New CMS Payment Models Put Patients Above Paperwork

While my recent columns have put me on the defensive regarding primary care trends, I’m thrilled to see CMS not only acknowledge but reinforce the important role of primary care in achieving optimal overall health and well-being through the recent introduction of its Primary Care Initiative Medicare payment models. At the heart of the introduction is a threefold goal: reduce administrative burdens, empower PCPs to spend more quality time with patients, and reduce overall healthcare costs. I’m not the only one applauding. The Patient Centered Primary Care Collaborative (PCPCC) cites the CMS move as reinforcement of the role primary care plays not only in health, but healthcare value.

There are five models falling under one of two categories, Primary Care First (for individual practices) and Direct Contracting (for large organizations like ACOs, Medicare Advantage Plans and MCOs); all models are geared to patients with chronic conditions and serious illnesses:

1. Primary Care First (PCF)
2. Primary Care First – High Need Populations
3. Direct Contracting – Global
4. Direct Contracting – Professional
5. Direct Contracting – Geographic

Primary Care First (PCF) is the model Medical Network One will enthusiastically recommend to high performing providers/practices. There is up to a 50 percent gain in reimbursement and only a 10 percent downside […]

Compliance Corner: The Data Bank Provides Guidance on the Use of Proctorships

Wachler & Associates, P.C

The National Practitioner Data Bank (Data Bank) published an article in the May 2019 issue of NPDB Insights that provides significant guidance regarding when proctoring is reportable. Proctoring can come in many different forms and has several different names depending on the hospital, such as monitoring, mentoring, or preceptoring. Regardless of the name, hospital-assigned proctorship agreements can be a useful tool to help evaluate a practitioner when a hospital has concerns about clinical competence. This is especially true because certain proctorships can be structured to avoid a report to the Data Bank. When that is accomplished, hospitals are able strike a rare balance between adequately addressing competency concerns and not tarnishing a practitioner’s reputation and career.

According to the Data Bank, when a hospital is deciding whether it should report the assignment of a proctor, it should consider the role of the proctor and whether that role limits the practitioner’s privileges. A hospital should report proctoring if: (1) it is a result of a professional review action related to professional competence or conduct, (2) it is a limitation on the practitioner’s privileges, and (3) it is in effect for more than 30 days. As such, if as […]

Legal Cannabis, Michigan And Public Health

Last Nov. 6, in lieu of a legislative decision that never took place, the Michigan voters approved the legalization of marijuana for recreational use by adults. That made our state the first in the Midwest to have such policy, complementing the previous implementation of the medical marijuana use. The statute included the proviso that recreational marijuana was to be allowed on persons of 21 years old and above, and that certain rules and regulations were to be developed via legislation to organize the cultivation, process, distribution and sales of the approved substance by a state certified system.

As of May 6, six months after the approval, a rather confusing environment is in front of us. And we have only six more months to be up and running. First, if medical marijuana is a substance that treats certain medical conditions, we must know that indeed the results of its use shows an improvement on those conditions as part of the public health effort to improve population health and practice evidence-based medical care.

The Michigan public, the state Department of Health and the practicing physicians are entitled to see those results to justify supporting the medical use of cannabis in the improvement of the debilitating conditions […]

Lansing Lines

State Medicaid Official Placed On Leave Following Negligence Accusation

Michigan’s chief medical director for Medicaid was placed on administrative leave May 9 after accusations of negligence and deficiencies in patient care.

Dr. David Neff, who had been recognized for helping combat the state’s opioid crisis, is accused of failing to meet minimal standards and violating his general duty as a health care provider, according to an administrative complaint filed by the Michigan Department of Licensing and Regulatory Affairs (LARA) that MIRS received via a Freedom of Information Act request May 31.

LARA spokesperson David Harns said the department is not commenting outside the administrative complaint.

Lynn Suftin, spokesperson with the Michigan Department of Health and Human Services, confirmed Neff’s leave from his $191,184 a year position began May 9. She also said the department is not offering further comments.

