Law Commons^™

The Medicare Appeals Crisis: Why Mediation Is The Medicine, Michelle Ellis

Pepperdine Dispute Resolution Law Journal

This article will explore how unmeritorious RAC-reversals recently polluted the Medicare appeals process, and how this has led to a crisis for both providers and the United States Department of Health & