Is Common-Law Contract Theory Superior to the No Surprises Act?

A new article from David Orentlicher et al.:

"Limiting Overall Hospital Costs by Capping Out-of-Network Rates" [Free Download]
Annals of Health Law, Vol. 32, No. 2 (2023)

DAVID ORENTLICHER, University of Nevada, Las Vegas, William S. Boyd School of Law
Email: david.orentlicher@unlv.edu

KYRA MORGAN, Nevada Department of Health and Human Services

BARAK D. RICHMAN, Duke University, School of Law, CERC, Stanford Univ. School of Medicine
Email: richman@law.duke.edu

Abstract:

Contract theory offers a simple and wildly effective solution to surprise bills: Hospital admissions contracts are contracts with open price terms, which contract law imputes with market rates. This solution not only obviated the costly, time-consuming, and complicated (and still unimplemented) legislative fix in the No Surprises Act, but it also is a superior solution since it introduces superior incentives to disclose, compete, and economize. 

Using data from the Nevada Department of Health and Turquoise Health, this paper explores the theory and empirics of employing contract law's solution to hospital surprise bills and its superiority over other legislative interventions.

Reproductive Rights after Dobbs: New Article in SMU Law Review

"Pregnancy Risk and Coerced Interventions after Dobbs" [Free Download]
SMU Law Review, Vol. 76, No. 1 (2023)

ELIZABETH KUKURA, Drexel University Thomas R. Kline School of Law
Email: kukura@drexel.edu

Abstract:

Only nine months after the Supreme Court eliminated the federal constitutional right to abortion in Dobbs v. Jackson Women's Health Organization, fourteen states had banned abortion entirely, and experts estimate the ultimate number of states imposing complete or near-complete restrictions on abortion care will likely rise to twenty-four. Millions of people with the capacity for pregnancy now (or will soon) live in places where getting pregnant means there is no choice other than to carry the pregnancy to term and give birth. One underappreciated, though critically important, impact of Dobbs is the extent to which newly enacted abortion restrictions will increase both the number of people with high-risk pregnancies and, relatedly, the number of people who are coerced into medical treatment during labor and delivery. Such mistreatment in the form of coerced interventions will compound the harm of forced pregnancy after Dobbs with negative consequences for the physical and emotional well-being of birthing people and their babies.

Public Health Law Priorities to Pursue While Congress Recesses

The American Public Health Association (APHA) sent out its call to action during the current Congressional recess. In addition to providing advice on how to press your views on public-health issues while the Senators and Representatives are away, the APHA missive provides links to a wealth of policy papers, reports, and the like across a broad spectrum of public health. And its not only about Congress. As the APHA suggests, state and local officials -- traditional wielders of "police powers" -- also need to be educated about public health, about which so much misinformation and disinformation emerged during COVID. And there are op-ed opportunities. The list goes on . . . .

Congressional recess is here (July 31 – Sept. 11 for the House and July 31 – Sept. 4 for the Senate) which makes this month the perfect time to raise your public health voice and urge your members of Congress to take action. Join the Speak for Health campaign with APHA’s suggested advocacy activities:

•  Got a minute? Head over to APHA’s action alerts and send a quick message to your elected officials on a variety of topics including environmental health, reproductive rights, gun violence and public health funding.
• Schedule a meeting with your members of Congress, virtually or in person, to discuss public health priorities. You can call their local offices for details on scheduling a meeting.
• When speaking to elected officials, point to APHA’s 2023 advocacy priorities as key areas for action.
• Boost your advocacy efforts with issue fact sheets that summarize priority advocacy issues and state fact sheets that break down public health in each state.
• Write and submit an op-ed to your local paper. APHA offers op-ed writing tips and sample op-eds on gun violence, climate change, public health funding and reproductive health which you can request by emailing speakforhealth@apha.org.
• Engage elected officials on social media about their support for public health. You can include social media shareable images found on the Speak for Health page, and make sure you use the hashtag #SpeakForHealth!
• Attend a town hall and ask your elected official key questions about their commitment to supporting public health. You can contact their office to ask when the next town hall is scheduled.

Your voice helps shape how members of Congress view critical public health issues, and your community’s public health concerns deserve to be heard by our nation’s leaders. Join us and Speak for Health — for today and for future generations.

The APHA 2023 advocacy priorities cover a lot of territory and offer something for everybody:

• Increase and protect funding for vital public health agencies and programs and strengthen the nation’s public health infrastructure. 
• Uphold the Affordable Care Act and expand access to health coverage and services. 
• Address the health impacts of climate change. 
• Protect access to reproductive health care. 
• Pass a 2023 Farm Bill to protect nutrition security. 
• Protect nutrition standards for children. 
• Uphold and strengthen critical public health laws and regulations and reverse damaging rollbacks. 
• Address the nation’s gun violence epidemic.

For more information on APHA’s advocacy priorities, visit https://www.apha.org/advocacy or contact Don Hoppert at Donald.Hoppert@apha.org or Jordan Wolfe at Jordan.Wolfe@apha.org.   

Henrietta Lacks -- Still Immortal -- Family Settles Suit Against Thermo Fisher Scientific

Anyone who has read The Immortal Life of Henrietta Lacks is familiar with the story. Cancer cells from Henrietta Lacks's cervix were grown in a lab in the 50s after it was shown that, unlike most cells, they could reproduce in vitro. This made them incredibly valuable for biologic research:

Research using the HeLa cells has led to the development of vaccines treatments for diseases including cancer, Parkinson’s and the flu. The cells have also been used by researchers around the world and have been cited in more than 110,000 scientific publications, according to the National Institutes of Health. (NY Times, Aug. 1, 2023)

But Ms. Lacks -- who was black and being treated in a segregated ward at Johns Hopkins -- wasn't informed that her cells were harvested for research and didn't consent to their use. And for more than 70 years biotech firms have reaped millions in profits from the use of her cells.  

