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Apple, Google Are Jumping Into Health Care. Is Amazon Next?

Apple’s iPhone 6 is just weeks from release and will kick off Apple’s new health care strategy. Google’s working on its own plan to chase the health care market too.

The two companies’ moves have gotten plenty of buzz. (The power of the iPhone alone guarantees that Apple’s strategy will be closely scrutinized.)

But is another tech company — Amazon — about to make its own important play for health care business?

There’s reason to wonder: Amazon executives recently held a meeting with top FDA officials, Darius Tahir reports in an interesting scoop for Modern Healthcare.

For now, details are sparse.

  • Tahir reports that Amazon “leadership” met with FDA “leadership” one month ago.
  • Only one official’s name is actually known: Howard Sklamberg, FDA’s deputy commissioner for global regulatory operations and policy.

It could mean nothing — the FDA might’ve been telling Amazon to clean up its messy prescription-drug market — or it could mean everything.

After all, when Apple executives privately met with FDA in 2013, it was a tip-off that Apple was planning to pursue the health care market. (A plan that will take effect when Apple unveils the iPhone 6 and iOS 8 in two weeks.)

Also See: Leaked Details About Apple’s iPhone 6 / HealthKit Rollout

What Did They Discuss?

No one from Amazon or the FDA was willing to divulge details of their conversations. But several industry observers spoke up to say the meeting suggests big moves ahead.

“It would seem to me that [Amazon] would be exploring changes in high-level policy,” Bradley Merrill Thompson, a lawyer at Epstein Becker Green, and a member of an FDA advisory panel, told Modern Healthcare‘s Tahir.

I also reached out to my colleague Ken Kleinberg, who helps lead health IT research at Advisory Board Company Advisory Board Company. What could Amazon and FDA possibly have discussed?

Kleinberg noted that FDA oversees many potential business lines that might be relevant to Amazon’s short-term plans and long-term planning.

“It’s a complex issue,” Kleinberg said. “There are FDA regulatory distinctions between manufacturing, marketing, and selling medical devices. There are regulatory distinctions between devices used for wellness, which often aren’t regulated, and ones used for disease management.”

“And in some cases, the device itself is not the issue — it’s how it is marketed.”

Several Possible Scenarios

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Obamacare Or Not, Republicans Should Focus On Reducing The Cost Of Health …

For all the endless talk about reforming the health care system these past five years, it’s remarkable how little we’ve done to solve its actual problems. Spending hundreds of billions of taxpayer dollars to subsidize insurance coverage for several million people? That’s the easy part. The hard part is addressing the fact that American health care is so expensive.

The high price of U.S. health care is the fundamental reason tens of millions of Americans are uninsured. It’s the principal suppressor of middle-class wage growth. It’s a constant threat to businesses’ operating margins, and it’s the primary driver of the federal debt.

In May the American Health Policy Institute surveyed the chief human resource officers of 360 large employers, representing 10 million workers. When asked what troubled them the most about the Affordable Care Act, 85% said “increasing access to the health care system without making significant improvements in the efficiency and affordability of that system.” Only 6% believed that “the ACA will help my company more effectively control health care costs”; 82% disagreed.

According to the Congressional Budget Office’s 2014 Long-Term Budget Outlook, the United States remains on an “unsustainable” trajectory, driven entirely by growth in the big federal health care entitlements: Medicare, Medicaid and Obamacare.

Democrats haven’t solved this problem, but neither has the GOP. House Republicans have voted six times to repeal ObamaCare in its entirety. But they haven’t once brought a bill to the floor that would replace Obamacare with a more attractive set of reforms.

Transcend figure 04

The CBO projects that by the next presidential election 36 million Americans will be on Obamacare-sponsored insurance: 12 million under the law’s Medicaid expansion and 24 million on the new insurance exchanges. Whether they admit it or not, no Republican can win the White House in 2016 campaigning on taking away health coverage for 36 million people.

What should Republicans do? Focus on the real problem. The principal reason for America’s high health care costs is the fact that so few of us pay for it directly. Switzerland and Singapore, the most market-oriented health systems in the world, give consumers control of their own health care dollars and expect their citizens to shop for care and coverage. The results are remarkable: Swiss public health care spending is 45% of U.S. levels, per capita, and Singapore’s only 20%. We wouldn’t have a budget deficit if we had that kind of performance.

