With all the hazards lurking amid the beauty of the Rockies — altitude sickness, lightning, black bears, ticks, giardia, even bubonic plague — the one thing you wouldn't expect to worry about is swine flu.

After all, the H1N1 pandemic has been declared over and, anyway, flu seems most transmissible in crowded, indoor places.

Nonetheless, we just spotted a poster warning of the dangers of swine flu and the benefits of hand washing on the wall of a primitive privy deep in Rocky Mountain National Park.

 

Jane Viste, a spokeswoman for the Larimer County Health Department, said she created the posters over a year ago, and gave them to a network of "public information communicators" in the county.

Then they "put it where they felt it would best get attention," which presumably includes the outdoor sanitation facilities. One, she said was "at altitude," over 12,000 feet.

She noted that even though H1N1 is no longer such a threat, it’s "always good" to remind people to wash their hands.

There was no running water for hand washing or even a flush toilet where we saw the poster. So in this case, a hand sanitizer dispenser had to do.

Looking for something to do over the Labor Day weekend?

Why not try to solve the nation's problem with health care costs? There could be a thousand bucks in it for you.

That's the prize in an essay contest being launched next week by a nonprofit group that wants doctors and other health care workers to be more mindful of the costs of medical tests and other procedures they order.

 

The group, called Costs of Care, was founded by Dr. Neel Shah, a graduate of Brown Medical School and the Harvard Kennedy School of Government now doing a residency in Obstetrics and Gynecology at Brigham and Women's Hospital.

Shah, like many young doctors, worries that medical professionals are too often taught medicine in a vacuum — they learn what to do, but not how much things cost.

"Given that medical bills are the No. 1 cause of personal bankruptcy in this country, and that doctors are the ones that decide what goes on the bill, it makes sense for doctors to be more cost-aware," says Shah.

And that's the goal of the group — to provide doctors, particularly those in the emergency room, with the cost of tests and treatment they are likely to order.

So back to that contest: There will be two categories (and two $1,000 prizes); one for patients, and one for clinicians (including doctors, nurses, medical students).

Judges will include former U.S. Health and Human Services Secretary Michael Leavitt, Boston surgeon and New Yorker writer Atul Gawande, and former Massachusetts Governor and Democratic Presidential Candidate Michael Dukakis.

They're looking for stories about the effect of medical costs on care, including bills that were higher than expected, or a time when a patient or doctor wanted to find out how much something cost, but couldn't.

Essays should be no longer than 750 words. Winners will be announced later this year.

There's no cost to enter the contest. Natch.

Who's sponsoring it? Well, three big insurers — Harvard Pilgrim HealthCare, Tufts Health Plan and Blue Cross and Blue Shield of Massachusetts — and Beth Israel Deaconess Medical Center.

If you tell me just a little bit about yourself, I can make a pretty good guess about the prescription drugs in you medicine chest.

For starters, if you live in the U.S. I'll guess you're taking at least one prescription drug. I'll be right about half the time, according to data just published by the Centers for Disease Control and Prevention.

In the last decade, prescription drug use in the U.S. has risen to the point that 48.3 percent of people take at least one prescription medicine. That's up almost 5 percentage points from the the 43.5 of people taking prescription drug of some kind at the end of the '90s.

Now, in fact, nearly a third of Americans take two or more prescription drugs.

Who's on what? The top choices vary by age.

 

Kids (aged 11 and under) are big users of asthma drugs — 9.6 percent of their prescriptions.

Adolescents (12 to 19) also take a lot of asthma drugs, but the most frequently prescribed medicines for this group are for ADHD — 6.1 percent of prescriptions.

Adults (20 to 59) are most likely taking an antidepressant — 10.8 percent of prescriptions — followed closely by painkillers at 10.1 percent.

Older Adults (60 and up) are, as you might expect, the group that's taking the most medicines. Some 44.9 percent are taking a drug to treat cholesterol. Next most popular are two types of blood pressure meds, with 26.4 percent taking a beta blocker and 19.9 percent taking a diuretic.

Nearly 9 in 10 older people take at least one prescription drug. And, 36.7 percent of them take five or more drugs.

Taking drugs like Fosamax to fight brittle bones isn't a lot of fun.

The directions sternly say you've got to swallow them first thing in the morning, before you eat or drink a thing. You can only wash the medicine down with a lot of water (no coffee!) and then must sit or stand upright for at least half an hour. Then after you've eaten something, maybe you can wander back to bed or get on with your day.