The NY Times reports (above) that the family has settled its suit against one of the biotech firms for an undisclosed amount. In a news conference yesterday, a spokesman for the family said the fight for justice will go on.

Her story is a perfect storm of racialized medicine, immature research ethics, and money. I'd like to think it couldn't happen in this day and age, but with U.S. and European firms exporting ethically sketchy research to Third-World countries, that is more of a hope than a prediction.

House & Senate Pass Bipartisan Bill to Reform Organ Procurement Transplantation Network

Last Thursday evening (7/27), in a rare bipartisan move, the Senate passed H.R. 2544 (entitled the “Securing the U.S. Organ Procurement and Transplantation Network Act”) without change, and the bill is now on President Biden's desk for his signature. The bill amends 42 U.S.C. § 274 for essentially one purpose.

Federal law currently authorizes the Secretary of HHS to contract with "a private nonprofit entity that has an expertise in organ procurement and transplantation" to operate the OPTN. Since the creation of the Network in 1984, that entity has been UNOS, a Virginia nonprofit. There has been growing unhappiness with UNOS's operation of the network, which led Congress to pass H.R. 2544. It strikes the language quoted above and replaces it with language that says the OPTN "shall . . . be operated through awards to public or private entities made by the Secretary." 

One group -- representing nephrologists and transplant professionals who have had to to work under UNOS's rules for nearly 40 years -- seem pretty happy:

"The American Society of Nephrology (ASN) is grateful for steadfast, bipartisan leadership on behalf of transplant patients demonstrated by tonight's passage of the Securing the U.S. OPTN Act," said Michelle A. Josephson, MD, FASN, ASN President. "The United States transplant system was put into place nearly 40 years ago. As the transplant field has changed over time, Congress' establishment of a modern policy infrastructure to support transplant care means that our field can continue to grow, meeting the needs of the thousands of Americans who would benefit from a kidney transplant."

Roll Call has done some interesting background reporting (7/28/2023) on the concerns that led to the passage of this bill:

 A Senate Finance Committee investigation released last year found that hundreds of people have developed diseases from transplanted organs, and 70 people died between 2008 and 2015 from those illnesses.

The committee argued that such mistakes were allowed to happen because of UNOS’s lack of oversight of organ procurement organizations

A record-high 21.3 percent of procured kidneys were not transplanted in 2020, according to the Scientific Registry of Transplant Recipients. 

More than 100,000 Americans are currently waiting for an organ — mainly kidneys — and an estimated 17 people die each day on the waiting list.

I'm not 100% convinced that UNOS was responsible for all of these lapses. We'll see if bringing in a new company, based on a competitive bid process, makes a difference.

Provider Screws Up its Bill to Medicare, Tries to Stick Patient with 100% of Charge

Today's featured Surprise Bill of the Month (KFF Health News, NPR (July 27, 2023)) involves a 74-year-old gentleman who needed vascular surgery in his leg to relieve pain caused by low circulation. He got the surgery, and it provided him with some relief. The relief was short-lived, though, when a collection agency started sending notices of delinquency in pay for the anesthesia services to the tune of $3,000. The patient is on Medicare and is a long-time owner of a supplemental policy from Humana. His reasonable expectation was that Medicare would be the primary payer and Humana the secondary, and that his out-of-pocket payment would be $0.

After much effort, the patient -- his wife, actually, who worked tirelessly to get a little justice -- discovered that the anesthesiology firm (private-equity-owned North American Partners in Anesthesiology, with thousands of providers in 21 states) failed to bill Medicare until 17 months after the surgery. Medicare requires all bills to be submitted within 12 months and refused to pay. Humana's supplemental policy doesn't pay if a service isn't covered by Medicare. Also, the bill submitted to Medicare, in addition to being late, show that a nurse anesthetist and an anesthesiologist were both present for the entire duration of the surgery, which is a red flag for Medicare and required explanation before Medicare will pay. According to the story, "A [Medicare] quarterly summary notice said while the time limit for filing the claims had expired, [the patient] also could not be billed." That should have been the end of it, right?

Instead of simply eating the charge, NAPA billed the patient for the full $3,000. (The patient says the first he knew of the bill was when he was contacted by a collection agency.) To noöne's surprise, the "News & Insights" page on NAPA's website has no mention of this national story. Meaning no disrespect for Mom-and-Pop businesses everywhere, this is the kind of screw-up that you might expect from a small, family-owned practice that struggles to keep up with the paperwork demands of a busy medical practice. But NAPA is one of the big boys. It has computers and presumably employs billing specialists to keep track of its "thousands of providers in 21 states." 

Pharmaceutical Firms Seek to Block Price Negotiations with Medicare

The New York Times has an excellent piece (23/24 July) on the drug industry's efforts to derail drug-pricing negotiations with Medicare that are authorized by the Inflation Reduction Act. As the deadline for starting negotiations nears, lawsuits have been filed by Johnson & Johnson; Bristol Myers Squibb;  Astellas Pharma; the National Infusion Center Association (NICA), the Global Colon Cancer Association (GCCA), and the Pharmaceutical Research and Manufacturers of America (PhRMA) (read here); and Merck. 

