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Daily Archives: November 15, 2017

California Fines Anthem $5 Million For Failing to Address Consumer Grievances

California’s managed-care regulator has fined insurance giant Anthem Blue Cross $5 million for repeatedly failing to resolve consumer grievances in a timely manner.

The state Department of Managed Health Care criticized Anthem, the nation’s second-largest health insurer, for systemic violations and a long history of flouting the law in regard to consumer complaints.

“Anthem Blue Cross’ failures to comply with the law surrounding grievance and appeals rights are long-standing, ongoing and unacceptable,” said Shelley Rouillard, director of the Department of Managed Health Care. “Anthem knows this is a huge problem, but they haven’t addressed it.”

Before this latest action, California had already fined Anthem more than $6 million collectively for grievance-system violations since 2002.

The state said it identified 245 grievance-system violations during this latest investigation of consumer complaints at Anthem from 2013 to 2016.

Rouillard cited one example in which Anthem denied a submitted claim for an extensive surgical procedure, even though it had issued prior approval for the operation. Twenty-two calls contesting the denial ” placed by the patient, the patient’s spouse, the couple’s insurance broker and the medical provider — failed to resolve the complaint. It was not until the patient sought help from the managed-care agency, more than six months after the treatment, that Anthem paid the claim.

Anthem Inc. could not be immediately reached for comment. The company, based in Indianapolis, sells Blue Cross policies in California and 13 other states.

California is known for having tough consumer protection laws on health coverage and for assisting policyholders when they exhaust their appeals with insurers. In other actions, the state has fined insurers for overstating the extent of their doctor networks and for denying patients timely access to mental health treatment.

Jamie Court, president of Consumer Watchdog, an advocacy group in Santa Monica, Calif., said the regulatory response to these problems varies greatly by state.  He singled out New York, Washington and Kansas as some of the states with good track records of holding health insurers accountable.

“The real problem is when states don’t act there is not a great avenue for the consumer. It’s very hard to bring legal action,” Court said. “Anthem definitely needed a wake-up call. But this will also send a message to other insurers.”

Nationally, consumers continue to express their displeasure with health insurers over a wide range of issues, including denials for treatment, billing disputes and the lack of in-network doctors.

Verified complaints related to health insurance and accident coverage rose 12 percent in 2016 compared to the previous year, totaling 53,680, according to data compiled by the National Association of Insurance Commissioners. The data only includes incidents in which state regulators confirmed there was a violation or error by the insurer involved.

Court and other advocates welcomed the significant fine in California and said this is just the latest example of Anthem’s failure to uphold basic consumer protections.

Overall, state officials said that calls to Anthem’s customer service department often led to repeated transfers of calls and that the company failed to follow up with enrollees.

After previous fines, Anthem has pledged to provide more training to employees and to better track grievances and appeals in order to reduce delays.

“If you look at the history of Anthem and the penalties assessed over the years, they are definitely an outlier compared to other health plans,” Rouillard said.

“All the plans have some issues with grievances, but nothing to the degree we are seeing with Anthem.”

The managed-care department said a health plan’s grievance program is critical, so that consumers know they have the right to pursue an independent medical review or file a complaint with regulators if they are dissatisfied with the insurer’s decision. The grievance system can also help insurers identify systemic problems and improve customer service, state officials said.

The state’s independent medical review program allows consumers to have their case heard by doctors who are not tied to their health plan. The cases often arise when an insurer denies a patient’s request for treatment or a prescription drug.

In 2016, insurance company denials were overturned in nearly 70 percent of medical review cases and patients received the requested treatment, according to state officials.

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How Older Patients Can Dodge Pitfalls Entrenched In Health Care System

Being old and sick in America frequently means a doctor won’t ask you about troublesome concerns you deal with day to day — difficulty walking, dizziness, a leaky bladder, sleep disturbances memory lapses, and more.

It means that if you€™re hospitalized, you have a good chance of being treated by a physician you’ve never met and undergoing questionable tests and treatments that might end up compromising your health.

