Health Policy Commons^™

How The Supreme Court's Medicaid Decision May Affect Health Centers: An Early Estimate, Katherine J. Hayes, Peter Shin, Sara J. Rosenbaum

Geiger Gibson/RCHN Community Health Foundation Research Collaborative

The nation's federally funded health centers are the principal source of primary health care for medically underserved populations. In CY 2011, more than 1,200 health centers, operating in more than 8,500 urban and rural locations, served 20.2 million patients, 36 percent of whom were uninsured and 93 percent of whom had family incomes below twice the federal poverty level. Federal grants provide core support to health centers, but Medicaid represents the largest single health center financing mechanism, accounting for 39 percent of revenues. Medicaid revenue growth allows health centers to preserve their core grant funding to reach uninsured patients while …

Health Information Privacy In The Correctional Environment, Melissa M. Goldstein

Health Policy and Management Faculty Publications

Information technology is considered a transformative element in health care because it facilitates the transparency and sharing of health information, which have always been central to the practice of medicine and the delivery of high-quality care. The widespread use of electronic health records (EHRs) and electronic health information exchange, among other technologies, is considered essential to improving the quality of care, reducing medical errors, reducing health disparities, and advancing the delivery of patient-centered medical care.

Examining The Evidentiary Basis Of Congress's Commerce Clause Power To Address Individuals' Health Insurance Status, Sara J. Rosenbaum, Leighton C. Ku, Paula M. Lantz, Holly Mead, Michal Mcdowell

Health Policy and Management Faculty Publications

Chief among the issues that the United States Supreme Court considers in United States Department of Health and Human Services et al. v Florida et al. is the questionof whether Congress has the constitutional power to apply a “minimum essential coverage requirement” on most nonelderly Americans. Opponents of the provision (referred to under the Act as the “Individual Responsibility” requirement) argue that compelling individuals to buy affordable health insurance coverage exceeds Congressional powers. By contrast, the United States Department of Justice and supporters of the law assert that the minimum coverage requirement is consistent with a long line of Supreme …

Health Care Outlook For 2011 And Beyond: The Legal, Policy And Political Landscape, Mark L. Hayes

Health Policy and Management Faculty Posters and Presentations

No abstract provided.

Medicaid And Access To The Courts, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

The Medicaid program is grounded in a statute that is one of the most complex of all federal laws. An insurer of more than 60 million people — and poised to begin serving 16 million more by 2019 — Medicaid will be reexamined this year, in all its legal complexities, by the U.S. Supreme Court, which has agreed to hear California's appeal in the case Maxwell-Jolly v. Independent Living Center of Southern California. The Court's ruling could fundamentally alter states' accountability to beneficiaries and providers when their official conduct allegedly violates Medicaid's essential federal requirements.

A "Broader Regulatory Scheme"-- The Constitutionality Of Health Care Reform, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

The fundamental goal of the ACA is no less than the preservation of the U.S. health care system. In a country that depends on health insurance to finance care, preservation cannot happen without a comprehensive regulatory scheme that reaches from coast to coast and sets the minimum rules of market entry and operation for health insurers. The glide path to this new system is long and complex, but the law's end point is clear and visionary, and its constitutionality--at least in this first round--is incontrovertible.

Medical-Legal Partnerships: Addressing The Unmet Legal Needs Of Health Center Patients, Peter Shin, Fraser Rothenberg Byrne, Emily Jones, Joel B. Teitelbaum, Lee Repasch, Sara J. Rosenbaum

Geiger Gibson/RCHN Community Health Foundation Research Collaborative

Medical-legal partnerships (MLPs), now available at over 180 hospitals and health centers across 38 states, are an important option for addressing the legal needs affecting low-income and vulnerable patients, and thereby improving their overall health. We estimate that each year, anywhere between 50 and 85 percent of health centers users - or between ten and 17 million people - experience unmet legal needs, many of which negatively impact their health. In a medical-legal partnership, health care staff at hospitals, clinics, and other sites are trained to screen for health-related legal issues, refer the patient to an affiliated lawyer or legal …

The Health Information Technology Provisions In The American Recovery And Reinvestment Act Of 2009, Taylor Burke

Health Policy and Management Faculty Publications

This installment of Law and the Public’s Health explores the comprehensive reforms contained in the American Recovery and Reinvestment Act of 2009, whose implementation is expected to transform the use of health information technology as part of Medicare, Medicaid, and public health practice.