As the Times piece points out, the policy arguments for and against  price negotiations focus on (1) how much of a financial hit the firms will take as a result of lower prices for drugs covered by Medicare and (2) the impact of those reductions on R&D and ultimately on the number of new drugs that will not get to market over the next decade:

A study released last month that was funded by the Biotechnology Innovation Organization . . . warned that the pricing provisions would discourage innovation, resulting in as many as 139 fewer drug approvals over the next 10 years.

But that assessment is at odds with an analysis by the [nonpartisan] Congressional Budget Office, which estimated that the law would result in only one fewer drug approval over a decade and about 13 fewer drugs over the next 30 years. 

The calculations are actually quite difficult to nail down. Consider, for example, that we don't know which drugs will be included in future negotiations (and therefore what the projected savings to Medicare will be). And then there's the spillover effect. Most if not all the most expensive drugs whose prices will be negotiated have competitors, and there is likely to be an effect on the competitors' drug prices. Modeling all these variables can account for much if not all of the difference between the two estimates, but I will take any estimate from a pharma trade group with a large dose of salt.

Price Transparency Rules: 2/3 of Hospitals are Not Complying

According to a recent story from The Hill, Patient Rights Advocate.Org (PRA.Org) has issued a report (July 20) that details a shocking (but not surprising?) level of noncompliance with the requirements of the No Surprises Act, which was intended to eliminate surprise medical bills, with a particular focus on disputes arising from the use of out-of-network providers. (I've posted on this subject here (2021), here (same), and here (2023).)

According to the report -- the fifth semi-annual report published by PRA.Org -- compliance has improved steadily since CMS issued its final rule implementing the Act in August 2022, but 64% of the 2,000 hospitals and health systems surveyed remain partially or totally out of compliance. 

One might expect the largest providers to have the resources to implement billing reforms, but the results among that group are pretty dismal:

Compliance varied widely among the largest hospital systems we reviewed. 

•  None (0%) of the hospitals we reviewed which were owned by HCA Healthcare, Tenet Healthcare, Providence, Avera Health, UPMC, Baylor Scott & White Health, and Mercy were found to be fully compliant.
•  Consistent with prior reports, none of the hospitals owned by the largest hospital system in the country, HCA Healthcare, were found to be in full compliance, with a significant amount of its hospitals posting illegible, nonconforming files.
•  Substantial improvements since our last report include: 88% of hospitals owned by CommonSpirit Health, 97% of hospitals owned by Community Health Systems, and 98% of hospitals owned by Kaiser Permanente were found to be in full compliance. 
• Forty hospitals exhibited 'backsliding,' with an assessment of Noncompliant in the current report after having been assessed as Compliant in our prior report. 

Maybe people of a certain age should stay off social media altogether

The president of Thomas Jefferson University and dean ad interim of TJU's medical school, stepped down this past week, three months after (in the words of a Philadelphia Inquirer article) "liking controversial tweets about COVID-19 vaccines and gender reassignment surgery for children on his official presidential Twitter account." 

The tweets are quoted in the Inquirer article and are straight out of the MAGA playbook. Mark Tykocinski, 70, claimed he used the "like" function to bookmark tweets that he wanted to revisit and research. 

I don't know about that.

On every Twitter message, there's a heart icon to "like" and a flag memo to "bookmark." They are side-by-side; it's hard to see one and not also see the other, though understanding their differences requires an internet search. One crucial difference is that "likes" are public and "bookmarks" remain private. There are lots of sources for this information, including Twitter itself. 

This sounds easy, but for someone old enough to be enrolled in Medicare, it might still be confusing, just as most social media platforms are to me. I am an incredible doofus when it comes to Twitter and Facebook and absolutely hopeless trying to navigate Instagram. TikTok frightens me, so I don't even contemplate going there. In my defense, I will turn 74 in a little over a month. "Influencers" in my world suggest ways to mix a better martini. When it comes to Barbenheimer, I am more comfortable on the "heimer" part of that meme. (It it a "meme"? What, exactly, is a meme? Does something have to move or make noise to be a meme, or can a word or phrase be a meme?)

The bottom line for Tykocinski is that he either agreed with the tweets, which is baffling for a competent molecular immunologist, or he is reckless in his untutored approach to Twitter. There is a reason TJU and every other university and college has professionals who manage institutional social media.

The lesson is an important one for all of us in the health care field, from pre-med college students to med students to residents to doctors and allied health professionals. Be very sparing and very careful in what you post. "Unprofessional conduct" is a subjective judgment, and the beholder whose eyes matter is not, at the end of the day, the person who posts.

Q: When is a Doctor not a "Doctor"?

A: When she (and the nursing field is still predominately women) has a doctorate (could be a D.N.P. or a Ph.D. or . . .  It really doesn't matter, as long as it's not a medical doctorate). That's how California sees it anyway. 

Becker's Hospital Review (July 18) reports on a challenge to California's law: 

Under California law, only physicians and surgeons can use the word "doctor" or the prefix "Dr." In November, Sarah Erny, a nurse practitioner with a doctorate, was found violating the law by allegedly describing herself as a doctor on professional websites and social media. She was fined $20,000 by the state and another $2,500 by the state medical association.

In June, three nurse practitioners with doctorates of nursing sued the California attorney general, leaders of the medical board of California and leaders of the state board of registered nurses, arguing they have a right to call themselves doctors. 

States have a legitimate interest in avoiding deceptive practices, such as deceiving patients about whether they are consulting a medical doctor (M.D. or D.O.) or some other person with a doctorate. And nurses have an interest in honestly and accurately informing the public about their advanced practice credentials. A number of states prohibit the use of the term "Doctor" by non-physicians, so the outcome of this litigation is a matter of national interest. It's actually an international issue, as described by a 2016 article in the Canadian Association of Medicine Journal. 