Efforts to reach Neff were not successful. A response to LARA’s complaint was filed May 31, but that report wasn’t immediately available for release.

The May 1 complaint filed with the Michigan Board of Osteopathic Medicine and Surgery alleges Neff overprescribed controlled substances to some patients in his part-time medical practice.

Specifically, the complaint alleges Neff didn’t request MAPS reports prior to prescribing controlled substances medication to patients between June 1 and September […]

House Passes Insurance Reform With Mandated Rate Rollbacks

House Republicans stuck together and, with the support of three Democrats, pushed through sweeping reforms to the state’s 40-year-old auto insurance.
Michigan’s auto insurance customers would see guaranteed rate rollbacks, choice in personal injury coverage and a fee schedule for medical providers under a plan that moved 61-49 at 2 a.m. Thursday morning, 18 hours after the Senate passed similar changes.

Unlike the Senate version, HB 4397 will give the Department of Insurance and Financial Services (DIFS) the power to prevent non-driving factors from affecting rates. It also mandates that between 10 and 100 percent of previous personal injury protection (PIP) costs, meaning some ratepayers can opt out of the Michigan Catastrophic Claims Association’s (MCCA) unlimited, lifetime coverage.

Despite the concessions made on the two issues that Democrats and Gov. Gretchen Whitmer cited as reasons for their opposition on May 7, most Dems were a no vote. Instead, Democrats pivoted to talking about the people who will choose to take lesser coverage and “be left in the cold” if they get in a catastrophic car accident.

The governor joined Democrats in the caucus room for about 10 minutes May 8, but left the chamber without commenting to the media to give a reaction to the plan.

Democrats who voted in […]

Even Doctors Can’t Navigate Our ‘Broken Health Care System’

Dr. Hasan Shanawani was overcome by frustration. So, he picked up his cellphone and began sharing on Twitter his family’s enraging experiences with the U.S. health care system.
It was an act of defiance — and desperation. Like millions of people who are sick or old and the families who care for them, this physician was disheartened by the health care system’s complexity and its all-too-frequent absence of caring and compassion.

Shanawani, a high-ranking physician at the Department of Veterans Affairs, had learned the day before that his 83-year-old father, also a physician, was hospitalized in New Jersey with a spinal fracture. But instead of being admitted as an inpatient, his dad was classified as an “observation care” patient — an outpatient status that Shanawani knew could have unfavorable consequences, both medically and financially.

On the phone with a hospital care coordinator, Shanawani pressed for an explanation. Why was his dad, who had metastatic stage 4 prostate cancer and an unstable spine, not considered eligible for a hospital admission? Why had an emergency room doctor told the family the night before that his father met admission criteria?

Sidestepping Shanawani’s questions, the care coordinator didn’t provide answers. Later, another senior nurse in the hospital unit didn’t respond when […]

Watch Your Step, PCPs—Mission Creep Is Tripping Up Primary Care

As any regular reader of this column knows, I’m a big booster of the pharmacy profession and have been committed to maximizing the skill level and reach of pharmacists when it comes to primary care. That’s why our organization was among the first Patient Care Organizations (formerly PO’s) in Michigan to actively recruit pharmacists into care management training programs and to seek out pharmacists to serve as care managers at large primary care practices within our network. It’s been gratifying to see other Patient Care Organizations follow suit.

Still, I was taken aback when I read a recent Detroit Free Press article with the headline, “Flocking to pharmacies instead of the family doctor.” Yes, it’s fitting and overdue to see pharmacists getting the recognition they deserve for the invaluable role they play in the health care continuum. With newer pharmacy service offerings like vaccines and treatment for relatively simple ailments via the Minute Clinic type model, much needed access to care has been enhanced because of pharmacists and the large consumer-driven entities that support them. That’s to be applauded.