An Analysis Of The Implications Of The Stupak/Pitts Amendment For Coverage Of Medically Indicated Abortions, Sara J. Rosenbaum, Lara Cartwright-Smith, Ross Margulies, Susan F. Wood, D. Richard Mauery

Health Policy and Management Faculty Publications

This analysis examines the implications for coverage of medically indicated abortions under the Stupak/Pitts Amendment (Stupak/Pitts) to H.R. 3962, the Affordable Health Care for America Act. In this analysis we focus on the Amendment's implications for the health benefit services industry as a whole. We also consider the Amendment's implications for the growth of a market for public or private supplemental coverage of medically indicated abortions. Finally, we examine the issues that may arise as insurers attempt to implement coverage determinations in which abortion may be a consequence of a condition, rather than the primary basis of treatment.

Analysis Of The Extent To Which State Insurance Laws Mandate Coverage And Payment Of Vaccines And Vaccine Administration Fees During Periods Of Declared Public Health Emergencies, Sara J. Rosenbaum, Nancy Lopez, Ross Margulies

Health Policy and Management Faculty Publications

This analysis examines whether state insurance laws require health insurers, as a condition of doing business, to pay the costs associated with the administration of immunizations during declared public health emergencies. As is the case with the current H1N1 emergency, a public health emergency triggers nationwide distribution of free vaccine. But even when vaccine is distributed free of charge, its administration poses costs to private physicians and charges can be significant. As a result, the Institute of Medicine has identified vaccine administration as a potential financial barrier to care. Most communities have limited numbers of public health workers and professional …

Health Care Fraud, Sara J. Rosenbaum, Nancy Lopez, Scott Stifler

Health Policy and Management Faculty Publications

Adequate safeguards against health care fraud are essential to the proper functioning of any health care system. This analysis examines health care fraud in the U.S., and its findings underscore the importance to national health reform of comprehensive anti-fraud protections covering both public and private health insurance industry. This analysis, funded by the Robert Wood Johnson Foundation, examines health care fraud in a national policy context.

Do Medicaid And Chip Measure Errors Correctly?, Leighton C. Ku

Health Policy and Management Issue Briefs

Measuring and reducing errors in Medicaid and CHIP is important, but the current program and the proposed regulatory provisions are flawed and misleading. Reducing errors should involve not only reducing payments that are issued in error, but reducing the rate at which eligible applicants are erroneously denied Medicaid coverage. CMS should give develop a better, more valid approach to error determination when there are cases of missing or insufficient provider or eligibility data and issue a new proposed rule that offers a new approach or approaches.

The Application Of The Emergency Medical Treatment And Labor Act (Emtala) To Hospital Inpatients, Lara Cartwright-Smith, Sara J. Rosenbaum, Karen Belli, Elaine Purcell, Tasmeen S. Weik

Health Policy and Management Issue Briefs

This issue brief provides a brief overview of the Emergency Medical Treatment and Labor Act (EMTALA) and focuses on its application to hospital inpatients. EMTALA applies differently to patients than non-patients, and also applies differently to patients admitted through the emergency department than patients admitted as regular inpatients. In addition, courts and the Centers for Medicare and Medicaid Services (CMS) have differed in their interpretation of the statute. Depending on the specific facts of any particular case, EMTALA may or may not have implications for specialty-related transfers and discharges.

Medicaid And Case Management To Promote Healthy Child Development, Sara J. Rosenbaum, Kay Johnson, Emily Jones, Anne R. Markus

Health Policy and Management Faculty Publications

This policy brief presents options for financing and delivering case management services to low-income and special-needs children in Medicaid. The analysis builds on a literature review of case management, a review of the legal underpinnings of Medicaid case management, and consultation with experts in the fields of health care finance and program operations. It aims to inform the policy community about the importance of case management for assuring the health and development of our youngest and most vulnerable children.

Health Information Technology In The United States: On The Cusp Of Change, 2009, Sara J. Rosenbaum, Melissa M. Goldstein, Lee Repasch, Catherine M. Desroches, Ashish K. Jha

Health Policy and Management Faculty Publications

In this report we use the data collected for ONCHIT to focus on EHR adoption in the inpatient setting. We report on several important policy issues. These include the rate of adoption of EHRs among U.S. hospitals generally and among safety-net hospitals, changes in both state and federal policy, and the potential of EHRs to change the quality measurement enterprise.