There's a First Amendment issue here. The strict scrutiny accorded to state-imposed content-based restrictions on speech requires that the state's use of its police powers be the least restrictive means possible. Wouldn't California accomplish its goal by  requiring that anyone using the prefix "Dr." add their doctoral degree(s) after their name? This appears to be how it is handled in Texas. If the degree isn't a medical degree, how likely is it that patients would be deceived? I'm on the side of the nurses on this one.

Contra: When speech is deemed to be "commercial speech," the level of judicial scrutiny is "intermediate," not "strict." A claim by California that the nurses are engaged in commercial speech would require an inquiry into the circumstances surrounding their use of the title "Doctor." Business cards? Professional listings on a job board? Letterhead? 

Medical boards and professional associations are constantly fighting to protect the boundaries of their profession against interlopers. They traditionally do so in the name of good patient care. This dispute has that feature, as well. It should be interesting. 

New Proposed Merger Guidelines from FTC & DOJ

 

In a previous post (May 25, 2023), I featured some of the criticisms leveled by Daniel Sokol and Dick Pierce against the emerging M&A policy at the FTC under the leadership of Lina Khan. It's not likely that the revised merger guidelines released by DOJ and FTC on July 19 will do much to soften their criticism. 

Of particular interest for health lawyers, consider these more or less parallel developments:

• July 14: the two agencies withdrew the Statements of Antitrust Enforcement Policy in Health Care and the Statement of Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program. ACOs represent a major innovation in the 2010 Patient Protection and Affordable Care Act, and a major part of ACO-related policy was the antitrust protection issued by the FTC and DOJ. The ACO initiative hasn't been a roaring success, and if the FTC and DOJ tighten the enforcement screws on ACOs, that could be the end of the road for them.
• July 20: at an open meeting, the FTC voted to issue a statement that discourages reliance on 11 prior advocacy letters and reports issued between 2004 and 2014 related to pharmacy benefit managers.

These are interesting times, indeed, for health-care antitrust counsel and their clients.

American Indian/Alaska Native Health Equity; Private Sector Opportunities

Health Affairs' fourth installment (July 21) of the past week in its Forefront series, "Private Sector Solutions For Health Equity," is written by two principals in Indigenous Pact, a public-benefit corporation whose mission is "[to] provide health care benefits and reimbursement to American Indians and Alaska Native and promote the autonomy and sovereignty of American Indian tribal government over the health of their people.”

The article is a comprehensive review of the hurdles currently faced by indigenous peoples in obtaining health care goods and services, which they introduce with this observation:

The story of American Indian/Alaska Native (AI/AN) health is fractured by genocide and systematic, forced migration away from lands that nourished good health. What existed unsullied for thousands of years was essentially wiped away when colonial settlers stepped foot onto the land that is now called the United States. And what exists now are pieces of brokenness and transgenerational trauma that pervade nearly every aspect of indigenous health.

There’s a well-known, albeit sardonic, pronouncement in Indian Country that admonishes, “You’d better get sick by June or there won’t be any money left—and if you do need medical intervention, it’d better be life or limb because those are the only things that will get authorized.” Unfortunately, it’s funny because it’s true.

The solutions are broad, ambitious, and unflinching. It's way past time to address the needs of this country's original occupants. 

Employers Can Improve Reproductive Health Equity

This is the third in this week's Health Affairs short series on Private Sector Solutions For Health Equity: "Employers Can Help Raise The Bar For Reproductive Health Equity" (July 20) by Sinsi Hernández-Cancio, JD,  vice president for health justice at the National Partnership for Women & Families.

The main focus of the article is on maternal health, which the author frames this way:

We need to solve the maternal health crisis for three main reasons. First and foremost, we must put an end to our status as the most dangerous place to give birth among high-income countries. Second, this crisis is the clearest example of the impact of racism and other structural inequities on the lives and well-being of women and their families. Finally, we know that the healthiest start possible for every person supports a positive life trajectory, while poor maternal and infant health can have long-reaching negative consequences on the health and well-being of both mom and baby.

 Her solutions are multi-tiered, mostly long-term, and hard to read without feeling some despair, e.g.:

• "expand[] their employee health coverage to include out-of-state services for those seeking reproductive care, and also gender-affirming care"
• "invest[] philanthropic dollars in reproductive health advocacy groups such as Planned Parenthood" and in general increase advocacy efforts aimed at improving, not destroying, their employees health care option
• "focus on improving clinical care–especially providing culturally centered, whole-person care that considers the patient’s life context. But health care institutions can and should do more, including aligning their hiring and workplace policies with equity goals, collaboratively partnering with community-based organizations, and pushing for improved policies at various decision making tables"
• diversify "their workforce, especially at leadership levels. According to a 2020 report from Mercer, a business consulting company, 64 percent of corporate entry-level positions were held by white employees; at the executive level that number jumped to 85 percent. The health care industry is no exception. Roughly nine out of ten hospital CEOs are white. Only 15 percent of health care CEOs are women, despite women comprising a large majority of health care workers, including the maternal health workforce."
• "focus[] on the dignity, personal agency, and bodily autonomy of birthing people. Among the recommendations: screening for and helping to meet patients’ physical, mental, and social health needs, and measuring respectful care for internal improvement and accountability. This includes understanding and addressing how structural inequities undermine people’s health."
• "collaborate and co-create with community-based partners"

The basic lesson here is that maternal health won't get significantly better if we wait for initiatives and funding to come from the public sector, nor can it happen without the public sector. One engine for change is companies that are willing to put resources -- including time and money -- into improving health for their employees.