Transcend figure 01

This month the Manhattan Institute published my new 68-page proposal, “Transcending Obamacare: A Patient-Centered Plan for Near Universal Coverage and Permanent Fiscal Solvency.” The plan gradually moves the U.S. toward a consumer-driven system in which more Americans are using health savings accounts and shopping for their own coverage.

The overall framework is fairly simple: First, deregulate the Obamacare exchanges so people can truly shop for coverage they want and need. Second, migrate Medicaid enrollees and future retirees onto the reformed exchanges. Third, tackle the problem of consolidated hospital systems that exploit their market power to charge prices far above what a free market would bear.

Based on our CBO-style modeling, the plan reduces the cost of single insurance policies by an average of 17%. Over 30 years it reduces the deficit by $8 trillion, while reducing tax revenues by $2.5 trillion. And because it makes health insurance less costly, we estimate that 12 million more Americans will freely choose to buy it.

Importantly, while the plan is perfectly compatible with Republicans’ “repeal and replace” slogan, it doesn’t actually require the repeal of Obamacare to work. By putting patients back in charge of their own health dollars, it would unleash a torrent of medical innovation. And instead of arguing over taxes and spending, we can get back to saving people’s lives.

*    *    *

AVIK ROY is Forbes’ Opinion Editor and a Senior Fellow at the Manhattan Institute for Policy Research.

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Mental Health Meets ‘Moneyball’ In San Antonio

Leon Evans, director of the community mental health system for Bexar County and San Antonio, broke through barriers that had hindered care.i

Leon Evans, director of the community mental health system for Bexar County and San Antonio, broke through barriers that had hindered care.

Jenny Gold/Kaiser Health News

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Jenny Gold/Kaiser Health News

Leon Evans, director of the community mental health system for Bexar County and San Antonio, broke through barriers that had hindered care.

Leon Evans, director of the community mental health system for Bexar County and San Antonio, broke through barriers that had hindered care.

Jenny Gold/Kaiser Health News

The jails aren’t overflowing in San Antonio anymore. People with serious mental illnesses have a place to go for treatment and the city has saved $10 million a year on. How did it happen?

“You know Brad Pitt in the movie Moneyball?” asks Gilbert Gonzalez, Director for the Bexar County Mental Health Department. “Well, the success in that movie was based on the data and analytics. We needed to do the same thing.”

Gonzalez’s task was to look at all the money San Antonio was spending on mental health in one way or another.

Just eight years ago, the jails, hospitals, courts, police and mental health department in Bexar County all worked separately.

Each part of the system was encountering the same people with serious illnesses, but the people were just cycling through, not getting better. Gonzalez found that the city was spending enormous sums of money while taking care of people with mental illness poorly.

So Leon Evans, director of the community mental health system for Bexar County and San Antonio, got everyone talking. That turned out to be the most challenging piece of the puzzle.

“If you think law enforcement and mental health workers have anything in common, we don’t,” says Evans. “We speak a different language. We have different goals. There’s not a lot of trust there.”

Officers Ned Bandoske (left) and Ernest Stevens are part of San Antonio's mental health squad  a six-person unit that answers the frequent emergency calls where mental illness may play a role.

But once the decision-makers saw what could be done if they pooled their resources, every sector chipped in and the county built a single, integrated system where people with mental illnesses could actually get better.

Among other things, the San Antonio center has a 48-hour inpatient psychiatric unit, outpatient primary care and psychiatric services, help with substance abuse, housing for people with mental illnesses and job training. More than 18,000 people pass through the Restoration Center each year.

“San Antonio is ahead of what’s a growing trend across the country to try to build a non-hospital alternative for people who are experiencing a psychiatric emergency, often with co-occurring alcohol or other drug abuse,” says Dr. Mark Munetz, a psychiatrist and professor at Northeast Ohio Medical University who toured the Restoration Center last year.

But he says the San Antonio model might not work everywhere. The Restoration Center and homeless shelter, he says, felt like “a psychiatric oasis, removing the people from the most central part of the city. It felt a little like segregating people in that part of the city, especially with the homeless shelter next door. I’m not sure how that would fly in other parts of the country.”

Nonetheless, the rest of the country has started to notice. City officials say every state in the country has sent delegates to San Antonio to see if they can model their own mental health systems after this one.

