Putting A Lid On Needless Medical Tests

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Doctors desk with patients test results, samples, stethoscope and blood pressure gaugeIt is common knowledge in medicine: Doctors routinely order tests on hospital patients that are unnecessary and wasteful. Sutter Health, a giant hospital chain in Northern California, thought it had found a simple solution.

The Sacramento-based health system deleted the button physicians used to order daily blood tests. “We took it out and could not wait to see the data,” said Marie Giusto, a Sutter Health executive.

Alas, the number of orders hardly changed. That is because the hospital’s medical-records software “has this cool ability to let you save your favorites,” Giusto said at a recent presentation to other hospital executives and physicians. “It had become a habit.”

There are plenty of opportunities to trim waste in America’s $3.4 trillion health care system — but, as the Sutter example illustrates, it is often not as simple as it seems.

Some experts estimate that at least $200 billion is wasted annually on excessive testing and treatment. This overly aggressive care can also harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year.

“The changes that need to be made do not appear unrealistic, yet they seem to take an awful lot of time,” said Dr. Jeff Rideout, chief executive of the Integrated Healthcare Association, an Oakland, Calif., nonprofit group that promotes quality improvement. “We have been patient too long.”

In California, that sense of frustration has led three of the state’s biggest health care purchasers to band together and promote care that is safer and more cost-effective. The California Public Employees’ Retirement System (CalPERS), the Covered California insurance exchange and the state’s Medicaid program, known as Medi-Cal — which collectively serve more than 15 million patients — are leading the initiative.

Progress may be slow, but there have been some encouraging signs. In San Diego, for instance, the Sharp Rees-Stealy Medical Group said it cut unnecessary lab tests more than 10 percent by educating both doctors and patients about overuse.

A large public hospital, Los Angeles County-University of Southern California Medical Center, eliminated preoperative testing deemed superfluous before routine cataract surgery. As a result, patients on average received the surgery six months sooner.

These efforts were sparked by the Choosing Wisely campaign, a national effort launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation. The group asked medical societies to identify at least five common tests or procedures that often provide little benefit.

The campaign, also backed by Consumer Reports, encourages medical providers to hand out wallet-sized cards to patients with questions they should ask to determine whether they truly need a procedure.

Critics have blamed Choosing Wisely for playing it too safe and not going after some of the more lucrative procedures, such as certain spine operations and arthroscopic knee surgeries.

Daniel Wolfson, chief operating officer at the ABIM Foundation, said the Choosing Wisely campaign has been successful with unwarranted care. “I think we need massive change and that could take fifteen or more years,” Wolfson said.

Initially, the group focused on  reducing opioid use and avoiding overtreatment for patients suffering low-back pain.

Dr. Richard Sun, co-chairman of the Smart Care group and a medical consultant at CalPERS, said he is pursuing safer, more affordable treatments for low-back pain, a condition that cost the state agency $107 million in 2015. “One challenge is developing metrics that everyone can agree upon to measure improvement,” he said.

For patients, overtreatment can be more than a minor annoyance. Galen Gunther, a 59-year-old from Oakland, said that during treatment for colorectal cancer a decade ago he was subjected needlessly to repeated blood draws, often because the doctors could not find documentation of earlier results. Later, he said, he was overexposed to radiation, leaving him permanently scarred.

“Every doctor I saw wanted to run the same tests, over and over again,” Gunther said. “Nobody wanted to take responsibility.”

At Cedars-Sinai Medical Center in Los Angeles, officials said that economic incentives still drive hospitals to think that more is better.

“We have excellent patient outcomes, but it is at a very high cost,” said Dr. Harry Sax, executive vice chairman for surgery at Cedars-Sinai. “There is still a continued financial incentive to do that test, do that procedure and do something more.”

In addition to financial motives, Sax said, many physicians still practice defensive medicine out of fear of malpractice litigation. Also, some patients and their families expect antibiotics to be prescribed for a sore throat or a CT scan for a bump on the head.

To cut down on needless care, Cedars-Sinai arranged for doctors to be alerted electronically when they ordered tests or drugs that run contrary to 18 Choosing Wisely recommendations.

The hospital analyzed alerts from 26,424 patient encounters from 2013 to 2016. All of the guidelines were followed in 6 percent of those cases, or 1,591 encounters.