Almost four years ago, Texans Care for Children (TCC) issued a report, Healthy Moms Raising Healthy Babies: Central Texas and Statewide Challenges and Opportunities to Support Maternal Behavioral Health During the First Year After Childbirth (Oct. 2019). One section addressed "What Factors Contribute to Racial Disparities in Maternal Health Outcomes?" The factors include:

• Implicit biases in our health care system can affect the quality of health care provided, decision making, and how health programs are carried out. 
• Chronic stress, including the physical toll of stress related to structural racism, increases health risks for mothers and babies. 
• Discrimination, both past and present, negatively affects social determinants of health — such as housing, food scarcity, and education, among others. 
• Lack of access to health insurance disproportionately affects people of color and limits the ability to manage health conditions before and after pregnancy. 

The depth and complexity of social and cultural roots of the problem reinforce the conclusion I drew from Ms. Hernández-Cancio's article: It's going to take a lot of work, a lot of investment, and a lot of time to improve maternal health in this country. 

One thing the legislature and Governor Abbott could do with the stroke of a pen and at almost no cost to the state is take up the federal government's invitation to expand Medicaid eligibility and let the United States pay for nearly all of the additional cost. As the TCC report noted:

In Texas, Black and Hispanic women are more likely to be uninsured than White women. Seventeen percent of nonelderly Black adults in Texas, 29 percent of nonelderly Hispanic adults, and 12 percent of nonelderly White adults in the state were uninsured in 2017.

Recent research found that states that offer Medicaid insurance to cover low-wage adults who do not have insurance through their job experienced a decrease in disparities for Black families with respect to maternal mortality, infant death, preterm birth, and low birth weight babies. Specifically:

Analysis of data from 2010 to 2016 found that infant deaths have declined across most states, but the decline was more than 50 percent greater in states that offer health coverage before, during, and after pregnancy — with the decline in infant deaths greatest among Black infants.

Research found that coverage for low-wage workers before, during, and after pregnancy was associated with “significant improvements in disparities for black infants relative to white infants for the four outcomes studied: preterm birth, very preterm birth, low birth weight, and very low birth weight.” 

Is a drop of empathy too much to ask of our state leaders? This is the question I've been asking on this blog for years (here, here, here, here, and here). When we find that our leaders are unmoved by the deaths of women who need life-saving abortions and women dying during and after childbirth, it ought to be a question that decides elections.

U.S. Child and Teen Firearm Mortality is Off the Chart. Literally.

Following up on my Father's Day post about firearms.  The Kaiser Family Foundation has released a new issue brief: "Child and Teen Firearm Mortality in the U.S. and Peer Countries". One graphic tells the story:

It's the #1 cause of death (by a pretty wide margin) for minors (ages 1-17), ahead of motor vehicles, cancer, and all other causes.

It's a short paper with an important message. The concluding paragraph raises an issue that doesn't get a lot of coverage in the popular press:

Exposure and use of firearms also have implications for mental health. Research suggests that youth may experience symptoms of post-traumatic stress disorder and anxiety in response to gun violence. Specifically, survivors of firearm-related injuries, including youth survivors, may be at increased risk of mental health conditions and substance use disorders. Furthermore, gun violence disproportionately affects many children of color, particularly Black children, and children living in areas with a high concentration of poverty.

This is a public health issue and ought to be understood as a public health law issue as well. When will legislatures wake up?

Gene Editing: New Report from Third International Summit

This is a must-read document for students of bioethics, teachers, and practitioners. Here are the details:

NEW PROCEEDINGS OF A WORKSHOP—IN BRIEF

Third International Summit on Human Genome Editing: Expanding Capabilities, Participation, and Access

The proceedings of the Third International Summit on Human Genome Editing, which took place on March 6-8, 2023 in London, are now available in a free PDF (readable and downloadable).

Building on previous events held in Washington, D.C. (2015) and Hong Kong (2018), the third summit examined scientific advances that have occurred since the previous summits and the need for global dialogue and collaboration on the safe and ethical application of human genome editing.

The first two days of the summit focused largely on somatic human genome editing, where the cells being altered are non-reproductive cells - as a result genetic changes cannot be passed on to future generations.

The third day of the summit broadened the discussion to include heritable human genome editing, in which genetic changes could be passed on to descendants.

The summit proceedings highlight the presentations and discussions of the event. 

The summit was organized by the UK Royal Society and Academy of Medical Sciences, the U.S. National Academy of Sciences and National Academy of Medicine, and UNESCO-The World Academy of Sciences for the advancement of science in developing countries (TWAS).  

For fogies like me, I assumed the conference would be all about CRISPR-Cas9 (the technique that garnered its co-inventors a Nobel Prize), but that gene-editing technique is yesterday's news:

The CRISPR-Cas9 system discovered by Doudna and Emmanuelle Charpentier is still a widely used tool in genome editing, but newer systems are even more powerful and precise. Techniques known as base editing and prime editing enable efficient and precise gene correction in a wide variety of cell types without requiring that both strands of the DNA molecule be broken, minimizing the possibility of DNA deletions, insertions, or rearrangements that can result from double-stranded DNA breaks. Many laboratories have used prime editing to treat diseases in animal models of human disease, and some of these techniques have been applied in clinical trials. [Proceedings, p. 4]

The ethical concerns, like the Dude, abide: accessibility and affordability of somatic gene editing, the lack of infrastructure and expertise in developing countries, the difficulty and complexity of determining the value of new therapies, the need to engage the public in sophisticated policy discussions, appropriate oversight of experiments, and probably the most polarizing topic of all: germline and heritable gene editing. 