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Why More, Not Fewer, People Might Start Getting Health Insurance Through Work

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Health Gorilla Bags $1.2M To Grow Its Online Diagnostic Test Marketplace

Another funding round in the digital healthcare space, with US online diagnostic test marketplace startup Health Gorilla (previously called Informedika) pulling in $1.2 million in new seed financing, led by True Ventures. The startup says it expects a more substantial Series A round to follow shortly, in the coming months.

Health Gorilla/Informedika was founded back in 2011, and has pulled in a total of $1.7 million in seed funding for its platform, including its latest chunk. It’s grown to have more than 500,000 patient health records in its system and plans to use the new financing for continued expansion of the platform.

Health Gorilla’s online marketplace links doctors and clinicians with more than 9,000 diagnostic labs and more than 35,000 radiology centers, enabling online ordering and digitally delivered results to speed up the process and reduce-based paperwork admin (such as sending and receiving faxes).

It argues that a centralised,single point of entry  marketplace for ordering diagnostic tests streamlines the process for doctors by removing the need to negotiate multiple different incumbent systems, as well as by offering real-time access to results. It also intends to open up patient access to its platform so individual results can be communicated by doctors to their patients via its system — again with a focus on time and efficiency savings.

Health Gorilla says the marketplace is HIPPA compliant and supports ONC modular certified MU2 at no extra charge. Its business model is to offer its system free to doctors but to charge a small fee per order to the labs and centers using its platform.

Commenting on the funding round in a statement, Jon Callaghan, founding partner at True Ventures said: “The existing healthcare market is characterized by large, incumbent systems, which are increasingly opaque and cumbersome.  The market hasn’t kept up with the best innovations in software, and Health Gorilla’s system brings speed, transparency and convenience to doctors and patients across the US.  We’re delighted and pleased to participate as a key HealthGorilla partner and look forward to their continued success.”

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What if There Was an Ebola Case in Boston?

The World Health Organization announced Wednesday that the death toll from the West Africa Ebola outbreak has risen to 1,350. The Boston Public Health Commission (BPHC) hosted a media briefing Wednesday morning with various leaders of the city’s public health branches to outline the plans for the “very low” likelihood that the deadly Ebola virus disease (EVD) would make it to Massachusetts.

“While the risk to our residents is very low, it is always better to prepare so that we can appropriately identify and care for suspect cases and work with the community to prevent further illness,” said Dr. Barbara Ferrer, executive director of the Boston Public Health Commission (BPHC) at the briefing. “We want a well-coordinated plan in place in the event a case of EVD is found in the city.”

Tips to avoid Ebola while traveling.

In an interview this afternoon with, Dr. Ferrer outlined the various city organizations that have coordinated their effort and planned response if there were to be a suspect or confirmed case of Ebola in Massachusetts. Boston Emergency Medical Services, Massachusetts Port Authority, as well as the US Customs and Border Protection at the airport are all prepared in case of an outbreak.

“Lots of people travel to places in West Africa and have no exposure to Ebola, so it doesn’t mean if you have syumptoms of illness that your symptoms necessarily correlate with symptoms of Ebola,” said Dr. Ferrer. “You’re only going to transmit when you’re in very close contact with someone who is already showing signs of illness.”

Since March 2014, more than 1,000 people have been infected with Ebola in Guinea, Sierra Leone, and Liberia, while one case has been reported as a result of air travel in Nigeria. With the international call for health care workers to travel to Africa to help treat the victims and help contain the spread of this deadly virus, the Boston public health officials are simply preparing for the risk of exposure that medical outreach and travel carries with it. The virus is spread when an individual is exposed to the bodily fluids of a person infected with Ebola.

People most likely to have contact with Ebola are health care workers treating Ebola patients, as well as family members or friends who are interacting with an infected individual on an intimate level, said Dr. Ferrer. “We obviously applaud those people who go to help. Health care workers who are leaving from the United States are leaving with a lot of protective equipment, so we have a lot of confidence that they will remain safe.”

Whether people are traveling for business, personal, or volunteer obligations, no one is required to notify the public health department of their travel, or even of their return, unless they begin to display symptoms (a fever of at least 100.4 degrees Farenheit), and were at risk of unprotected exposure to an infected person. If a suspect case does arise, health officials said that individual will be isolated at a local hospital and treated with supportive care while tests are done to determine whether or not the individual has contracted the Ebola virus.

