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AAD members vote to remove board member
Members of the American Academy of Dermatology have voted to remove a board member for launching an organization that offered board certification to physician assistants (PAs).
Of 6,467 votes cast, , which met the two-thirds threshold required for board removal. The vote follows a unanimous decision by the AAD/A board to present AAD members with a resolution to dismiss Dr. Dinehart for his involvement with the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists. Dr. Dinehart’s association with the group violated his fiduciary duties to the AAD/A and represented a conflict of interest, according to the AAD/A board.
In an interview with Dermatology News, Dr. Dinehart said it was an honor and privilege to serve on the board, and that he was disappointed by those who chose to rescind his election. Most people who study the issue will realize the recent events were precipitated by a turf battle between dermatologists and dermatology PAs, he added.
“I want to emphasize my record of service to dermatology not only in Arkansas but also across the United States and internationally,” Dr. Dinehart said in the interview. “I have always been committed to doing what is best for patients and our specialty and will continue to do so. In addition to providing direct patient care, I am a tireless educator, willing to teach all health professionals whether they are medical students, physician assistants, residents, family doctors, or other physician specialists. I appreciate the opportunity I have had to serve you and look forward to continuing to express my vision for excellence in dermatology as I move forward in my career.”
In a statement to members, AAD/A Secretary Treasurer Marta Van Beek, MD, said the issue has been a difficult matter for the AAD/A to address, but that the voting results clearly represent the will of members.
“I want to thank the members for their thoughtful participation in the process and their continued engagement with the AAD/A as we return our focus to the important work that we are undertaking on behalf of our specialty and our patients,” Dr. Van Beek, professor of dermatology, University of Iowa, Iowa City, said in the statement.
The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 31, the petition had collected 4,200 signatures.
AAD President George J. Hruza, MD, said that Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA LLC was in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an American Board of Medical Specialties or American Osteopathic Association medical board. The for-profit venture would enable PAs to advertise themselves as board certified, Dr. Hruza said in a previous interview with Dermatology News. He added that the group was “set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist.
In a letter to AAD members, Dr. Dinehart however, said the ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of PAs in dermatology. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology,” according to Dr. Dinehart. He called the removal vote a drastic measure and contended that his actions did not justify dismissal from the AAD/A board.
After learning of the board’s concerns, Dr. Dinehart discontinued his relationship with the ABDPA and ended its operations.
Members voted on Dr. Dinehart’s position from Oct. 21 to Oct. 29. The seat vacated by the recall election will be filled through the AAD/A’s annual election, which opens Saturday, March 21, 2020, according to the AAD/A. The successful candidate will be selected to start their term immediately and fill the vacated seat until the close of the 2022 AAD/A Annual Meeting.
Members of the American Academy of Dermatology have voted to remove a board member for launching an organization that offered board certification to physician assistants (PAs).
Of 6,467 votes cast, , which met the two-thirds threshold required for board removal. The vote follows a unanimous decision by the AAD/A board to present AAD members with a resolution to dismiss Dr. Dinehart for his involvement with the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists. Dr. Dinehart’s association with the group violated his fiduciary duties to the AAD/A and represented a conflict of interest, according to the AAD/A board.
In an interview with Dermatology News, Dr. Dinehart said it was an honor and privilege to serve on the board, and that he was disappointed by those who chose to rescind his election. Most people who study the issue will realize the recent events were precipitated by a turf battle between dermatologists and dermatology PAs, he added.
“I want to emphasize my record of service to dermatology not only in Arkansas but also across the United States and internationally,” Dr. Dinehart said in the interview. “I have always been committed to doing what is best for patients and our specialty and will continue to do so. In addition to providing direct patient care, I am a tireless educator, willing to teach all health professionals whether they are medical students, physician assistants, residents, family doctors, or other physician specialists. I appreciate the opportunity I have had to serve you and look forward to continuing to express my vision for excellence in dermatology as I move forward in my career.”
In a statement to members, AAD/A Secretary Treasurer Marta Van Beek, MD, said the issue has been a difficult matter for the AAD/A to address, but that the voting results clearly represent the will of members.
“I want to thank the members for their thoughtful participation in the process and their continued engagement with the AAD/A as we return our focus to the important work that we are undertaking on behalf of our specialty and our patients,” Dr. Van Beek, professor of dermatology, University of Iowa, Iowa City, said in the statement.
The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 31, the petition had collected 4,200 signatures.
AAD President George J. Hruza, MD, said that Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA LLC was in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an American Board of Medical Specialties or American Osteopathic Association medical board. The for-profit venture would enable PAs to advertise themselves as board certified, Dr. Hruza said in a previous interview with Dermatology News. He added that the group was “set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist.
In a letter to AAD members, Dr. Dinehart however, said the ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of PAs in dermatology. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology,” according to Dr. Dinehart. He called the removal vote a drastic measure and contended that his actions did not justify dismissal from the AAD/A board.
After learning of the board’s concerns, Dr. Dinehart discontinued his relationship with the ABDPA and ended its operations.
Members voted on Dr. Dinehart’s position from Oct. 21 to Oct. 29. The seat vacated by the recall election will be filled through the AAD/A’s annual election, which opens Saturday, March 21, 2020, according to the AAD/A. The successful candidate will be selected to start their term immediately and fill the vacated seat until the close of the 2022 AAD/A Annual Meeting.
Members of the American Academy of Dermatology have voted to remove a board member for launching an organization that offered board certification to physician assistants (PAs).
Of 6,467 votes cast, , which met the two-thirds threshold required for board removal. The vote follows a unanimous decision by the AAD/A board to present AAD members with a resolution to dismiss Dr. Dinehart for his involvement with the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists. Dr. Dinehart’s association with the group violated his fiduciary duties to the AAD/A and represented a conflict of interest, according to the AAD/A board.
In an interview with Dermatology News, Dr. Dinehart said it was an honor and privilege to serve on the board, and that he was disappointed by those who chose to rescind his election. Most people who study the issue will realize the recent events were precipitated by a turf battle between dermatologists and dermatology PAs, he added.
“I want to emphasize my record of service to dermatology not only in Arkansas but also across the United States and internationally,” Dr. Dinehart said in the interview. “I have always been committed to doing what is best for patients and our specialty and will continue to do so. In addition to providing direct patient care, I am a tireless educator, willing to teach all health professionals whether they are medical students, physician assistants, residents, family doctors, or other physician specialists. I appreciate the opportunity I have had to serve you and look forward to continuing to express my vision for excellence in dermatology as I move forward in my career.”
In a statement to members, AAD/A Secretary Treasurer Marta Van Beek, MD, said the issue has been a difficult matter for the AAD/A to address, but that the voting results clearly represent the will of members.
“I want to thank the members for their thoughtful participation in the process and their continued engagement with the AAD/A as we return our focus to the important work that we are undertaking on behalf of our specialty and our patients,” Dr. Van Beek, professor of dermatology, University of Iowa, Iowa City, said in the statement.
The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 31, the petition had collected 4,200 signatures.
AAD President George J. Hruza, MD, said that Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA LLC was in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an American Board of Medical Specialties or American Osteopathic Association medical board. The for-profit venture would enable PAs to advertise themselves as board certified, Dr. Hruza said in a previous interview with Dermatology News. He added that the group was “set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist.
In a letter to AAD members, Dr. Dinehart however, said the ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of PAs in dermatology. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology,” according to Dr. Dinehart. He called the removal vote a drastic measure and contended that his actions did not justify dismissal from the AAD/A board.
After learning of the board’s concerns, Dr. Dinehart discontinued his relationship with the ABDPA and ended its operations.
Members voted on Dr. Dinehart’s position from Oct. 21 to Oct. 29. The seat vacated by the recall election will be filled through the AAD/A’s annual election, which opens Saturday, March 21, 2020, according to the AAD/A. The successful candidate will be selected to start their term immediately and fill the vacated seat until the close of the 2022 AAD/A Annual Meeting.
Judge blocks Alabama abortion ban
A federal judge has temporarily barred Alabama’s near total abortion ban from taking effect.
In an Oct. 29 decision, Myron H. Thompson, District Court Judge for the Middle District of Alabama, North Division, wrote . Judge Thompson halted the measure, which was scheduled to take effect on Nov. 15, while the lawsuit continues through the courts.
“As stated previously, banning abortion before viability violates Supreme Court precedent,” Judge Thompson wrote in the opinion. “No alleged state interest can overcome this clear mandate. Thus, as a ban on pre-viability abortion, the act contravenes established law.”
Alabama Gov. Kay Ivey (R) signed the “Human Life Protection Act” into law on May 15. The measure bans abortion at every pregnancy stage and penalizes physicians with a Class A felony for performing an abortion and charges them with a Class C felony for attempting to perform an abortion. The law includes an exception if a woman’s life is at risk, but not for cases of rape or incest.
The federal court’s decision affirms that women have a right to access safe, legal abortion, Alexis McGill Johnson, president and CEO of Planned Parenthood Federation of America said in a statement. Planned Parenthood Federation of America, The American Civil Liberties Union, and the ACLU of Alabama are representing the plaintiffs in the lawsuit, which include Alabama physicians and patients.
“Politicians in Alabama, and across the country, are putting people’s health and lives at risk in their attempts to ban abortion outright in this country,” Ms. Johnson said in the statement. “Today’s victory means people can still access the health care they need across Alabama – for now. We will continue to fight to ensure that everyone can access health care – including safe, legal abortion.”
Alabama Attorney General Steve Marshall said the district court’s decision to temporarily halt the law was not unexpected.
“As we have stated before, the state’s objective is to advance our case to the U.S. Supreme Court where we intend to submit evidence that supports our argument that Roe and Casey were wrongly decided and that the Constitution does not prohibit states from protecting unborn children from abortion,” Mr. Marshall said in a statement.
The Alabama decision comes just weeks after the U.S. Supreme Court agreed to hear an abortion-related challenge out of Louisiana. June Medical Services v. Gee centers on the constitutionality of a Louisiana law that requires any doctor performing an abortion to have admitting privileges at a nearby hospital. The high court likely will hear that case in early 2020.
A federal judge has temporarily barred Alabama’s near total abortion ban from taking effect.
In an Oct. 29 decision, Myron H. Thompson, District Court Judge for the Middle District of Alabama, North Division, wrote . Judge Thompson halted the measure, which was scheduled to take effect on Nov. 15, while the lawsuit continues through the courts.
“As stated previously, banning abortion before viability violates Supreme Court precedent,” Judge Thompson wrote in the opinion. “No alleged state interest can overcome this clear mandate. Thus, as a ban on pre-viability abortion, the act contravenes established law.”
Alabama Gov. Kay Ivey (R) signed the “Human Life Protection Act” into law on May 15. The measure bans abortion at every pregnancy stage and penalizes physicians with a Class A felony for performing an abortion and charges them with a Class C felony for attempting to perform an abortion. The law includes an exception if a woman’s life is at risk, but not for cases of rape or incest.
The federal court’s decision affirms that women have a right to access safe, legal abortion, Alexis McGill Johnson, president and CEO of Planned Parenthood Federation of America said in a statement. Planned Parenthood Federation of America, The American Civil Liberties Union, and the ACLU of Alabama are representing the plaintiffs in the lawsuit, which include Alabama physicians and patients.
“Politicians in Alabama, and across the country, are putting people’s health and lives at risk in their attempts to ban abortion outright in this country,” Ms. Johnson said in the statement. “Today’s victory means people can still access the health care they need across Alabama – for now. We will continue to fight to ensure that everyone can access health care – including safe, legal abortion.”
Alabama Attorney General Steve Marshall said the district court’s decision to temporarily halt the law was not unexpected.
“As we have stated before, the state’s objective is to advance our case to the U.S. Supreme Court where we intend to submit evidence that supports our argument that Roe and Casey were wrongly decided and that the Constitution does not prohibit states from protecting unborn children from abortion,” Mr. Marshall said in a statement.
The Alabama decision comes just weeks after the U.S. Supreme Court agreed to hear an abortion-related challenge out of Louisiana. June Medical Services v. Gee centers on the constitutionality of a Louisiana law that requires any doctor performing an abortion to have admitting privileges at a nearby hospital. The high court likely will hear that case in early 2020.
A federal judge has temporarily barred Alabama’s near total abortion ban from taking effect.
In an Oct. 29 decision, Myron H. Thompson, District Court Judge for the Middle District of Alabama, North Division, wrote . Judge Thompson halted the measure, which was scheduled to take effect on Nov. 15, while the lawsuit continues through the courts.
“As stated previously, banning abortion before viability violates Supreme Court precedent,” Judge Thompson wrote in the opinion. “No alleged state interest can overcome this clear mandate. Thus, as a ban on pre-viability abortion, the act contravenes established law.”
Alabama Gov. Kay Ivey (R) signed the “Human Life Protection Act” into law on May 15. The measure bans abortion at every pregnancy stage and penalizes physicians with a Class A felony for performing an abortion and charges them with a Class C felony for attempting to perform an abortion. The law includes an exception if a woman’s life is at risk, but not for cases of rape or incest.
The federal court’s decision affirms that women have a right to access safe, legal abortion, Alexis McGill Johnson, president and CEO of Planned Parenthood Federation of America said in a statement. Planned Parenthood Federation of America, The American Civil Liberties Union, and the ACLU of Alabama are representing the plaintiffs in the lawsuit, which include Alabama physicians and patients.
“Politicians in Alabama, and across the country, are putting people’s health and lives at risk in their attempts to ban abortion outright in this country,” Ms. Johnson said in the statement. “Today’s victory means people can still access the health care they need across Alabama – for now. We will continue to fight to ensure that everyone can access health care – including safe, legal abortion.”
Alabama Attorney General Steve Marshall said the district court’s decision to temporarily halt the law was not unexpected.
“As we have stated before, the state’s objective is to advance our case to the U.S. Supreme Court where we intend to submit evidence that supports our argument that Roe and Casey were wrongly decided and that the Constitution does not prohibit states from protecting unborn children from abortion,” Mr. Marshall said in a statement.
The Alabama decision comes just weeks after the U.S. Supreme Court agreed to hear an abortion-related challenge out of Louisiana. June Medical Services v. Gee centers on the constitutionality of a Louisiana law that requires any doctor performing an abortion to have admitting privileges at a nearby hospital. The high court likely will hear that case in early 2020.