Private-Sector Strategies to Address Disparities in Access to Mental Health Resources

Health Affairs just published the second of four articles on private-sector strategies to address disparities in access to health care: "Addressing The Mental Health Equity Crisis: Can The Private Sector Lead?" The author is Wizdom Powell, Ph.D., M.P.H. (recently named one of the 25 Essential Voices on Black Mental Health). 

"Crisis" is not hyperbole. As inequitable as access to health care is in general, access to mental health care is even more problematic. Helping a friend or family member to be seen, evaluated, and into appropriate treatment is the medical equivalent of banging your head against a brick wall over and over again. As Dr. Powell writes, "By any measure, an all-hands-on-deck approach is needed." She continues:

Health disparities, or preventable differences in the burden of chronic disease and health outcomes, are a driving force behind mental health inequities. Our health equity problem is of our own making, created by artificial caste distinctions, persistent racism, and how we structure our economy and investments in health care; the status of health care disparities is determined, largely, in the ways that the private sector either confronts them or looks away. It is also valuable to recognize that the wicked problem of health inequity is not immutable and that our lack of sustained advancement has more to do with internalized myths of complexity than with our societal capacity.

Wicked problems aren’t unsolvable; instead, they offer many paths to a solution. Just as we have created the problems, we can create the solutions as well. This requires the private sector to do what can prove difficult for public sector leaders—invest resources in pursuing a mental health equity moonshot. The private sector is uniquely positioned and resourced to take the lead in marshaling solutions that will deliver the rapidity and scale necessary to address these troubling trends and ultimately advance health equity. 

Read the article and learn about DEIBJ (Diversity, Equity, Inclusion, Belonging & Justice) and SDGs (the United Nations' Sustainable Development Goals). The article is a quick read and well worth your time. 

JAMA: SCOTUS Decision on Race in College Admissions Will Worsen Health Care Inequities

New online and free article in JAMA: "The Supreme Court’s Rulings on Race Neutrality Threaten Progress in Medicine and Health," by public health scholars Harald Schmidt, Lawrence O. Gostin, and  Michelle A. Williams.

The first paragraph should whet your appetite for more:

In landmark rulings, the US Supreme Court significantly restricted race-conscious admissions policies in higher education, a chilling echo of its evisceration of settled law on abortion. In principle, race neutrality is desirable—but it is one thing to set aside race in a society with genuine equal opportunity, and another to do so where stark differences persist in opportunities and outcomes, fueled by a 400-year history of systemic racism. While the Court focused on education, its rulings could have broad and pernicious implications for health. They could upend programs designed to achieve equity and actively harm population health.

Private Solutions to Address Disparities in Access to Health Care

The excellent journal Health Affairs has kicked off another series of articles in their Forefront feature "Private Sector Solutions for Health Equity." Today's essay is "Public-Private Partnerships To Advance Cardiovascular Health Equity: The Million Hearts Initiative" by Yvonne Commodore-Mensah (Johns Hopkins), Oluwabunmi Ogungbe (Johns Hopkins), and Lisa A. Cooper (Johns Hopkins, 2007 MacArthur Fellow, elected member of National Academy of Medicine). 

There will apparently be four articles this week running through Friday, July 18. Stay tuned . . . 

False Claims Act Settlement with EHR Provider for $31 Million

First, $31 million is a significant piece of change. Second, this was a qui tam relator ("whistleblower") case initiated by two health care professionals at a facility that used the defendant's software; the relators  collected $5.58 million for their trouble. Third, it represents a rare foray by the government into the world of healthcare tech; defendant was NextGen Healthcare Inc. (NextGen), an electronic health record (EHR) technology vendor.

In brief, NextGen was accused of selling EHR software that wasn't properly tested or certified. Medicare money was paid for the development of the software, and NextGen's assertion that its software was properly tested and certified was false. The company was also accused of violating the Anti-Kickback Law, which makes it illegal to pay anyone anything (directly or indirectly, overtly or covertly, in cash or in kind) for a referral (or to induce a referral) of an item or service for which a federal health program (like Medicare) will pay. According to the announcement from DOJ's Office of Public Affairs, "NextGen [allegedly] knowingly gave credits, often worth as much as $10,000, to current customers whose recommendation of NextGen’s EHR software led to a new sale. The government alleges that other remuneration, including tickets to sporting events and entertainment, was also provided to induce purchases and referrals."

Something Old, Something New (Hellacious Health Fraud (VI))

 

Here are a couple of recent cases that caught my eye. First, the old style of health care fraud:

• Evergreen Hospice, LLC (Evergreen), a hospice company located in Tulsa, Oklahoma, appears to be a Mom & Pop operation that advertises a Servant Attitude ("We are givers, not takers. We are listeners, not talkers. We are promoters of others and will perform our roles with humility and dignity") and touts their institutional commit to Ethics ("We will not participate in or tolerate dishonesty or unethical behavior"). On June 29 DOJ announced that Evergreen agreed to pay $48,830.70 to resolve allegations that it violated the False Claims Act by knowingly submitting false claims to Medicare for hospice care provided to beneficiaries who were not terminally ill. Medicare's hospice program requires a physician's certification that the patient/beneficiary is terminally ill, i.e., will probably die within 6 months. The settlement announcement included the usual boilerplate that liability was not established. The U.S. Attorney's announcement added: "'Unfortunately, some healthcare providers seek to defraud Medicare by billing unnecessary hospice services. Left unchecked, this misconduct would deplete funds available for terminally ill patients desperately in need of the relief that hospice care provides."