Yet, pharmacists and pharmacies are not equipped to offer integrated care that treats both behavioral and physical health; they are not set up to coordinate care […]

Bureaucracy: The Bane Of Physician Practice

Doctor, if you have recently visited with upper hospital management in the plush executive suite, it was most surely you who stood out conspicuously. Being greeted by one of the administrative secretaries, you were asked to be seated and wait along with others, consultants, lower level management, salesmen, business associates, insurance executives and maybe even golf buddies. You were notable as the only one not appearing in sartorial splendor, groomed to the hilt, well rested and adorned in a three-piece suit. You were the person bleary-eyed from the night shift or up all night with an emergency, dressed in a white coat with pockets full of papers and baggy greens or blues. Curious though, it is you, the physician, who is responsible for all of their incomes.

Granted, as healthcare has become a complex, shifting regulatory nightmare with falling reimbursement rates and myriad payment mechanisms, hospital management has become more complicated. Looking for the easy way out of revenue erosion, managements’ expensive consultants have likely suggested reducing costs; and the most important driver of costs in virtually all hospitals is the medical staff. While physician compensation accounts for only 8 percent of healthcare spending, physician decisions account for up to 80 percent of […]

Court Orders HHS to Clear Medicare Appeals Backlog

On Nov. 1, 2018, U.S. District Court Judge Boasberg ruled that the U.S. Dept. of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022.

As of the end of 2018, there was a backlog of 426,594 appeals. Judge Boasberg’s ruling imposes a timetable for reducing the backlog of appeals. Specifically, HHS must clear 19 percent of the appeals by the end of fiscal year 2019; 49 percent of the appeals by the end of fiscal year 2020; 75 percent by the end of fiscal year 2021; and eliminate the backlog entirely by the end of 2022. Beginning on Dec. 31, 2018, HHS must file quarterly status reports on its progress.
This long-awaited ruling comes years after the American Hospital Association (AHA) filed the lawsuit alleging that HHS was violating federal law by failing to process appeals according to statutorily-mandated timeframes. Federal regulations require appeals at the Administrative Law Judge (ALJ) hearing level to be completed within 90 days following the date the request for hearing is received by the Office of Medicare Hearings and Appeals (OMHA).[1] The current average processing time, however, for a case pending at the ALJ level is more than […]

Trump Administration And Democrats Return Health Law To Political Center Stage

“The Mueller Report” is so last week’s news. Health care has returned in force as the dominant political issue in Washington, reflecting what voters have been telling pollsters for the past year.

The Trump administration moved night to get more in line with President Donald Trump’s voter base by endorsing a Texas federal judge’s December opinion that the entire Affordable Care Act should be struck down as unconstitutional.

After he arrived at the Capitol for lunch with Republican senators Tuesday, Trump endorsed the change, suggesting it will usher in Republican priorities instead. “The Republican Party will soon be known as the ‘party of health care!’” he told reporters.

Less than two hours later, House Democrats unveiled their proposals to not only protect the health law, but also expand it — including extending help paying premiums and other costs to families higher up the income scale than those now eligible and reinstating cuts made by the administration for outreach to help people sign up for coverage.

Speaker Nancy Pelosi said that, since taking control of the House in January, Democrats have been fighting to preserve the health law and “voted on Day One” to file a motion in the Texas court case to support the ACA.

The arguments are […]

Uncertain Future For Michigan’s Medicaid Work After Court Ruling

Critics of Medicaid work requirements say that a U.S. district judge’s ruling disapproving work requirements for Medicaid recipients in Kentucky and Arkansas could lead to a similar ruling in Michigan.

Judge James Boaasberg in Washington, D.C., recently ruled work requirements to receive Medicaid in Kentucky and Arkansas are “arbitrary and capricious.” That may also affect states with similar laws, according to Families USA, a nonprofit health care organization.

Michigan is one of those. Republican lawmakers pursued work requirements for Medicaid recipients enrolled in the Healthy Michigan Plan last year. They take effect next year.

Sen. Mike Shirkey (R-Clarklake) sponsored the bill that added the work requirements after President Donald Trump approved states to do so in 2017.

