to venue with respect to any such action or proceeding, and any right of jurisdiction on account of the place of residence or domicile of any party hereto.

Termination.
American Patient Rights Association may terminate, change, suspend or discontinue any aspect of the Website or the Website’s services at any time. American Patient Rights Association may restrict, suspend or terminate your access to the Website and/or its services if we believe you are in breach of our terms and conditions or applicable law, or for any other reason without notice or liability. American Patient Rights Association maintains a policy that provides for the termination in appropriate circumstances of the Web Site use privileges of users who are repeat infringers of intellectual property rights.

Changes to Terms of Use.
American Patient Rights Association reserves the right, at its sole discretion, to change, modify, add or remove any portion of the Terms and Conditions, in whole or in part, at any time. Changes in the Terms and Conditions will be effective when posted. Your continued use of the Website and/or the services made available on or through the Website after any changes to the Terms and Conditions are posted will be considered acceptance of those changes.

Miscellaneous.
The Terms and Conditions, and the relationship between you and us, shall be governed by the laws of the State of Florida, United States of America, without regard to conflict of law provisions. You agree that any cause of action that may arise under the Terms and Conditions shall be commenced and be heard in the appropriate court in the State of Florida, Lake County, United States of America. You agree to submit to the personal and exclusive jurisdiction of the courts located within Lake County in the State of Florida. Our failure to exercise or enforce any right or provision of the Terms and Conditions shall not constitute a waiver of such right or provision. If any provision of the Terms and Conditions is found by a court of competent jurisdiction to be invalid, the parties nevertheless agree that the court should endeavor to give effect to the parties’ intentions as reflected in the provision, and the other provisions of the Terms and Conditions remain in full force and effect.

Supplemental Terms.

None.

The text, video, and other information (the “Content”) provided on the American Patient Rights Association Website is for informational purposes only and is not comprehensive for any one topic. The Content is not intended to provide or substitute for professional medical advice, diagnosis, or treatment. The Content is not intended to be — and therefore should not be interpreted as — recommendation(s) for any specific treatment plan, product, or provider. Use of the American Patient Rights Association Website does not create a doctor-patient relationship. Any questions regarding individual medical conditions should be directed to a health care professional.

If you have any concerns about your health, consult your physician promptly. Never disregard or delay individual medical advice or care because of something you saw or read on this Site. We strive for timeliness and accuracy of all content; however, we cannot guarantee this. The Site and Content are provided “AS IS.” Use of the Site and the Content, and reliance on any information obtained, is at your own risk.

American Patient Rights Association websites, including those under the domains AmericanPatient.org, Americapatient.org, americapatient.com, usapra.com and uspra.org do not collect any personal information about site visitors other than registration information for those who choose to register.

Information provided by Google Analytics, used to track general information about visitor traffic to American Patient Rights Association websites, includes only the Internet Service Provider, browser name, and referring page used by any visitor.

Information about visitors who email technical or editorial questions to American Patient Rights Association is retained only as long as is necessary to provide a sufficient reply. This information is used only by American Patient Rights Association and is never sold or compiled and offered to any third party without permission.