A Place for Death In Health Care

California Healthcare News first published this article on October 10, 2017.

A place for death in health care“Art is the tree of life.  Science is the tree of death.”  — William Blake

When President Obama signed the 2010 Patient Protection and Affordable Care Act into law on March 23, 2010, the word “death” appeared in the 903 pages of Public Law 111-148 a mere fifteen times. However, the concept of death plays an integral role in defining the institution of health care in the United States, often in the form of increased funding from or on behalf of a health care provider to forestall its inevitable arrival. At the same time, health care has an abundance of codified rules and regulations, and hospitals and providers must adhere to a stringent standard of care governing the provider-patient encounter.  Within this equation, death is a total wild card, and the inestimable stress it places upon our health care system remains completely unpredictable.

A Matter of Life and Death

If health care’s primary function is to challenge death, Medicare bears the brunt in this modern age, especially when it comes to crafting the rules that govern care for nearly one out of every five U.S. residents, not to mention the additional 22% of the population who receive benefits under state Medicaid programs. Between federal statutes, federal regulations, administrative decisions and Medicare’s online billing manual, it was likely easier to procure a second coin for a return trip with Charon back across the rivers Styx and Acheron than it is to actually understand the infrastructure within which the United States spent $646 billion for Medicare and $545 billion for Medicaid in 2015, the equivalent of 40% of the national health expenditures for that year. … Read more →

An Unhealthy Congressional Mess0

The Los Angeles Daily Journal first published this articleAn Unhealthy Congressional Mess, on July 27, 2017.

Wooden puppet with a headache
Wooden puppet with a headache

“Genius is finding the invisible link between things.” — Vladimir Nabokov

The scope of medical technology is continually evolving. In 1967, a South African surgeon removed the heart from a twenty-five-year-old female car-accident victim and placed it into the chest of a fifty-five-year-old male dying of heart disease.  The surgery was the first success of its kind, and the patient lived for an additional eighteen days. Ten years later at Columbia-Presbyterian Medical Center in New York City, a heart transplant recipient survived fourteen months after surgery. Seven years after that, Columbia surgeons performed the first successful pediatric heart transplant. Centuries in the making, this particular miracle of modern medicine today boasts 3,500 annual heart transplants world-wide who live an average of fifteen years longer thanks to earlier trials.

The successes of modern medicine are the product of painstaking research, unprecedented and sometimes unavoidable patience, and a bit of good fortune, but the innumerable losses of the past lie in the shadows of each monumental breakthrough. The national infrastructure within which this fantasy becomes reality, however, appears to exist in stark contrast to the very reason behind its purpose.  In many ways, the chaos inherent in the current process by which Congress attempts to alter the course of the Affordable Care Act (“ACA”), exacerbated by any presidential “inspirations” delivered in messages of 140 characters or less, has transformed the stark reality of today’s health care structure into something far more surreal than swapping hearts, at least to those limited few who actually understand the status of the ACA as the Republican controlled Congress attempts to unravel it. … Read more →

The Senator Will See You Now0

California Healthcare News first published this article “The Senator Will See You Now” on July 11, 2017.

The Senator Will See You Now“It occurred to me that my speech or my silence, indeed any action of mine, would be a mere futility.”  — Joseph Conrad

On May 4, 2017, the U.S. House of Representatives passed the American Health Care Act of 2017 (“AHCA”) by a picayune margin of just four votes. Commonly referred to as the most recent legislation designed to “repeal and replace” the 2010 Patient Protection and Affordable Care Act (the “ACA”), the Senatorial counterpart to the ACHA, known as the Better Care Reconciliation Act of 2017 (“BCRA”), today rests in the hands of 52 Republican, 46 Democratic and 2 Independent U.S. Senators, as the nation waits for word on the fate of the ACA and President Obama’s legacy in the spectrum of health care reform.