“Michigan has very similar laws to those in Kentucky and Arkansas since we followed through with passing these laws so soon after,” said Alex Rossman, the communications director for the Michigan League for Public Policy. “A lot of the reasons that the judge decided work requirements shouldn’t be there applies to Michigan, as well.”

The Healthy Michigan Plan expanded Medicaid health care coverage to another 600,000 people whose income would be too high to receive federal Medicaid, said Bob Wheaton, a public information officer for the Michigan Department of Health and Human Services.

“There […]

Let’s Not Let The WSU Board Of Governors Kerfuffle Set A Precedent For Board Behavior

Because my column is due a few weeks prior to publication, I can only hope that the ugliness of the Wayne State University Board of Governors schism has diminished by the time you are reading this. Still, I am compelled to comment on what has disintegrated into personal name calling and the appearance of grandstanding by some board members. Lost in all this seems to be an understanding of the mission and values of a university and the role of its board of governors.

While I don’t want to get involved here in the discussion on whether University boards of governors should be appointed or elected, the fact of the matter is that as it stands now, board members are elected by Michigan residents. Hence, the board’s constituents are not just the students, faculty and employees of the university, but the entire state. As taxpayers, we all contribute to Michigan’s public institutions of higher learning and should rightly expect that BOGs have education and the state’s best interests at heart. That’s not what I’m seeing on the current board.

The key responsibilities of the Wayne State University Board of Governors, as stated on their website include, “…choosing the university presidents, supervising the control and direction […]

Authority Health Board Names New President/CEO

The Authority Health Board of Directors has named Loretta V. Bush, MSA, president and CEO of Authority Health, effective May 1, announced Gail Warden, Chairman of the Authority Health Board. Ms. Bush will replace Chris Allen, who has served as president of Authority Health since its inception in 2004, who will retire on April 30.

“I am pleased to announce that Loretta Bush will be our new president and CEO,” Gail Warden said. “Her extensive experience in public health practice and administration makes her an excellent candidate to lead our organization in the next phase of its history. She has impressive background addressing the complex health issues of the uninsured, underinsured and vulnerable populations.”

Ms. Bush has served as chief executive officer of the Michigan Primary Care Association, which represents community health centers throughout the state.

Prior to this position, Ms. Bush served as Group Executive/Health Officer for the Detroit Department of Health and Wellness Promotion and the Department of Health Services, Director of Public Health/Health Officer for the Wayne County Department of Public Health, Director of the Division of Health, Wellness and Disease Control, Michigan Department of Community Health, and Administrator of the HIV/AIDS Programs for the City of Detroit Health Department.

Ms. Bush has a Bachelor of […]

National Practitioner Data Bank Urges Hospitals to Provide More Discipline Info

The National Practitioner Data Bank (Data Bank) has published an article in the April 2019 issue of NPDB Insights that urges reporting entities to include a detailed narrative when submitting an Adverse Action Report. The Data Bank’s stated purpose for requesting detailed information is to give organizations a more complete picture of what occurred to assist in making critical hiring and credentialing decisions. However, it will also result in healthcare providers being saddled with a career-damaging Data Bank report that contain inaccurate details and contested facts. Importantly, options are available to these providers to help minimize the damage. More specifically, healthcare providers have the right to submit a Subject Statement to the report at any time to give a more accurate and complete picture of what occurred.

By way of background, the Data Bank is an alert system that collects and discloses certain adverse information about physicians and other healthcare providers. A report to the Data Bank can significantly impact a healthcare provider’s reputation and career. NPDB Insights is published by the Data Bank to provide guidance to users on topics such as eligibility, querying and reporting requirements, and the dispute process. The April 2019 version of NPDB Insights contains an […]


GOP Lawmakers Think DHHS Caro Study A Sham
Two Republicans representing Tuscola County say the state has already made up its mind about moving the replacement Caro Center, based on emails published by a TV station.