Sax said Cedars-Sinai studied the rate of complications, readmissions, length of stay and direct cost of care among the patients in whose cases the guidelines were followed and compared those outcomes with cases where adherence was less than 50 percent.

In the group that did not follow the guidelines, patients had a 14 percent higher incidence of readmission and 29 percent higher risk of complications. Those complications and longer stays increased the cost of care by 7 percent, according to the hospital.

In 2013, the first year of implementation of Choosing Wisely guidelines, Cedars-Sinai said it avoided $6 million in medical spending.

For perspective, Cedars-Sinai is one the largest hospitals in the nation with $3.3 billion in revenue for the fiscal year ending June 30, 2017. It reported a net income of $301 million.

In Northern California, Sutter has incorporated more than 130 Choosing Wisely recommendations as part of a broader effort to reduce variation in care. In all, Sutter said, it has saved about $66 million since 2011.

That is a significant sum. However, during the same period, Sutter reported $2.7 billion in profits. Last year alone, it posted an operating profit of $554 million on revenue of nearly $12 billion.

Giusto said her team of employees tasked with changing physician behavior and eliminating these variations is separate from administrators who are focused on maximizing reimbursement. She said there can be conflicting forces within a hospital.

“We get really excited about a project with [emergency department] doctors on reducing CT scans for abdominal pain,” said Giusto, director of Sutter’s office of patient experience. “Then I can hear the administration say, that was a [Medicare] fee-for-service patient and we just lost money, right?”

Giusto meets with doctors to present data on how many tests or prescriptions they order and how that compares to others. At one clinic, she shared slides showing that some doctors were ordering more than 70 opioid pills at a time while others prescribed fewer than 20. In response, Sutter set a goal of 28 tablets in hopes of reducing opioid abuse.

“Most of the physicians changed,” Giusto said. “But there were still two who said, ‘Sorry, but I’m going to keep doing it the same as always.’

Life Insurance Denied?

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lady-at-table-frustratedThis story is told by an intern and then a doctor who spent over 35 years around medical records with a never ceasing amazement of how frequently people are shocked about the data found in their medical records. 

Be it a prescription never filled, a physician’s comment never broached with the patient, a procedure recommended but never discussed, a diagnosis made without patient acknowledgement, or an error made in the transcription process, millions of Americans are detrimentally affected each year because of inaccurate medical record keeping and documentation.

Medical Errors Aplenty

Regretfully, such mistakes (the term “mistakes” because people should never accuse anyone of endangering a patient’s life) do cause catastrophic events in the lives of millions. Be it a minor mistake [such as inaccurate data about one’s height, weight or date of visit] or a major mistake [such as an organ removal, amputation or family history data] these mistakes should be promptly addressed and corrected in a person’s medical records.

According to many news articles, 12 million Americans (or 1 in every 20 patients) are misdiagnosed every year. How much of this misdiagnosis is based on errant information in medical records is unknown. But the rate is significant enough that people — notably applicants for a life insurance policy — should not rest until they have rectified such inaccuracies.

When the doctor recently visited a local hospital’s emergency room for a deep cut in his leg, he requested his medical records to see what had been recorded. Here is what was discovered:

  1. He was given an injection of lidocaine.
  2. He was given a complete level 3 physical exam.
  3. He was bandaged and the bleeding was controlled.

The problem: None of this was accurate. He had bandaged and controlled the bleeding before he drove to the emergency room; if he hadn’t he would have bled to death (he cut an artery in his leg). Additionally, no medical person touched him in the emergency room, so how could it have been recorded that he was given and completed a level 3 exam or an injection of lidocaine?

He ended up leaving the emergency room after several hours of waiting. But to submit a bill, hospital staff had to document in the medical record that they had followed through with something. However, when he challenged the medical record, staff made corrections and reduced his bill accordingly.

This should be warning to people that things get documented in their medical records without their knowledge or consent (especially if there is a third party payor involved) more frequently than they would like to contemplate. Yes, we all want to trust our doctors and healthcare providers, but they are human. And humans make mistakes.

So people should never believe that all their medical records are accurate until the documents have been reviewed. Then do not rest until the records are accurate.