It means that if you subsequently seek rehabilitation at a skilled nursing facility, you’ll encounter another medical team that doesn’t know you or understand your at-home circumstances. Typically, a doctor won’t see you very often. In her new book, “Old & Sick in America: The Journey Through the Health Care System,” Dr. Muriel Gillick, a professor of population medicine at Harvard Medical School and director of the Program in Aging at Harvard Pilgrim Health Care Institute, delves deeply into these concerns and why they’re widespread.

Her answer: a complex set of forces is responsible.  Some examples:

  • Medical training doesn’t make geriatric expertise a priority.
  • Care at bottom-line-oriented hospitals is driven by the availability of sophisticated technology.
  • Drug companies and medical device manufacturers want to see their products adopted widely and offer incentives to ensure this happens.
  • Medicare, the governmentâs influential health program for seniors, pays more for procedures than for the intensive counseling that older adults and caregivers need.

In an interview, Gillick offered thoughts about how older adults and their caregivers can navigate this treacherous terrain. Her remarks have been edited for clarity and length:

Q: What perils do older adults encounter as they travel through the health care system?

The journey usually begins in the doctor’s office, so let’s start there. In general, physicians tend to focus on different organ systems. The heart. The lungs. The kidneys. They don’t focus so much on conditions that cross various organ systems, so-called geriatric syndromes. Things like falling, becoming confused or dealing with incontinence.

Q: What can people do about that?

Older people are often unwilling to bring these issues to the attention of their doctors. But if a family member is accompanying the patient, they should speak up.

In some practices, a nurse practitioner may be more attuned to these issues than the physician. So, it’s a good idea to learn who in the medical office you go to is good at what.

Another approach is to request a geriatric assessment or consultation that will bring these issues to the forefront.

Q: How do geriatric assessments work?

A geriatric assessment does two major things. It looks at the whole person. And it focuses on that person’s functioning — on what they can do. Can they dress themselves, walk, get to the bathroom? Can they cook meals? Take a bus downtown? Balance their checkbook?

An outpatient geriatric assessment is typically 1½ to two hours and conducted by an interdisciplinary team. A social worker or a mental health professional will ask about the persons family situation. Are they living alone? Do they have support? A nurse practitioner will look at physical function. And a physician will go over medical concerns and examine the cognitive performance of the individual. Then, the team pulls all these pieces together to look at what’s going on with that person.

When someone starts being frail — having consistent difficulty doing things — an assessment of this kind is often a good idea.

Q: The next step you talk about in your book is the hospital.

One of the big perils in the hospital is technology, which is also its great virtue.  Technology can improve quality of life and be life-extending. But, sometimes, it creates endless complications.

An example are imaging tests such as CT scans. Physicians hardly think of this as an invasive test. But often one has to administer a dye to see what’s going on.  That dye can cause kidney failure in someone with impaired kidney function — something that’s common in older adults.

Sometimes there’s no real need for scans. An example would be an older person who becomes acutely confused in the hospital, which happens a lot. The appropriate response is to look at what’s causing the confusion and take away the offending agent. Often, that’s a medication that was started in the hospital. Or, it’s an infection. But the routine knee-jerk reaction is to do a CT scan to rule out the possibility of a stroke or bleeding in the brain.

For the most part, doctors want to do whatever it takes to diagnose a problem.  For younger patients, this may make sense. But for frail older patients with multiple medical conditions, a cascade of complications can result.

Q: What do you advise older patients and their families do?

When a test is proposed, ask the doctor “how important is it to pursue this diagnosis” and “how will the results change what you do?”

It’s also reasonable to say something along the lines of “every time I™ve had a test, it seems like I get into some kind of trouble. So, I really want to know, with this test or this treatment, what kind of trouble could I get into?”

Q: In your book, you talk about how a doctor-patient relationship can be sidelined when someone goes to the hospital. Instead, hospitalists provide care. How should people respond?

It’s really important to give that doctor a sense of the patient and who they are.  Say, your 88-year-old mother is in the hospital, and she’s become profoundly confused. The doctor doesn’t know what she was like a week or a month ago. He may assume she has dementia unless he hears otherwise. He won’t understand it might be delirium.