Dermatologist who organized PA group faces backlash
Whether a board member for the American Academy of Dermatology and the AAD Association (AAD/A) violated his fiduciary duties by launching an organization that offered board certification to physician assistants (PAs) will soon be decided by AAD members.
In mid-October, AAD President George J. Hruza, MD, said Dr. Dinehart violated his duties when he became sole organizer of the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists, according to a message from Dr. Hruza to members. The use of the words “American Board of Dermatology” in the ABDPA name created confusion to patients and threatened to undermine the value of ABD certification held by AAD/A fellows, Dr. Hruza said.
“Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA, LLC., is in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an ABMS/AOA [American Board of Medical Specialties or American Osteopathic Association] medical board, such as the American Board of Dermatology,” Dr. Hruza said in an interview with Dermatology News. “This for-profit venture would enable physician assistants to advertise themselves as board certified. The [AAD/A] board in its unanimous decision deemed that the new ABDPA was set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist. This is contrary to the AAD/A’s position on this matter. As such, Dr. Dinehart’s involvement in forming and organizing the ABDPA violated his fiduciary duty to act in the best interests of the AAD/A and to abide by AAD/A policies.”
In a letter to AAD members, Dr. Dinehart called the removal vote a “drastic measure” and said he has done nothing to justify dismissal from the AAD/A board. The ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of physician assistants in dermatology, Dr. Dinehart wrote. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology.”
After learning of the board’s concerns, Dr. Dinehart said he discontinued his relationship with the ABDPA and ensured its operations had ended out of respect for the academy. He believes the matter could have been handled much differently.
“I did not violate any bylaws,” Dr. Dinehart said in an interview with Dermatology News. “While I understand that there are certain members of the AAD that personally oppose the growing use of physician assistants in dermatology practices, it is a common practice among many AAD members, and it is not contrary to or detrimental to any of the purposes of the AAD.”
Dr. Dinehart contends he did not run afoul of the AAD/A’s position statement on Truth in Advertising and Professional Credential Disclosure because the statement pertains to AAD/A members and prohibits members from advertising board certifications by nonapproved boards. He emphasized that PAs are not members and said he would never represent or advertise a physician assistant as having a certification equivalent to a board-certified dermatologist or being capable of equivalent credentials.
In addition, he said his involvement with the new organization did not conflict with the AAD’s Practice of Dermatology: Protecting and Preserving Patient Safety and Quality Care position statement, which opposes the independent or unsupervised practice of dermatology procedures by nonphysicians.
“Neither the ADBPA nor the certification it intended to offer would have allowed physician assistants to engage in the independent or unsupervised practice of specific dermatology procedures, and any physician assistant who did so would be subject to the same repercussions that currently exist,” Dr. Dinehart said in the interview.
The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 24, the petition had collected 2,496 signatures.
Monica Madray, MD, a dermatologist based in Georgetown, Tex., who signed the petition, said the ABDPA further muddied the waters in an already confusing world of “providers” and non–dermatology boarded physicians practicing and advertising themselves as dermatologists.
“Patients truly don’t know the difference in training between physicians and midlevels, and by ‘board certifying’ PAs in dermatology, it gets much more confusing,” Dr. Madray said in an interview. “I also think there was a huge financial conflict of interest for Dr. Dinehart to start and run this board as he oversees many midlevels. Frankly, it didn’t pass the sniff test.”
Vivian Bucay, MD, a dermatologist based in San Antonio who signed the petition, said that, if Dr. Dinehart was interested in starting an organization such as the ABDPA, he should have first presented the idea to the AAD/A board and asked for feedback.
“This came [to light] after a press release,” Dr. Bucay said in an interview. “I don’t have an issue with trying to improve and set the bar for what dermatology physician assistants should do. It’s the manner in which it was gone about. In this day and age, we have to disclose any potential conflicts of interest. If we all have to do that as members of the American Society of Dermatologic Surgery or members of the AAD when presenting for continuing medical education, then why would there not be the same standard for a board member to disclose a conflict of interest?”
Dr. Dinehart for his part said the board never gave him an opportunity to respond to its accusations or share his side of the story before initiating the removal vote.
“The board should not have been pressured by a vocal minority of the membership, rushed to judgment, and expedited a special removal vote less than 2 weeks after the board claims it first became aware of the formation of ABDPA,” he said in the interview. “The board should have ... evaluated the alleged conflict and provided me a reasonable opportunity to cure the alleged conflict as provided by the AAD/A’s conflict of interest rules. Had the board allowed me that opportunity, as required, this whole situation could have been resolved.”
Dr. Hruza, however, said the board’s actions came after reviewing evidence with Dr. Dinehart in private, which allowed him to make a statement and provided him a chance to answer questions from the board. He was also afforded several opportunities to resign, which he declined, Dr. Hruza said in the interview.
“I regret that we have been put in this difficult position and that the question must be put to the membership for a painful vote,” Dr. Hruza said. “The academy has a lot of important work to do to advocate for our members and our patients. This issue has been an unfortunate distraction from that important work.”
Daniel M. Siegel, MD, a New York–based dermatologist and former AAD president, said in an interview with Dermatology News that he plans to vote to keep Dr. Dinehart on the board. Dr. Dinehart has been a dedicated advocate for the specialty for more than 30 years and his recent misstep does not rise to the level of board removal, Dr. Siegel said. A social media environment that easily enables people to get fired up about almost any subject and quickly stoke anger in others contributed to overreaction of the situation, he added.
“In retrospect, it was not in the best interests of the AAD, but it was nothing criminal,” Dr. Siegel said in the interview. “He had a business idea, it got a lot negative feedback, and he did the right thing about it. Taking such an aggressive punitive approach for a transgression that was fairly minor is a bad precedent to set.”
Voting on Dr. Dinehart’s position opened on Oct. 21 and will close on Oct. 29. A removal decision requires a two-thirds vote by at least 10% of the voting membership.
Whether a board member for the American Academy of Dermatology and the AAD Association (AAD/A) violated his fiduciary duties by launching an organization that offered board certification to physician assistants (PAs) will soon be decided by AAD members.
In mid-October, AAD President George J. Hruza, MD, said Dr. Dinehart violated his duties when he became sole organizer of the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists, according to a message from Dr. Hruza to members. The use of the words “American Board of Dermatology” in the ABDPA name created confusion to patients and threatened to undermine the value of ABD certification held by AAD/A fellows, Dr. Hruza said.
“Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA, LLC., is in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an ABMS/AOA [American Board of Medical Specialties or American Osteopathic Association] medical board, such as the American Board of Dermatology,” Dr. Hruza said in an interview with Dermatology News. “This for-profit venture would enable physician assistants to advertise themselves as board certified. The [AAD/A] board in its unanimous decision deemed that the new ABDPA was set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist. This is contrary to the AAD/A’s position on this matter. As such, Dr. Dinehart’s involvement in forming and organizing the ABDPA violated his fiduciary duty to act in the best interests of the AAD/A and to abide by AAD/A policies.”
In a letter to AAD members, Dr. Dinehart called the removal vote a “drastic measure” and said he has done nothing to justify dismissal from the AAD/A board. The ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of physician assistants in dermatology, Dr. Dinehart wrote. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology.”
After learning of the board’s concerns, Dr. Dinehart said he discontinued his relationship with the ABDPA and ensured its operations had ended out of respect for the academy. He believes the matter could have been handled much differently.
“I did not violate any bylaws,” Dr. Dinehart said in an interview with Dermatology News. “While I understand that there are certain members of the AAD that personally oppose the growing use of physician assistants in dermatology practices, it is a common practice among many AAD members, and it is not contrary to or detrimental to any of the purposes of the AAD.”
Dr. Dinehart contends he did not run afoul of the AAD/A’s position statement on Truth in Advertising and Professional Credential Disclosure because the statement pertains to AAD/A members and prohibits members from advertising board certifications by nonapproved boards. He emphasized that PAs are not members and said he would never represent or advertise a physician assistant as having a certification equivalent to a board-certified dermatologist or being capable of equivalent credentials.
In addition, he said his involvement with the new organization did not conflict with the AAD’s Practice of Dermatology: Protecting and Preserving Patient Safety and Quality Care position statement, which opposes the independent or unsupervised practice of dermatology procedures by nonphysicians.
“Neither the ADBPA nor the certification it intended to offer would have allowed physician assistants to engage in the independent or unsupervised practice of specific dermatology procedures, and any physician assistant who did so would be subject to the same repercussions that currently exist,” Dr. Dinehart said in the interview.
The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 24, the petition had collected 2,496 signatures.
Monica Madray, MD, a dermatologist based in Georgetown, Tex., who signed the petition, said the ABDPA further muddied the waters in an already confusing world of “providers” and non–dermatology boarded physicians practicing and advertising themselves as dermatologists.
“Patients truly don’t know the difference in training between physicians and midlevels, and by ‘board certifying’ PAs in dermatology, it gets much more confusing,” Dr. Madray said in an interview. “I also think there was a huge financial conflict of interest for Dr. Dinehart to start and run this board as he oversees many midlevels. Frankly, it didn’t pass the sniff test.”
Vivian Bucay, MD, a dermatologist based in San Antonio who signed the petition, said that, if Dr. Dinehart was interested in starting an organization such as the ABDPA, he should have first presented the idea to the AAD/A board and asked for feedback.
“This came [to light] after a press release,” Dr. Bucay said in an interview. “I don’t have an issue with trying to improve and set the bar for what dermatology physician assistants should do. It’s the manner in which it was gone about. In this day and age, we have to disclose any potential conflicts of interest. If we all have to do that as members of the American Society of Dermatologic Surgery or members of the AAD when presenting for continuing medical education, then why would there not be the same standard for a board member to disclose a conflict of interest?”
Dr. Dinehart for his part said the board never gave him an opportunity to respond to its accusations or share his side of the story before initiating the removal vote.
“The board should not have been pressured by a vocal minority of the membership, rushed to judgment, and expedited a special removal vote less than 2 weeks after the board claims it first became aware of the formation of ABDPA,” he said in the interview. “The board should have ... evaluated the alleged conflict and provided me a reasonable opportunity to cure the alleged conflict as provided by the AAD/A’s conflict of interest rules. Had the board allowed me that opportunity, as required, this whole situation could have been resolved.”
Dr. Hruza, however, said the board’s actions came after reviewing evidence with Dr. Dinehart in private, which allowed him to make a statement and provided him a chance to answer questions from the board. He was also afforded several opportunities to resign, which he declined, Dr. Hruza said in the interview.
“I regret that we have been put in this difficult position and that the question must be put to the membership for a painful vote,” Dr. Hruza said. “The academy has a lot of important work to do to advocate for our members and our patients. This issue has been an unfortunate distraction from that important work.”
Daniel M. Siegel, MD, a New York–based dermatologist and former AAD president, said in an interview with Dermatology News that he plans to vote to keep Dr. Dinehart on the board. Dr. Dinehart has been a dedicated advocate for the specialty for more than 30 years and his recent misstep does not rise to the level of board removal, Dr. Siegel said. A social media environment that easily enables people to get fired up about almost any subject and quickly stoke anger in others contributed to overreaction of the situation, he added.
“In retrospect, it was not in the best interests of the AAD, but it was nothing criminal,” Dr. Siegel said in the interview. “He had a business idea, it got a lot negative feedback, and he did the right thing about it. Taking such an aggressive punitive approach for a transgression that was fairly minor is a bad precedent to set.”
Voting on Dr. Dinehart’s position opened on Oct. 21 and will close on Oct. 29. A removal decision requires a two-thirds vote by at least 10% of the voting membership.
Whether a board member for the American Academy of Dermatology and the AAD Association (AAD/A) violated his fiduciary duties by launching an organization that offered board certification to physician assistants (PAs) will soon be decided by AAD members.
In mid-October, AAD President George J. Hruza, MD, said Dr. Dinehart violated his duties when he became sole organizer of the American Board of Dermatology Physician Assistants (ABDPA), an organization that planned to offer board certification to PAs who work with dermatologists, according to a message from Dr. Hruza to members. The use of the words “American Board of Dermatology” in the ABDPA name created confusion to patients and threatened to undermine the value of ABD certification held by AAD/A fellows, Dr. Hruza said.
“Dr. Dinehart’s action to incorporate and organize the for-profit entity ABDPA, LLC., is in direct contradiction to the AAD’s Truth in Advertising and Professional Disclosure policy that states that practitioners should not advertise that they are board certified unless they are certified by an ABMS/AOA [American Board of Medical Specialties or American Osteopathic Association] medical board, such as the American Board of Dermatology,” Dr. Hruza said in an interview with Dermatology News. “This for-profit venture would enable physician assistants to advertise themselves as board certified. The [AAD/A] board in its unanimous decision deemed that the new ABDPA was set up to potentially mislead patients into thinking that physician assistants with this certification would have training and experience equivalent to an ABD-certified dermatologist. This is contrary to the AAD/A’s position on this matter. As such, Dr. Dinehart’s involvement in forming and organizing the ABDPA violated his fiduciary duty to act in the best interests of the AAD/A and to abide by AAD/A policies.”
In a letter to AAD members, Dr. Dinehart called the removal vote a “drastic measure” and said he has done nothing to justify dismissal from the AAD/A board. The ABDPA was intended to improve patient care by establishing certain educational, training, and professional standards for the growing number of physician assistants in dermatology, Dr. Dinehart wrote. That mission was not in conflict with AAD’s values, but rather, the ABDPA would have furthered AAD’s purpose “to promote the highest standards in allied health professionals and services as they relate to dermatology.”
After learning of the board’s concerns, Dr. Dinehart said he discontinued his relationship with the ABDPA and ensured its operations had ended out of respect for the academy. He believes the matter could have been handled much differently.
“I did not violate any bylaws,” Dr. Dinehart said in an interview with Dermatology News. “While I understand that there are certain members of the AAD that personally oppose the growing use of physician assistants in dermatology practices, it is a common practice among many AAD members, and it is not contrary to or detrimental to any of the purposes of the AAD.”
