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Social determinants of health (“SDOH”) consider the non-clinical factors that can profoundly impact an individual’s well-being. They are extensive and often overlap, including housing instability, food insecurity, the inability to afford and obtain medications and more. Research has indicated that healthcare systems that connect patients to basic resources have observed improvements in population health metrics, fostered trust with their patient base, and experienced reduced hospitalization costs.

Continue Reading CMS Augments “In Lieu Of Services” Medicaid Guidance to Support State Medicaid Managed Care Efforts to Address Social Determinants of Health

*This article was originally posted in Law360 on November 4, 2019

With the rise of artificial intelligence and machine learning, clinical decision support, or CDS, software presents a novel opportunity to analyze immensely large amounts of data for patterns or other information that may be relevant to a particular patient’s diagnosis or health care options. Continue Reading Adapting To FDA’s Proposal For Diagnosis Support Software

On May 1, 2019, the Department of Justice (“DOJ”) filed an initial brief (the “Brief”) with the U.S. Court of Appeals for the Fifth Circuit (the “Fifth Circuit”) on behalf of the United States, in favor of upholding the lower court’s decision that found the entire Patient Protection and Affordable Care Act (the “ACA”) unconstitutional.

As we discussed previously in our December 2018 blog post, a federal district court judge in Texas struck down the entire ACA by ruling that the “individual mandate,” which was reduced to $0 as part of the 2017 Tax Cuts and Jobs Act, no longer raises revenue and thus is no longer a constitutional exercise of Congress’s taxing power. The judge went on to determine that the unconstitutional individual mandate was inseverable from the rest of the ACA and therefore, the entire ACA was unconstitutional. The decision was then appealed to the Fifth Circuit. Continue Reading Update to Texas v. United States: DOJ Files a Brief in Support of Eliminating the ACA

In a September 14, 2018 Proclamation, President Donald Trump announced that the week of September 16 through September 22, 2018 would be Prescription Opioid and Heroin Epidemic Awareness Week (“Awareness Week”). As described in the Proclamation, the goal of Awareness Week is to “raise awareness about the prescription opioid and heroin epidemic and to consider concrete follow up activities.” Continue Reading Congress Passes “SUPPORT for Patients and Communities Act” — A Rare Example of Bi-Partisanship

The Texas Medical Association (TMA) and Blue Cross Blue Shield of Texas are launching a new services company, TMA PracticeEdge, to facilitate bringing the benefits of value-based reimbursements to the state’s independent physicians.

Independent practitioners face challenges to participating in (and benefitting from) alternatives to fee-for-service payment, such as having the funds necessary to invest upfront in resources for improved care management. TMA PracticeEdge aims to help providers address the barriers. The company, for example, will offer consultations on basic practice management and administrative simplification, assistance with the implementation of health information technology infrastructure, and experience with risk-based contracts. Additional services will be available for practices interested in creating care teams or developing an Accountable Care Organization.

Continue Reading New Venture Seeks to Support Independent Physicians in Texas

Approximately one-third of Medicaid spending, $136 billion, is on long-term services and supports (LTSS).  While the majority of Medicaid LTSS takes place in institutional settings, such as nursing facilities and mental health facilities, there is an ongoing emphasis on the role of non-institutional facilities. A growing number of states, from 8 in 2004 to 16 in 2012 and an expected 26 through 2014, are adopting a managed care approach to expanding home-and community-based services. This transition is commonly referred to as a “rebalancing” of LTSS systems.

Continue Reading New Approaches – and Increasing Oversight – for Medicaid Managed Long Term Services and Support

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On January 5, 2023, the U.S. Department of Health and Human Services (“HHS”) published a notice of proposed rulemaking entitled “Safeguarding the Rights of Conscience as Protected by Federal Statutes” (the “Proposed Rule“). In this article we provide a brief summary of the Proposed Rule, while also examining the statutory amendments and previous rulemakings that create its foundation.

Continue Reading HHS Issues Proposed Rule to Provide Clarity on Rights of Conscience in Healthcare
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Introduction: Defining Interprofessional Consultation

In a January 5, 2023, letter to state health officials, the Centers for Medicare & Medicaid Services (“CMS”) clarified a Medicaid and Children’s Health Insurance Program (“CHIP”) policy on the coverage and payment of interprofessional consultations (the “Guidance”). An interprofessional consultation occurs when the patient’s treating physician requests the opinion and/or advice from a specialist practitioner without the patient making face-to-face contact with the specialist practitioner. The new CMS guidance clarifies that it is permissible for Medicaid and CHIP to provide reimbursement for an interprofessional consultation when the consultation is for the direct benefit of the patient without the patient’s presence.[1]

Continue Reading CMS Issues Interprofessional Consultation Guidance
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One of the topics I followed with keen interest this week at the J.P. Morgan Healthcare Conference is how our healthcare industry today is addressing the mental health needs of Americans. Like much of the rest of healthcare, it is a mix of exciting innovation, contradictions, siloed approaches and the entrepreneurial Wild West. Pull up your favorite couch or chair, and let’s dive in and take a look together.

Continue Reading Day 4 Notes from the 41st Annual J.P. Morgan Healthcare Conference
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Here’s a new word I heard today that I will awkwardly insert into my next conversation – “transrupt.” It is what happens when you have simultaneous disruption and transformation that both damages the existing system and creates (hopefully) a new and better system. Using it in a sentence: “Amazon transrupted how books are sold.” Or perhaps more apropos to this week – “Someone needs to transrupt the orthopedic/ MSK (musculoskeletal conditions) sector.”

Continue Reading Day 3 Notes from the 41st Annual J.P. Morgan Healthcare Conference