You or a caregiver want to come across as someone who can make it easier for the doctor to do his or her job — versus someone who’s a nuisance. You want to build trust, not annoyance.

Q: What about skilled nursing facilities?

These are settings that people go to after the hospital, to get rehabilitation.  Typically, the contact with doctors is minimal after an initial evaluation, though there’s a spectrum as to how much medical care there is.

A subset of older adults go to rehab just to get physical therapy after they’ve had a joint replacement or a hip fracture. They are really pretty stable, medically. If they get good physical therapy and nursing care, it’s probably OK that the doctor isn’t around much.

But there are also older patients who come to skilled nursing facilities, or SNFs, after having had one complication after another in the hospital. These patients can be very fragile, with many medical problems. They’re at risk of getting some new problem in the SNF — perhaps an infection ” or an exacerbation of one of the problems they already have that hasn’t resolved.

Q: What do you recommend?

When you arrive at an SNF, it’s a new cast of characters. A physician whom you’ll see fleetingly. Nurses. Physical therapists. Aides. If you’re a caregiver, make sure you have face-to-face time with these staffers.

SNFs are required within the first week or so to have a care planning meeting with the team. They’re supposed to invite patients and their representatives to the meeting. This is a good place to say something along the lines of “My mother has been through a lot, and now that we’ve met you and seen what you can do, we’d like you to do your best to treat her here and not send her back to the hospital.â€

You have to have trust to make that happen. The family has to trust the medical team. And the team has to trust that the family isn’t going to get upset and sue them. A meeting of this kind has the potential to allow everyone to figure out what’s important and what the plan will be going forward.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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California Firm Running Physician Practices Is Closing Down as Scrutiny Ramps Up

SynerMed, a company that manages physician practices serving hundreds of thousands of Medicaid and Medicare patients across California, is planning to shut down amid scrutiny from state regulators and health insurers.

The company’s chief executive, James Mason, notified employees in an internal email Nov. 6, obtained by Kaiser Health News, that audits by health plans found “several system and control failures within medical management and other departments.”

As a result, Mason wrote, the company “will begin the legal and operational steps to shut down all operations.†He said he was working on the transition of SynerMeds clients to another management firm within the next 180 days.

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Separately, the California Department of Managed Health Care confirmed it is investigating the company.

There is an open investigation of SynerMed, but the details are confidential right now,” said spokesman Rodger Butler. His agency monitors the financial solvency and claims-payment practices of many physician groups that contract with health plans.

The company’s sudden decision to shut down has sparked alarm among some doctors and medical groups that have relied on the company to handle their finances and business operations.

For years, SynerMed has served as a key middleman between health plans and independent physician practices, handling insurance contracting, paying claims and performing other administrative tasks so doctors can focus on treating patients. That role has expanded as millions more Californians are enrolled in Medicaid managed-care plans under the Affordable Care Act.

SynerMed has billed itself as “one of the largest Medicaid/Medicare management service organizations in the nation. Last year, the company boasted that it had enrollment of 1 million patients in California, aided by an influx of enrollees who got coverage under the federal health law.

Mason, the CEO, didn’t respond to requests for comment. The company referred calls to its general counsel, but she couldn’t be reached.

In his email to employees, Mason said he had “discovered certain internal control issues within the medical management department.”

“Well,” he wrote, “as a result of the manner in which those issues were disclosed to the health plans and regulatory agencies, we have been subject to unannounced audits by almost all of our health plan partners.”

The CEO said two medical groups, AlphaCare and EHS (Employee Health Systems) Medical Group, have already terminated their contracts with SynerMed.

“I am heartbroken and saddened by these events after we have worked so hard to build our reputation as a company that operates with integrity,” Mason wrote in his email to employees.

Part of SynerMed’s growth had come from managing care for low-income seniors and people with disabilities who are eligible for both Medicare and Medicaid, called Medi-Cal in California. The state has been at the forefront nationally in trying to shift those “dual-eligible” patients into managed-care plans, which are paid a fixed rate per patient to coordinate a range of medical care.

A spokesman for the Medi-Cal program said the agency had no information to share on SynerMed.