ABC 12 got its hands on emails from Gov. Gretchen Whitmer administration officials discussing the future of the proposed replacement for the psychiatric facility, including messages from Robert Gordon, director of the Michigan Department of Health and Human Services.

According to the report, Gordon in January “increasingly believes that closing Caro entirely is the correct path forward.”

In another email “within weeks,” Gordon suggested the idea of forming a commission “that would help us get the right answer, building support for that answer, and perhaps hold off the Legislature from doing anything rash,” according to the report.

It was in that same email that Gordon said a leading idea was to instead expand the Center for Forensic Psychiatry in Saline and build a smaller location in a better location than Caro.

In mid-March, the state publicly announced it would halt construction on the new Caro Center and hire a consultant to study where best to locate the project.

The state had already broken ground under the previous administration on a new psychiatric facility located close to […]

IN MY OPINION: Predictable Economic Consequences

Economics is apolitical. Economists can and often do have biases. But there are basic economic principles that are accepted. There are empiric data that provide the proof for their reliability. Trying to plough through healthcare and arrive at logical economic conclusions for a non-economist is not that easy. But hang in there if you can, and follow along as an attempt is made to do just that.

Healthcare is, like most everything, a scarce resource. Besides that, it is so complex that no single person or any limited group of persons is capable of completely planning and supervising the goods and services included in healthcare. It requires elaborate coordination of multitudes of producers of both goods and services. An unchallengeable statement by Armand Alchien is as follows. “The modes of coordination in a basic private property, individualistic society have dominated all other forms in productivity, growth and freedom.”

A free good or service exists when there is no scarcity; it is hard to think of any. Healthcare is certainly not one of them. Even if a zero price is charged, healthcare cannot be free. Consuming healthcare for “free”, really at a zero price, does not convert this limited, scarce, service into a “free” service. […]

Taking Another Shot At Lower Drug Prices

The head-spinning experience of navigating the pharmaceutical pricing world came to town Feb. 28, leaving lawmakers and laypeople alike with no greater understanding of why the entire scheme leaves consumers light in the pocket.

The basics are clear. Drug companies set the price for their drugs, but rarely does anyone pay it, Peter Fotos, PhRMA’s Chicago-based regional director for state advocacy told the House Health Policy Committee.

Generally, health insurers go through this relatively new layer of bureaucracy called Pharmacy Benefit Management (PBM) companies to negotiate cheaper rates based on bulk purchases. Then there are other assorted rebates and discounts patients can score. When the smoke clears, about 33 percent of the initial list price disappears.

In 2017, pharmaceutical companies paid $153 billion in rebates, up from $74 billion in 2012.

All of this led Rep. James Lower (R-Cedar Lake) to ask the obvious question: “Why do the clawbacks? Why do the rebates? Why not have a lower price to begin with and not go through this bureaucratic nightmare?”

The answer: That is the way it is. Apparently, there are rebates available for people buying in volume. Everyone wants the sweet deal. Human resource people do not want to mess with it so these PBMs take care of it for […]

Americans Ready To Crack Down On Drug Prices

Large majorities of Americans from both major parties support steps to control prescription drug costs such as showing prices in ads, removing barriers to generics and letting patients get less expensive drugs from Canada, a new poll shows.

By a 9-to-1 ratio, Republicans, Democrats and independents favor making drug companies show list prices in their advertising, says a new survey from the Kaiser Family Foundation. Highly advertised medicines such as Humira, for arthritis, cost tens of thousands of dollars a year, even after discounts.

Although Republicans tend to frown on government control over commerce, 8 in 10 Republican respondents said they support giving negotiating power to the $700 billion Medicare program in order to lower drug prices for seniors.

More than 70 percent of all respondents back importing drugs from Canada and capping out-of-pocket Medicare costs. More than 80 percent said they favor making it easier for less expensive generics to compete with brand-name drugs.

As President Donald Trump and Congress vow to act against drug inflation and journalists chronicle patients experiencing medical and financial shock from drug expenses, increasing numbers of Americans blame pharmaceutical companies for high health care costs.