An Assessment Of Legal Issues Raised In "High Performing" Health Plan Quality And Efficiency Tiering Arrangements: Can The Patient Be Saved?, Sara J. Rosenbaum, Sarah Kornblet, Phyllis Borzi

Health Policy and Management Faculty Publications

A legal analysis released by The George Washington University School of Public Health and Health Services and the Robert Wood Johnson Foundation affirms the legality under federal and state law of physician ranking systems used by health plan provider networks. This analysis examines seven types of possible legal allegations against physicians tiering, concluding how the approach is undertaken plays a significant role in determining legal backlash.

An Analysis Of The Medicaid Imd Exclusion, Sara J. Rosenbaum, Joel B. Teitelbaum, D. Richard Mauery

Health Policy and Management Faculty Publications

This report examines the Medicaid Institutions for Mental Disease (IMD) exclusion, one of the very few instances in which federal Medicaid law prohibits federal contribution to the cost of medically necessary care furnished by licensed medical care providers to enrolled program beneficiaries. The report begins with a brief overview of Medicaid's role in financing care for conditions and illnesses classified as "mental diseases" under professional medical guidelines and the allocation of state and federal funding responsibilities under Medicaid. The report then reviews the elements of the Medicaid IMD exclusion, as well as key judicial and administrative rulings related to the …

Behavioral Health And Managed Care Contracting Under Schip, Sara J. Rosenbaum, Colleen Sonosky, Karen Shaw, D. Richard Mauery

Health Policy and Management Issue Briefs

This Policy Brief examines behavioral health managed care contracting under separately administered State Children's Health Insurance Programs (SCHIP), i.e., programs that operate under the direct authority of Title XXI of the Social Security Act rather than as expansions of Medicaid. Most separate SCHIP programs buy managed care style health insurance for some or most of their enrolled children. Because Title XXI provides states with far greater administrative flexibility than Medicaid with respect to coverage and benefit design, provision of services, and administration of managed care arrangements, studying separate SCHIP managed care products sheds important light on how states might approach …

Model Managed Care Contract For Health Professionals And Clinical Providers Of Mental Illness And Addiction Disorder Treatment And Prevention Services, Sara J. Rosenbaum, Joel B. Teitelbaum, Brian Kamoie, D. Richard Mauery

Health Policy and Management Faculty Publications

The contracting process is one that health care professionals oftentimes find complex and confusing. Furthermore, studies of managed care service contracts between managed care organizations and health professionals who furnish mental illness and addiction disorder prevention and treatment services have found that these contracts often heavily favor the managed care organization by allowing the MCO broad latitude over a network professional's service responsibilities, the rate of payment for covered benefits and extensive discretion over treatment decision-making.

As an aid to its members, the American Medical Association (AMA) has drafted a "model" provider agreement that gives physicians in both individual and …

Olmstead V L.C.: Federal Implementation Guidelines, And Analysis Of Recent Cases Regarding Medicaid Coverage Of Long Term Care Services For Persons With Disabilities, Sara J. Rosenbaum

Health Policy and Management Issue Briefs

This analysis reviews the key elements of the United States Supreme Court's 1999 decision in Olmstead v L.C. as well as Federal implementation guidelines issued by the United States Department and Human Services. The Olmstead decision interprets the Americans with Disabilities Act ("ADA," PL 101-336), whose requirements apply to the use of all public funds. However, Medicaid represents the single largest source of public funding for both institutional and non-institutional services for persons with disabilities. As a result, when states expend Medicaid funds on care for persons with disabilities, two independent sets of legal requirements are triggered: those contained in …

The Devolution Of Managed Care Contractor Duties: Analysis And Implications For Public Policy In Managed Behavioral Health Care, Sara J. Rosenbaum, Anne R. Markus, Joel B. Teitelbaum, Marcie Zakheim, Michael Golde