SynerMed is a subsidiary of PAMC, Ltd., which also owns Pacific Alliance Medical Center in Los Angeles’ Chinatown. The hospital agreed to pay $42 million in June to settle federal allegations of improper kickbacks to referring physicians.

The U.S. Justice Department said Pacific Alliance Medical Center agreed to the settlement to resolve a whistleblower lawsuit alleging that the hospital submitted false claims to Medi-Cal and Medicare. In a news release at the time, federal officials said the hospital and its owners did not admit liability in settling the case.

The hospital is closing later this month. Officials there attributed the closure to the fact that the lease on the property is ending and it wasn’t financially feasible to retrofit facilities to meet the state’s seismic requirements.

In a statement to Kaiser Health News, PAMC said “there is no connection between the closure of [the hospital] and any matters involving SynerMed. SynerMed is a wholly owned subsidiary that provides completely different services.”

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Viewpoints: Using The Health Law To Pay For Tax Reform; HHS Secretary’s Challenge: Defining Affordability

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Tactic Of Using New Patents To Extend A Monopoly On A Drug Is Widespread, Study Finds

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Perspectives: HHS Pick Sends Message That Pharma Gravy Train Will Keep Chugging Along

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During HHS Nominee’s Tenure At Eli Lilly, Company Tripled Price Of A Top-Selling Insulin Drug

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First Edition: November 15, 2017

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Can Apps Slay The Medical Bill Dragon?

Rachael Norman needed to submit a pile of out-of-network medical bills to her insurance company for reimbursement. Short on time, she started searching for a company that could do that tedious work for her.

She failed to find one, so she started one herself.

Norman said her company, Better, along with a handful of other Silicon Valley start-ups, is attempting to usher medical billing technology into the 21st century. Banking, transportation, furniture and grocery shopping can all be managed with some fancy finger work on smartphone screens. She and other entrepreneurs wondered: Why not medical bills?

Today, Norman’s clients submit digital copies of their out-of-network bills through an app on their phones. Better’s employees navigate the bureaucratic thicket to track down reimbursements — and keep Ǫ percent of the money they recover from insurers.

The company has processed millions of dollars in claims, for everything from psychiatry to acupuncture to contact lenses, Norman said. The majority of Better€™s customers have Preferred Provider Organizations (PPOs) or other types of insurance policies with out-of-network benefits. Unlike visiting in-network doctors, patients using out-of-network services often must pay upfront, then ask for reimbursement from their insurer later.

“For a lot of people, it becomes magic that we’re able to solve those problems and get them the money they are owed from insurance,” said Norman, who founded Oakland-based Better about a year and a half ago.

Better is among a new breed of start-ups trying to lead customers through the labyrinth of medical billing. Each has taken on a different aspect of billing — helping patients file claims, scanning bills for errors or making charges easier to understand.

But in their quest to revolutionize an industry, these start-ups face a variety of obstacles, including trouble getting access to medical records and difficulty cracking complex insurance policies. Some of the young companies are flourishing. Others are folding.

Pairing a technological solution with an industry that still uses faxes, distant call centers and snail-mailed bills can prove challenging. “You can’t automate repeated phone calls to a guy in a basement who doesn’t want to do his job,” said Victor Echevarria, whose company, Remedy Labs, folded two years after he founded it.

The emergence of these businesses reflects the fact that medical billing is a complicated, often byzantine process that can mystify even the savviest consumers. Adding insult, these bills often start to pile up while patients are still at their lowest — either dealing with serious medical issues, or just beginning to recover.

Kristin-Leigh Brezinski, who works for a small tech company in Seattle, said she started using Better to address a pile of therapy bills she’d been meaning to submit for reimbursement. She had put off the task partly because she knew it would be a headache to spend hours on interminable phone calls, she said.

“I didn’t really want to sit on hold for the rest of my life,” said Brezinski, 28. She liked Better’s service so much that she continues to use it and has recommended it to others.

Experts agree that consumers need help tackling costly and complicated medical bills.

“Medical problems and medical bills are very likely to be the straw that breaks the camel’s back of a family’s finances,” said Anthony Wright, executive director of Health Access California, a health care consumer advocacy organization.