An American, Dr. Kent Brantly, is now recovering from the deadly virus in Atlanta for the 21-day incubation period after treating patients in Africa. A Boston case would undergo a similar treatment in a local hospital. Only a two Americans have contracted Ebola so far after caring for infected patients. According to the World Health Organization, at least 170 African health workers treating patients with Ebola have contracted it themselves. More than 80 of them have died.

Health officials report that this six-month-long outbreak of Ebola is the largest ever observed, and they expect it will continue into the fall. This is the first time the disease, which results in a hemorrhagic fever, has ever been observed in West Africa. It is also the first time the disease has reached densely populated urban areas. The case mortality rate for Ebola varies between 50 and 90 percent.

This morning’s media briefing in Boston was the first of many public awareness campaign steps city health officials are taking in order to prepare Massachusetts and Boston in the case of an outbreak.

“As a result of years of practice, investment and responding to real emergencies, hospitals in Boston are well equipped and trained to appropriately and safely care for a suspect case of EVD,” said John Erwin, executive director of the Conference of Boston Teaching Hospitals at the briefing. “To ensure the best possible preparations, however, hospitals will need the support of city, state and federal health officials. That’s why this planning effort is so important.”

Part of preventing the virus from arriving in the United States is discouraging Americans from traveling to the affected countries and possibly carrying the virus back home with them. The Centers for Disease Control and Prevention have issued a Level 3 travel advisory, warning US residents to avoid all nonessential travel to Guinea, Liberia, and Sierra Leone.

“Every successful preparedness campaign requires the support and strong involvement of the community,” said Atyia Martin, director of the BPHC Public Health Preparedness Program. “We will work hard to make sure that residents have the information and resources that they need to stay informed and healthy. That is what this effort is all about.”

Learn more about the Ebola and the city’s public awareness campaign at

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Community Health Systems hacked, records of nearly 4.5 million patients stolen


REUTERS/Kacper Pempel

Hospital giant Community Health Systems said on Monday that the personal information of nearly 4.5 million patients was stolen by hackers in an attack believed to originate from China. 

In a filing with the U.S. Securities and Exchange Commission, the company, which operates 206 hospitals in 29 states, reported that the hackers used “sophisticated malware” to attack the company’s security systems and copy and transfer hospital data.

The company used cybersecurity firm Mandiant to investigate the incident which it believes occurred in April and June.

In the filing, the company reports that all malware has been removed from its systems and is currently making further provisions to protect against future attacks. Federal authorities and Mandiant report that these attacks usually involve the theft of “valuable intellectual property, such as equipment and medical device development data,” but that non-medical patient identification information like names and addresses was stolen.

The company said this information “does not include patient credit card, medical or clinical information,” but is still protected under the Health Insurance Portability and Accountability Act (HIPAA). In response to the breach, the company has notified people whose information was stolen, and is offering them identify theft protection services. Community Health Systems is insured to protect itself from these kinds of attacks, and does not believe its “business or financial results” will be affected. 

This is the latest in a string of recent U.S. cybersecurity attacks. The U.S. Investigation Services (USIS), the main provider of background checks in the U.S., reported an attack on its corporate network earlier this month – possibly launched by a foreign power.  

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Its Mental Health Treatment System Saves San Antonio Millions

Texas ranks 49th out of 50 states in how much funding it commits to mental health. But San Antonio has become a model for other mental health systems. It has saved $50 million over the past 5 years.

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Mental Health Cops Help Reweave Social Safety Net In San Antonio

Officers Ned Bandoske (left) and Ernest Stevens are part of San Antonio's mental health squad  a six-person unit that answers the frequent emergency calls where mental illness may play a role.

Officers Ned Bandoske (left) and Ernest Stevens are part of San Antonio’s mental health squad — a six-person unit that answers the frequent emergency calls where mental illness may play a role.

Jenny Gold/Kaiser Health News

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Jenny Gold/Kaiser Health News

It’s almost 4 p.m., and police officers Ernest Stevens and Ned Bandoske have been driving around town in their unmarked black SUV since early this morning. The officers are part of San Antonio’s mental health squad — a six-person unit that answers the frequent emergency calls where mental illness may be an issue.

The officers spot a call for help on their laptop from a group home across town.

“A male individual put a blanket on fire this morning,” Stevens reads from the blotter. “He’s arguing … and is a danger to himself and others. He’s off his medications.”