Why the rigmarole? If the medicine backs up into your esophagus it's painful and may cause damage.

Now a study out of the U.K. finds that people who filled at least 10 prescriptions of drugs such as Fosamax (technically, oral bisphosphonates) were almost twice as likely to develop cancer of the esophagus, an often fatal condition, than similar people who didn't take the medicines at all.

 

Over time, serious acid reflux can irritate the esophagus and raise the risk for developing cancer, so that may be the problem here.

Don't panic about the latest study, though. The findings don't prove the osteoporosis drugs caused the cancers. And, even if a link is nailed down eventually, the cancer risk remains pretty low in absolute terms.

For people age 60 to 79, the biggest bunch in the study, you'd expect to see about 1 case of esophageal cancer in 1,000 people over five years. This would increase to about 2 cases per 1,000 for people taking oral bisphosphonates. The results appear in the latest issue of BMJ, the British Medial Journal.

An accompanying editorial written by an epidemiologist at the U.S. Food and Drug Administration says the results aren't conclusive. Still, the research, along with previous reports of esophageal cancer, argues for caution in prescribing the medicines and reinforcement of the instructions to patient for taking the drugs.

Well, we didn't think today was going to be all-diet-pills-all-the-time, but here we are with another post on the subject.

Japanese drug giant Takeda and San Diego-based Orexigen have struck a marketing partnership to sell Contrave, an experimental weight-loss pill Orexigen has submitted to the Food and Drug Administration for approval.

 

The medicine combines bupropion, a drug most often used as an antidepressant, with naltrexone, a medicine used mainly for addiction.

Under terms of the Takeda deal, Orexigen is getting $50 million right away. Eventually the company could get more than $1 billion from Takeda, if everything goes well with the FDA and on the market.

That's not guaranteed. In July, a panel of experts advised the FDA not to approve Qnexa, a rival diet pill, because of concerns about risk.

Indeed, a recent nationwide survey done for NPR found that Americans are leery of weight loss medicines. Cost and side effects are turnoffs for many people. About a quarter of people surveyed said a successful drug would have to help them lose between about 20 and 30 pounds. A similar proportion said about 10 to 20 pounds would be enough.

Data from Orexigen studies showed that people who completed a year of treatment with Contrave lost an average of 17 1/2 lbs, or more than 8 percent of their weight.

The FDA is expected to make a decision on Contrave early next year.

Have you taken a pill or supplement to lose weight? Would you?

With several drugmakers working on new medicines to help overweight people shed pounds, we wondered how Americans view the idea these days.

A bunch of previous medicines, most notably the two-drug combination known as fen-phen, have been tripped up by side effects. In July, an expert panel advising the Food and Drug Administration recommended against approval of a new pill, citing safety concerns. And just this week, new data on risks posed by the daily diet pill Meridia, available since 1997, have led some to call for its withdrawal from the market.

We asked the folks at Thomson Reuters to help us gauge public opinion on diet drugs and supplements. In early August, they talked with more than 3,000 people, and asked for information on their weights and heights to help put the answers in perspective.

 

Some 58 percent of the people surveyed had body mass indexes of 25 or more, meaning they are overweight, obese or morbidly obese. That's about what we expected — other surveys have shown that about two-thirds of Americans have some sort of weight problem.

More than half of those surveyed — 52 percent — said they have tried to lose weight in the last year. About three-quarters of those who are obese or morbidly obese have tried to do so. The most common goal, reported by about a third of respondents, was to lose between about 10 and 20 pounds.

OK, so weight's a common problem and most people with extra pounds are trying to slim down. But have they ever turned to a prescription drug, over-the-counter medicine or supplement for help?

Not really. Only 15 percent ever have tried one, the survey found. The morbidly obese were most likely to have done so, with 35 percent having taken something at some point.

One reason may be cost. Nearly three-quarters of the people polled say they're unwilling to spend any money out of their own pocket for a weight-loss medicine or supplement. That finding was pretty consistent, regardless of age, income or education. For those willing to pay something, less than $25 a month was the most tolerable amount and seemed OK to about 18 percent of people surveyed.

How much weight would someone have to lose to consider a medicine or supplement to be worthwhile? About a quarter of people said around 10 to 20 pounds, and about the same proportion figured around 20 to 30 pounds would be the right goal. The more people weighed, the more they said they'd need to lose to call a medicine or supplement successful.

Finally, what about side effects? Every medicine has some. What would people tolerate in a diet remedy? Nearly half of those surveyed — 49 percent — said they wouldn't accept any side effects. Forty-six percent said they would be OK with minor problems such as a headache or dry mouth.