There should be no cause for alarm when it comes to the hospital institution, enveloped as it is by a veritable blanket of seasoned health care practitioners with access to a formidable armory replete with 21st century medicine that defies science fiction, including cutting-edge technology that may have finally surpassed the elusive tricorder.  As the average life expectancy in the United States hovers on the cusp of 79 years, due in part to the acceptance of mental health parity and near elimination of yellow fever, smallpox, malaria, measles and diphtheria, the nation should be proud of its health care system and supportive of the estimated 23% of the nation’s $7 trillion annual budget it consumes.Read more →

The House that Cried Wolf0

This article “The House that Cried Wolf” first appeared in the Daily Journal on May 10, 2017.

iStock_000009605208Medium“The hardest thing of all is to find a black cat in a dark room, especially if there is no cat.”  – Confucius

An Exercise in Futility?

When it comes to the Patient Protection and Affordable Care Act (the “ACA”), there is one thing on which both proponents and detractors can agree – this curious, far-reaching, highly controversial bill is a survivalist. Fraught with controversy and conflict from its inception, the bill found itself with a target on its back less than one full year after President Obama signed it into law, as the “Repealing the Job-Killing Health Care Law Act,” introduced in January 2011, passed the House of Representatives (the “House”) by a lopsided vote of 245-189. Four months later, a bill to repeal the ACA’s funding for health insurance exchanges passed the House by a similar margin of 55 votes. In 2012, the “Repeal of Obamacare Act” passed the house by a vote of 244-185, followed close behind by a 2013 bill of like-minded intent which passed the House by a vote of 299-195. Still another passed the House in 2015 by a vote of 239-186.  Whether threatened by death from subcommittee or senatorial action, Obamacare nonetheless persevered through these partisan attacks.

Throughout Obama’s tenure, numerous other attempts designed to retard or even sabotage various aspects of the ACA passed the House with flying colors, such as the 2014 bill suspending the Individual Mandate penalty. It was not until 2015, however, that both the House and Senate passed the “Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015,” a bill vetoed by President Obama in early 2016.  Most recently, on May 4, 2017, the House passed the latest attempt to repeal and replace the ACA by a slim margin of four votes (217-213). Fueled by the nation’s enigmatic, 45th President and coming just six months after the Chicago Cubs won their first World series in 108 years, the “American Health Care Act of 2017” (“AHCA”) seems to have everyone’s attention, even if the actual contents of H.R. 1628 remain elusive at best to both experts and laymen alike.Read more →

A Time to Kill HIPAA1

This article “A Time to Kill HIPAA” first appeared in the Daily Journal on May 5, 2017.

iStock_000006020673Large“Sarcasm:  the last refuge of modest and chaste-souled people when the privacy of their soul is coarsely and intrusively invaded.” – Fyodor Mikhailovich Dostoevsky

Imagine a world in which a basic identification card contained a lifetime of medical information, immediately accessible during a routine physical or life-threatening emergency. The technology behind such seeming science fiction could heal a fragmented health care system, affording providers access to critical information in a timely manner to ensure the highest standard of care with maximum efficiency.  Only a few years ago, such inefficiencies inherent at the core of American health care provision resulted in as much as $226 billion in increased spending annually, yet salient health care information remained just out of a provider’s technical reach.

The greatest obstacle standing between American health care and the elusive, omnipotent digital medical record turns 21 this summer, the equivalent of a modern-day Methuselah in an industry defined by zeros and ones. Born the same year Google launched and the price of gasoline was $1.22 per gallon, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) sought to improve portability and continuity of health insurance coverage by, among other things, adopting standards for organizations to develop ways in which electronic health transactions could improve health care while also addressing the security of electronic health information systems. HIPAA’s privacy component debuted in 1999, followed by a series of modifications in 2002, as well as the addition of a security rule in 2003 and an enforcement rule addendum in 2006.  Changes in health care and technology during the first decade of HIPAA ultimately led to the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which specifically focused on the privacy and security concerns associated with electronic transmission of health information by strengthening the civil and criminal enforcement components within HIPAA.