Dr. Dinehart contends he did not run afoul of the AAD/A’s position statement on Truth in Advertising and Professional Credential Disclosure because the statement pertains to AAD/A members and prohibits members from advertising board certifications by nonapproved boards. He emphasized that PAs are not members and said he would never represent or advertise a physician assistant as having a certification equivalent to a board-certified dermatologist or being capable of equivalent credentials.
In addition, he said his involvement with the new organization did not conflict with the AAD’s Practice of Dermatology: Protecting and Preserving Patient Safety and Quality Care position statement, which opposes the independent or unsupervised practice of dermatology procedures by nonphysicians.
“Neither the ADBPA nor the certification it intended to offer would have allowed physician assistants to engage in the independent or unsupervised practice of specific dermatology procedures, and any physician assistant who did so would be subject to the same repercussions that currently exist,” Dr. Dinehart said in the interview.
The ABDPA was formed legally at the end of September and announced its official launch on Oct. 7. The new organization immediately drew criticism from dermatologists and triggered an online petition that denounced the group and called for Dr Dinehart’s removal from the AAD/A board. The petition, started by an anonymous dermatologist, states Dr. Dinehart’s concurrent relationships with the AAD and the ABDPA represent a major conflict of interest. As of Oct. 24, the petition had collected 2,496 signatures.
Monica Madray, MD, a dermatologist based in Georgetown, Tex., who signed the petition, said the ABDPA further muddied the waters in an already confusing world of “providers” and non–dermatology boarded physicians practicing and advertising themselves as dermatologists.
“Patients truly don’t know the difference in training between physicians and midlevels, and by ‘board certifying’ PAs in dermatology, it gets much more confusing,” Dr. Madray said in an interview. “I also think there was a huge financial conflict of interest for Dr. Dinehart to start and run this board as he oversees many midlevels. Frankly, it didn’t pass the sniff test.”
Vivian Bucay, MD, a dermatologist based in San Antonio who signed the petition, said that, if Dr. Dinehart was interested in starting an organization such as the ABDPA, he should have first presented the idea to the AAD/A board and asked for feedback.
“This came [to light] after a press release,” Dr. Bucay said in an interview. “I don’t have an issue with trying to improve and set the bar for what dermatology physician assistants should do. It’s the manner in which it was gone about. In this day and age, we have to disclose any potential conflicts of interest. If we all have to do that as members of the American Society of Dermatologic Surgery or members of the AAD when presenting for continuing medical education, then why would there not be the same standard for a board member to disclose a conflict of interest?”
Dr. Dinehart for his part said the board never gave him an opportunity to respond to its accusations or share his side of the story before initiating the removal vote.
“The board should not have been pressured by a vocal minority of the membership, rushed to judgment, and expedited a special removal vote less than 2 weeks after the board claims it first became aware of the formation of ABDPA,” he said in the interview. “The board should have ... evaluated the alleged conflict and provided me a reasonable opportunity to cure the alleged conflict as provided by the AAD/A’s conflict of interest rules. Had the board allowed me that opportunity, as required, this whole situation could have been resolved.”
Dr. Hruza, however, said the board’s actions came after reviewing evidence with Dr. Dinehart in private, which allowed him to make a statement and provided him a chance to answer questions from the board. He was also afforded several opportunities to resign, which he declined, Dr. Hruza said in the interview.
“I regret that we have been put in this difficult position and that the question must be put to the membership for a painful vote,” Dr. Hruza said. “The academy has a lot of important work to do to advocate for our members and our patients. This issue has been an unfortunate distraction from that important work.”
Daniel M. Siegel, MD, a New York–based dermatologist and former AAD president, said in an interview with Dermatology News that he plans to vote to keep Dr. Dinehart on the board. Dr. Dinehart has been a dedicated advocate for the specialty for more than 30 years and his recent misstep does not rise to the level of board removal, Dr. Siegel said. A social media environment that easily enables people to get fired up about almost any subject and quickly stoke anger in others contributed to overreaction of the situation, he added.
“In retrospect, it was not in the best interests of the AAD, but it was nothing criminal,” Dr. Siegel said in the interview. “He had a business idea, it got a lot negative feedback, and he did the right thing about it. Taking such an aggressive punitive approach for a transgression that was fairly minor is a bad precedent to set.”
Voting on Dr. Dinehart’s position opened on Oct. 21 and will close on Oct. 29. A removal decision requires a two-thirds vote by at least 10% of the voting membership.
Court of Appeals to decide fate of Medicaid work requirements
The debate over whether states can impose work requirements on Medicaid recipients is now in the hands of a federal appeals court.
The U.S. Court of Appeals for the District of Columbia heard oral arguments Oct. 11, 2019, in two cases that challenge state waivers that require work as part of Medicaid eligibility.
In Stewart v. Azar, 16 patients from Kentucky are suing the Department of Health & Human Services over its approval of changes to Kentucky’s Medicaid program that include work requirements, premiums, and lockouts. In Gresham v. Azar, several Arkansas residents are challenging HHS over the approval of modifications to Arkansas’ Medicaid program that require work requirements and eliminate retroactive coverage.
The restrictive conditions in the Medicaid waivers would cause thousands of Medicaid enrollees to lose coverage, according to Jane Perkins, legal director for the National Health Law Program, an advocacy firm representing the plaintiffs.
“Section 1115 of the Social Security Act only allows the [HHS] Secretary to approve experimental projects that further Medicaid’s purpose of furnishing medical assistance to low-income people,” Ms. Perkins said in a statement. “These waiver projects do not further this objective. By the government’s own framing, they are intended to transform Medicaid and explode Medicaid expansion. Only Congress can rewrite a statute – not this administration. We hope the appellate court will uphold the well-reasoned opinions of the district court.”
HHS argues that it has the authority to allow any experimental, pilot, or demonstration project likely to promote the objectives of Medicaid, which in addition to medical assistance include rehabilitation services that help patients attain or retain independence or self-care. The waivers from Kentucky and Arkansas are consistent with these objectives, attorneys for HHS argued in court documents.
Kentucky’s waiver project promotes beneficiary health and financial independence, while Arkansas’ demonstration is likely to assist in improving health outcomes through strategies that promote community engagement and address health determinants, according to letters from the Centers for Medicare & Medicaid Service approving the projects.
Arkansas’ demonstration project, approved in March 2018, includes a requirement that adults aged 19-49 years complete 80 hours per month of community engagement activities, such as employment, education, job-skills training, or community service, as a condition of continued Medicaid eligibility. Kentucky’s proposal, approved in November 2018, requires Medicaid patients to spend at least 80 hours per month on qualified activities, including employment, job skills training, education, community services and/or participation in substance use disorder treatment.
Medicaid patients in both states sued HHS shortly after the waivers were approved, arguing that the work requirements were arbitrary and capricious and that the agency exceeded its statutory authority in approving the projects. The U.S. District Court for the District of Columbia ruled in favor of the patients in March 2019, finding that HHS failed to fully consider the impact of the Kentucky and Arkansas changes on current and future Medicaid beneficiaries. In a decision for Kentucky and a separate ruling for Arkansas, the court vacated HHS’ approval of the projects and remanded both waivers back to HHS for reconsideration. In the interim, officials in both Kentucky and Arkansas halted implementation of the work requirements. The Department of Justice appealed in both cases.
According to court documents, 18,000 Arkansans lost coverage for failure to comply with the work requirements before the regulations were halted. In Kentucky, the state estimates that 95,000 Kentuckians could lose coverage if the project goes into effect.
A decision by the appeals court is expected by December 2019.
The debate over whether states can impose work requirements on Medicaid recipients is now in the hands of a federal appeals court.
The U.S. Court of Appeals for the District of Columbia heard oral arguments Oct. 11, 2019, in two cases that challenge state waivers that require work as part of Medicaid eligibility.
In Stewart v. Azar, 16 patients from Kentucky are suing the Department of Health & Human Services over its approval of changes to Kentucky’s Medicaid program that include work requirements, premiums, and lockouts. In Gresham v. Azar, several Arkansas residents are challenging HHS over the approval of modifications to Arkansas’ Medicaid program that require work requirements and eliminate retroactive coverage.
The restrictive conditions in the Medicaid waivers would cause thousands of Medicaid enrollees to lose coverage, according to Jane Perkins, legal director for the National Health Law Program, an advocacy firm representing the plaintiffs.
“Section 1115 of the Social Security Act only allows the [HHS] Secretary to approve experimental projects that further Medicaid’s purpose of furnishing medical assistance to low-income people,” Ms. Perkins said in a statement. “These waiver projects do not further this objective. By the government’s own framing, they are intended to transform Medicaid and explode Medicaid expansion. Only Congress can rewrite a statute – not this administration. We hope the appellate court will uphold the well-reasoned opinions of the district court.”
HHS argues that it has the authority to allow any experimental, pilot, or demonstration project likely to promote the objectives of Medicaid, which in addition to medical assistance include rehabilitation services that help patients attain or retain independence or self-care. The waivers from Kentucky and Arkansas are consistent with these objectives, attorneys for HHS argued in court documents.
Kentucky’s waiver project promotes beneficiary health and financial independence, while Arkansas’ demonstration is likely to assist in improving health outcomes through strategies that promote community engagement and address health determinants, according to letters from the Centers for Medicare & Medicaid Service approving the projects.
Arkansas’ demonstration project, approved in March 2018, includes a requirement that adults aged 19-49 years complete 80 hours per month of community engagement activities, such as employment, education, job-skills training, or community service, as a condition of continued Medicaid eligibility. Kentucky’s proposal, approved in November 2018, requires Medicaid patients to spend at least 80 hours per month on qualified activities, including employment, job skills training, education, community services and/or participation in substance use disorder treatment.
Medicaid patients in both states sued HHS shortly after the waivers were approved, arguing that the work requirements were arbitrary and capricious and that the agency exceeded its statutory authority in approving the projects. The U.S. District Court for the District of Columbia ruled in favor of the patients in March 2019, finding that HHS failed to fully consider the impact of the Kentucky and Arkansas changes on current and future Medicaid beneficiaries. In a decision for Kentucky and a separate ruling for Arkansas, the court vacated HHS’ approval of the projects and remanded both waivers back to HHS for reconsideration. In the interim, officials in both Kentucky and Arkansas halted implementation of the work requirements. The Department of Justice appealed in both cases.
According to court documents, 18,000 Arkansans lost coverage for failure to comply with the work requirements before the regulations were halted. In Kentucky, the state estimates that 95,000 Kentuckians could lose coverage if the project goes into effect.
A decision by the appeals court is expected by December 2019.
The debate over whether states can impose work requirements on Medicaid recipients is now in the hands of a federal appeals court.
The U.S. Court of Appeals for the District of Columbia heard oral arguments Oct. 11, 2019, in two cases that challenge state waivers that require work as part of Medicaid eligibility.
In Stewart v. Azar, 16 patients from Kentucky are suing the Department of Health & Human Services over its approval of changes to Kentucky’s Medicaid program that include work requirements, premiums, and lockouts. In Gresham v. Azar, several Arkansas residents are challenging HHS over the approval of modifications to Arkansas’ Medicaid program that require work requirements and eliminate retroactive coverage.
The restrictive conditions in the Medicaid waivers would cause thousands of Medicaid enrollees to lose coverage, according to Jane Perkins, legal director for the National Health Law Program, an advocacy firm representing the plaintiffs.
“Section 1115 of the Social Security Act only allows the [HHS] Secretary to approve experimental projects that further Medicaid’s purpose of furnishing medical assistance to low-income people,” Ms. Perkins said in a statement. “These waiver projects do not further this objective. By the government’s own framing, they are intended to transform Medicaid and explode Medicaid expansion. Only Congress can rewrite a statute – not this administration. We hope the appellate court will uphold the well-reasoned opinions of the district court.”
HHS argues that it has the authority to allow any experimental, pilot, or demonstration project likely to promote the objectives of Medicaid, which in addition to medical assistance include rehabilitation services that help patients attain or retain independence or self-care. The waivers from Kentucky and Arkansas are consistent with these objectives, attorneys for HHS argued in court documents.
Kentucky’s waiver project promotes beneficiary health and financial independence, while Arkansas’ demonstration is likely to assist in improving health outcomes through strategies that promote community engagement and address health determinants, according to letters from the Centers for Medicare & Medicaid Service approving the projects.
Arkansas’ demonstration project, approved in March 2018, includes a requirement that adults aged 19-49 years complete 80 hours per month of community engagement activities, such as employment, education, job-skills training, or community service, as a condition of continued Medicaid eligibility. Kentucky’s proposal, approved in November 2018, requires Medicaid patients to spend at least 80 hours per month on qualified activities, including employment, job skills training, education, community services and/or participation in substance use disorder treatment.
Medicaid patients in both states sued HHS shortly after the waivers were approved, arguing that the work requirements were arbitrary and capricious and that the agency exceeded its statutory authority in approving the projects. The U.S. District Court for the District of Columbia ruled in favor of the patients in March 2019, finding that HHS failed to fully consider the impact of the Kentucky and Arkansas changes on current and future Medicaid beneficiaries. In a decision for Kentucky and a separate ruling for Arkansas, the court vacated HHS’ approval of the projects and remanded both waivers back to HHS for reconsideration. In the interim, officials in both Kentucky and Arkansas halted implementation of the work requirements. The Department of Justice appealed in both cases.
According to court documents, 18,000 Arkansans lost coverage for failure to comply with the work requirements before the regulations were halted. In Kentucky, the state estimates that 95,000 Kentuckians could lose coverage if the project goes into effect.
A decision by the appeals court is expected by December 2019.
Changes to public charge rule blocked by courts
In three separate decisions, the U.S. District Court for the Southern District of New York, the U.S. District Court for the Northern District of California, and the U.S. District Court for the Eastern District of Washington temporarily barred the administration’s changes to the public charge rule from moving forward. The judges said lawsuits challenging the rule are likely to prevail in court.
The injunctions are much needed to protect patients and families, said R. Shawn Martin, senior vice president of advocacy, practice advancement, and policy for the American Academy of Family Physicians.
“The court decisions are important,” Mr. Martin said in an interview. “The AAFP believes that the public charge rule, as proposed by the administration, would have an immediate and negative impact on the health of thousands of people, including children. There is evidence that policies such as this create a culture where patients forgo interactions with the health care system out of fear. We should never be a country that compromises the health and well-being of individuals, especially those that are most vulnerable.”