For the morbidly obese, the picture was different. Only 19 percent of those respondents put the side-effect bar at zero. Two-thirds of them would tolerate minor side effects. Some 11 percent would accept moderate problems (such as insomnia), and nearly 4 percent would be wiling to risk severe trouble such as liver or heart complications.

The survey had a margin of error of plus or minus 1.8 percentage points.

Click here to see the questions asked and get the full results.

Employers' health insurance premiums haven't actually gone up very much for 2010. But you wouldn't know that if you're an employee.

That's because, for the first time since it started keeping track a decade ago, this year's survey of employers by the Kaiser Family Foundation and Health Research and Educational Trust found those employers passing along virtually all of the increase in the cost of health coverage to their workers.

The result? "Worker contributions to premiums went up 14 percent this year and the employer share did not go up at all," Kaiser President and CEO Drew Altman tells Shots.

 

How much money is riding? The average premium went up $482 for workers with family policy.

Over time the news for workers has been bad and getting worse for a while. "The employee's share of premiums is up 159 percent in the last 10 years, while wages are up 42 percent," Altman says.

The latest — and almost complete — transfer of higher health insurance costs to employees is significant, he says. "It just speaks to the pressure that companies are under, especially small companies, from the recession," he says. "And it also speaks to how badly people need to hold onto their jobs in the recession — that they will absorb those benefit cuts because they need those jobs."

But Altman says the upward creep of all sorts of health costs for employees, including deductibles and copayments, raises a more ominous question about affordability of health care for the majority of Americans who still get their insurance on the job.

"While we were all focused on expanding coverage in the health reform debate, I think what we missed is that while that debate was going on, what we call health insurance in the country has actually been changing an awful lot," he said. "So what most people get as health insurance today just doesn't look very much like the more comprehensive health insurance their parents got."

And because the politics of the health overhaul debate "were don't touch employer insurance very much," he says, the result is "the basic trend for the 160, 170 million people with employer-based insurance is that insurance is going to slowly change, and people will be in plans with greater cost-sharing and higher deductibles."

Thirteen years ago the Food and Drug Administration approved a diet pill called Meridia.

Now, finally, we're finding out details on exactly how much the daily appetite suppressant increases the odds for heart attacks and strokes. And the findings led top editors at the New England Journal of Medicine to label Meridia "another flawed diet pill" and call for it to be yanked from the market.

The FDA is convening a meeting of expert advisers next month to review the latest data and to make recommendations about the drug. Here's what they'll be considering.

A study of nearly 10,000 obese or overweight people at high risk for cardiovascular trouble found Meridia increased the risk of nonfatal heart attacks by 28 percent and nonfatal strokes by 36 percent compared to a sugar pill.

 

Among the patients, all 55 and older, who took Meridia for an average of about 3 1/2 years, the rate of nonfatal heart attack was 4.1 percent compared with 3.2 percent for those on placebo. For nonfatal strokes the rates were 2.6 percent on Meridia vs. 1.9 percent on placebo.

Even before Meridia, an appetite suppressant, hit the market, the agency was concerned about the daily pill's tendency to raise blood pressure and increase heart rate and the chances it could put patients at greater risk for cardiovascular disease. Others figured significant weight loss for people taking the drug could improve heart health.

The study's authors took comfort in the findings that deaths from strokes and heart attack weren't significantly higher among the people who took the diet pill instead of placebo. Average blood pressure fell a little in both groups. The results, they said, showed the drug shouldn't be used by people with pre-existing cardiovascular conditions.  Abbott, Meridia's maker, funded the research.

But, as the NEJM editorial concludes, the whole rationale for using the medicine is suspect because in this clinical trial the net weight lost was 4.5 percent — less than the 5 percent that FDA considers the minimum for such drugs — and there was no improvement, as was anticipated, for cardiovascular disease.

Ultimately, Meridia's risks outweigh the benefits, the editorial says, and "it difficult to discern a credible rationale for keeping this medication on the market."

The men of the USS Kirk were trained as warriors, not as caregivers. So they didn't think of what they did more than three decades ago as significant.

But their rescue of 20,000 to 30,000 Vietnamese refugees, in the last days of the Vietnam War, is now being recognized as one of the most important humanitarian missions in the history of the U.S. Navy.