Wright said the Affordable Care Act provided some protection for people, such as banning annual and lifetime limits on coverage and capping out-of-pocket maximums.

Many states, including California, have also adopted consumer protections against surprise medical bills. These are the often costly charges consumers receive from out-of-network providers, even though they went to an in-network facility.

Despite those advances, Wright said many aspects of medical billing remain a major problem for consumers. He thinks apps might help patients navigate certain issues, but policy fixes could be even more effective.

For example, an app could notify consumers when they’ve hit their annual out-of-pocket maximum, but the state could simply require insurers to provide that notice, negating the need for the app.

“I would love to put in place some laws and consumer protections that make some of these apps obsolete,” Wright said.

The landscape isn’t necessarily friendly to medical billing start-ups, as Echevarria discovered after he founded San Francisco-based Remedy Labs two years ago.

He was inspired to tackle the problem of medical overbilling after his infant son had to go to the emergency room for a fever-related seizure and his family incurred about $12,000 dollars in medical bills, many of them laced with errors.

Co-founder Marija Ringwelski had looked at her own bills and found errors about 80 percent of the time. The two decided to build a platform similar to Credit Karma, the popular credit and financial management platform that offers a free credit score and free credit monitoring. Only this one would be for medical bills.

“Everybody wanted that product, Echevarria said. “They wanted the medical bill version of identity protection.”

Using new technology and a team of experts that scrutinized clients’ medical bills in search of errors, Remedy eventually figured out how to operate efficiently in all ways but one, Echevarria said: While patients had a legal right to their own medical information, many billing offices refused to hand it over to third parties.

“The industry operates in a way that is decades old,” he said. While a lot of the operation could be automated, some of it remains frustratingly hands-on and time-intensive, he said.

The problem proved insurmountable, and the company went out of business this past summer.

Even if companies manage to get their hands on required medical records, insurance policies are extremely complicated and can be difficult to navigate, said Betsy Imholz, special projects director for Consumers Union.

Rules vary among companies, and regulations among states, she said. To help an individual, companies must comb through piles of documents and figure out each customer’s specific situation. As Remedy’s experience illustrates, that process canâ€t always be accomplished with simple technology.

There’s also a marketing problem: Many consumers œdon’t realize there’s help to be had,” said Mark Hall, director of the Health Law and Policy Program at Wake Forest University’s School of Law.

Palo Alto-based Simplee addressed some of these challenges by shifting its business model.

Rather than directly serving consumers — as it did when it was a new start-up seven years ago — Simplee now markets its software to hospitals. Its clients currently include more than 400 hospitals and more than 2,000 clinics.

The software gives patients access to all of their bills in one place and attempts to make charges easier for them to understand. It also allows patients to see detailed explanations of charges and to create payment plans when necessary, said John Adractas, the companyâ€s chief commercial officer.

“It’s not like there’s one formula for how to tackle health care problems,” Adractas said.

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The Power Of #MeToo: Why Hashtag Sparks ‘Groundswell’ Of Sharing — And Healing

As a Ph.D. candidate in the social sciences more than 20 years ago, Duana Welch, 49, had done enough research to know the consequences she’d face by reporting sexual harassment in the workplace.

“When women came forward with allegations of sexual abuse and sexual harassment, the woman was the person blamed and the woman was not believed,” she said. “I was very angry that I would pay the price for coming forward. I knew what would happen.”

Like most who’ve had similar experiences, Welch, a relationship expert in Eugene, Ore., kept quiet. She wanted to bury the inappropriate encounters initiated by men who outranked her in the workplace. Welch worried that her fledgling career would be doomed.

That was until #MeToo.

“I jumped in immediately,” she said. “I knew that this was our moment. It was the first time I became very public about abuses and inappropriate sexual conduct that I’ve experienced.”

But figuring out why Welch and the millions who have posted on social media using #MeToo isn’t as simple as chalking it up to the power of the hashtag. Rather, a complex set of psychological and sociological factors is at work. Sparked by revelations about Hollywood titan Harvey Weinstein, the mushrooming list of accused harassers and those unwilling to stay silent any longer illustrate that what’s happening with this avalanche of disclosures is more than just a show of strength in numbers.