Together, HIPAA and HITECH revolutionized the way health care providers (also known as “covered entities”) and the non-clinical entities with which they teamed (also known as “business associates”) shared and made available for use patient health information (PHI). With such broad definitions of “breach” and the resultant draconian punishments for noncompliance, HITECH sent the act of sharing health care information back in time in many ways, forcing providers to rely upon the United States Post Office to deliver highly personal, often time-sensitive, sometimes life or death information, while improvements were made to the infrastructures within which electronic and facsimile transmissions took place. Purportedly simplified in 2013 through even more regulatory modifications, modern day HIPAA regulation affords practically no room for error for those who utilize technology as a way to improve the delivery of health care in the United States. As it turns out, we have come to learn that health care is more about perseverance than perfection.Read more →

Intricacies of the Modern Health Care Behemoth0

California Healthcare News first published this article, Intricacies of the Modern Health Care Behemoth, on April  4, 2017.

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“For every complex problem there is an answer that is clear, simple and wrong.” – Henry Louis Mencken

Known by some as the 2010 Patient Protection and Affordable Care Act, others by the often sardonic alias “Obamacare,” and most recently highlighted through contentious “repeal and replace” rhetoric, health care reform has reemerged as a hot topic of discussion in households across the country. Those affected by this issue include anyone who (1) is currently sick or has been sick in the past, (2) has a friend or family member that is dealing or has dealt with an illness, or (3) is or knows someone who may one day receive that plastic bracelet bestowing the title of “hospital patient.” Basically, this refers to every American. And yet, so great is the divisiveness on how best to manage health care in the modern age, the Affordable Care Act (ACA) now finds itself in a paralytic state as advocates and critics tangle over the vast complexities at its core. The only commonality is the recognition that there is no simple solution.

Is Health Care Really So Complicated?

Complex by necessity, America’s current health care system may appear elaborate, ridiculous or even labyrinthine in turns, and changing even the smallest fraction involves delving deep into the belly of the beast. For example, Medicare disproportionate share hospital (DSH) adjustment provisions rely upon a statutory formula to calculate DSH patient percentage which is equal to the sum of the percentage of Medicare inpatient days attributable to patients eligible for both Medicare Part A and Supplemental Security Income (SSI), and the percentage of total inpatient days attributable to patients eligible for Medicaid by not Medicare Part A. With this in mind, even the health care layman is quick to realize that, in labeling DSH adjustments (DSH Patient Percent = (Medicare SSI Days / Total Medicare Days) + Medicaid, Non-Medicare Days / Total Patient Days), one is forced to learn the equivalent of a new language. … Read more →

Repealing the Affordable Care Act – What Could Possibly Go Wrong?0

California Healthcare News first published Repealing the Affordable Care Act — What Could Possibly Go Wrong? on January 9, 2017.

Repealing the Affordable Care Act What Could Possibly Go Wrong?“Necessity is not an established fact, but an interpretation.” – Friedrich Nietzsche

Evolution or Devolution?

In a constant state of flux, the American health care system has struggled to exist in the present since the introduction of Medicare in 1965.  Both in terms of medical care and its delivery, our nation’s health care system must continually evolve if it is to keep up with advances in science, technology and the treatment of disease, as well as the way we access these advances. As a result, each generation’s health care must balance providing that which has come to be expected with the need to expand coverage and modern methods of care.  As a nation, we depend upon those in highest office to monitor such changes, adding provisions where applicable and paring down what is no longer practical. Much of the divided nation fears that come January 20, 2017, Barack Obama’s legacy, the Affordable Care Act, may find itself vulnerable to a single stroke of the pen, potentially leaving millions of Americans without meaningful access to medical care. Others will celebrate as Donald John Trump accepts the role of 45th President of the United States. The only immediate certainty for modern American health care is that both sides will continue to argue whether the Affordable Care Act is a frivolous luxury or a social necessity. … Read more →

Supreme Court Decision Adds More Confusion to False Claims Act0

This article, Supreme Court Decision Adds More Confusion to False Claims Act, was first published July 12, 2016 at California Healthcare News.