One of the first places to recognize the Kirk is the Navy's Medical Department. Vice Admiral Adam Robinson, the Navy Surgeon General, showed up at the July reunion of the Kirk's crew in Springfield, Va., to thank the officers and men from the small destroyer escort. That was a big step because, for several years, the Navy said it had no record that the Kirk was even present during the 1975 evacuation of Saigon.

 

Robinson's department deploys the Navy's hospital ships, the USNS Comfort and the USNS Mercy. The Comfort was sent to the Gulf Coast after Hurricane Katrina five years ago and to Haiti after the earthquake there in January. Robinson says those missions showed the growing role for the Navy to carry out humanitarian work.

And it's that growing role that also led to Robinson's interest in the story of what the Kirk did 35 years ago. Robinson is sponsoring the work of Jan Herman, of the Navy Medical Department, to document the Kirk's mission in a film and a book.

Herman says the Kirk's story got "left in the dust" because of bitterness over Vietnam. When the war ended, Americans didn't want to hear stories about the war, he says.

But another reason, he says, is that the men themselves didn't think of what they did as significant. The Kirk, designed to hunt submarines, didn't see combat. When the ship's crew was ordered back to Vietnam — by itself, as the rest of the Navy was leaving — the men saw themselves as "just doing our job," says Captain Paul Jacobs.

The ship steamed to Con Son Island, where the last ships from South Vietnam's Navy were awaiting rescue. On board the 30-some Navy ships — and even more small fishing boats and rusted cargo ships — were an estimated 20,000 to 30,000 refugees.

"So here they are suddenly involved in this drama. It has nothing to do with firing torpedoes or guns," says Herman of the Kirk's crew. "It has nothing to do with any of that. It has to do with taking care of babies and feeding women and children. And I think for warriors, that doesn't come naturally. But they did it because it was something they had to do on the spot, and they did it. And they did it extremely well."

The ship escorted the refugees to safety, later meeting up with other U.S. Navy ships. About half the refugees were women, children and babies. The Kirk's crew fed them, gave them fresh water and cared for the sick.

But still, it wasn't something people talked about. "It's certainly not something you go bragging about to your fellow warriors: I diapered a baby today," Herman said.

That started to change when the men of the Kirk began to hold reunions. They would wonder what happened to the men, women and children they saved. They started to seek them out and when they found them — and heard the stories of their successful lives — the members of the Kirk crew began to understand that their humanitarian mission was as important as the military mission they'd been trained for.

To tell this forgotten story of the Kirk's rescue mission, NPR interviewed more than 20 American and Vietnamese participants and looked at hundreds of photographs and other records, many of which had never been made public before.

This time last year college kids were stressing out about swine flu, hard as that is to believe in hindsight. With students streaming back to campuses, we wondered what health concerns are topping the agenda now.

We checked in with Dr. Al Glass, president of the American College Health Association, and the heads of health services at some colleges around the country to get a bead on what students face this time around.

Here are their top five issues:

 

1. Mental Health

"Mental health issues in a broad sense certainly remain a primary issue," Glass says. Stress is a biggie.

Dr. Susan Even, director of the University of Missouri's student health center, agrees. At Mizzou, which is expecting a record enrollment this year, adjustment to a big school just compounds the problem, she says.

The University of Maryland's student health center offers help to students dealing with stress and anxiety, including acupuncture and meditation. "We are very supportive of alternative medicine," says Dr. Sacared Bodison, director of the student health center.

2. Sleep

All-nighters and good health don't mix. Students should pay more attention to getting enough sleep.

"College and university students tend to keep schedules that are really different from people who are out having jobs in the world," Glass says. Unfortunately, that's nothing new. Only 11 percent of college students in a sample of 191 undergrads had good quality sleep, a 2001 study in the Journal of American College Health found.

3. Infectious Disease

Although some students died from swine flu last year,"it didn't turn out to be the pandemic of illness that people were worried about," says John H. Turco, director of the Dartmouth College health service.

Still, the focus on H1N1 led to cultural changes at Dartmouth, Turco says. More people became aware of disease prevention and use of hand sanitizers has become routine.

Glass says infectious disease is a perennial concern. There's no particular bug on the radar this year, but "exposure to other infectious illnesses — colds, upper respiratory infections, influenza" are inevitable.

Vaccines can help against some of the usual suspects. The Centers for Disease Control and Prevention recommends these for teens and colleges students.

4. Exercise

Weight problems are everywhere, even college campuses. So what else does the CDC recommend? Exercise.

Adults should be active at least 2 1/2 hours a week. But some students may not be getting enough. Glass says too many college kids aren't heeding the advice and warns that college students aren't immune to the obesity epidemic.

