Home2019-01-17T20:58:16-05:00

White House Enlists Doctors and Hospitals To Combat Gun Violence

By SAMANTHA YOUNG

The White House is calling on hospital executives, doctors, and other health care leaders to take bolder steps to prevent gun violence by gathering more data about gunshot injuries and routinely counseling patients about safe use of firearms.

Biden administration officials are hosting back-to-back events Thursday and Friday at the White House for about 160 health care officials, calling gun violence a “public health crisis” that requires them to act.

The strategy also reflects a stark political reality: Congress has been deadlocked on most gun-related legislation for years, with a deep divide between Republicans and Democrats. If Democratic President Joe Biden wants to get anything done quickly, he will need to look outside the Capitol. He has already enlisted educators to talk to parents about safe gun storage and community workers to help at-risk youth.

“The president has been clear: This is a public health crisis. So, to solve it, we need the leaders from the health care sector,” Rob Wilcox, a deputy director of the White House Office of Gun Violence Prevention, told KFF Health News. “Those are the leaders that run the health systems and hospitals that we go to for treatment, and it’s those doctors, nurses, practitioners on the front lines.”

Health experts have long described [Read More]

Hospitals, Pharma At Odds Over Drug Pricing Program

A Rep. Alabas A. Farhat (D-Dearborn) bill prohibiting pharmaceutical manufacturers from denying access to drugs based on participation in a drug pricing program for low-income patients received a first day of testimony in a House committee.

Farhat said the legislation would address skyrocketing prescription drug prices, but pharmaceutical industry stakeholders said they feel the bill, and the “340B” program as a whole, gives an unfair advantage to hospital and chain pharmacies that don’t pass the savings onto their patients.

The 340B Drug Pricing Program is a 32-year-old, federal program to get pharmaceutical manufacturers to discount some of their most expensive prescription drugs, Farhat said, and requires these manufacturers to sell outpatient drugs to organizations that care for uninsured or low-income patients.

The program requires discounts be provided specifically to cancer hospitals, children’s hospitals, hospitals serving a high percentage of Medicaid patients, rural referral centers and sole community hospitals.

There are just under 90 340B hospitals in Michigan now, according to a handout from the Michigan Health and Hospital Association.

Farhat’s HB 5350 would prohibit manufacturers from denying or discriminating against 340B entities purchasing drugs, including those to be dispensed or administered under a contract pharmacy arrangement.

He said during testimony before the House Insurance and Financial Services Committee that the bill will expand [Read More]

ADELMAN’S ANALYSIS: Tricia Keith: A Milestone Too Long In The Making

By SUSAN ADELMAN, MD
Tricia Keith has just been appointed CEO of Blue Cross Blue Shield of Michigan, becoming the first woman to attain that position since 1929, the year the company was first organized. She comes to this position after a career of steadily rising through the ranks of the organization since she joined in 2006. Her last appointment was as Chief Operating Officer and President of the Emerging Markets Division. In 2018, a profile of her in Detroit Business gave her titles as executive vice president, chief of staff, and corporate secretary of Blue Cross Blue Shield of Michigan in Detroit. In these positions, Tricia Keith oversaw 300 employees, a managed care subsidiary called Blue Cross Complete, the Blues Medicare business, and a $110 million budget. In this new position, she oversees 9,000 employees.

Keith is a Michigan native who grew up just outside of Ludington and graduated from Central Michigan University. Her rise to prominence must not have been what her family might have expected of their little girl as they worked the farm that had been in the family for three generations, but times have changed.

Early on, Keith decided that life in agriculture was not for her. When she went off to college, [Read More]

COMPLIANCE CORNER: Reproductive Healthcare Final Rule Ushers in New Requirements for HIPAA Privacy Compliance

JENNI COLAGIOVANNI
Wachler & Associates, P.C.

On April 26, 2024, the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) published a Final Rule introducing modifications to the HIPAA Privacy Rule that limit the use or disclosure of reproductive healthcare information (RHI) for certain non-health care purposes.[1] Titled the “HIPAA Privacy Rule to Support Reproductive Health Care Privacy,” the Final Rule prohibits disclosure of protected health information (PHI) related to lawful reproductive health care under certain circumstances. The Final Rule incorporates several changes for HIPAA-covered entities and business associates including a requirement for entities to obtain an attestation in connection with certain requests for reproductive healthcare information, updates to business associate agreements and HIPAA policies and training, and updates to Notices of Privacy Practices (NPPs).