And something new(-ish):

• A key feature of 2010's Patient Protection and Affordable Care Act (PPACA, ACA, or Obamacare) offered state governments a deal. It was well known that many states had substantial populations of individuals who were not old enough to qualify for Medicare and had too much income to qualify for Medicaid. (States get to establish the eligibility criteria for Medicaid and some, like mine, disqualify individuals at a ridiculously low income level.) The federal government's offer: cap your eligibility at 133% of the federal poverty level (effectively 138% of FPL after accounting for the 5% income disregard feature of Medicaid) and we will pay 100% of the cost of expanded coverage for the first few years, 95% for the next few years, and 90% from then on. In return, states (including California) agreed that at least 85% of the services provided to the expanded population would be for "allowed medical expenses." Shortfalls would need to be returned to the state and ultimately to the U.S.

The four defendants in this case are [1] a county organized health system (COHS) that contracts to arrange for the provision of health care services under California’s Medicaid program (Medi-Cal) in Santa Barbara County and San Luis Obispo County, California; [2] a not-for-profit hospital network operating in Santa Barbara County; [3] a non-profit outpatient clinic operating in Santa Barbara County; and  [4] a non-profit community health center operating in Santa Barbara and San Luis Obispo Counties. The four allegedly violated the False Claims Acts (state and federal) by falsely certifying that they met the 85% minimum from 2014-16. The net result was that Medicaid expansion funds were used to subsidize non-Medicaid services. 

The four defendants settled the suit for $68 million, of which $12.58 million will go to the whistleblower, the former medical director of the COHC. 

More on Nonprofit Hospitals and Tax-Exempt Status

Just a quick followup on my previous posting on this topic (July 13). On July 15 the New England Journal of Medicine posted an on-line "Perspectives" piece (possibly free) that examines the question whether nonprofit hospitals deserve their tax-exempt status. The article covers much of the same ground as my post, but it adds some data to further the policy discussion, such as:

[I]n previous work we compared nonprofit and for-profit hospitals on measures of charity care and Medicaid shortfalls — the two largest components of community benefit by amount of spending. For-profit hospitals don’t receive tax exemptions and aren’t legally obligated to provide community benefit. In 2018, for every $100 of expenses incurred, nonprofit hospitals in aggregate spent $2.30 on charity care, as compared with $3.80 spent by for-profit hospitals. And in 2019, nonprofit and for-profit hospitals had similar Medicaid shortfalls as a share of total expenses. . . . These data suggest that many nonprofit hospitals don’t provide enough charity care or have a substantial enough Medicaid shortfall (relative to for-profit hospitals) to justify their favorable tax treatment. 

The article continues with additional policy-based concerns and ends with a valuable suggestion:

There are insufficient data to compare the amount of community benefit provided by individual nonprofit hospitals with the subsidies they receive. To close this information gap, the IRS could revise Schedule H of Form 990 to require nonprofit hospitals to report on forgone federal, state, and local taxes (broken out separately); savings associated with using tax-exempt bonds; gross profits from the 340B program, if applicable; and charitable contributions received by the hospital, with standardized reporting for each of these elements. . . .  Disclosure might not be sufficient to catalyze changes in hospital behavior, but we believe greater visibility is a prerequisite for policy action. 

 

Telemedicine Fraud

Here's an excellent review of a recent law review article on "Telemedicine Scams." The target article is by Katrice Bridges Copeland in 108 Iowa L. Rev. 69 (2022). The review is by Zack Buck in a recent Jotwell entry (July 7, 2023). His conclusion: 

Professor Copeland’s article—the first to address fraud in telemedicine—is a holistic and complete treatment of a pernicious problem in America’s health care system. . . . By adroitly focusing on the potential threats of a major new delivery mechanism such as telemedicine, she has made us aware of the next major frontier in health care fraud and abuse enforcement. In an area with such hope and promise in addressing America’s health care access challenges, and with the Public Health Emergency coming to an end, her warnings must be heeded to enable telemedicine to flourish while preventing the worst frauds from taking root.

The DOJ and HHS/OIG have brought numerous prosecutions for telemedicine fraud in recent years. The article by Prof. Copeland suggests we've only seen the beginning. 

Violent attacks on hospital staff: What's the solution?

The reports of violent attacks on doctors and nurses in hospitals, clinics, medical offices, and other health care settings keep coming in. From The Hospitalist (Mar. 1, 2023):

Even before the onset of the COVID-19 pandemic, health care workers suffered more workplace injuries as a result of violence than any other profession, with approximately 654,000 harmed annually, according to American Hospital Association studies. Since the pandemic began, violence against hospital employees alone has markedly increased. For example, 44% of nurses reported an increase in physical violence and 68% reported an increase in verbal abuse. (emphasis added)

The weapons tend to be knives and guns. Maybe it's a sign of the times, with random violence increasing all around us each year, there seems to be a steady stream of stories of violent attacks against health care personnel. (See, e.g., American Association of Critical-Care Nurses (blog)). I have further thoughts, but first, consider a recent example: "Man charged in fatal shooting of Tennessee surgeon" (Becker's Hospital Review, July 13). The shooter had reportedly been seen in this orthopedic surgery clinic earlier in the day, returned to the clinic, and shot the orthopedic surgeon.

It goes without saying that violence against doctors, nurses, and other health care workers simply shouldn't be a thing. We remember the political assassination of Dr. George Tiller 14 years ago while he was ushering in a worship service at his church in Wichita, Kansas. The killer was described as an "anti-abortion extremist." But much more violence and threats of violence occur every day in ordinary clinical settings. The work of clinical staff is performed with often emotionally fraught individuals (patients, family members), and then there are others with perceived grievances against the health care system or the world. The CDC has a useful list of risk factors:

The clinical setting is one of intensified emotions. Patients who are at risk of perpetrating violence include those who:

• are under the influence of drugs or alcohol
• are in pain
• have a history of violence
• have cognitive impairment
• are in the forensic (criminal justice) system
• are angry about clinical relationships, e.g., in response to perceived authoritarian attitude or excessive force used by the health provider
• have certain psychiatric diagnoses and/or medical diagnoses.