5. Alcohol

Glass says a discussion about college health wouldn't be complete without talking about alcohol use.

"If [students] would make the decision to drink in college — which, certainly, we're all aware a large number of them do — to make those choices about what to drink, how much to drink those kinds of things need to be optimally made in a very responsible way," Glass says.

According to the National Institute on Alcohol Abuse and Alcoholism, about 4 in 5 college students drink. And when asked, 2 in 5 say they've been on a drinking in the past few weeks. Nearly 600,000 college students are injured while under the influence of alcohol each year.

When you hear about Botox, the temporary wrinkle remover, you might think about Hollywood stars or even how the local doctor, dentist's office or spa has begun offering shots of the stuff, too.

But the selling of Botox has gone far beyond cosmetics. And Allergan, the drug's maker, has just agreed to settle federal charges and pay the government $600 million in fines.

First, Allergan will plead guilty to marketing Botox between 2000 and 2005 for uses the Food and Drug Administration hadn't approved. And those uses were anything but cosmetic. The company allegedly encouraged doctors to give Botox shots for treatment of headaches, pain, spasticity and juvenile cerebral palsy.

 

The price to Allergan for putting that charge behind it is a criminal guilty plea and a $375 million fine.

The FDA has approved most of the uses since the time Allergan was touting them off-label, but treatment of chronic migraine pain is still under review.

Botox, a pharmaceutical version of botulinum toxin, works by blocking nerves that control muscles. In cosmetic uses, the blocked nerves cause muscles to relax and that, in turn, helps reduce wrinkles for a few months. For other conditions, the medicine can prevent muscles from going into spasms, becoming stiff or causing pain.

Allergan denied civil claims that its selling of Botox led to overbilling of federal health programs, including Medicare and Medicaid. But it's paying $225 million to settle them in any event.

At a media briefing, federal officials said the company had beefed up its reimbursement department to help train doctors in billing the government for unapproved uses of Botox. The company also allegedly paid kickbacks to doctors, sometimes under the guise of educational grants.

The government's case got rolling when people who had worked for Allergan on off-label promotion filed sealed lawsuits laying out the scheme. See the details starting on page 8, for instance.

One noteworthy twist in the Botox case is that Allergan agreed to withdraw a lawsuit challenging the FDA's authority to regulate off-label marketing.

FDA Commissioner Margaret Hamburg said the agency was pleased by that decision, adding "The off-label promotion of drugs threates the public health and the regulatory framework of FDA."

Finally, the feds pointed out that $600 million is a lot of money and should serve as a deterrent to this sort of behavior in the future. Still, the settlement is nowhere near the $2.3 billion settlement agreed to by Pfizer almost exactly a year ago.

On the other hand, Allergan is paying $50 million more than the $550 million Goldman Sachs shelled out to make federal claims of investor fraud go away.

Lawyers for the Justice Department have made their case for a federal judge to restore funding of research with embryonic human stem cells.

Last month, a judge's decision temporarily blocked the government from funding that sort of work while a bigger lawsuit brought by scientists who work with adult stem cells proceeds. The decision has cast doubt on the future of a wide range of research using embryonic cells.

In arguments filed Tuesday, the Justice Department said the injunction should be lifted to " avoid terminating research projects midstream, invalidating results in process and impeding years of scientific progress toward finding new treatments for devastating illnesses" ranging from diabetes to spinal cord injuries.

 

In support, the government lawyers attached a 12-page statement from National Institutes of Health Director Francis Collins on what's at stake if the funding block continues.

The high points:

• NIH has sunk $546 million into human embryonic stem cell research since 2002, and the payoff from the early work is now in jeopardy.
• Adult stem cells, alternatives to the controversial human embryonic ones, have been known for 50 years, yet in all that time researchers have been unable to overcome "serious limitations" on their use.
• Even temporary funding stoppages could seriously set back research that has been years in the making because it's hard to restart.

Well, at least this August, unlike the one a year ago, didn't feature all those raucous town hall meetings where opponents of health care overhaul dominating the news.

Yet, according to the monthly tracking poll by the Kaiser Family Foundation, even this quieter summer saw public opinion on what's now the health law of the land slip a little.

The monthly poll saw favorable ratings for the law drop from 50 percent in July to 43 percent in August. At the same time, however, respondents remain almost evenly split in how they think they will be personally affected; with 29 percent saying they will be better off, 30 percent predicting they will be worse off, and 36 percent saying they still don't know.