âAdmissions of being a victim are stigmatizing, said John Pryor, a professor of psychology emeritus at Illinois State University who has studied sexual harassment for more than 30 years and is participating in a National Academy of Sciences study of sexual harassment in STEM fields — science, technology, engineering and mathematics.

“Research has shown that people with stigmatizing conditions that can be hidden often engage in what is called ‘label avoidance.€™ With regard to sexual harassment, the more people who come forward and say ‘me, too,’ the less stigmatizing the label,” he said.

Gayle Pitman, a professor of psychology and women’s studies at Sacramento City College in California, said the sense she’s gotten from the #MeToo posts are “almost like a catharsis.”

“‘Finally, I can release this.’ There’s also some fear. ‘What happens now that I outed myself? What are people going to think of me and how am I going to feel now?’” she said. “There is definitely a possibility of reliving a traumatic experience or dredging up past wounds. A lot of people who have been victims of sexual violence probably have untreated PTSD [post-traumatic stress disorder] and can lie dormant for a long time until something triggers it — even a deliberate disclosure.”

The risk of triggering a traumatic experience is lessened as more women step up and validate the experience. “You think less that it’s my fault and I did something wrong and you’re blaming yourself,” said Lucia Gilbert of San Jose, Calif., a professor emerita of psychology at Santa Clara University. “It validates that you have been validated. Now there’s a validation in the culture, and that’s huge.”

Social media is at the heart of this change, experts agree.

“It connects one person’s story to a much broader story and simultaneously creates heft to your story. It’s not just me. My voice is a part of this giant groundswell,” said Amanda Lenhart, of the nonpartisan think tank New America, who has studied the internet and American life at the research institute Data & Society as well as at the Pew Research Center.

Although viewed as a critic of social media, psychology professor Jean Twenge of San Diego State University — whose book “iGen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy — and Completely Unprepared for Adulthood — and What That Means for the Rest of Us” explores the detrimental effects of smartphones on youth — said the #MeToo trend illustrates the positives of social media.

“It allows people to band together and share their stories at lightning speed,” she said. “The workplace certainly ups the stakes for the person experiencing the sexual harassment, and it also ups the level of anger because you’re talking about someone’s livelihood. You’re talking about a career or feeding their kids. Part of the conversation is not just the Hollywood starlet but the cashier at the grocery store.”

Women may believe now is a safer time to disclose what they wouldn’t have before, said Gilbert.

“Women are speaking up, and the political environment feels different,” she said. The worldwide women’s march on Jan. 21 “was huge. Women may better understand the importance of fighting for their rights.”

She suggests that change is possible when power shifts to more women at the top in certain traditionally male-dominated industries, such as the entertainment and media arenas, politics, the sciences and tech.

“It’s much harder to change the pattern of behavior and the sense of entitlement when you don’t change the power differential,” Gilbert said.

In his 1995 study of more than 2,600 employees at a government agency with more than 8,000 employees in 37 offices nationwide, Pryor found that office norms and the workplace culture are underlying factors — which hasn’t really changed in the decades since.

“If you look at women in those offices, office by office, women were more likely to say they were sexually harassed in the offices where the men said it was tolerated,” Pryor said.

Family law attorney Cindi Graham, 53, of Amarillo, Texas, knows all about how such behavior can be tolerated.

“There’s a lawyer who says inappropriate statements, and everybody just laughs and says that’s who he is,” she said. “It’s offensive. He’ll blatantly stare at women’s breasts. He won’t go so far as grope, but he’ll leer.”

Welch said the inappropriate behavior and harassment she experienced ranged from having a supervisor expose himself to her in his office (which caused her to quickly transfer and take a pay cut) to being harassed over a two-year period by a man whose office was located in her path.

“He had a lot of power, including power over my career,” she said. “I found another way to get into the building and he came to my office and said, €˜It’s starting to feel like you’re avoiding me.€™â

“In my early 20s, my story would have been an isolated event brushed away and me blamed for it,” Welch said. “I wanted to add to what I see is a really important cause. Now most people are believing us.â

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