Three Very Good Reasons for Checking

Verifying the accuracy of medical records can:

  1. Save people’s lives;
  2. Save them money; and (not least)
  3. Keep them from being denied life insurance coverage.

Yes, medical record mistakes can be life-threatening, but even if not, such errors are (more often than not) detrimental to people’s pocket books and their ability to get the life insurance coverage they deserve and need.

According to the story, the doctor’s medical records, once corrected, saved him nearly $1,000. Many people have saved money on life insurance premiums by getting their medical records corrected. And some have gone from a denial of life insurance coverage to full coverage.

People’s medical records are a third party witness for them or against them — especially if there are legal questions about their healthcare. And so it is imperative they know what has been documented in their records.

And, by the way, do not think that the Health Information Portability and Accountability Act (HIPAA) does anything to prevent such mistakes from happening or always protect people.  HIPAA provides insurance carriers and government facilities with the ability to collect information they need to advance the Patient Protection and Affordability Care Act (ACA).

Of course, we all know now how effective the Patient Protection and Affordability Care Act is, with nearly 50 percent of co-ops failing and even more of them subject to failure.

It is not unusual for a person applying for life insurance to find out for the first time about what is contained in their medical records. They should not apply for life insurance coverage only to make sure their medical records are 100 percent correct. They should simply ask for copies of their records whenever they visit their healthcare provider.

If they do not recognize or understand what is documented in their medical records, then should persist in getting clarification until they are comfortable with the information, because the documentation is about them. It’s their life, their money and their health. If they don’t do this, nobody will — and that could be devastating.

Medicare Advantage Plan Audits

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Billing and Patient

Negligent, lax auditing has given overcharging encouragement to Medicare Part C advantage health insurance plans.

With the mounting evidence that federal officials have been overpaying some Medicare Part C advantage health insurance plans by tens of millions of dollars a year, the government revisited efforts to reclaim as much money as possible.

Records of the Centers for Medicare and Medicaid Services reveals that officials there as early as 2008 identified a group of privately run Medicare Part C Advantage health insurance plans they suspected of ripping off the government.

CMS officials chose to do only 30 in-depth financial audits to recover overpayments each year, even though the records make clear they could complete many more.

In February 2012, CMS announced it would do just that — which meant about 5 percent of the roughly 600 Medicare Advantage contracts in force would be audited in a year.

The agency expected to complete the first batch of the Medicare Advantage audits, which covered 2011 spending, and to “recoup overpayments” in early 2014, according to another document. But it has yet to do so. A spokesman said the Medicare agency “anticipates completing” the audits in 2016.

The CMS records were recently released to the Center for Public Integrity through a court order in a Freedom of Information Act lawsuit.

Since 2004, the government has paid the health plans using a risk score it calculates for each patient based on diseases reported by the health plans. Medicare expects to pay higher rates for sicker people and less for those in good health. But overspending tied to fast-rising risk scores has cost taxpayers billions of dollars in recent years, as the Center for Public Integrity reported in a series of articles published in 2014, leading to widespread suspicions that some risk scores are being purposefully inflated.

Many of the records released by CMS are heavily redacted, with dates and the names of their authors sometimes missing. More than 1,400 pages have been “withheld in their entirety” by CMS, including names of the health plans and how much they were overpaid.

 The government’s relaxed pace in chasing down overpayments — and the secrecy surrounding the audit results — brought a sharp rebuke from Senate Judiciary Committee Chairman Charles Grassley.

“The agencies are responsible for getting the payments right in the first place and pursuing full refunds of all over-payments for the taxpayers,” the Iowa Republican said in a statement.

“The agencies also have an obligation to be as transparent as possible in the public interest about a taxpayer-funded program,” Grassley added.

The CMS records make clear that Medicare Advantage overpayments have piled up mainly because the complex formula relying on risk scores that is used to pay the plans has few safeguards to discourage abuse. One memo describes it as an “honor system.”

A CMS spokesman didn’t directly address written questions posed by the Center for Public Integrity about the history of the audits. But the agency offered a statement that read in part: “CMS takes seriously program integrity and payment accuracy in Medicare Advantage, and is taking steps to protect taxpayers, Medicare beneficiaries, and the Medicare program.”

The CMS records include an earlier confidential audit of 2005 payments to 22 Medicare Advantage health plans; it showed that auditors couldn’t confirm that 31 percent of the patients had the diseases Medicare was paying plans to treat.