Wooden puppet with a headache

“The darkest places in hell are reserved for those who maintain their neutrality in times of moral crisis.” — Dante Alighieri

As modern medicine continues its attempts to bridge the gap between body and mind to provide more comprehensive care for patients, so too must the Federal Government address this gray area while endeavoring to regulate care for those less tangible medical issues of the mind.  The already elaborate labyrinth known as the Medicare Act has recently grown even more chaotic under the recent Supreme Court decision Universal Health Services, Inc. v. United States (ex rel. Escobar), which further blurs the line between false and fraudulent claims.

Teenage Medicaid beneficiary Yarushka Rivera sought guidance at Arbour Counseling Services in Lawrence, Massachusetts. The facility diagnosed Rivera as bipolar, although the Arbour “Ph.D.” rendering this opinion failed to disclose that her degree was from an unaccredited Internet-based college, or that Massachusetts had rejected her application for licensure as a psychologist. Twenty-three other Arbour “clinicians” also lacked the purported mental health professional licensures Arbour professed to represent. Not surprisingly, the service’s “prescribing psychiatrist” was in fact a registered nurse who lacked the credentials to do so. Arbour also misrepresented various payment codes, such as “family” or “individual” therapy, and it was discovered to have lied in its attempt to garner National Provider Identification (NPI) numbers for its non-practitioners. Needless to say, Rivera’s mother Carmen Correa and stepfather Julio Escobar were not pleased upon learning of the facility’s transgressions from an Arbour counselor five years into Rivera’s treatment.Read more →

Health Care Is Not One Word Or One Person0

This articleHealth Care Is Not One Word Or One Person, first appeared in the Los Angeles Daily Journal on February 24, 2016.

Health care is not one word or one person

“The truth is rarely pure and never simple.” — Oscar Wilde

With the passing of Justice Antonin Scalia, the Supreme Court has lost a brilliant legal scholar and formidable protector of the U.S. Constitution. Scalia both earned respect and instilled fear during his 30-year tenure supervising America’s political climate. While his legacy ought to take precedence during this time of mourning, widespread panic over the future of health care reform threatens to overshadow the passing of Scalia the individual in favor of highlighting the ways in which his unexpected death may advance partisan agendas.

History has shown that a single justice can have a dramatic effect on the formation and defense of policy. In 1896, Justice John Marshall Harlan disagreed with those Supreme Court justices who believed that the Constitution allowed “equal but separate” public transportation accommodations for black and white citizens. His solitary dissent in Plessy v. Ferguson argued otherwise, stating that the Constitution did not create a “superior, dominant, ruling class of citizens” in the United States, and that the Constitution was itself color-blind. Fifty-eight years later, a unified Supreme Court made history with Brown v. Board of Education of Topeka in holding that “separate but equal” had no place in public education.Read more →

Health Care’s Adventures in Wonderland0

This article by Craig B. Garner[1] and Jessica Weizenbluth[2], Health Care’s Adventures in Wonderland: Provider Agreements for Electronic Records, was first published in February 2016 in California Health Law News.

iStock_000068974059_Large“Now, here, you see, it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!”[3]

I.  INTRODUCTION

Y93.J1: Activity, piano playing[4]

Today’s health care provides its own spin on the word “complex,”[5] while at the same time forging possible paths to what may be “unwinnable” scenarios.[6] For the modern physician[7], the universe within which he or she exists requires updated definitions for words such as “complex” and “challenging,” especially as that “perfect storm”[8] also known as health care reform continues to age. Somewhere in between the 2015 Physician Quality Reporting System (“PQRS”)[9], the Physician Value Based Payment Modifying Policies (“VBP”)[10] and tenth revision of the International Statistical Classification of Diseases and Related Health Problems (also known as ICD-10),[11] physicians find themselves still struggling to adopt electronic health records (“EHR”) in practice.[12]

As technology continues to evolve, there remains a general landscape with which those in the health care field must familiarize themselves. Even from this challenging vantage point, providers still have opportunities to bolster their position and practice their craft as they continue down the digital path and adopt an EHR system for which the Federal Government established incentive payments.[13]Read more →