Health Policy and Management Faculty Publications

This study, undertaken by the Center for Health Services Research and Policy at the George Washington University (GWU) School of Public Health and Health Services for the United States Department of Health and Human Services' Substance Abuse and Mental Health Services Administration, analyzes the devolution of the legal duties assumed by managed care organizations (MCOs) in their contracts with group purchasers. Specifically, this study examines the delegation of MCO contractual duties related to member care and services to individual network providers by comparing the language used in master contracts between purchasers and MCOs with the language contained in agreements with …

An Overview Of Legal Developments In Managed Care Caselaw And Selected Case Studies Of Legal Developments In State Contracting For Managed Behavioral Health Services, Sara J. Rosenbaum, D. Richard Mauery, Joel B. Teitelbaum

Health Policy and Management Issue Briefs

This analysis provides an overview of recent legal developments in managed care case law. Three types of cases are reviewed: claims brought by managed care enrollees against managed care companies and health plans; cases related either directly or indirectly to managed care and brought by both beneficiaries and managed care organizations against state Medicaid agencies and other public agencies engaged in the purchase of managed care; and cases brought by individual health professionals against managed care organizations.

Behavioral Health Benefits For Public Employees: Effect Of Mental Health Parity Legislation, Phyllis Borzi, Sara J. Rosenbaum

Health Policy and Management Issue Briefs

Recently, the Center for Health Services Research and Policy through a grant from the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, examined contracts providing for mental health benefits for state employees in eight states to assess whether legislative attempts to require parity between physical and mental illnesses resulted in noticeable differences in behavioral health benefits for state employees.

We concluded that, except in states that have mandated full parity for some or all types of mental illnesses, behavioral health benefits for state employees have not changed significantly as a result of …

Pegram V Herdrich: Implications For Consumer Protections In Managed Care, Sara J. Rosenbaum, Joel B. Teitelbaum

Health Policy and Management Faculty Publications

This Report, prepared for the Substance Abuse and Mental Health Services Administration, provides a brief overview of the United States Supreme Court's landmark decision in Pegram v Herdrich (hereinafter referred to as Herdrich). This report begins with a brief overview of the debate in the courts over how to distinguish between legal challenges to the conduct of managed care companies in which all state remedies are preempted by ERISA and those that may proceed under state law. It then summarizes the facts of the Herdrich case and the Court's holding. The report concludes with a discussion of the implications of …

Selected Key Issues In The Development And Drafting Of Public Managed Behavioral Health Care Carve-Out Contracts, Joel B. Teitelbaum, Sara J. Rosenbaum, William Burgess, Leilani Decourcy

Health Policy and Management Issue Briefs

The development of managed behavioral health care carve-out contracts covering a discrete subset of benefits available for use by persons with mental health and/or substance abuse disorders poses major challenges for public purchasers. This Issue Brief explores several key issues that arise when drafting such agreements. Many of the issues that arise in the drafting of carve-out agreements will require the public purchaser to resolve basic policy questions well before the drafting of requests for proposals or contracts can proceed.

An Overview Of Medicaid Managed Care Litigation, Sara J. Rosenbaum, Joel B. Teitelbaum, Christopher Kirby, Linda Priebe, Tal Klement

Health Policy and Management Issue Briefs

This Issue Brief is intended as one of several in the Managed Behavioral Health Care Issue Brief Series that deals with managed behavioral health care from a purely legal point of view.

Since the enactment of Medicaid in 1965, states have had the option of offering beneficiaries enrollment in managed care arrangements. With the advent of mandatory managed care reaching millions of beneficiaries (including a growing proportion of disabled recipients), the amount and scope of litigation involving Medicaid managed care plans can be expected to grow. A review of the current litigation regarding Medicaid managed care reveals two basic types …

An Evaluation Of Contracts Between Managed Care Organizations And Community Mental Health And Substance Abuse Treatment And Prevention Agencies, Sara J. Rosenbaum, Karen Silver, Elizabeth Wehr

Health Policy and Management Faculty Publications

This study represents a descriptive, point-in-time examination of the structure and content of provider network agreements between managed care organizations (MCOs) and community mental health and substance abuse (MH/SA) treatment and prevention agencies. This is not a study of the quality of managed care systems. Instead, this analysis is designed to assess provider contracts (one of the basic legal instruments on which the managed care system rests) and to identify the meaning of these instruments for MH/SA service providers, group purchasers, MCOs, individual consumers and their families, and public policy.