Clinics are designed to be open and welcoming, not armed fortresses. Doctors and nurses don't pack heat, and possession of a firearm on hospital property is universally prohibited (except in states where such prohibitions are themselves prohibited). They are vulnerable professionals -- first responders and health care workers -- who spend their careers comforting and healing. Violence is obscene and should be unthinkable in any workplace, including elementary schools, places of worship, and health care settings. 

There is no shortage of resources for dealing with violence in hospitals and clinics, including programs and best practices suggested or endorsed by the following:

• the American Hospital Association (Hospitals Against Violence; 2022 fact sheet)
• the federal Occupational Safety and Health Administration (OSHA) (report)
• the Centers for Medicare and Medicaid Services (CMS) (report)
• the Centers for Disease Prevention and Control (CDC) (course materials)

Health care settings are especially risky places to work, as many of the resources quoted and cited above establish. While we're at it, let's not forget the gun culture, the threat of which permeates every aspect of our lives. I wrote about this on Father's Day. The insanity has to stop.

Nonprofit hospitals: state and local tax authorities are again questioning tax-exemptions

Here's a great article from Kaiser Health News (July 11) on recent controversies over tax exemptions for hospitals. 

Tax-exempt status is not a "right"; it has to be earned. That means -- among other things -- that executive pay can't be excessive (or else the tax authorities will conclude the hospital is being run for private and not public benefit) and there has to be a convincing showing of tangible public benefit (uncompensated charity care, educational programs, research, etc.). 

The Kaiser piece starts with an example of the stakes involved in a typical case:

The public school system [in Pottstown, PA] had to scramble in 2018 when the local hospital, newly purchased, was converted to a tax-exempt nonprofit entity.

The takeover by Tower Health meant the 219-bed Pottstown Hospital no longer had to pay federal and state taxes. It also no longer had to pay local property taxes, taking away more than $900,000 a year from the already underfunded Pottstown School District, school officials said.

The district, about an hour’s drive from Philadelphia, had no choice but to trim expenses. It cut teacher aide positions and eliminated middle school foreign language classes.

“We have less curriculum, less [sic] coaches, less transportation,” said Superintendent Stephen Rodriguez. 

The school system appealed Pottstown Hospital’s new nonprofit status, and earlier this year a state court struck down the facility’s property tax break. It cited the “eye-popping” compensation for multiple Tower Health executives as contrary to how Pennsylvania law defines a charity.  

The court decision, which Tower Health is appealing, stunned the nonprofit hospital industry, which includes roughly 3,000 nongovernment tax-exempt hospitals nationwide.

The nonprofit hospital industry should not have been stunned. A wave of official scepticism over claims of tax-exempt status was ushered in at least 38 years ago with the case of Utah County v. Intermountain Healthcare, Inc., 709 P.2d 265 (Utah 1985). And jurisdiction after jurisdiction has viewed tax-exempt hospitals through a critical lens, often concluding that the hospitals in question were virtually indistinguishable from their for-profit competitors and that the public benefits from the nonprofits were too scant to justify the foregone tax receipts. 

This might be less of a problem if the IRS still required some level of charity care for a hospital to qualify for federal tax exemption, as it did from 1956 to 1969. (Compare Rev. Ruling 56-185 (exempt hospital must be operated "to the extent of its financial ability for those not able to pay for the services rendered") with Rev. Ruling 69-545 ("Revenue Ruling 56-185 is hereby modified to remove therefrom the requirements relating to caring for patients without charge or at rates below cost").) See GAO, Tax Administration: IRS Oversight of Hospitals' Tax-Exempt Status (April 26, 2023).

Obamacare added § 501(r) to the Internal Revenue Code to address certain aspects of the problem created by Rev. Rul 69-545, but it did not change the fundamental rule that a hospital may obtain tax-exempt status without offering a drop of unreimbursed charity care.

For its part, Texas (for once) far exceeds the federal standard by requiring minimum amounts of community benefit -- specifically including unreimbursed charity care and government-sponsored indigent health care -- in order for a hospital to qualify as a nonprofit entity under § 311.045 of the Health & Safety Code and for tax-exempt status as a charity under § 11.1801 of the Tax Code. 

COVID-19: GAO Recommendations Can Help Federal Agencies Better Prepare for Future Public Health Emergencies

There's a general consensus that COVID-19 exposed gaps in this country's state and federal public health infrastructure (in the broadest sense of that word). So when Congress passed the CARES Act, it included a provision for the Government Accountability Office (GAO) to report regularly on the public health and economic effects of the pandemic and the federal response. 

GAO's most recent report was issued yesterday (July 11; quick summary). This report includes the topics of (1) public health preparedness, (2) improper payments and fraud, (3) vulnerable populations, (4) distribution of federal COVID-19 funding, and (5) COVID-19 and the economy. It also includes updates for selected indicators related to public health, the economy, and federal COVID-19 funding and spending.

The report provides a wealth of information on how the federal government's $4.7 trillion pandemic-related expenditures have been spent. It also reviews the major areas in which our response was not up to the task. Finally, the report "includes several key data updates and five enclosures that summarize and highlight standalone reports issued from April 2022 (the date of our last comprehensive report) through April 2023 on the following topics: public health preparedness, improper payments and fraud, vulnerable populations, distribution of federal COVID-19 funding, and COVID-19 and the economy."