White House Press Secretary Stephanie Grisham called the court rulings extremely disappointing and said the recent changes to the public charge rule restore integrity to the immigration system.
“The rulings today prevent our nation’s immigration officers from ensuring that immigrants seeking entry to the United States will be self-sufficient and instead allow noncitizens to continue taking advantage of our generous but limited public resources reserved for vulnerable Americans,” Ms. Graham said in a statement. “These injunctions are the latest inexplicable example of the administration being ordered to comply with the flawed or lawless guidance of a previous administration instead of the actual laws passed by Congress.”
Under the longstanding public charge rule, officials can refuse to admit immigrants into the United States – or to adjust their legal status – if they are deemed likely to become a public charge. Previously, immigration officers considered cash aid, such as Temporary Assistance for Needy Families or long-term institutionalized care, as potential public charge reasons for denial.
The revised regulation, which was scheduled to take effect on Oct. 15, 2019, would allow officials to consider previously excluded programs in their determination, including nonemergency Medicaid for nonpregnant adults, the Supplemental Nutrition Assistance Program, and several housing programs. The revised regulation would continue to allow immigrants to access emergency medical care and disaster relief without public charge repercussions.
Eight legal challenges were immediately filed against the rule changes, including a complaint issued in Washington state by 14 states. On Oct. 11, Judge Rosanna Malouf Peterson, U.S. district judge for the Eastern District of Washington, issued a nationwide ban of the revised public charge regulation, ruling that the plaintiff states will suffer irreparable harm if the rule moves forward.
“The plaintiff states have shown a significant threat of irreparable injury as a result of the impending enactment of the public charge rule by numerous individuals disenrolling from benefits for which they or their relatives were qualified, out of fear or confusion, that accepting those noncash public benefits will deprive them of an opportunity for legal permanent residency,” Judge Peterson wrote in her decision. “The plaintiff states have further demonstrated how that chilling effect predictably would cause irreparable injury by creating long-term costs to the plaintiff states from providing ongoing triage for residents who have missed opportunities for timely diagnoses, vaccinations, or building a strong foundation in childhood that will allow U.S. citizen children and future U.S. citizens to flourish and contribute to their communities as taxpaying adults.”
Judge Phyllis J. Hamilton, U.S. district judge for the Northern District of California, ruled similarly on Oct. 11, as did George Benjamin Daniels of the U.S. District Court for the Southern District of New York.
Physician associations previously voiced opposition to the administration’s changes to the public charge rule. In a joint statement, the AAFP, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, the American College of Physicians, and the American Psychiatric Association expressed concern that the new regulation will discourage immigrants from seeking needed health care since such assistance may be used to deny green cards and visas, or even lead to deportations.
“Rather than face that threat, impacted patients currently served by our members almost certainly will avoid needed care from their trusted physicians, jeopardizing their own health and that of their communities,” the medical societies stated. “Many of our members have already witnessed this chilling effect among their own patient populations, with patients avoiding health services and programs out of fear.”
In three separate decisions, the U.S. District Court for the Southern District of New York, the U.S. District Court for the Northern District of California, and the U.S. District Court for the Eastern District of Washington temporarily barred the administration’s changes to the public charge rule from moving forward. The judges said lawsuits challenging the rule are likely to prevail in court.
The injunctions are much needed to protect patients and families, said R. Shawn Martin, senior vice president of advocacy, practice advancement, and policy for the American Academy of Family Physicians.
“The court decisions are important,” Mr. Martin said in an interview. “The AAFP believes that the public charge rule, as proposed by the administration, would have an immediate and negative impact on the health of thousands of people, including children. There is evidence that policies such as this create a culture where patients forgo interactions with the health care system out of fear. We should never be a country that compromises the health and well-being of individuals, especially those that are most vulnerable.”
White House Press Secretary Stephanie Grisham called the court rulings extremely disappointing and said the recent changes to the public charge rule restore integrity to the immigration system.
“The rulings today prevent our nation’s immigration officers from ensuring that immigrants seeking entry to the United States will be self-sufficient and instead allow noncitizens to continue taking advantage of our generous but limited public resources reserved for vulnerable Americans,” Ms. Graham said in a statement. “These injunctions are the latest inexplicable example of the administration being ordered to comply with the flawed or lawless guidance of a previous administration instead of the actual laws passed by Congress.”
Under the longstanding public charge rule, officials can refuse to admit immigrants into the United States – or to adjust their legal status – if they are deemed likely to become a public charge. Previously, immigration officers considered cash aid, such as Temporary Assistance for Needy Families or long-term institutionalized care, as potential public charge reasons for denial.
The revised regulation, which was scheduled to take effect on Oct. 15, 2019, would allow officials to consider previously excluded programs in their determination, including nonemergency Medicaid for nonpregnant adults, the Supplemental Nutrition Assistance Program, and several housing programs. The revised regulation would continue to allow immigrants to access emergency medical care and disaster relief without public charge repercussions.
Eight legal challenges were immediately filed against the rule changes, including a complaint issued in Washington state by 14 states. On Oct. 11, Judge Rosanna Malouf Peterson, U.S. district judge for the Eastern District of Washington, issued a nationwide ban of the revised public charge regulation, ruling that the plaintiff states will suffer irreparable harm if the rule moves forward.
“The plaintiff states have shown a significant threat of irreparable injury as a result of the impending enactment of the public charge rule by numerous individuals disenrolling from benefits for which they or their relatives were qualified, out of fear or confusion, that accepting those noncash public benefits will deprive them of an opportunity for legal permanent residency,” Judge Peterson wrote in her decision. “The plaintiff states have further demonstrated how that chilling effect predictably would cause irreparable injury by creating long-term costs to the plaintiff states from providing ongoing triage for residents who have missed opportunities for timely diagnoses, vaccinations, or building a strong foundation in childhood that will allow U.S. citizen children and future U.S. citizens to flourish and contribute to their communities as taxpaying adults.”
Judge Phyllis J. Hamilton, U.S. district judge for the Northern District of California, ruled similarly on Oct. 11, as did George Benjamin Daniels of the U.S. District Court for the Southern District of New York.
Physician associations previously voiced opposition to the administration’s changes to the public charge rule. In a joint statement, the AAFP, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, the American College of Physicians, and the American Psychiatric Association expressed concern that the new regulation will discourage immigrants from seeking needed health care since such assistance may be used to deny green cards and visas, or even lead to deportations.
“Rather than face that threat, impacted patients currently served by our members almost certainly will avoid needed care from their trusted physicians, jeopardizing their own health and that of their communities,” the medical societies stated. “Many of our members have already witnessed this chilling effect among their own patient populations, with patients avoiding health services and programs out of fear.”
In three separate decisions, the U.S. District Court for the Southern District of New York, the U.S. District Court for the Northern District of California, and the U.S. District Court for the Eastern District of Washington temporarily barred the administration’s changes to the public charge rule from moving forward. The judges said lawsuits challenging the rule are likely to prevail in court.
The injunctions are much needed to protect patients and families, said R. Shawn Martin, senior vice president of advocacy, practice advancement, and policy for the American Academy of Family Physicians.
“The court decisions are important,” Mr. Martin said in an interview. “The AAFP believes that the public charge rule, as proposed by the administration, would have an immediate and negative impact on the health of thousands of people, including children. There is evidence that policies such as this create a culture where patients forgo interactions with the health care system out of fear. We should never be a country that compromises the health and well-being of individuals, especially those that are most vulnerable.”
White House Press Secretary Stephanie Grisham called the court rulings extremely disappointing and said the recent changes to the public charge rule restore integrity to the immigration system.
“The rulings today prevent our nation’s immigration officers from ensuring that immigrants seeking entry to the United States will be self-sufficient and instead allow noncitizens to continue taking advantage of our generous but limited public resources reserved for vulnerable Americans,” Ms. Graham said in a statement. “These injunctions are the latest inexplicable example of the administration being ordered to comply with the flawed or lawless guidance of a previous administration instead of the actual laws passed by Congress.”
Under the longstanding public charge rule, officials can refuse to admit immigrants into the United States – or to adjust their legal status – if they are deemed likely to become a public charge. Previously, immigration officers considered cash aid, such as Temporary Assistance for Needy Families or long-term institutionalized care, as potential public charge reasons for denial.
The revised regulation, which was scheduled to take effect on Oct. 15, 2019, would allow officials to consider previously excluded programs in their determination, including nonemergency Medicaid for nonpregnant adults, the Supplemental Nutrition Assistance Program, and several housing programs. The revised regulation would continue to allow immigrants to access emergency medical care and disaster relief without public charge repercussions.
Eight legal challenges were immediately filed against the rule changes, including a complaint issued in Washington state by 14 states. On Oct. 11, Judge Rosanna Malouf Peterson, U.S. district judge for the Eastern District of Washington, issued a nationwide ban of the revised public charge regulation, ruling that the plaintiff states will suffer irreparable harm if the rule moves forward.
“The plaintiff states have shown a significant threat of irreparable injury as a result of the impending enactment of the public charge rule by numerous individuals disenrolling from benefits for which they or their relatives were qualified, out of fear or confusion, that accepting those noncash public benefits will deprive them of an opportunity for legal permanent residency,” Judge Peterson wrote in her decision. “The plaintiff states have further demonstrated how that chilling effect predictably would cause irreparable injury by creating long-term costs to the plaintiff states from providing ongoing triage for residents who have missed opportunities for timely diagnoses, vaccinations, or building a strong foundation in childhood that will allow U.S. citizen children and future U.S. citizens to flourish and contribute to their communities as taxpaying adults.”
Judge Phyllis J. Hamilton, U.S. district judge for the Northern District of California, ruled similarly on Oct. 11, as did George Benjamin Daniels of the U.S. District Court for the Southern District of New York.
Physician associations previously voiced opposition to the administration’s changes to the public charge rule. In a joint statement, the AAFP, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, the American College of Physicians, and the American Psychiatric Association expressed concern that the new regulation will discourage immigrants from seeking needed health care since such assistance may be used to deny green cards and visas, or even lead to deportations.
“Rather than face that threat, impacted patients currently served by our members almost certainly will avoid needed care from their trusted physicians, jeopardizing their own health and that of their communities,” the medical societies stated. “Many of our members have already witnessed this chilling effect among their own patient populations, with patients avoiding health services and programs out of fear.”
HHS floats Stark/anti-kickback revisions to support value-based care
The long-awaited reforms would create permanent exemptions and safe harbors to protect doctors participating in legitimate value-based arrangements. If finalized, the proposals also would offer flexibility for innovation and improved care coordination, while easing the compliance burden for health care professionals and maintaining safeguards against actual fraud and abuse, according to the U.S. Department of Health & Human Services.
The proposals acknowledge that the Stark Law has been an unintentional roadblock to value-based programs in part because it circumscribed parties’ exchanges of rewards for good behavior, said Donna K. Thiel, a Washington-based health law attorney.
“This should be helpful to doctors in that it removes some of the risk in such arrangements under the existing law,” she said in an interview. “If finalized, the new regulations will alleviate some roadblocks created by the Stark Law with respect to hospital-physician and other arrangements designed to enhance care coordination, improve quality, and reduce waste. Likewise, the changes to the [Anti-Kickback Statute] and Beneficiary Inducement laws loosen the reins on compensation arrangements that might be technical violations of those laws where the arrangement fosters [value-based payments] or efficiency, transparency, or innovation in the provision of health care.”
“These proposed rules would be a historic reform of how healthcare is regulated in America,” HHS Deputy Secretary Eric Hargan said in a statement. “They are part of a much broader effort to update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based health care system, while maintaining the important protections patients need.”
The two proposed measures – one rule by the Centers for Medicare and Medicaid Services and the other rule by the Office of Inspector General – include safe harbors for certain remuneration exchanged among participants in a value-based arrangement that fosters better coordinated and managed patient care. This includes care arrangements that improve quality, health outcomes, and efficiency, value-based arrangements with substantial downside financial risk, and value-based arrangements with full financial risk.
In addition, the proposals would protect certain tools and supports shared or delivered under patient engagement and support arrangements to improve quality, health outcomes, and efficiency. For example, a specialty physician practice could share data analytics services with a primary care physician practice in an effort to coordinate care and better manage shared patients, according to the HHS.
If finalized, the changes would modify existing safe harbor for personal services and management contracts to add flexibility with respect to outcomes-based payments and part-time arrangements, according to a fact sheet by the OIG. The rule would also modify existing safe harbors for local transportation to expand and modify mileage limits for rural areas and for transportation for discharged patients.
The proposals include guidance on several requirements that must be met for physicians and health care providers to comply with the Stark Law. For example, compensation provided to a doctor by another health care provider generally must be at fair-market value. As part of the proposals, the HHS offers guidance on how to determine if compensation meets this requirement and provides clarity on a range of other technical compliance requirements.
If the rules are approved, more physicians may be encouraged to become part of value-based arrangements, according to Anjali N.C. Downs, a health law attorney based in Washington.
“As stakeholders have long known, physicians are key components to achieving value-based health care delivery and payment systems,” Ms. Downs said in an interview. “The proposed rules remove regulatory barriers that chill physician’s willingness and ability to participate in or even consider participating in integrated care delivery models, alternative payment models, and incentive based arrangements based on outcomes and reductions in cost.”
However, Ms. Thiel noted the proposed rules do not scale back the affected laws as comprehensively as some stakeholders hoped.
“Some would like to see the Stark law repealed completely, opining that the Stark Law has become too complex, creating obstacles in the transition from the fee-for-service model,” Ms. Thiel said. “Because Stark is a strict liability law, meaning no proof of specific intent to violate is required, providers and doctors can violate Stark even when there is no corrupt intent involved. This new regulation purports to fix some of those issues, but others will remain. Some in the industry believe full repeal is necessary to allow the health industry to move forward with pay-for-performance initiatives.”
The agency is also proposing a safe harbor for donations of cybersecurity technology and services between aligned providers in both the fee-for-service and the value-based settings. For example, a local hospital looking to improve its cybersecurity and that of nearby providers could donate cybersecurity software to each physician that refers patients to its hospital, according to the HHS. In addition, the proposals would add protections for certain cybersecurity technology included as part of an electronic health records (EHR) arrangement.
Physician organizations expressed cautious optimism about the proposed changes.