A few minutes later, the SUV pulls up in front of the group home. A thin 24-year-old sits on a wooden bench out back, wearing a black hoodie.

“You’re Mason?” asks Bandoske. “What happened to your blanket?” Eight years ago, the next stop for someone like Mason would have been a hospital emergency room or jail. (Because of his condition, NPR is not using Mason’s last name.) But the Bexar County jail, in San Antonio, was so overcrowded — largely with people with serious mental illnesses — that the state was getting ready to levy fines.

The Los Angeles County Sheriff's Twin Towers Correctional Facility is part of the largest municipal jail system in the United States. Many of its nearly 4,000 inmates are deemed mentally ill.

A hearse leaves the Deeds family home in Millboro, Va., on Tuesday, after 24-year-old Austin Gus Deeds died in an apparent suicide.

This sort of situation is not unusual: Across the country, jails hold 10 times as many people with serious mental illness as state hospitals do, according to a recent report from the Treatment Advocacy Center, a national nonprofit that lobbies for better treatment options for people with mental illness.

To deal with the problem, San Antonio and Bexar County have transformed their mental health system into a program considered a model for the rest of the nation. Today, the jails aren’t full, and the city and county have saved $50 million over the past five years.

The effort has focused on an idea called “smart justice” — basically, diverting people with serious mental illness out of jail and into treatment instead.

San Antonio’s new approach starts with the kind of interaction Bandoske and Stevens are having with Mason. The troubled young man is hunched over, and his eyes dart back and forth between the two officers. He mumbles answers to the officers’ questions, sometimes stopping to stare at a spot in the distance. For outsiders, it’s hard to know what’s going on, but the officers say they can tell Mason is hallucinating. Bandoske kneels in front of him, trying to maintain eye contact and get Mason’s attention.

Officer Stevens responds to an emergency mental health call in regards to Mason, 24, at a group home in San Antonio.i

Officer Stevens responds to an emergency mental health call in regards to Mason, 24, at a group home in San Antonio.

Jenny Gold/Kaiser Health News

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Jenny Gold/Kaiser Health News

Officer Stevens responds to an emergency mental health call in regards to Mason, 24, at a group home in San Antonio.

Officer Stevens responds to an emergency mental health call in regards to Mason, 24, at a group home in San Antonio.

Jenny Gold/Kaiser Health News

“Are you hearing some voices right now?” Bandoske asks. “You are, aren’t you? What are the voices telling you?” Mason is silent, but Bandoske persists. “Hey Mason, you’re seeing something that I’m not seeing. What is it?”

These officers seem more like social workers than law enforcers. Stevens says that’s a huge change from his early days on the police force.

“We had absolutely no training 20 years ago in the police academy on how to deal with mental health disturbances,” recalls Stevens.

Back then, the police were repeatedly arresting the same people; many not only had a serious mental illness but were also addicted to drugs or alcohol, and were often homeless. And whether they went to the jail or the ER, it was expensive for everyone — the jails, the hospitals and the police department that had to pay for overtime while cops waited at the hospital.

San Antonio’s response was to require all officers to take a 40-hour course called Crisis Intervention Training, to learn how to handle mental health crises.

But even with strong programs, there’s only so much that training alone can do; there’s still the problem of where to take patients like Mason.

San Antonio tackled that problem, too.

People who commit a felony still go to jail, regardless of their mental status. And those who need extensive medical care are taken to the hospital.

But for patients like Mason, San Antonio built another option: the Restoration Center, a separate facility with a full array of mental and physical health services.

The center was the brainchild of Leon Evans, director of San Antonio’s mental health department.

When he took over the department 14 years ago, Evans says not one of the county or city agencies and nonprofits that deal with mental illness was talking to another. The jails, hospitals, courts, police and mental health department all worked in separate silos.

“People who fund these services only look at their little, small piece of the pie and whether there is a return on investment,” says Evans.

So, with the help of a county judge, Evans worked to get the funders together to talk about the money they were all spending on mental health. Once they stopped looking at mental health as an isolated expense, the groups realized they were spending enormous sums of money and offering poor care. Pooling their resources instead, they found, could offer significant savings.

Everyone contributed funding to create the Restoration Center. It offers a 48-hour inpatient psychiatric unit; outpatient services for psychiatric and primary care; centers for drug or alcohol detox; a 90-day recovery program for substance abuse; plus housing for people with mental illnesses, and even job training.