The Final Rule was issued in response to the changing legal landscape, in particular the U.S. Supreme Court’s 2022 decision in Dobbs v Jackson Women’s Health Organization[2], which overturned the precedent protecting a constitutional right to abortion.  In the wake of Dobbs, the Final Rule describes an increase in the likelihood that an individual’s PHI may be disclosed in ways that cause harm to the interests that HIPAA seek to protect, including the trust [Read More]

LEGAL LEANINGS: Ramping Up: Antitrust Enforcement in Healthcare

By L.PAHL ZINN & PATRICK MASTERSON
Dickinson Wright

It has been a rapid-fire start to 2024 with antitrust enforcers within the Biden administration ramping up regulatory scrutiny across the U.S.—and healthcare is at the center of it.

These efforts started in December 2023 when the Federal Trade Commission (the “FTC” or “Commission”) and Antitrust Division of the Department of Justice (the “DOJ”) released the final 2023 Merger Guidelines, which drastically restructured the framework used to evaluate mergers. Notably, several new guidelines are aimed squarely at healthcare. The new Merger Guidelines significantly lowered thresholds applied to assess whether a merger is presumptively anticompetitive and introduced novel guidelines, including a special interest in “roll-up” acquisitions and unique theories of competitive harm. Soon to follow was the FTC and DOJ embarking on broader enforcement efforts; some of which directly target the healthcare sector. Such trends and developments warrant continued assessment from healthcare organizations and participants.

Enforcement Agencies Show Signs of Increased Scrutiny on Private Equity’s Growing Presence in Healthcare

On February 29, 2024—less than two months after releasing the new Merger guidelines—the FTC, DOJ, and the U.S. Department of Health and Human Services jointly launched a cross-government public inquiry into private equity and other corporations’ increasing control over healthcare. The cross-government inquiry [Read More]

Bird Flu Tests Are Hard To Get. So How Will We Know When To Sound the Pandemic Alarm?

By AMY MAXMEN & ARTHUR ALLEN

Stanford University infectious disease doctor Abraar Karan has seen a lot of patients with runny noses, fevers, and irritated eyes lately. Such symptoms could signal allergies, COVID, or a cold. This year, there’s another suspect, bird flu — but there’s no way for most doctors to know.

If the government doesn’t prepare to ramp up H5N1 bird flu testing, he and other researchers warn, the United States could be caught off guard again by a pandemic.

“We’re making the same mistakes today that we made with COVID,” Deborah Birx, who served as former President Donald Trump’s coronavirus response coordinator, said June 4 on CNN.

To become a pandemic, the H5N1 bird flu virus would need to spread from person to person. The best way to keep tabs on that possibility is by testing people.

Scientifically speaking, many diagnostic laboratories could detect the virus. However, red tape, billing issues, and minimal investment are barriers to quickly ramping up widespread availability of testing. At the moment, the Food and Drug Administration has authorized only the Centers for Disease Control and Prevention’s bird flu test, which is used only for people who work closely with livestock.

State and federal authorities have detected bird flu in dairy cattle in 12 [Read More]

LANSING LINES

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

Whitmer Signs Telemedicine Parity, Asbestos, Teacher Licenses, And Mental Health

Gov. Gretchen Whitmer signed nine bills recently with several directed at insurance and telehealth, along with asbestos abatement, licensing for teachers and children’s mental health intervention policy.

Whitmer signed HB 4579 , HB 4580 , HB 4213 , and HB 4131 , which all add up to requiring health insurance companies, Medicaid and Healthy Michigan to cover telemedicine services at the same rate as going to physically see the doctor.

Republicans said the bills would drive up health care costs, while Reps. Natalie Price (D-Berkley)Felicia Brabec (D-Ann Arbor)Christine Morse (D-Kalamazoo), and Tullio Liberati, JR. (D-Allen Park) said they make sure that everyone has access to health care services.

“The pandemic exposed accessibility concerns in our health care system. With more providers now offering telehealth options, it only makes sense to keep the reimbursement rates the same for telehealth appointments and in-person visits,” Brabec said.

Two of the bills, HB 4186 and HB 4188 , were part of the package that would heighten standards set for the removal of asbestos.