“While the [American Medical Association] is assessing the full scope of today’s proposals, we are pleased to see that the administration has acknowledged a need for policy revisions in response to potential barriers that impede the delivery of patient-centric care,” AMA President Patrice A. Harris, MD, said in a statement. “Currently, the Stark Law and Anti-Kickback Statute can have a negative impact on the ability of physicians to assist with coordination because they inhibit collaborative partnerships, care continuity, and the engagement of patients in their care. These obstacles can hinder the health care system’s movement to value-based care.”
The proposed rules have been submitted to the Federal Registry and are not yet published. The HHS will accept mail and electronic comments about the proposals up to 75 days after publication in the registry.
The long-awaited reforms would create permanent exemptions and safe harbors to protect doctors participating in legitimate value-based arrangements. If finalized, the proposals also would offer flexibility for innovation and improved care coordination, while easing the compliance burden for health care professionals and maintaining safeguards against actual fraud and abuse, according to the U.S. Department of Health & Human Services.
The proposals acknowledge that the Stark Law has been an unintentional roadblock to value-based programs in part because it circumscribed parties’ exchanges of rewards for good behavior, said Donna K. Thiel, a Washington-based health law attorney.
“This should be helpful to doctors in that it removes some of the risk in such arrangements under the existing law,” she said in an interview. “If finalized, the new regulations will alleviate some roadblocks created by the Stark Law with respect to hospital-physician and other arrangements designed to enhance care coordination, improve quality, and reduce waste. Likewise, the changes to the [Anti-Kickback Statute] and Beneficiary Inducement laws loosen the reins on compensation arrangements that might be technical violations of those laws where the arrangement fosters [value-based payments] or efficiency, transparency, or innovation in the provision of health care.”
“These proposed rules would be a historic reform of how healthcare is regulated in America,” HHS Deputy Secretary Eric Hargan said in a statement. “They are part of a much broader effort to update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based health care system, while maintaining the important protections patients need.”
The two proposed measures – one rule by the Centers for Medicare and Medicaid Services and the other rule by the Office of Inspector General – include safe harbors for certain remuneration exchanged among participants in a value-based arrangement that fosters better coordinated and managed patient care. This includes care arrangements that improve quality, health outcomes, and efficiency, value-based arrangements with substantial downside financial risk, and value-based arrangements with full financial risk.
In addition, the proposals would protect certain tools and supports shared or delivered under patient engagement and support arrangements to improve quality, health outcomes, and efficiency. For example, a specialty physician practice could share data analytics services with a primary care physician practice in an effort to coordinate care and better manage shared patients, according to the HHS.
If finalized, the changes would modify existing safe harbor for personal services and management contracts to add flexibility with respect to outcomes-based payments and part-time arrangements, according to a fact sheet by the OIG. The rule would also modify existing safe harbors for local transportation to expand and modify mileage limits for rural areas and for transportation for discharged patients.
The proposals include guidance on several requirements that must be met for physicians and health care providers to comply with the Stark Law. For example, compensation provided to a doctor by another health care provider generally must be at fair-market value. As part of the proposals, the HHS offers guidance on how to determine if compensation meets this requirement and provides clarity on a range of other technical compliance requirements.
If the rules are approved, more physicians may be encouraged to become part of value-based arrangements, according to Anjali N.C. Downs, a health law attorney based in Washington.
“As stakeholders have long known, physicians are key components to achieving value-based health care delivery and payment systems,” Ms. Downs said in an interview. “The proposed rules remove regulatory barriers that chill physician’s willingness and ability to participate in or even consider participating in integrated care delivery models, alternative payment models, and incentive based arrangements based on outcomes and reductions in cost.”
However, Ms. Thiel noted the proposed rules do not scale back the affected laws as comprehensively as some stakeholders hoped.
“Some would like to see the Stark law repealed completely, opining that the Stark Law has become too complex, creating obstacles in the transition from the fee-for-service model,” Ms. Thiel said. “Because Stark is a strict liability law, meaning no proof of specific intent to violate is required, providers and doctors can violate Stark even when there is no corrupt intent involved. This new regulation purports to fix some of those issues, but others will remain. Some in the industry believe full repeal is necessary to allow the health industry to move forward with pay-for-performance initiatives.”
The agency is also proposing a safe harbor for donations of cybersecurity technology and services between aligned providers in both the fee-for-service and the value-based settings. For example, a local hospital looking to improve its cybersecurity and that of nearby providers could donate cybersecurity software to each physician that refers patients to its hospital, according to the HHS. In addition, the proposals would add protections for certain cybersecurity technology included as part of an electronic health records (EHR) arrangement.
Physician organizations expressed cautious optimism about the proposed changes.
“While the [American Medical Association] is assessing the full scope of today’s proposals, we are pleased to see that the administration has acknowledged a need for policy revisions in response to potential barriers that impede the delivery of patient-centric care,” AMA President Patrice A. Harris, MD, said in a statement. “Currently, the Stark Law and Anti-Kickback Statute can have a negative impact on the ability of physicians to assist with coordination because they inhibit collaborative partnerships, care continuity, and the engagement of patients in their care. These obstacles can hinder the health care system’s movement to value-based care.”
The proposed rules have been submitted to the Federal Registry and are not yet published. The HHS will accept mail and electronic comments about the proposals up to 75 days after publication in the registry.
The long-awaited reforms would create permanent exemptions and safe harbors to protect doctors participating in legitimate value-based arrangements. If finalized, the proposals also would offer flexibility for innovation and improved care coordination, while easing the compliance burden for health care professionals and maintaining safeguards against actual fraud and abuse, according to the U.S. Department of Health & Human Services.
The proposals acknowledge that the Stark Law has been an unintentional roadblock to value-based programs in part because it circumscribed parties’ exchanges of rewards for good behavior, said Donna K. Thiel, a Washington-based health law attorney.
“This should be helpful to doctors in that it removes some of the risk in such arrangements under the existing law,” she said in an interview. “If finalized, the new regulations will alleviate some roadblocks created by the Stark Law with respect to hospital-physician and other arrangements designed to enhance care coordination, improve quality, and reduce waste. Likewise, the changes to the [Anti-Kickback Statute] and Beneficiary Inducement laws loosen the reins on compensation arrangements that might be technical violations of those laws where the arrangement fosters [value-based payments] or efficiency, transparency, or innovation in the provision of health care.”
“These proposed rules would be a historic reform of how healthcare is regulated in America,” HHS Deputy Secretary Eric Hargan said in a statement. “They are part of a much broader effort to update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based health care system, while maintaining the important protections patients need.”
The two proposed measures – one rule by the Centers for Medicare and Medicaid Services and the other rule by the Office of Inspector General – include safe harbors for certain remuneration exchanged among participants in a value-based arrangement that fosters better coordinated and managed patient care. This includes care arrangements that improve quality, health outcomes, and efficiency, value-based arrangements with substantial downside financial risk, and value-based arrangements with full financial risk.
In addition, the proposals would protect certain tools and supports shared or delivered under patient engagement and support arrangements to improve quality, health outcomes, and efficiency. For example, a specialty physician practice could share data analytics services with a primary care physician practice in an effort to coordinate care and better manage shared patients, according to the HHS.
If finalized, the changes would modify existing safe harbor for personal services and management contracts to add flexibility with respect to outcomes-based payments and part-time arrangements, according to a fact sheet by the OIG. The rule would also modify existing safe harbors for local transportation to expand and modify mileage limits for rural areas and for transportation for discharged patients.
The proposals include guidance on several requirements that must be met for physicians and health care providers to comply with the Stark Law. For example, compensation provided to a doctor by another health care provider generally must be at fair-market value. As part of the proposals, the HHS offers guidance on how to determine if compensation meets this requirement and provides clarity on a range of other technical compliance requirements.
If the rules are approved, more physicians may be encouraged to become part of value-based arrangements, according to Anjali N.C. Downs, a health law attorney based in Washington.
“As stakeholders have long known, physicians are key components to achieving value-based health care delivery and payment systems,” Ms. Downs said in an interview. “The proposed rules remove regulatory barriers that chill physician’s willingness and ability to participate in or even consider participating in integrated care delivery models, alternative payment models, and incentive based arrangements based on outcomes and reductions in cost.”
However, Ms. Thiel noted the proposed rules do not scale back the affected laws as comprehensively as some stakeholders hoped.
“Some would like to see the Stark law repealed completely, opining that the Stark Law has become too complex, creating obstacles in the transition from the fee-for-service model,” Ms. Thiel said. “Because Stark is a strict liability law, meaning no proof of specific intent to violate is required, providers and doctors can violate Stark even when there is no corrupt intent involved. This new regulation purports to fix some of those issues, but others will remain. Some in the industry believe full repeal is necessary to allow the health industry to move forward with pay-for-performance initiatives.”
The agency is also proposing a safe harbor for donations of cybersecurity technology and services between aligned providers in both the fee-for-service and the value-based settings. For example, a local hospital looking to improve its cybersecurity and that of nearby providers could donate cybersecurity software to each physician that refers patients to its hospital, according to the HHS. In addition, the proposals would add protections for certain cybersecurity technology included as part of an electronic health records (EHR) arrangement.
Physician organizations expressed cautious optimism about the proposed changes.
“While the [American Medical Association] is assessing the full scope of today’s proposals, we are pleased to see that the administration has acknowledged a need for policy revisions in response to potential barriers that impede the delivery of patient-centric care,” AMA President Patrice A. Harris, MD, said in a statement. “Currently, the Stark Law and Anti-Kickback Statute can have a negative impact on the ability of physicians to assist with coordination because they inhibit collaborative partnerships, care continuity, and the engagement of patients in their care. These obstacles can hinder the health care system’s movement to value-based care.”
The proposed rules have been submitted to the Federal Registry and are not yet published. The HHS will accept mail and electronic comments about the proposals up to 75 days after publication in the registry.
Trump: No health insurance, no U.S. entry
Health insurance or the ability to pay for care soon will be a requirement for immigrants seeking U.S. visas, under a proclamation from President Trump.
Effective Nov. 3, 2019, visa applicants must demonstrate to immigration authorities that they can obtain coverage by an approved health insurer within 30 days of entering the United States or show evidence they possess the financial resources to pay for foreseeable medical costs. Approved coverage includes, but is not limited to, an employer-sponsored plan, an unsubsidized health plan offered in the individual market, a family member’s plan, or a visitor health insurance plan that provides coverage for at least 364 days, according to the proclamation.
President Trump said that the restriction protects Americans from bearing the burden of uncompensated health care costs generated by immigrants.
“While our health care system grapples with the challenges caused by uncompensated care, the United States government is making the problem worse by admitting thousands of aliens who have not demonstrated any ability to pay for their health care costs,” President Trump said in the proclamation. “Notably, data show that lawful immigrants are about three times more likely than United States citizens to lack health insurance. Immigrants who enter this country should not further saddle our health care system, and subsequently American taxpayers, with higher costs.”
The rule does not apply to refugees or asylum seekers, immigrants holding valid visas prior to Nov. 3, noncitizen children of U.S. citizens, unaccompanied minors, or permanent residents returning to the country after less than a year overseas.
The rule is the latest in a series of immigration restrictions by President Trump. Most recently in August 2019, the Trump administration amended the federal public charge rule, a longstanding policy that allows authorities to refuse to admit immigrants into the United States – or to adjust their legal status – if they are deemed likely to become a public charge. The revised regulation allows officials to consider previously excluded programs in their determination, including nonemergency Medicaid for nonpregnant adults, the Supplemental Nutrition Assistance Program, and several housing programs.
The proclamation is consistent with the President’s recent public charge rule, and it is sound immigration policy, said Dale Wilcox, executive director and general counsel for the Immigration Reform Law Institute.
“If U.S. citizens are responsible for the health care costs of the world, then the world will show up at our doorstep for free health care,” Mr. Wilcox said in an interview. “That is unfair to American citizens and would financially devastate health care providers. The impact of this proclamation would be a more manageable immigration policy that welcomes immigrants who will contribute to our country as well as benefit from it.”
J. Wesley Boyd, MD, of the Center for Bioethics at Harvard University, Boston, said he was saddened to learn about the proclamation, adding that the Trump administration is relying on inaccurate information and falsified facts to justify the new restriction. Dr. Boyd, cofounder of the Human Rights and Asylum Clinic at Cambridge Health Alliance in Cambridge, Mass., coauthored a 2018 study finding that immigrants pay more into the U.S. health care system than they use.
That analysis, which examined 188 peer-reviewed studies related to immigrants and U.S. health care expenditures, found that per capita expenditures from private and public insurance sources were about 40% lower for immigrants, compared with native-born Americans. Expenditures for undocumented immigrants were even lower. Immigrants also made a greater contribution to Medicare’s trust fund than they withdrew, the study found (Int J Health Serv. 2018 Aug. 8 doi: 10.1177/0020731418791963).
Immigrants use less health care resources because they are generally younger and healthier than native-born Americans, and they are less likely to access health care services – regardless of health status, Dr. Boyd said in an interview. In addition, many immigrants who contribute to Medicare through payroll and/or taxes are no longer in the U.S. when they reach Medicare age.
“The Trump administration, in this case, is making yet another set of excuses for why they are trying to keep immigrants out of the country,” Dr. Boyd said. “The potential impact of this restriction is devastating. Obviously, the Trump administration is doing anything that it possibly can to try to limit immigrants from coming into our country and seeking a better life for themselves.”
The proclamation also could have a chilling effect on immigrants currently in the United States who are in need of medical treatment, Dr. Boyd noted.
“The real effect is you’re going to have immigrants who are already here, not [accessing] health care when they need it, for fear they somehow become known to the government,” he said.
Health insurance or the ability to pay for care soon will be a requirement for immigrants seeking U.S. visas, under a proclamation from President Trump.
Effective Nov. 3, 2019, visa applicants must demonstrate to immigration authorities that they can obtain coverage by an approved health insurer within 30 days of entering the United States or show evidence they possess the financial resources to pay for foreseeable medical costs. Approved coverage includes, but is not limited to, an employer-sponsored plan, an unsubsidized health plan offered in the individual market, a family member’s plan, or a visitor health insurance plan that provides coverage for at least 364 days, according to the proclamation.
President Trump said that the restriction protects Americans from bearing the burden of uncompensated health care costs generated by immigrants.