Some plans were much worse than others. The average error rate for 17 of the 22 plans was more than 10 percent above the norm, with some even higher. The confidential 2005 audit, conducted by consulting firm BearingPoint, projected 2005 losses at $4.2 billion from what it termed a “substantial overpayment” to Medicare Advantage plans.

The audits are called RADV, for Risk Adjustment Data Validation. Auditors review medical records of a sample of 201 patients to verify they have the diseases their health plan is being paid to treat.

CMS officials also appeared to have doubts about the legality of RADV because it lacked a formal appeals process. The health plans were not penalized until February 2012 — even though officials knew payment errors were wasting billions of tax dollars.

Audits for 2007, for instance, dragged on for more than five years before ending with a whimper. CMS had anticipated collecting from $500 million to $800 million from 37 health plans audited that year.

That never happened. Instead, CMS collected less than $14 million, and some health plans, including UnitedHealth Care, have spent years appealing to get at least some of that money recovered.

The Centers for Medicare and Medicaid Services, which is part of the Department of Health and Human Services, spends about $17 million a year conducting RADV audits and estimating payment errors. So far, these efforts have returned about $15 million to the agency.

By contrast, other medical fraud and abuse efforts are said to more than pay for themselves. HHS announced in March 2015 that fraud recovery efforts by the department returned $7.70 for every dollar spent.

CMS officials have said the threat of being audited, and a provision of the Affordable Care Act requiring prompt return of any excess payments, have led Medicare Advantage insurance plans to voluntarily send back more than $1 billion to the Treasury**, mostly since 2010.

The CMS spokesman said audits of 30 Medicare Advantage insurance company contracts and their spending from 2012 have begun and that plans were chosen based on how aggressively they report diagnosis codes to CMS for payment.

But Steve Ellis, vice president of the budget watchdog group Taxpayers for Common Sense, said it was troubling that the audits have not delivered better results. “You really have to enforce audits and act on them and not let the bad actors off the hook,” he said.

**Please note:  When millions of dollars are paid to settle a Medicare or Medicaid false claim allegation, where is the reclaimed money allocated? Some of the fines, mostly paid by health care companies, are rewarded to whistleblowers…close to $2.5 billion from 2009 to 2014. Another portion goes to the Crime Victims Fund and other funding goes to the Healthcare Fraud and Abuse Control Program.  So, what happens to the remaining Medicare fraud reclaimed tax dollars? Well, the remainder of recaptured fraud dollars is placed in the Department of Justice “slush fund” with a present balance of $9 billion. And, is used for what the department considers important matters such as terrorism. To reiterate, a large portion of the money is not returned to Medicare or Medicaid for replacement of illegal payments to fraudsters.





How to Take Charge of Your Medical Records

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Couple and LaptopPatients have a lot to gain by getting access to their health information. Knowing where to get it and what to do with it is key. And, it’s your health. So it’s time you took control of all the information about your health. That’s the message a growing number of patient advocates are trying to spread to American health-care consumers. 

For most people, of course, it’s all too easy to simply leave their health records in the hands of doctors and hospitals. But that’s a big mistake, the advocates argue. First, it gives doctors too much power over information that is vital to patients, and it creates opportunities for errors. Perhaps more important, it keeps patients from using the information themselves for their own benefit.

“For consumers to start requesting and using their health information, it will be a game-changer for the health-care system,” says Christine Bechtel, a consultant for the National Partnership for Women and Families who spearheads the Get My Health Data campaign to get patients to ask doctors for their records. “Once we unlock the data, there’s an enormous amount we can do with it.”

Indeed, taking charge of your own records helps circumvent “data lock”—where one doctor’s records system can’t talk with another’s, or when hospitals make a fuss about transferring files to competing providers. By obtaining your records, you can serve as your own data hub and give out information when you are consulting specialists, seeking second opinions or shopping for less expensive care.

Controlling your data can also be a matter of safety, advocates argue. Studies show that 400,000 Americans die every year beause of medical errors, including 80,000 because doctors don’t have in hand the information they need. “This is an epidemic we can cure if patients can carry that information everywhere they go,” says Bettina Experton, CEO of health-care software maker Humetrix.