Reps. Donavan McKinney (D-Detroit) and Abraham Aiyash (D-Hamtramck) said the safety legislation surrounding asbestos was a win for the environment and communities.

“Asbestos is a killer; there [Read More]

Medicaid Reimbursements Get Big Lift In Senate Budget

The Senate wants more than $194.9 million in Medicaid reimbursement rate increases in next year’s budget, based on a Fiscal Year (FY) 2025 spending bill that moved out of subcommittee late last month.

The plan also boosts Michigan’s health and human services spending by more than $1.97 billion.

“Uplifting the Medicaid reimbursement payments was a top priority in this budget cycle,” said Sen. Sylvia Santana (D-Detroit), chair of the Senate Department of Health and Human Services Appropriations Subcommittee. “We looked at the top five billing codes in the state, and allocated values accordingly. That was a priority for me.”

Under the $37.7 billion DHHS budget in SB 767, $54.66 million ($14.5 million from the General Fund) went to raise rates for outpatient facilities that accept Medicaid and Medicare patients. In 2021, according to a July 2023 study by Health Management Associates (HMA), the average total cost per visit to these facilities was $267.74 while payment rates were $171.55.

Other reimbursement rate increases will go toward autism applied behavioral analysts, boosting available reimbursements to up to $70 per hour.

Also receiving higher Medicaid reimbursement rates are office visits, some dental care, certain anesthesia services, private duty nursing and speech therapy services.

For new patient visits, including 30-minute visits where there’s a low [Read More]

Biden Team’s Tightrope: Reining In Rogue Obamacare Agents Without Slowing Enrollment

By JULIE APPLEBY

President Joe Biden counts among his accomplishments the record-high number of people, more than 21 million, who enrolled in Obamacare plans this year. Behind the scenes, however, federal regulators are contending with a problem that affects people’s coverage: rogue brokers who have signed people up for Affordable Care Act plans, or switched them into new ones, without their permission.

Fighting the problem presents tension for the administration: how to thwart the bad actors without affecting ACA sign-ups.

Complaints about these unauthorized changes — which can cause affected policyholders to lose access to medical care, pay higher deductibles, or even incur surprise tax bills — rose sharply in recent months, according to brokers who contacted KFF Health News and federal workers who asked not to be identified.

Ronnell Nolan, president and CEO of the trade association Health Agents for America, said her group has suggested to the Centers for Medicare & Medicaid Services that it add two-factor authentication to healthcare.gov or send text alerts to consumers if an agent tries to access their accounts. But the agency told her it doesn’t always have up-to-date contact information.

“We’ve given them a whole host of ideas,” she said. “They say, ‘Be careful what you wish for.’ But we don’t mind going an [Read More]

ADELMAN’S ANALYSIS: Stuck in a Time Warp

By SUSAN ADELMAN, MD
When I entered the medical profession 50 years ago, those were the good old days for doctors. Physicians enjoyed a windfall when Medicare and Medicaid were passed, then the appearance of new pharmaceuticals and surgical techniques enabled doctors to cure more conditions, which meant they had more lucrative business. Once regarded as poor, now doctors had the image of fat cats, rich targets to be taken down.

In 1993 the Clinton Healthcare Reform Task Force was in full throttle, and I had the dubious privilege of representing the AMA on a Healthcare Professionals Review Committee—not part of the Task Force, an afterthought.  The committee was created after I asked the AMA about joining the Task Force, and the AMA Executive mentioned at a Washington conference that the AMA did not have representation on it. Newspapers across the country gleefully heehawed that the AMA had not been invited. The rest is history.

Members of this committee included doctors, nurses, social workers, physician assistants, pharmacists, a healthcare administrator, and other professionals involved with healthcare. Neither name nor place tags indicated who practiced what profession, certainly not who was a doctor.  No such elitism would contaminate this group!

In those days the AMA Council on Medical Service, on [Read More]

COMPLIANCE CORNER: Small Medicare Audits Put Your Billing Privileges at Risk

By KAITLYN DELBENE
Wachler & Associates, PC

The authority to revoke the Medicare billing privileges of enrolled providers is one of many program integrity tools used by the Centers for Medicare & Medicaid Services (“CMS”) to curb fraud, waste, and abuse in the federal healthcare programs. While CMS has generally stated that its revocation authority is intended to protect the Medicare program and its beneficiaries from overt abuse, ongoing expansions to the grounds for revocation have swept many well-intentioned providers into CMS’s crosshairs. Increasingly, relatively very small audit findings, e.g., amounting to $5,000 or less in alleged overpayments, if left un-appealed by the provider, are leading CMS contractors to pursue disproportionately severe revocation actions based on alleged abuse of billing privileges. Providers faced with audit findings should be cognizant of CMS’s revocation authority and should make it a standard practice to seriously engage in the appeals process when faced with audit findings by CMS or its contractors.