“While our health care system grapples with the challenges caused by uncompensated care, the United States government is making the problem worse by admitting thousands of aliens who have not demonstrated any ability to pay for their health care costs,” President Trump said in the proclamation. “Notably, data show that lawful immigrants are about three times more likely than United States citizens to lack health insurance. Immigrants who enter this country should not further saddle our health care system, and subsequently American taxpayers, with higher costs.”
The rule does not apply to refugees or asylum seekers, immigrants holding valid visas prior to Nov. 3, noncitizen children of U.S. citizens, unaccompanied minors, or permanent residents returning to the country after less than a year overseas.
The rule is the latest in a series of immigration restrictions by President Trump. Most recently in August 2019, the Trump administration amended the federal public charge rule, a longstanding policy that allows authorities to refuse to admit immigrants into the United States – or to adjust their legal status – if they are deemed likely to become a public charge. The revised regulation allows officials to consider previously excluded programs in their determination, including nonemergency Medicaid for nonpregnant adults, the Supplemental Nutrition Assistance Program, and several housing programs.
The proclamation is consistent with the President’s recent public charge rule, and it is sound immigration policy, said Dale Wilcox, executive director and general counsel for the Immigration Reform Law Institute.
“If U.S. citizens are responsible for the health care costs of the world, then the world will show up at our doorstep for free health care,” Mr. Wilcox said in an interview. “That is unfair to American citizens and would financially devastate health care providers. The impact of this proclamation would be a more manageable immigration policy that welcomes immigrants who will contribute to our country as well as benefit from it.”
J. Wesley Boyd, MD, of the Center for Bioethics at Harvard University, Boston, said he was saddened to learn about the proclamation, adding that the Trump administration is relying on inaccurate information and falsified facts to justify the new restriction. Dr. Boyd, cofounder of the Human Rights and Asylum Clinic at Cambridge Health Alliance in Cambridge, Mass., coauthored a 2018 study finding that immigrants pay more into the U.S. health care system than they use.
That analysis, which examined 188 peer-reviewed studies related to immigrants and U.S. health care expenditures, found that per capita expenditures from private and public insurance sources were about 40% lower for immigrants, compared with native-born Americans. Expenditures for undocumented immigrants were even lower. Immigrants also made a greater contribution to Medicare’s trust fund than they withdrew, the study found (Int J Health Serv. 2018 Aug. 8 doi: 10.1177/0020731418791963).
Immigrants use less health care resources because they are generally younger and healthier than native-born Americans, and they are less likely to access health care services – regardless of health status, Dr. Boyd said in an interview. In addition, many immigrants who contribute to Medicare through payroll and/or taxes are no longer in the U.S. when they reach Medicare age.
“The Trump administration, in this case, is making yet another set of excuses for why they are trying to keep immigrants out of the country,” Dr. Boyd said. “The potential impact of this restriction is devastating. Obviously, the Trump administration is doing anything that it possibly can to try to limit immigrants from coming into our country and seeking a better life for themselves.”
The proclamation also could have a chilling effect on immigrants currently in the United States who are in need of medical treatment, Dr. Boyd noted.
“The real effect is you’re going to have immigrants who are already here, not [accessing] health care when they need it, for fear they somehow become known to the government,” he said.
Health insurance or the ability to pay for care soon will be a requirement for immigrants seeking U.S. visas, under a proclamation from President Trump.
Effective Nov. 3, 2019, visa applicants must demonstrate to immigration authorities that they can obtain coverage by an approved health insurer within 30 days of entering the United States or show evidence they possess the financial resources to pay for foreseeable medical costs. Approved coverage includes, but is not limited to, an employer-sponsored plan, an unsubsidized health plan offered in the individual market, a family member’s plan, or a visitor health insurance plan that provides coverage for at least 364 days, according to the proclamation.
President Trump said that the restriction protects Americans from bearing the burden of uncompensated health care costs generated by immigrants.
“While our health care system grapples with the challenges caused by uncompensated care, the United States government is making the problem worse by admitting thousands of aliens who have not demonstrated any ability to pay for their health care costs,” President Trump said in the proclamation. “Notably, data show that lawful immigrants are about three times more likely than United States citizens to lack health insurance. Immigrants who enter this country should not further saddle our health care system, and subsequently American taxpayers, with higher costs.”
The rule does not apply to refugees or asylum seekers, immigrants holding valid visas prior to Nov. 3, noncitizen children of U.S. citizens, unaccompanied minors, or permanent residents returning to the country after less than a year overseas.
The rule is the latest in a series of immigration restrictions by President Trump. Most recently in August 2019, the Trump administration amended the federal public charge rule, a longstanding policy that allows authorities to refuse to admit immigrants into the United States – or to adjust their legal status – if they are deemed likely to become a public charge. The revised regulation allows officials to consider previously excluded programs in their determination, including nonemergency Medicaid for nonpregnant adults, the Supplemental Nutrition Assistance Program, and several housing programs.
The proclamation is consistent with the President’s recent public charge rule, and it is sound immigration policy, said Dale Wilcox, executive director and general counsel for the Immigration Reform Law Institute.
“If U.S. citizens are responsible for the health care costs of the world, then the world will show up at our doorstep for free health care,” Mr. Wilcox said in an interview. “That is unfair to American citizens and would financially devastate health care providers. The impact of this proclamation would be a more manageable immigration policy that welcomes immigrants who will contribute to our country as well as benefit from it.”
J. Wesley Boyd, MD, of the Center for Bioethics at Harvard University, Boston, said he was saddened to learn about the proclamation, adding that the Trump administration is relying on inaccurate information and falsified facts to justify the new restriction. Dr. Boyd, cofounder of the Human Rights and Asylum Clinic at Cambridge Health Alliance in Cambridge, Mass., coauthored a 2018 study finding that immigrants pay more into the U.S. health care system than they use.
That analysis, which examined 188 peer-reviewed studies related to immigrants and U.S. health care expenditures, found that per capita expenditures from private and public insurance sources were about 40% lower for immigrants, compared with native-born Americans. Expenditures for undocumented immigrants were even lower. Immigrants also made a greater contribution to Medicare’s trust fund than they withdrew, the study found (Int J Health Serv. 2018 Aug. 8 doi: 10.1177/0020731418791963).
Immigrants use less health care resources because they are generally younger and healthier than native-born Americans, and they are less likely to access health care services – regardless of health status, Dr. Boyd said in an interview. In addition, many immigrants who contribute to Medicare through payroll and/or taxes are no longer in the U.S. when they reach Medicare age.
“The Trump administration, in this case, is making yet another set of excuses for why they are trying to keep immigrants out of the country,” Dr. Boyd said. “The potential impact of this restriction is devastating. Obviously, the Trump administration is doing anything that it possibly can to try to limit immigrants from coming into our country and seeking a better life for themselves.”
The proclamation also could have a chilling effect on immigrants currently in the United States who are in need of medical treatment, Dr. Boyd noted.
“The real effect is you’re going to have immigrants who are already here, not [accessing] health care when they need it, for fear they somehow become known to the government,” he said.
Appeals court to hear prescription drug privacy rights case
An appeals court may soon decide whether federal authorities can access a patient’s medical records through a statewide prescription drug monitoring database without a warrant or if such searches infringe upon privacy rights.
On Oct. 10, the 1st U.S. Circuit Court of Appeals will hear arguments in U.S. Department of Justice v. Jonas, which centers on an investigatory subpoena issued by the U.S. Drug Enforcement Agency in 2018 that sought records about a certain patient from New Hampshire’s Prescription Drug Monitoring Program (PDMP). The subpoena’s recipient, PDMP program manager Michelle Ricco-Jonas, refused to comply, citing state law that prohibits law enforcement from accessing the database without a court order based on probable cause. Releasing PDMP records to authorities without cause violate patients’ privacy protections under the Fourth Amendment, Ms. Jonas and the New Hampshire Attorney General’s Office argued.
The U.S. Department of Justice sued to enforce the subpoena, contending that the DEA’s authority to investigate suspected criminal drug activity preempts New Hampshire’s law under the Supremacy Clause. In November 2018, U.S. Magistrate Judge Andrea K. Johnstone agreed with the DOJ and recommended the district judge grant the government’s motion to enforce the subpoena, a decision affirmed by the U.S. District Court for the District of New Hampshire in January 2019. The court ruled the government met its burden to satisfy the modest requirements for enforcement of the subpoena. Attorneys for New Hampshire appealed to the 1st Circuit.
The case is being closely watched by states, physician groups, pharmacies, and patient advocacy groups. In a joint court brief by the New Hampshire Medical Society and the American Civil Liberties Union, the organizations urged the appeals court to protect patient privacy by finding in favor of New Hampshire.
“The DEA has sought to enforce a subpoena that both injures Jonas and threatens to invade the Fourth Amendment privacy rights of individuals whose private medical information resides in the database, and whose privacy and confidentiality Jonas is statutorily charged with protecting. ... but who have no ability to challenge that impending harm,” the groups wrote in the brief. “The prescription records at issue in this case reveal intimate, private, and potentially stigmatizing details about patients’ health, including details of those patients’ underlying medical conditions. For that reason, as with other medical records, people have a reasonable expectation of privacy in them.”
Oregon’s PDMP faced a similar legal challenge in 2012. In that case, the DEA attempted to access the records of one patient and two prescribing physicians from Oregon’s prescription database. The state sued to prevent release of the records, and the ACLU intervened as a plaintiff on behalf of several unnamed patients and a doctor. A district court ruled in favor of the plaintiffs, finding that the DEA’s actions constituted a Fourth Amendment violation. However, the 9th U.S. Circuit Court in 2017 overturned the decision, ruling that federal law regarding administrative subpoenas trumps Oregon law. In addition, the appeals court ruled that the ACLU lacked standing to intervene and seek relief different from that sought by Oregon. By invalidating ACLU from the suit, the Fourth Amendment argument was never resolved by the 9th Circuit.
New Hampshire is one of 49 states that have Prescription Drug Monitoring Programs in addition to the District of Columbia. The programs collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by physicians and pharmacies with the aim of reducing prescription drug abuse and diversion.
An appeals court may soon decide whether federal authorities can access a patient’s medical records through a statewide prescription drug monitoring database without a warrant or if such searches infringe upon privacy rights.
On Oct. 10, the 1st U.S. Circuit Court of Appeals will hear arguments in U.S. Department of Justice v. Jonas, which centers on an investigatory subpoena issued by the U.S. Drug Enforcement Agency in 2018 that sought records about a certain patient from New Hampshire’s Prescription Drug Monitoring Program (PDMP). The subpoena’s recipient, PDMP program manager Michelle Ricco-Jonas, refused to comply, citing state law that prohibits law enforcement from accessing the database without a court order based on probable cause. Releasing PDMP records to authorities without cause violate patients’ privacy protections under the Fourth Amendment, Ms. Jonas and the New Hampshire Attorney General’s Office argued.
The U.S. Department of Justice sued to enforce the subpoena, contending that the DEA’s authority to investigate suspected criminal drug activity preempts New Hampshire’s law under the Supremacy Clause. In November 2018, U.S. Magistrate Judge Andrea K. Johnstone agreed with the DOJ and recommended the district judge grant the government’s motion to enforce the subpoena, a decision affirmed by the U.S. District Court for the District of New Hampshire in January 2019. The court ruled the government met its burden to satisfy the modest requirements for enforcement of the subpoena. Attorneys for New Hampshire appealed to the 1st Circuit.
The case is being closely watched by states, physician groups, pharmacies, and patient advocacy groups. In a joint court brief by the New Hampshire Medical Society and the American Civil Liberties Union, the organizations urged the appeals court to protect patient privacy by finding in favor of New Hampshire.
“The DEA has sought to enforce a subpoena that both injures Jonas and threatens to invade the Fourth Amendment privacy rights of individuals whose private medical information resides in the database, and whose privacy and confidentiality Jonas is statutorily charged with protecting. ... but who have no ability to challenge that impending harm,” the groups wrote in the brief. “The prescription records at issue in this case reveal intimate, private, and potentially stigmatizing details about patients’ health, including details of those patients’ underlying medical conditions. For that reason, as with other medical records, people have a reasonable expectation of privacy in them.”
Oregon’s PDMP faced a similar legal challenge in 2012. In that case, the DEA attempted to access the records of one patient and two prescribing physicians from Oregon’s prescription database. The state sued to prevent release of the records, and the ACLU intervened as a plaintiff on behalf of several unnamed patients and a doctor. A district court ruled in favor of the plaintiffs, finding that the DEA’s actions constituted a Fourth Amendment violation. However, the 9th U.S. Circuit Court in 2017 overturned the decision, ruling that federal law regarding administrative subpoenas trumps Oregon law. In addition, the appeals court ruled that the ACLU lacked standing to intervene and seek relief different from that sought by Oregon. By invalidating ACLU from the suit, the Fourth Amendment argument was never resolved by the 9th Circuit.
New Hampshire is one of 49 states that have Prescription Drug Monitoring Programs in addition to the District of Columbia. The programs collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by physicians and pharmacies with the aim of reducing prescription drug abuse and diversion.
An appeals court may soon decide whether federal authorities can access a patient’s medical records through a statewide prescription drug monitoring database without a warrant or if such searches infringe upon privacy rights.
On Oct. 10, the 1st U.S. Circuit Court of Appeals will hear arguments in U.S. Department of Justice v. Jonas, which centers on an investigatory subpoena issued by the U.S. Drug Enforcement Agency in 2018 that sought records about a certain patient from New Hampshire’s Prescription Drug Monitoring Program (PDMP). The subpoena’s recipient, PDMP program manager Michelle Ricco-Jonas, refused to comply, citing state law that prohibits law enforcement from accessing the database without a court order based on probable cause. Releasing PDMP records to authorities without cause violate patients’ privacy protections under the Fourth Amendment, Ms. Jonas and the New Hampshire Attorney General’s Office argued.
The U.S. Department of Justice sued to enforce the subpoena, contending that the DEA’s authority to investigate suspected criminal drug activity preempts New Hampshire’s law under the Supremacy Clause. In November 2018, U.S. Magistrate Judge Andrea K. Johnstone agreed with the DOJ and recommended the district judge grant the government’s motion to enforce the subpoena, a decision affirmed by the U.S. District Court for the District of New Hampshire in January 2019. The court ruled the government met its burden to satisfy the modest requirements for enforcement of the subpoena. Attorneys for New Hampshire appealed to the 1st Circuit.