 

Kaiser President and CEO Drew Altman says he doesn't read much into the monthly swings:

It really is like the stock market recently; it's trading in a narrow band. But if you step back, it really isn't moving. The public is split, has been split, and continues to be split. It's basically a third (saying they are more likely to support a candidate who voted for the bill) a third (saying they are more likely to oppose a candidate who voted for the bill) and a third (saying it won't affect their vote one way or the other).

To see what Altman's driving at, take a look at Talking Point Memo's health poll mashup, which averages the results from a bunch of different polls.

Still, Altman does allow that it's likely that the July upswing might have been due to the rollout that month of "a rapid barrage of announcements about very popular things" in the law, including new preventive health benefits for people with insurance, and new "high risk pools" to help provide insurance coverage to people with pre-existing health conditions.

And the August dip? "It's just a tough public opinion environment," he says. "Because they're crabby, understandably, about the economy. It's the thing that's sitting there for them to be upset about now."

But before Republicans get too excited, Altman says the poll also suggests the health law may not play much of a role in the upcoming mid-term election.

When pollsters asked those who said they were "angry" about the new law exactly what they were angry about, he says, "84 percent of them said they were angry about the general direction in Washington and health reform was just one of many things that was upsetting them."

If there's ever going to be progress in reducing the frequency of cesarean sections in this country, it sure will take a while.

The latest snapshot of how women give birth in the United States is sobering. Almost a third of women giving birth for the first time have C-sections. In the late '90s, about 1 in 5 of all deliveries were by cesarean.

One reason for the high proportion of C-sections now: 44 percent of attempted vaginal deliveries were induced, a decision which is twice as likely to lead to a cesarean. The medical records don't show whether the procedure was medically necessary.

 

"One message from this study is that physicians should use induction more judiciously," researcher Dr. Jun Zhang, told WebMD. "Another message is that they should probably slow down."

The findings, culled from the medical records of more than 230,000 births in the last decade, appear in the current American Journal of Obstetrics and Gynecology.

Some of the factors behind the rise of cesareans, now at the highest rate ever, are more older and obese moms, more twins and other multiple births, bigger babies and longer labor.

A surprising finding, according to the researchers, was that first-time moms were about as likely to have cesareans as women who'd previously had one.

"To make a significant impact on the high cesarean delivery rate in the United States, the focus should be preventing unnecessary primary cesarean deliveries..." the researchers say.

Their recommendations include:

• Reducing the rate of cesareans associated with induced labor.
• Coming up with standardized criteria for when to perform a c-section.
• Upping the odds that women who've had a cesarean will get the chance to try a vaginal delivery.

Up in New York, Democratic Attorney General (and gubernatorial candidate) Andrew Cuomo has started looking into predatory lending practices by dentists, chiropractors and other health care practitioners whose services often aren't covered by insurance.

Among the health care providers Cuomo claims are preying on vulnerable patients are some you might not expect: veterinarians.

As anyone who’s had a sick pet knows, however, charges at the vet can add up fast. Last year, while looking at health insurance for pets, NPR's David Kestenbaum found a hedgehog whose cancer care cost $2,700.

 

Back in 2003, Consumer Reports found veterinary care could be pretty pricey. Repairing a broken limb cost $350 on average. A doggy pacemaker could set you back $3,000. A simple wellness visit for a geriatric cat can cost as much as $340, the study found.

But few people have insurance to cover the bills.

So Cuomo's investigation focuses on health care credit cards, which he claims claims health care professionals pressure consumers into applying for. If the consumer puts the charges on the card, the provider gets paid within a few days. And, according to Cuomo, at least one card company gives practitioners a rebate of the fee they’re charged to offer the cards based on how much they generate in sales.

Although complaints about dentists predominate, consumer advocates say veterinary practices come in for their share of criticism, too.

The cards can be tempting to cash-strapped consumers. They often offer zero-interest loans during a promotional period of six months to more than a year.

But if the consumer doesn’t pay off the bill during that time, interest in excess of 25 percent is typically charged on the full amount, going back to the original date the service was provided.

Consumer advocates say there are other problems with the cards as well, including cases where consumers were misled into thinking they were signing up for an extended payment agreement with their provider rather than a credit card.

"Our advice is to steer clear,” says Mark Rukavina, executive director of the Access Project, a  Boston-based nonprofit that helps consumers resolve medical debts. Unless you’re confident you have the resources to pay off the amount before the teaser rate ends, "It will often just increase the pain."