More than 18,000 people pass through the Restoration Center each year, and officials say the coordinated approach has saved the city more than $10 million annually.

When Mason arrives at the center, nurse Catherine Riojas checks him in immediately. She gives Mason a physical and helps him get settled in an inpatient psychiatric unit that keeps patients for 48 hours.

And then, about 15 minutes after the police officers walked through the door of the center, they’re heading out again, ready to get back on the street.

“OK, Mason, good luck,” Stevens calls to the young man, and waves. “OK, buddy? Hope you feel better.”

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Community Health says data stolen in cyber attack from China

BOSTON/NEW YORK (Reuters) – Community Health Systems Inc (CYH.N), one of the biggest U.S. hospital groups, said on Monday it was the victim of a cyber attack from China, resulting in the theft of Social Security numbers and other personal data belonging to 4.5 million patients.

Security experts said the hacking group, known as “APT 18,” may have links to the Chinese government.

“APT 18″ typically targets companies in the aerospace and defense, construction and engineering, technology, financial services and healthcare industry, said Charles Carmakal, managing director with FireEye Inc’s (FEYE.O) Mandiant forensics unit, which led the investigation of the attack on Community Health in April and June.

“They have fairly advanced techniques for breaking into organizations as well as maintaining access for fairly long periods of times without getting detected,” he said.

The information stolen from Community Health included patient names, addresses, birth dates, telephone numbers and Social Security numbers of people who were referred or received services from doctors affiliated with the hospital group in the last five years, the company said in a regulatory filing.

The stolen data did not include medical or clinical information, credit card numbers, or any intellectual property such as data on medical device development, said Community Health, which has 206 hospitals in 29 states.

The attack is the largest of its type involving patient information since a U.S. Department of Health and Human Services website started tracking such breaches in 2009. The previous record, an attack on a Montana Department of Public Health server, was disclosed in June and affected about 1 million people.

Chinese hacking groups are known for seeking intellectual property, such as product design, or information that might be of use in business or political negotiations.

Social Security numbers and other personal data are typically stolen by cybercriminals to sell on underground exchanges for use by others in identity theft.

Over the past six months Mandiant has seen a spike in cyber attacks on healthcare providers, although this was the first case it had seen in which a sophisticated Chinese group has stolen personal data, according to Carmakal. Mandiant monitors about 20 hacking groups in China.


Cybersecurity has come under increased scrutiny at healthcare providers this year, both by law enforcement and attackers.

The FBI warned the industry in April that its protections were lax compared with other sectors, making it vulnerable to hackers looking for details that could be used to access bank accounts or obtain prescriptions.

Mandiant has tracked “APT 18″ for four years. When asked if the hackers were linked to the Chinese government, Carmakal said it was “a possibility” but declined to elaborate.

Another cybersecurity firm, CrowdStrike, which has also been monitoring “APT 18″ for about four years, said it believes the hackers are either backed by Beijing or work directly for the government, based on the targets they have chosen.

CrowdStrike Chief Technology Officer Dmitri Alperovitch said his firm has seen “APT 18″ targeting human rights groups and chemical companies.

“They are of above average skill” among Chinese hackers, said Alperovitch, whose company dubbed the group “Dynamite Panda.”

The issue of Chinese state-sponsored hacking is highly sensitive. Tensions between Washington and Beijing have grown since May, when a U.S. grand jury indicted five Chinese military officers on charges they hacked into American companies for sensitive manufacturing secrets. China has denied the charges.

FBI spokesman Joshua Campbell said his agency was investigating the Community Health case, but declined to elaborate.

The Department of Homeland Security said it believed the incident was isolated, although it shared technical details about the attack with other healthcare providers. An agency official told Reuters it was too soon to say who was behind the attack.

Community Health said it has removed malicious software used by the attackers from its systems and completed other remediation steps. It is now notifying patients and regulatory agencies, as required by law.

The company said it is insured against such losses and does not at this time expect a material adverse effect on financial results. Community Health’s stock rose 66 cents, or 1.3 percent, to close at $51.66 on the New York Stock Exchange on Monday.

(Reporting by Caroline Humer, Jim Finkle and Shailesh Kuber; Editing by Dan Grebler and Tiffany Wu)

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