The case is being closely watched by states, physician groups, pharmacies, and patient advocacy groups. In a joint court brief by the New Hampshire Medical Society and the American Civil Liberties Union, the organizations urged the appeals court to protect patient privacy by finding in favor of New Hampshire.
“The DEA has sought to enforce a subpoena that both injures Jonas and threatens to invade the Fourth Amendment privacy rights of individuals whose private medical information resides in the database, and whose privacy and confidentiality Jonas is statutorily charged with protecting. ... but who have no ability to challenge that impending harm,” the groups wrote in the brief. “The prescription records at issue in this case reveal intimate, private, and potentially stigmatizing details about patients’ health, including details of those patients’ underlying medical conditions. For that reason, as with other medical records, people have a reasonable expectation of privacy in them.”
Oregon’s PDMP faced a similar legal challenge in 2012. In that case, the DEA attempted to access the records of one patient and two prescribing physicians from Oregon’s prescription database. The state sued to prevent release of the records, and the ACLU intervened as a plaintiff on behalf of several unnamed patients and a doctor. A district court ruled in favor of the plaintiffs, finding that the DEA’s actions constituted a Fourth Amendment violation. However, the 9th U.S. Circuit Court in 2017 overturned the decision, ruling that federal law regarding administrative subpoenas trumps Oregon law. In addition, the appeals court ruled that the ACLU lacked standing to intervene and seek relief different from that sought by Oregon. By invalidating ACLU from the suit, the Fourth Amendment argument was never resolved by the 9th Circuit.
New Hampshire is one of 49 states that have Prescription Drug Monitoring Programs in addition to the District of Columbia. The programs collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by physicians and pharmacies with the aim of reducing prescription drug abuse and diversion.
Judge rules for insurer in doctor’s allocation lawsuit
A judge has sided with a medical malpractice insurer in a legal challenge that accused the company of misallocating blame among physicians after a liability settlement.
In a Sept. 27 decision, Judge Debra Squires-Lee of the Commonwealth of Massachusetts Superior Court ruled that Medical Professional Mutual Insurance Company (ProMutual) acted reasonably when it settled a medical liability claim for $500,000 against several health providers and allocated responsibility for 30% of the settlement ($150,000) to internist Nataly Minkina, MD. ProMutual was well within its rights and obligations when it settled the underlying claim and did not act in bad faith when assigning responsibility in the case, Judge Squires-Lee wrote in her 49-page ruling.
“At its heart, this case is about a multiple defendant malpractice lawsuit with finger pointing by Dr. Minkina against her codefendants and others, and a disagreement about ProMutual’s ultimate determination about how to allocate a global settlement with the plaintiffs amongst ProMutual’s insureds,” Judge Squires-Lee wrote in the decision. “Dr. Minkina strongly believes that she did not fail [the patient], that she acted reasonably, and that her treatment of [the patient] satisfied the standard of care. She also questions why ProMutual failed to allocate liability in the [patient’s] suit to other physicians. However ... the question for this court is whether ProMutual committed unfair or deceptive acts or practices in its settlement and allocation of its settlement. I conclude that ProMutual did not.”
The case stems from a patient’s lawsuit against Dr. Minkina and several others at Blue Hills Medical Associates in Braintree, Mass. The patient alleged that the health care professionals were responsible for a missed breast cancer diagnosis. Dr. Minkina saw the patient just once in 2002 while covering for another doctor. During the visit, she confirmed some nodularity in the 55-year-old women’s breast and referred her for a mammogram and an ultrasound. A radiologist twice reported no abnormalities, which Dr. Minkina said she relayed to the patient. Dr. Minkina left the practice shortly after.
The patient visited the practice several more times and was referred for another mammogram in 2006, the results of which revealed some signs of malignancy, according to court documents. However, a nurse at the practice misread, misunderstood, or overlooked the signs and recorded that “the benign breast condition had no changes,” according to court transcripts. Later that year, the patient visited the practice complaining of headaches and a droopy eye at which time her primary care physician diagnosed sinusitis and prescribed antibiotics. In 2007, the patient underwent magnetic resonance imaging of the brain and the breast, which revealed widespread metastatic carcinoma. She and her family sued Dr. Minkina and several others in June 2007. The patient died in 2008.
ProMutual settled the case against the defendants for $500,000 in 2008, allocating 30% of the liability to Dr. Minkina, 10% of the nurse practitioner, 60% to the medical practice, and no liability to the other doctors named. ProMutual contended Dr. Minkina bore more responsibility than the other health care professionals named for the delayed diagnosis because of causation factors and standard of care violations, namely that Dr. Minkina should have pursued a biopsy for the patient.
Dr. Minkina sued the insurer in 2012, claiming chiefly that the insurer allocated an unjustifiably high percentage of liability to her because she was no longer insured and because the company had an economic incentive to allocate a disproportionate percentage of responsibility and damages.
A lower court initially dismissed Dr. Minkina’s suit, but the Commonwealth of Massachusetts Appeals Court in 2015 overturned that decision, ruling the case could move forward. In 2018, the superior court agreed Dr. Minkina had a valid bad faith claim, stating that she had provided information about ProMutual’s conduct from which “a reasonable juror could infer the defendant’s bad faith in connection with its settling the underlying malpractice suit, including the allocation of liability.
But Judge Squires-Lee ruled that trial evidence showed that ProMutual did not act for its own benefit or favor other insureds over Dr. Minkina. The judge wrote that the insurer satisfied its contractual and legal obligations when defending the underlying legal claim.
Dr. Minkina said she was disappointed with the ruling, but that she is considering her legal avenues.
“[The] judge’s decision in my case against ProMutual is obviously disappointing, but it is not the first time [the] trial court decided against me in this case,” Dr. Minkina said in an interview. “It is a battle between David and Goliath, [a] single physician against [a] $3.6 billion insurance company with unlimited resources. The decision has just been announced and it is voluminous. I am still reading it and evaluating my options with my attorneys, but it is not the end of the road yet.”
ProMutual declined to comment about the decision.
A judge has sided with a medical malpractice insurer in a legal challenge that accused the company of misallocating blame among physicians after a liability settlement.
In a Sept. 27 decision, Judge Debra Squires-Lee of the Commonwealth of Massachusetts Superior Court ruled that Medical Professional Mutual Insurance Company (ProMutual) acted reasonably when it settled a medical liability claim for $500,000 against several health providers and allocated responsibility for 30% of the settlement ($150,000) to internist Nataly Minkina, MD. ProMutual was well within its rights and obligations when it settled the underlying claim and did not act in bad faith when assigning responsibility in the case, Judge Squires-Lee wrote in her 49-page ruling.
“At its heart, this case is about a multiple defendant malpractice lawsuit with finger pointing by Dr. Minkina against her codefendants and others, and a disagreement about ProMutual’s ultimate determination about how to allocate a global settlement with the plaintiffs amongst ProMutual’s insureds,” Judge Squires-Lee wrote in the decision. “Dr. Minkina strongly believes that she did not fail [the patient], that she acted reasonably, and that her treatment of [the patient] satisfied the standard of care. She also questions why ProMutual failed to allocate liability in the [patient’s] suit to other physicians. However ... the question for this court is whether ProMutual committed unfair or deceptive acts or practices in its settlement and allocation of its settlement. I conclude that ProMutual did not.”
The case stems from a patient’s lawsuit against Dr. Minkina and several others at Blue Hills Medical Associates in Braintree, Mass. The patient alleged that the health care professionals were responsible for a missed breast cancer diagnosis. Dr. Minkina saw the patient just once in 2002 while covering for another doctor. During the visit, she confirmed some nodularity in the 55-year-old women’s breast and referred her for a mammogram and an ultrasound. A radiologist twice reported no abnormalities, which Dr. Minkina said she relayed to the patient. Dr. Minkina left the practice shortly after.
The patient visited the practice several more times and was referred for another mammogram in 2006, the results of which revealed some signs of malignancy, according to court documents. However, a nurse at the practice misread, misunderstood, or overlooked the signs and recorded that “the benign breast condition had no changes,” according to court transcripts. Later that year, the patient visited the practice complaining of headaches and a droopy eye at which time her primary care physician diagnosed sinusitis and prescribed antibiotics. In 2007, the patient underwent magnetic resonance imaging of the brain and the breast, which revealed widespread metastatic carcinoma. She and her family sued Dr. Minkina and several others in June 2007. The patient died in 2008.
ProMutual settled the case against the defendants for $500,000 in 2008, allocating 30% of the liability to Dr. Minkina, 10% of the nurse practitioner, 60% to the medical practice, and no liability to the other doctors named. ProMutual contended Dr. Minkina bore more responsibility than the other health care professionals named for the delayed diagnosis because of causation factors and standard of care violations, namely that Dr. Minkina should have pursued a biopsy for the patient.
Dr. Minkina sued the insurer in 2012, claiming chiefly that the insurer allocated an unjustifiably high percentage of liability to her because she was no longer insured and because the company had an economic incentive to allocate a disproportionate percentage of responsibility and damages.
A lower court initially dismissed Dr. Minkina’s suit, but the Commonwealth of Massachusetts Appeals Court in 2015 overturned that decision, ruling the case could move forward. In 2018, the superior court agreed Dr. Minkina had a valid bad faith claim, stating that she had provided information about ProMutual’s conduct from which “a reasonable juror could infer the defendant’s bad faith in connection with its settling the underlying malpractice suit, including the allocation of liability.
But Judge Squires-Lee ruled that trial evidence showed that ProMutual did not act for its own benefit or favor other insureds over Dr. Minkina. The judge wrote that the insurer satisfied its contractual and legal obligations when defending the underlying legal claim.
Dr. Minkina said she was disappointed with the ruling, but that she is considering her legal avenues.
“[The] judge’s decision in my case against ProMutual is obviously disappointing, but it is not the first time [the] trial court decided against me in this case,” Dr. Minkina said in an interview. “It is a battle between David and Goliath, [a] single physician against [a] $3.6 billion insurance company with unlimited resources. The decision has just been announced and it is voluminous. I am still reading it and evaluating my options with my attorneys, but it is not the end of the road yet.”
ProMutual declined to comment about the decision.
A judge has sided with a medical malpractice insurer in a legal challenge that accused the company of misallocating blame among physicians after a liability settlement.
In a Sept. 27 decision, Judge Debra Squires-Lee of the Commonwealth of Massachusetts Superior Court ruled that Medical Professional Mutual Insurance Company (ProMutual) acted reasonably when it settled a medical liability claim for $500,000 against several health providers and allocated responsibility for 30% of the settlement ($150,000) to internist Nataly Minkina, MD. ProMutual was well within its rights and obligations when it settled the underlying claim and did not act in bad faith when assigning responsibility in the case, Judge Squires-Lee wrote in her 49-page ruling.
“At its heart, this case is about a multiple defendant malpractice lawsuit with finger pointing by Dr. Minkina against her codefendants and others, and a disagreement about ProMutual’s ultimate determination about how to allocate a global settlement with the plaintiffs amongst ProMutual’s insureds,” Judge Squires-Lee wrote in the decision. “Dr. Minkina strongly believes that she did not fail [the patient], that she acted reasonably, and that her treatment of [the patient] satisfied the standard of care. She also questions why ProMutual failed to allocate liability in the [patient’s] suit to other physicians. However ... the question for this court is whether ProMutual committed unfair or deceptive acts or practices in its settlement and allocation of its settlement. I conclude that ProMutual did not.”
The case stems from a patient’s lawsuit against Dr. Minkina and several others at Blue Hills Medical Associates in Braintree, Mass. The patient alleged that the health care professionals were responsible for a missed breast cancer diagnosis. Dr. Minkina saw the patient just once in 2002 while covering for another doctor. During the visit, she confirmed some nodularity in the 55-year-old women’s breast and referred her for a mammogram and an ultrasound. A radiologist twice reported no abnormalities, which Dr. Minkina said she relayed to the patient. Dr. Minkina left the practice shortly after.
The patient visited the practice several more times and was referred for another mammogram in 2006, the results of which revealed some signs of malignancy, according to court documents. However, a nurse at the practice misread, misunderstood, or overlooked the signs and recorded that “the benign breast condition had no changes,” according to court transcripts. Later that year, the patient visited the practice complaining of headaches and a droopy eye at which time her primary care physician diagnosed sinusitis and prescribed antibiotics. In 2007, the patient underwent magnetic resonance imaging of the brain and the breast, which revealed widespread metastatic carcinoma. She and her family sued Dr. Minkina and several others in June 2007. The patient died in 2008.
ProMutual settled the case against the defendants for $500,000 in 2008, allocating 30% of the liability to Dr. Minkina, 10% of the nurse practitioner, 60% to the medical practice, and no liability to the other doctors named. ProMutual contended Dr. Minkina bore more responsibility than the other health care professionals named for the delayed diagnosis because of causation factors and standard of care violations, namely that Dr. Minkina should have pursued a biopsy for the patient.
Dr. Minkina sued the insurer in 2012, claiming chiefly that the insurer allocated an unjustifiably high percentage of liability to her because she was no longer insured and because the company had an economic incentive to allocate a disproportionate percentage of responsibility and damages.
A lower court initially dismissed Dr. Minkina’s suit, but the Commonwealth of Massachusetts Appeals Court in 2015 overturned that decision, ruling the case could move forward. In 2018, the superior court agreed Dr. Minkina had a valid bad faith claim, stating that she had provided information about ProMutual’s conduct from which “a reasonable juror could infer the defendant’s bad faith in connection with its settling the underlying malpractice suit, including the allocation of liability.
But Judge Squires-Lee ruled that trial evidence showed that ProMutual did not act for its own benefit or favor other insureds over Dr. Minkina. The judge wrote that the insurer satisfied its contractual and legal obligations when defending the underlying legal claim.
Dr. Minkina said she was disappointed with the ruling, but that she is considering her legal avenues.
“[The] judge’s decision in my case against ProMutual is obviously disappointing, but it is not the first time [the] trial court decided against me in this case,” Dr. Minkina said in an interview. “It is a battle between David and Goliath, [a] single physician against [a] $3.6 billion insurance company with unlimited resources. The decision has just been announced and it is voluminous. I am still reading it and evaluating my options with my attorneys, but it is not the end of the road yet.”