CMS Expands Revocation Authority for Abuse of Billing Privileges under Section (a)(8)(ii)

CMS’s revocation authority is set forth at 42 CFR § 424.535, pursuant to which CMS may revoke a currently enrolled provider’s Medicare billing privileges and any corresponding provider agreement (or supplier agreement) for any of a list of ever-expanding [Read More]

LEGAL LEANINGS: Practice Buy-Sell Agreements: Drafters Beware

By RALPH Z. LEVY, JR.
Dickinson Wright

My prior article addressed tax issues in repurchasing equity in physicians and other practice groups. This article provides information about drafting buy-sell agreements for practice entities that include provisions for repurchasing equity from owners. These agreements limit an owner’s ability to transfer equity and require its sale if employment terminates or the owner retires, becomes disabled, or dies. Buy-sell agreements also help the practice entity comply with state law requirements that only active practicing professionals can own equity in the entity.

Topic 1:  Structuring the buy-sell agreement

Since buy-sell agreements require its owners to transfer equity in the practice group upon termination of employment, death, disability, or retirement (each, a “Trigger Event”), the practice group should identify its desired purchaser if a Trigger Event takes place. If the entity is the purchaser, the agreement will be a redemption agreement; if the other practice owners are the purchasers upon a Trigger Event, a cross-purchase agreement should be used. Regardless of which type of agreement is used, the agreement should specify how the purchase price for the equity is determined (fixed, formula value, etc.).

If the entity has many owners, it will be simpler to use a redemption buy-sell agreement and for the practice [Read More]

LANSING LINES: Cannabis Redo Could Open Up Michigan Industry

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

Cannabis Redo Could Open Up Michigan Industry

U.S. Attorney General Merrick Garland put forth a proposal to reclassify cannabis from a schedule I drug, along with heroin, to a schedule III drug, with some codeine combinations, which could change some rules in the Michigan industry.

Department of Justice Director of Public Affairs Xochitil Hinojosa said the proposal would need to be published by the federal register, which would then initiate the formal rule-making process. The Drug Enforcement Administration and DOJ had no further comment about a timeframe for the process or how long it could take.

Cannabis Regulatory Agency Director Brian Hanna said rescheduling would make research easier and make it easier for consumers to access.

He said businesses would also have access to more banking and the tax burden would be reduced.

“We will continue to monitor the situation and look forward to our part to keep Michigan as a national leader in the cannabis industry,” Hanna said.

Michigan Cannabis Industry Association Executive Director Robin Schneider said the rule promulgation process could take three years or longer and the Michigan industry would be participating in that process.

“This is likely one of the most overdue polices that [Read More]

LETTER: Second Amendment Rights And Gun Violence As A Public Health Issue

NOTE: The letter below appears partly in response to a story that appeared in the April 2024 edition of Healthcare Michigan.

EDITOR:

Any discussion of gun issues should begin with the reasons for and wisdom of the Second Amendment. The founders were quite clear on the rationale for this, so much so, that it was memorialized in the Constitution itself. Also rarely mentioned is the violence and even deaths prevented by armed law-abiding citizens.

Long lists of statistical data in a debate so immersed in political rhetoric, demagoguery and ideology should not be accepted as the final word. COVID has taught us that there are now two phrases that should evoke skepticism. They are “studies show” and “experts say.” That experts cannot solve the problem leads to several questions. Is it that they cannot or are unwilling or even apprehensive about stating objective truth because of the predictable political consequences? Perhaps they are looking at the wrong problem altogether.

One can wonder why scrutiny of our own U.S. culture and social factors might not provide objective easily observable insights even to those of us labeled as non-experts. The rule of law has moved from “equal and blind justice” to a politicized and ideologically progressive system that can hardly, if [Read More]

What to Know About the Roiling Debate Over U.S. Maternal Mortality Rates

This story was originally published by ProPublica.