A big impetus for these advocacy efforts: electronic health records. Spurred by $30 billion in incentives, doctors and hospitals have digitized millions of Americans’ medical files so they can be more easily analyzed and shared, with the goal of improving care and cutting costs. But it’s often been easier for government regulators, data-crunchers and bill collectors to access information on patients than it has been for patients themselves.

To be sure, not everyone thinks it’s a good idea for patients to take charge of their records. Some doctors, for instance, worry that patient files often contain confusing data that could make people needlessly upset or require time-consuming explanations.

Meanwhile,some people are too sick, too busy or too anxious to want to monitor their health data closely.

But a growing number of Americans are eager for access to their own records as they travel from doctor to doctor, or look for answers on their own. And more physicians say the more information patients have, the more invested they will be in their own care.

Managing medical records can take knowledge and perseverance—but it can bring many benefits, from simplifying paperwork to improving well-being. Here are five important steps to make the process as efficient as possible, and get the most out of it.

Demand Your Data…

If you’re intimidated about asking your doctor, bear in mind that they are your records. You have the right, under federal law, to obtain copies of your medical information from virtually any place you receive health-care services. Providers have 30 days to act and can charge for the cost of reproducing the records, but not searching for them or retrieving them. If you spot errors, you can request changes or add information to make the file more accurate.

Many hospitals and doctors have also earned Medicare bonuses by promising to make summaries of your records easily available electronically. Some large health systems, such as Kaiser Permanente, have set up online portals where patients can download summaries, as well as make appointments, order refills and leave messages for doctors. What’s more, about half of all Americans—including all Medicare and Veteran’s Administration patients—can access at least some of their health records, free of charge, through the government’s Blue Button program. People can check if their provider or hospital participates at the Blue Button Connector.

But overall, few patients have accessed their records—so few, in fact, that hospitals have complained about a Medicare rule that penalizes hospitals unless at least 5% of their patients access their records electronically. Federal regulators have proposed lowering the 5% requirement to just a single patient instead.

That, in turn, has provoked outrage from advocacy groups that say many providers haven’t told patients they have the right to see their records, or haven’t given them a way to do so.

Ms. Bechtel notes that hospitals also benefit when patients can scrutinize their records. “If I have my data, I can spot errors, avoid repeat tests, detect fraud,” she says. “Enabling consumers to help, to be a second set of eyes, to be really involved with their data, will improve care and save money in the end.”

Many physicians appreciate the oversight. Farzad Mostashari, a former federal official in charge of health-information technology who is also involved in the Get My Health Data campaign, tells a story about an encounter with a physician in Wisconsin. The doctor told him that since he was giving his patients copies of their records, he heard from at least one each week about an error they had spotted. He said, ” I love it! It’s cheaper than a lawsuit.”

Organize It…

Another benefit to getting hold of data is the chance to organize it in a way that makes it easy to understand and use. A host of software programs and mobile apps let consumers create personal health records to do just that, often for little or no cost.

Instead of having to sort through a collection of different files, patients can collect all of their health records, and those of family members, together in one place. Then they can leverage the information in any number of ways, such as tracking everyone’s medications, immunizations, vital signs, test results and appointments, as well as setting fitness goals and tracking their progress toward reaching them.

Early programs of this type attracted little interest, largely because users had to enter information manually. Newer versions can import data directly from electronic records, wearable devices and other sources.

Microsoft HealthVault, for example, can combine data from a wide variety of sources. One app even lets users import, store and share copies of their X-rays and other scans. HealthVault can also send letters to physicians’ offices and hospitals with instructions on how to send patients their electronic medical data securely.

And an ever-growing array of apps make medical records available on smartphones. IBlueButton, an app made by Humetrix, can convert the often unwieldy Medicare and VA records available on the Blue Button website into easily accessible form on an iPhone or Android phone, and clearly display every diagnosis; every doctor, hospital and ER visit; and every lab test, X-ray and prescription, including when and where it was filled. It can do the same for patient records held by many hospitals and doctors’ offices as well.

IBlueButton users can create separate folders for family members’ records, research medical terms and send their records to providers who have iBlueButton’s professional version.

Share It…

Having health information handy also allows people to share data as they see fit, without waiting for a doctor’s office to get around to doing it. That might mean sending a child’s immunization records to school, emailing photos of suspicious skin lesions to specialists or obtaining second opinions.