ProMutual declined to comment about the decision.
Tennessee’s Medicaid block grant proposal could have deep impacts
In late September, Gov. Bill Lee (R) submitted a draft proposal to the Trump administration requesting the government convert the federal share of the state’s Medicaid funding into a $7.9 billion lump sum.
Under the proposal, the federal spending cap would apply to currently eligible children and adults, patients covered based on disability, and currently eligible seniors, but not to newly eligible patients, prescription drugs, dually eligible enrollees, and reimbursement to disproportionate-share hospitals and critical access hospitals. The proposed block grant would increase on a per capita basis for new patients and would adjust annually for inflation.
Gov. Lee contends the block grant would allow for more efficiency in the state’s Medicaid program – called TennCare – and generate significant savings, which the state would split 50/50 with the federal government, according to the proposal.
“The traditional model of Medicaid financing is an outdated model of fundamentally misaligned incentives,” Gov. Lee said in the waiver request. “New models of Medicaid financing are needed that reward states for promoting value and health, not merely spending more money. Tennessee’s Medicaid block grant proposal represents a natural progression of the state’s history of nationally recognized innovation and financial management. It also ensures that TennCare members continue to receive high-quality, cost-effective care well into the future.”
Tennessee’s proposal aims to provide care to low-income recipients more efficiently, while breaking Medicaid’s “perverse dynamic” in which states seek to extract more money from the federal government, said Doug Badger, a visiting fellow in domestic policy studies at the conservative-leaning Heritage Foundation.
“The waiver would incentivize Tennessee to reduce federal spending while maintaining access to care,” Mr. Badger said in an interview. “It is an idea worth testing. Tennessee will have to convince federal officials that its proposal would maintain quality of care without increasing federal spending. If they clear those hurdles, the federal government should approve the waiver.”
However, Dan Hawkins, senior vice president for public policy and research at the nonpartisan National Association of Community Health Centers said the proposal contains some concerning omissions and extreme demands that could affect access to care. For instance, the waiver calls for complete exemption from federal Medicaid requirements, including managed care rules that ensure access and network adequacy protections, pregnancy care rules, requirements pertaining to the treatment of disabled adults and children, and early and periodic screening, diagnostic, and treatment (EPSDT) requirements. Under the waiver, the state would no longer be subject to federal oversight for its enrollment, coverage, or management decisions.
“The most shocking thing is that [Tennessee has] provided no estimate of impact on the population served, either in terms of their health or their ability to access care or the amount of money it would cost to serve them,” Mr. Hawkins said in an interview. “They are essentially saying, ‘Send [the block grant] to us and go away.’ ”
Without the federal protections, Tennessee could take any number of measures to reduce costs, adds Andy Schneider a research professor at Georgetown University and an analyst for Georgetown University Health Policy Institute’s Center for Children and Families, both in Washington. Mr. Schneider served as a senior advisor at the Centers for Medicare & Medicaid Services under the Obama administration.
“What would the state do in a world where it no longer had to follow federal rules in contracting with risk-based managed care organizations [MCOs] and in a world where it wanted to save money?” Mr. Schneider said in an interview. “Well, without the federal protections, it could reduce its payments on behalf of enrolled beneficiaries to the MCOs, it could not require the MCOs to have adequate provider networks, not require the MCOs to describe what services they were or were not providing, it could eliminate appeals protections for beneficiaries. Just let your imagination run wild.”
It is uncertain whether the waiver will be approved. Mr. Hawkins noted that CMS leadership has expressed support for the notion of a block grant. In his 2020 fiscal year federal budget for example, President Trump proposed a number of changes to Medicaid, including the potential for state Medicaid block grants or per capita caps. The Office of Management and Budget, meanwhile, is currently preparing guidance for state governments on creating block grants for Medicaid.
“On the other hand, this proposal is so outrageous I have to believe that even the federal government, even CMS, would blanch and come back requiring some additional changes in return for approving the proposal,” Mr. Hawkins said.
Mr. Schneider believes if the block grant is approved, it will likely face immediate litigation.
“The Department of Health & Human Services does not have the authority to give the state a block grant, only Congress can do that,” said Mr. Schneider who recently blogged about the proposal. “The reason for that is that, as the state makes clear in its proposal, it wants to reimagine the traditional Medicaid financing arrangement. That traditional financing arrangement has been in place since 1965. The executive branch can’t [change] it. It simply does not have the authority.”
Mr. Badger emphasized there is no shortage of speculation about the impact of fixed Medicaid allotments. What is needed now, he said, is evidence.
“A well-designed demonstration project will yield that evidence,” he said. “The statute gives the [HHS] Secretary authority to authorize demonstrations precisely to replace speculation with data. The best way to assess the impact of a fixed allotment is to test it in the real world.”
Tennessee will hold public hearings about its proposal in early October and collect feedback through Oct. 18. A final proposal is expected in November.
In late September, Gov. Bill Lee (R) submitted a draft proposal to the Trump administration requesting the government convert the federal share of the state’s Medicaid funding into a $7.9 billion lump sum.
Under the proposal, the federal spending cap would apply to currently eligible children and adults, patients covered based on disability, and currently eligible seniors, but not to newly eligible patients, prescription drugs, dually eligible enrollees, and reimbursement to disproportionate-share hospitals and critical access hospitals. The proposed block grant would increase on a per capita basis for new patients and would adjust annually for inflation.
Gov. Lee contends the block grant would allow for more efficiency in the state’s Medicaid program – called TennCare – and generate significant savings, which the state would split 50/50 with the federal government, according to the proposal.
“The traditional model of Medicaid financing is an outdated model of fundamentally misaligned incentives,” Gov. Lee said in the waiver request. “New models of Medicaid financing are needed that reward states for promoting value and health, not merely spending more money. Tennessee’s Medicaid block grant proposal represents a natural progression of the state’s history of nationally recognized innovation and financial management. It also ensures that TennCare members continue to receive high-quality, cost-effective care well into the future.”
Tennessee’s proposal aims to provide care to low-income recipients more efficiently, while breaking Medicaid’s “perverse dynamic” in which states seek to extract more money from the federal government, said Doug Badger, a visiting fellow in domestic policy studies at the conservative-leaning Heritage Foundation.
“The waiver would incentivize Tennessee to reduce federal spending while maintaining access to care,” Mr. Badger said in an interview. “It is an idea worth testing. Tennessee will have to convince federal officials that its proposal would maintain quality of care without increasing federal spending. If they clear those hurdles, the federal government should approve the waiver.”
However, Dan Hawkins, senior vice president for public policy and research at the nonpartisan National Association of Community Health Centers said the proposal contains some concerning omissions and extreme demands that could affect access to care. For instance, the waiver calls for complete exemption from federal Medicaid requirements, including managed care rules that ensure access and network adequacy protections, pregnancy care rules, requirements pertaining to the treatment of disabled adults and children, and early and periodic screening, diagnostic, and treatment (EPSDT) requirements. Under the waiver, the state would no longer be subject to federal oversight for its enrollment, coverage, or management decisions.
“The most shocking thing is that [Tennessee has] provided no estimate of impact on the population served, either in terms of their health or their ability to access care or the amount of money it would cost to serve them,” Mr. Hawkins said in an interview. “They are essentially saying, ‘Send [the block grant] to us and go away.’ ”
Without the federal protections, Tennessee could take any number of measures to reduce costs, adds Andy Schneider a research professor at Georgetown University and an analyst for Georgetown University Health Policy Institute’s Center for Children and Families, both in Washington. Mr. Schneider served as a senior advisor at the Centers for Medicare & Medicaid Services under the Obama administration.
“What would the state do in a world where it no longer had to follow federal rules in contracting with risk-based managed care organizations [MCOs] and in a world where it wanted to save money?” Mr. Schneider said in an interview. “Well, without the federal protections, it could reduce its payments on behalf of enrolled beneficiaries to the MCOs, it could not require the MCOs to have adequate provider networks, not require the MCOs to describe what services they were or were not providing, it could eliminate appeals protections for beneficiaries. Just let your imagination run wild.”
It is uncertain whether the waiver will be approved. Mr. Hawkins noted that CMS leadership has expressed support for the notion of a block grant. In his 2020 fiscal year federal budget for example, President Trump proposed a number of changes to Medicaid, including the potential for state Medicaid block grants or per capita caps. The Office of Management and Budget, meanwhile, is currently preparing guidance for state governments on creating block grants for Medicaid.
“On the other hand, this proposal is so outrageous I have to believe that even the federal government, even CMS, would blanch and come back requiring some additional changes in return for approving the proposal,” Mr. Hawkins said.
Mr. Schneider believes if the block grant is approved, it will likely face immediate litigation.
“The Department of Health & Human Services does not have the authority to give the state a block grant, only Congress can do that,” said Mr. Schneider who recently blogged about the proposal. “The reason for that is that, as the state makes clear in its proposal, it wants to reimagine the traditional Medicaid financing arrangement. That traditional financing arrangement has been in place since 1965. The executive branch can’t [change] it. It simply does not have the authority.”
Mr. Badger emphasized there is no shortage of speculation about the impact of fixed Medicaid allotments. What is needed now, he said, is evidence.
“A well-designed demonstration project will yield that evidence,” he said. “The statute gives the [HHS] Secretary authority to authorize demonstrations precisely to replace speculation with data. The best way to assess the impact of a fixed allotment is to test it in the real world.”
Tennessee will hold public hearings about its proposal in early October and collect feedback through Oct. 18. A final proposal is expected in November.
In late September, Gov. Bill Lee (R) submitted a draft proposal to the Trump administration requesting the government convert the federal share of the state’s Medicaid funding into a $7.9 billion lump sum.
Under the proposal, the federal spending cap would apply to currently eligible children and adults, patients covered based on disability, and currently eligible seniors, but not to newly eligible patients, prescription drugs, dually eligible enrollees, and reimbursement to disproportionate-share hospitals and critical access hospitals. The proposed block grant would increase on a per capita basis for new patients and would adjust annually for inflation.
Gov. Lee contends the block grant would allow for more efficiency in the state’s Medicaid program – called TennCare – and generate significant savings, which the state would split 50/50 with the federal government, according to the proposal.
“The traditional model of Medicaid financing is an outdated model of fundamentally misaligned incentives,” Gov. Lee said in the waiver request. “New models of Medicaid financing are needed that reward states for promoting value and health, not merely spending more money. Tennessee’s Medicaid block grant proposal represents a natural progression of the state’s history of nationally recognized innovation and financial management. It also ensures that TennCare members continue to receive high-quality, cost-effective care well into the future.”
Tennessee’s proposal aims to provide care to low-income recipients more efficiently, while breaking Medicaid’s “perverse dynamic” in which states seek to extract more money from the federal government, said Doug Badger, a visiting fellow in domestic policy studies at the conservative-leaning Heritage Foundation.
“The waiver would incentivize Tennessee to reduce federal spending while maintaining access to care,” Mr. Badger said in an interview. “It is an idea worth testing. Tennessee will have to convince federal officials that its proposal would maintain quality of care without increasing federal spending. If they clear those hurdles, the federal government should approve the waiver.”
However, Dan Hawkins, senior vice president for public policy and research at the nonpartisan National Association of Community Health Centers said the proposal contains some concerning omissions and extreme demands that could affect access to care. For instance, the waiver calls for complete exemption from federal Medicaid requirements, including managed care rules that ensure access and network adequacy protections, pregnancy care rules, requirements pertaining to the treatment of disabled adults and children, and early and periodic screening, diagnostic, and treatment (EPSDT) requirements. Under the waiver, the state would no longer be subject to federal oversight for its enrollment, coverage, or management decisions.
“The most shocking thing is that [Tennessee has] provided no estimate of impact on the population served, either in terms of their health or their ability to access care or the amount of money it would cost to serve them,” Mr. Hawkins said in an interview. “They are essentially saying, ‘Send [the block grant] to us and go away.’ ”
Without the federal protections, Tennessee could take any number of measures to reduce costs, adds Andy Schneider a research professor at Georgetown University and an analyst for Georgetown University Health Policy Institute’s Center for Children and Families, both in Washington. Mr. Schneider served as a senior advisor at the Centers for Medicare & Medicaid Services under the Obama administration.
“What would the state do in a world where it no longer had to follow federal rules in contracting with risk-based managed care organizations [MCOs] and in a world where it wanted to save money?” Mr. Schneider said in an interview. “Well, without the federal protections, it could reduce its payments on behalf of enrolled beneficiaries to the MCOs, it could not require the MCOs to have adequate provider networks, not require the MCOs to describe what services they were or were not providing, it could eliminate appeals protections for beneficiaries. Just let your imagination run wild.”
It is uncertain whether the waiver will be approved. Mr. Hawkins noted that CMS leadership has expressed support for the notion of a block grant. In his 2020 fiscal year federal budget for example, President Trump proposed a number of changes to Medicaid, including the potential for state Medicaid block grants or per capita caps. The Office of Management and Budget, meanwhile, is currently preparing guidance for state governments on creating block grants for Medicaid.
“On the other hand, this proposal is so outrageous I have to believe that even the federal government, even CMS, would blanch and come back requiring some additional changes in return for approving the proposal,” Mr. Hawkins said.
Mr. Schneider believes if the block grant is approved, it will likely face immediate litigation.
“The Department of Health & Human Services does not have the authority to give the state a block grant, only Congress can do that,” said Mr. Schneider who recently blogged about the proposal. “The reason for that is that, as the state makes clear in its proposal, it wants to reimagine the traditional Medicaid financing arrangement. That traditional financing arrangement has been in place since 1965. The executive branch can’t [change] it. It simply does not have the authority.”
Mr. Badger emphasized there is no shortage of speculation about the impact of fixed Medicaid allotments. What is needed now, he said, is evidence.
“A well-designed demonstration project will yield that evidence,” he said. “The statute gives the [HHS] Secretary authority to authorize demonstrations precisely to replace speculation with data. The best way to assess the impact of a fixed allotment is to test it in the real world.”
Tennessee will hold public hearings about its proposal in early October and collect feedback through Oct. 18. A final proposal is expected in November.