By ROBIN FIELDS
A new study challenged the accuracy of public health data on deaths related to pregnancy and childbirth — and the narrative of high and rising U.S. maternal mortality rates. An unusual public dispute has ensued.

Series: Lost Mothers: Maternal Care and Preventable Deaths

The U.S. has the highest rate of deaths related to pregnancy and childbirth in the developed world. Half of the deaths are preventable, victimizing women from a variety of races, backgrounds, educations and income levels.

An unusual public dispute has erupted among leading maternal health experts over whether the striking rise of U.S. maternal mortality rates over the past two decades was the real deal — or a statistical mirage.

The challenge to what has been a long-held view among public health officials came from researchers behind a new study published in the American Journal of Obstetrics & Gynecology.

The study concluded that maternal death rates put out by the Centers for Disease Control and Prevention have been substantially inflated by misclassified data. Using an alternate way of counting deaths related to pregnancy and childbirth, the study found, U.S. maternal mortality rates would be far lower than have been reported. And they’d be stable, not rising.

The pushback followed soon after.

The [Read More]

Why Even Public Health Experts Have Limited Insight Into Stopping Gun Violence in America

By CHRISTINE SPOLAR

Gun violence has exploded across the U.S. in recent years — from mass shootings at concerts and supermarkets to school fights settled with a bullet after the last bell.

Nearly every day of 2024 so far has brought more violence. On Feb. 14, gunfire broke out at the Super Bowl parade in Kansas City, killing one woman and injuring 22 others. Most events draw little attention — while the injuries and toll pile up.

Gun violence is among America’s most deadly and costly public health crises. But unlike other big killers — diseases like cancer and HIV or dangers like automobile crashes and cigarettes — sparse federal money goes to studying gun violence or preventing it.

That’s because of a one-sentence amendment tucked into the 1996 congressional budget bill: “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

Its author was Jay Dickey, an Arkansas Republican who called himself the “point man” for the National Rifle Association on Capitol Hill. And for nearly 25 years the amendment was perceived as a threat and all but paralyzed the CDC’s support and study of gun violence.

Even so, a small group of [Read More]

ADELMAN’S ANALYSIS: Does DEI Deliver ROI?

By SUSAN ADELMAN, MD
When I was a surgery resident at Henry Ford Hospital, we greeted each patient on morning rounds in the same way. Good morning, Mr. Jones. Good morning, Mrs. Smith. How are you today? Or something like that. At least it was courteous and respectful. It did not matter if Mr. Jones was black or white, poor or rich. On our rounds, and in discussion of patients, staff doctors modeled color-blind treatment of their patients when they trained the residents. They even would call a child Mr. Jones, out of habit, then laugh, realizing it sounded silly. And Diversity, Equity, Inclusion training (DEI) had not been invented yet.

We learned at the bedside exactly what our parents had taught us. “Do unto others as you would have them do unto you.”  This comes from the Bible: the Golden Rule.

We knew that some medical conditions were commoner in certain ethnic groups. That is part of medicine. Children have children’s diseases. Older people have geriatric conditions. Those with some black heritage have a higher risk of sickle cell anemia, thalassemia, or prostate cancer.  The government Office of Minority Health elaborates that they also are more prone to “heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, [Read More]

COMPLIANCE CORNER: Providers Face Ongoing Challenges From The Provider Relief Fund

By DANIEL AYYASH & SHEA MACE
Wachler & Associates, P.C.

Overview

In response to the enormous economic challenges faced by healthcare providers during the COVID-19 public health emergency (PHE), the Coronavirus Aid, Relief, and Economic Security (CARES) Act established the Provider Relief Fund (PRF) in an effort to provide financial support to providers across the nation. Congress allocated $178 billion to the PRF program, which was then disbursed to providers in multiple phases through general and targeted distributions. The Health Resources & Services Administration (HRSA), a subagency of the Department of Health and Human Services (HHS), was tasked with administering PRF disbursements and overseeing compliance with the program’s terms and conditions.

The primary compliance requirements attached to PRF distributions mandated that the funds only be used to prevent, prepare for, and respond to COVID-19, and that providers submit reports to HRSA regarding use of the funds. The reporting requirements, including the timeline for reporting, changed multiple times throughout the years following the program’s inception, creating significant confusion amongst providers.