“Anyone managing a chronic disease finds this out the hard way, carrying boxes of records from doctor to doctor,” says Joy Pritts, former chief privacy officer at the federal health information-technology agency. “Having electronic copies of your records makes that much easier.”

Having your own set of records to share can also remove the awkwardness of approaching a provider with a request. “A lot of people aren’t comfortable asking their doctor to send their records to another provider—it’s like asking your spouse if you can fool around,” says David McCallie, senior vice president for medical informatics at Cerner Corporation, an electronic-health-record vendor. “It would be much easier if you could just push a button and have your records flow.”

Giving family members or other caregivers a way to access critical information about you, such as your medications, allergies, blood type and major health issues, can literally be a life saver in an emergency, but they may not need to know your entire medical history. Microsoft HealthVault lets users invite other people to be custodians and decide what parts of their records to let them see.

Some apps are specifically designed for emergencies. An app called ICEBlueButton from Humetrix displays a code on a smartphone’s lock screen that paramedics can scan and read even if the user is unconscious. The app will display as much information as the user has decided to make available, and it can be programmed to automatically alert the user’s emergency contacts as well when the code is scanned. A newer version called SOS QR also broadcasts the user’s GPS location and can translate critical information into five languages as well.

One thing to bear in mind, though, is that while doctors are generally eager for specifics about your medical history, most insist on creating their own files for new patients, so you may still have to answer the same questions repeatedly.

And some physicians also warn patients that keeping information private because it seems sensitive or embarrassing can be dangerous. “Your cardiologist needs to know you’re taking Viagra,” says Lawrence Garber, an internist and director of medical informatics at the Reliant Medical Group in Worcester, Mass.

Generate It Yourself…

Health records aren’t the only place people can find information about their conditions. The universe of wearable devices is exploding—from tracking users’ steps walked and calories burned to monitoring heart rate, blood pressure, blood sugar, blood oxygenation and other potentially life-threatening issues.

If knowledge is power, these devices provide patients with unprecedented ability to keep themselves healthy or keep problems under control. People can figure out how much exercise they’re getting during the day, for instance, and how much they need to add to keep in shape. They can also get an instant update on their condition without having to wait for an appointment with their physician.

That’s a step some doctors like, too. “Why should you take a half-day out of your life to see me for 10 minutes and say that you’re fine?” says Daniel Sands, a Boston internist and founder of the nonprofit Society for Participatory Medicine. “I could say, ‘Check your own blood pressure, send it through the patient portal, and we’ll talk again in two weeks. ”

But many doctors are concerned about the security and accuracy of wearable devices, the potential for malpractice issues and the possibility of being overwhelmed with data they don’t need.

“There’s a distinction between solicited and unsolicited information,” Dr. Sands says. “You may want to track everything you do or eat during the day, and I may not be ready for that information.”

Indeed, patients who are part of the “quantified self” movement, and into charting every aspect of their lives, tend to be those who are already healthy, says Joseph Kvedar, a dermatologist and vice president of the Connected Health center at Partners HealthCare in Boston. “We’re more interested in the person who should be wearing a FitBit and is instead eating cheesecake on the couch.”

Protect It…

Having control of medical records brings plenty of benefits, but also a big responsibility: Storing that information on a personal computer or smartphone does make it vulnerable to loss, theft or hacking. Thieves could use a patient’s name and health-insurance numbers to obtain drugs or medical care illicitly, file fraudulent claims and leave the user with bogus charges. That means it’s critical to protect personal health records and medical apps with passwords and make sure any records they send and receive are encrypted.

What’s more, records loaded into a personal health record or other commercial app are no longer protected by the federal Health Insurance Portability and Accountability Act, or HIPAA. Most consumer fitness trackers aren’t covered by HIPAA either, which means the data they collect, including name and other identifying information, can be disclosed—even sold—by the developer. Many apps are free because they sell your data, so it pays to read the privacy policies closely. People could find themselves receiving many unsolicited marketing pitches.

Many experts point to Apple HealthKit’s policy as a model of privacy protection. Apple prohibits app developers from selling or using the data they collect for advertising or data-mining, except for purposes of health or health research. It also requires any apps it connects with to ask the user’s permission before accessing information about them “It’s really putting the user in the driver’s seat with respect to how their information gets used,” says Bud Tribble, the company’s vice president for software technology.