Expensive drugs are one of several factors in rising medical costs that strain government, employer and household […]

ON POINT WITH POs: Patient Care Organizations

What’s in a name? Sometimes, limitations. A physicians’ organization, for example, is the name given to organizations originally designed to help private practice physicians build and maintain an independent practice. Broadly speaking, the PO handled the foundational business aspects and insurance provider contracts of the practice, while the physicians tended to the needs of their patients and day-to-day operations. The role of POs in the past 10 years, however, has changed dramatically. Yes, we still negotiate contracts, trouble shoot patient registries and implement EHRs, but we also provide in-office care teams and care managers to support the 21st century model of medicine; and we introduce quality initiatives and measure their success. We partner with our members to enhance patient care and its delivery.

Perhaps the first tangible evidence of change in the PO community goes back to 2005, when Blue Cross Blue Shield of Michigan introduced the Physician Group Incentive Program (PGIP). Recognizing the million+ adult and pediatric patient population that Michigan POs represent, PGIP (now called Value Partnerships) has had tremendous success in recent years harnessing the collective power of these organizations to introduce patient-centric primary care initiatives such as the Patient-Centered Medical Home designation, the High-Intensity Care Management program for the frail […]

COMPLIANCE CORNER: Guidance On Leaves Of Absence

The National Practitioner Data Bank has published an article in a recent version of NPDB Insights to help clarify when a hospital privileging action is reportable to the Data Bank. Since a Data Bank report can have significant professional and economic ramifications, it is important for all healthcare providers to understand when a report is required and when one can be avoided.

By way of background, the Data Bank is an alert system that collects and discloses certain adverse information about physicians and other healthcare providers. An adverse report to the Data Bank can significantly impact a health care provider’s reputation and career. State licensing authorities, hospitals and other health care entities, and professional societies search the Data Bank when investigating qualifications. A response that contains an adverse report can act as a permanent blackmark and result in a denial of credentialing, loss or limitation of hospital privileges, loss or limitation of licensure, exclusion from participation in health plans, and increases in premiums or exclusion from professional liability insurance.

NPDB Insights is published by the Data Bank to serve as a forum to provide updated guidance to users on topics such as eligibility, querying and reporting requirements, and the dispute process. The December 2018 […]

LANSING LINES: Lawmakers Push Hospital Staff Ratios

Hospitals would have to hire more nurses to meet staff-to-patient ratios and avoid excessive overtime under a package of bills, known as the Safe Patient Care Act, introduced this in late February in the House and Senate.

The bills would set nurse-staffing levels according to what kind of care they provide. In the intensive care unit (ICU), the ratio would be one-to-one. On a medical-surgical floor, the ratio would be four patients per registered nurse. In post-partum, where baby and mother are fine, the level would be six-to-one, explained sponsor Rep. Jon Hoadley (D-Kalamazoo).

“We think this will encourage hospitals to do what they should be doing, which is to have enough nurses on staff and to be properly prepared for every situation,” said Dawn Kettinger of the Michigan Nurses Association. “A lot of nurses are leaving the profession because of unreasonable workload and unreasonable hours, putting them and their patients in jeopardy.

Until we make a real commitment to proper staffing and keep it at the levels that it should be, we are going to continue to lose nurses out of the profession. It is not just a matter of producing more nurses. It is also a matter of keeping them in the profession.”

Hospital human resources departments […]

Cannabis Advocates Look To End Controlled Substance Tag

A group of Michigan citizens and organizations is suing the Michigan Board of Pharmacy to eliminate marijuana from the Schedule I list of controlled substances.

The state’s Public Health Code, which was enacted in 1978, treats marijuana like opioids and heroin, and that is “unconstitutional under Michigan law,” wrote Michael Komorn, attorney for the residents and organizations in the complaint recently filed in the Court of Claims.

“Even opium, a ‘hard narcotic’ and the root of the opioid epidemic, is a Schedule 5 drug when sold in small concentrations,” he said. “As there is no rational basis to classify marijuana with hard narcotics, it now must be classified below Schedule 5. As no such schedule exists, marijuana must be de-scheduled.”