Furthermore, while HRSA stated that providers who received PRF funds were required to accept a corresponding set of terms and conditions, all providers who retained those funds for longer than 90 days without contacting HHS or returning the funds were [Read More]

LEGAL LEANINGS: Look Before You Leap – Early Determination Of Product Classification And Regulatory Pathway For FDA-Regulated Products

By BILLEE LIGHTVOET WARD, ESQ.
Dickinson Wright

The Food and Drug Administration (FDA) regulates foods and beverages, drugs and medical devices, biologics, dietary supplements, tobacco products, veterinary products, and cosmetics. Although these various product categories may appear to be clearly cut, the fact of the matter is that a product can very easily cross over from one product category to a different one as a result of issues such as in intended use, composition, labeling content or other claims, or other such issues that may seem to be inconsequential. At the earliest possible stage of product development, it is important to evaluate the identity of the product based on these and other factors, and to anticipate the manner in which the product will be marketed and advertised including, most significantly, the claims that will be made in relation to the product and its capabilities.

Product Classification. There are specific statutory definitions that ultimately dictate the categorization of a given FDA-regulated product. Consulting the applicable definitions and evaluating the specifics of a given product under applicable laws and FDA guidance documents is a technical and fact-specific exercise. Portions of the “drug” and “medical device” definitions help to illustrate how easily the lines can be crossed and result in [Read More]

LANSING LINES

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

DHHS Budget Asks: From Detroit Project To Chromotherapy Glasses

During the only House committee hearing over the two weeks of legislative spring break, Rep. Christine Morse (D-Kalamazoo)’s Appropriations subcommittee on Health and Human Services heard funding requests for everything from a new Detroit affordable housing and childcare campus to chromotherapy glasses.

Morse held the hearing to take public comment, which she said would be used to influence the budget-crafting process.

Among the requests heard was a $2.498 million ask to break ground on a combined housing and childcare project in downtown Detroit through MiSide, a Detroit-based nonprofit providing families with access to behavioral healthcare, employment, housing and childcare services.

Laura LeBlanc, executive director of philanthropy and external affairs with MiSide, said the nonprofit provides services to 25,000 people across Wayne County, and is looking to expand services in the Cody Rouge neighborhood of Detroit through a “healthy village initiative.”

LeBlanc said the first-of-its-kind program in metro Detroit will offer a combination of housing and childcare to a “community in desperate need,” using a freshly constructed two-tier campus.

“On the main level, it will offer 90 children access to child care, and then on the second floor we will [Read More]

Michigan Lawmaker Introduces Bill Requiring State Health Plans to Cover Cutting-Edge Cancer Treatments

This story was originally published by ProPublica.

By ROBIN FIELDS & MAYA MILLER
Spurred by a ProPublica story about an insurer that denied coverage of the only therapy that could have saved the life of a 50-year-old father of two, a Michigan lawmaker a bill early this month requiring health plans in the state to cover cutting-edge cancer treatments.

In February 2020, Forrest VanPatten died fighting Priority Health, one of Michigan’s largest health insurers, over its refusal to pay for CAR-T cell therapy, his last-chance treatment. The therapy works by genetically reengineering patients’ own cells, then infusing them back into the body to beat back their disease.

Michigan has long required insurers to cover proven cancer treatments, but according to internal emails, some Priority Health executives argued that CAR-T was a gene therapy, not a drug, and thus not subject to the state’s coverage mandate.

State Sen. Jeff Irwin, D-Ann Arbor, plans to file the new bill to make explicit that Michigan’s cancer treatment coverage mandate includes a new generation of genetic and immunotherapies, including CAR-T.

Earlier this year, Michigan’s top insurance regulator told health plans they had to cover these treatments. Irwin’s measure would codify that guidance, ensuring it’s not dependent on one regulator’s interpretation of the law. He said [Read More]

ADELMAN’S ANALYSIS: The High Cost  of Consolidation

By SUSAN ADELMAN, MD
On Oct. 19, 2023, the Free Press announced that Henry Ford Health and Ascension Michigan would form a joint venture. This will join Ascension’s Southeast Michigan hospitals with the Ascension Genesys Hospital in Grand Blanc and the Henry Ford hospitals, creating a system with more than 550 sites of care.  Among the eight Ascension hospitals are two Providence Hospitals, St. John Hospital, two Macomb Oakland Hospitals, River District Hospital, and the Brighton Center for Recovery. Joining them will be five Henry Ford hospitals and Health Alliance Plan. This all must pass antitrust review, but I cannot recall any of the mergers in Michigan failing to get approval.

Remember, the Beaumont Health and Spectrum Health systems merged in 2022 to form what is now Corewell Health. This included Beaumont Hospital Royal Oak, Oakwood Hospital (Beaumont Hospital Dearborn), and the Beaumont hospitals in Grosse Pointe, Farmington Hills, Troy, Big Rapids, Blodgett, Butterworth, the Helen DeVos Children’s Hospital, plus 17 more hospitals in western Michigan.

Meanwhile, Trinity Health of Livonia, which itself was a merger of the Holy Cross and Mercy hospitals, has joined several other Catholic institutions to form MercyOne, which now operates 420 medical facilities, largely in Iowa but also beyond. And the eight hospitals [Read More]

Watershed Moment As Community Health Workers Make It To Prime Time

By EWA MATUSZEWSKI
I believe we witnessed a breakthrough in getting the role of the community health worker (CHW) into the vernacular of common healthcare terms. That’s because I saw a news story about CHWs on local television – not a healthcare special or a “news hour” but standard local news programming. Thank you, Henry Ford Cancer Institute, for sharing with WDIV (the local NBC affiliate in Detroit,) how your mobilization of healthcare workers in the hospital setting is putting patients and their families at ease by helping navigate some of the non-clinical aspects of illness, hospital stays and care coordination.

The timing of the local news piece couldn’t have been better as our nonprofit learning organization, Practice Transformation Institute (PTI), was celebrating the gradation of two cohort classes of CHWs the week the feature aired. We showed the clip at the graduation ceremonies as an example of how the need for community health workers was not only growing but gaining attention beyond the healthcare and public health environment.

I do hope I haven’t turned off readers with my many columns referencing CHWs. But it’s a message that bears repeating. And that’s ultimately how ideas including medical messaging stick: clinical, academic, community, word-of-mouth, media. The emergence of CHWs [Read More]

COVID-Related Service Audits Create Problems For Primary Care Providers and Labs

By JENNIFER COLAGIOVANNI
Wachler & Associates, P.C.

Nearly four years after the COVID-19 pandemic began, healthcare providers continue to see payor audits and demands for repayment of services provided during the pandemic, primarily related to COVID-19 testing and lab services, as well as for evaluation and management (E/M) office and telehealth visits. Despite the fact that these services served a critical public health function during the pandemic, constantly changing and often unclear guidelines governing coverage and documentation of these services have created fertile ground for payors to allege after-the-fact that providers were not entitled to payment.

The audit issues asserted by payors tend to relate to the process used by the provider rather than issues related to any unique characteristics of a specific claim. Therefore, these allegations often lead to demands that the provider pay back a significant portion of reimbursements for the COVID-19 services they provided over a particular time period, often in the range of hundreds of thousands or even millions of dollars.

Audits of COVID-19 services have centered around several common issues:

E/M Visits:  E/M services were provided to assess symptomatic patients and those with known exposures, all against the backdrop of changing public health guidance and fluctuating positivity rates in local communities.  Depending on the practice [Read More]

Providers Face Government Scrutiny Over COVID Coverage For Uninsured

By ANDREW L. SPARKS
Dickinson Wright

The Families First Coronavirus Response Act (FFCRA) was enacted in March 2020 as part of the government’s response to the COVID-19 pandemic. The FFCRA, among other things, provided funds for diagnostic testing and services for people without insurance for COVID-19. These funds were distributed through the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (HRSA uninsured program). Providers seeking reimbursement under the HRSA uninsured program were required to enroll as a provider participant and check to ensure that patients were uninsured.

The HRSA uninsured program paid out more than $24.5 billion in claims. With the passage of the Fiscal Responsibility Act of 2023 and the related rescission of program funds, no further payments will be provided. However, given the significant expenditure of funds, government investigations and enforcement actions of the HRSA uninsured program are likely to continue for the foreseeable future.

The Standards for Determining HRSA Uninsured Status

HRSA requires that providers verify and attest that, to the best of the provider’s knowledge, the patient was uninsured at the time of the claim submission. For claims related to COVID testing, treatment of positive cases, and/or vaccine administration, this means the patient did not [Read More]

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