Komorn, president of the Michigan Medical Marijuana Association, also argued that by passing the Medical Marihuana Facilities Licensing Act (MMFLA), the “Legislature has by implication repealed . . . marijuana’s controlled substance status.”

The MMFLA and Michigan Controlled Substances Act (MCSA), he noted, are “fundamentally inconsistent and incapable of being harmonized.”

The lawsuit also takes aim at Board of Pharmacy’s Chair Nichole Cover, who is named as a defendant, because she oversees both the pharmacy board, which considers marijuana illegal, and is a member of the licensing board, where medical […]

Ads For Short-Term Plans Overwhelm Searches

Consumers shopping for insurance online last fall — using search terms such as “Obamacare plans,” “ACA enroll” and “cheap health insurance” — were most often directed to websites that promote individual health plans that didn’t meet consumer protections of the Affordable Care Act, according to a new study.

They also failed to get adequate information about those plans’ limitations, according to the analysis by researchers at Georgetown University’s Center on Health Insurance Reforms.

The study probed online marketing practices in eight states.
“It was disturbing, but not unexpected, to find such a high proportion of misleading ads and come-ons,” said Sabrina Corlette, the lead author. “That raises the risk that consumers could be duped into buying health insurance that they think offers comprehensive and secure coverage, but does not.”

The study focused primarily on the marketing of short-term plans, which don’t have to meet most ACA provisions, such as the requirement to cover preexisting conditions. The researchers found that regardless of the search term used, companies promoting or selling only these kinds of plans dominated the results.

Insurance regulators from each of the states told Corlette’s team that tracking the marketing and sales of short-term plans is challenging, as is educating consumers about the risks of limited coverage.

Michael […]

On Point With POs: Community Health Navigators

Community Health Navigators, Medical Assistants Gain New Respect—And Billing Codes
It’s not unusual for words and phrases to fall in and out of favor in the healthcare space, but it seems once they are assigned a billing code people start to take notice. Such is the case with “community health navigator.” Frequently used in conjunction with the social determinants of health (SDOH), the role of a community health navigator is rightly taking on significance as the go-to solution finder for the web of challenges that can vex consumers, often in the context of primary care, seeking non-medical answers to their quality of life issues.

Community health navigators are used in a variety of outreach organizations and have operated officially or unofficially throughout the years with an array of titles; yet their foray into primary care practice teams is relatively new. That makes sense though, as understanding of the role of social determinants of health continues to evolve and take root in primary care.

While community health navigators may be degreed social workers, such a specialty is not required. I prefer to think of them as individuals with no one particular professional degree; rather, curious and empathetic fact-finders with deep knowledge of community resources that can be […]

Compliance Corner: Eliminating Kickbacks

Effective Oct. 24, 2018, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) aims to combat the nationwide opioid and other substance abuse crisis by improving treatment and recovery options, increasing education and prevention, safeguarding communities, and fighting deadly synthetic drugs. The SUPPORT Act is a bipartisan, wide-ranging federal law comprised of over 70 individual bills, including the Eliminating Kickbacks in Recovery Act of 2018 (EKRA). EKRA establishes a new all-payor federal anti-kickback law applicable to recovery homes, clinical treatment facilities, and laboratories. While EKRA was intended to prohibit patient brokers who profit from “illicit referrals” of substance abuse patients, EKRA’s broad statutory language implicates common healthcare arrangements structured in compliance with existing federal and state fraud and abuse laws. Accordingly, healthcare providers and other entities and individuals in the healthcare industry must review all arrangements with recovery homes, clinical treatment facilities, and laboratories for compliance with EKRA.

EKRA prohibits knowingly and willfully soliciting, receiving, offering or paying remuneration, directly or indirectly, in return for referring a patient to, or in exchange for an individual using the services of, a recovery home, clinical treatment facility, or laboratory with respect […]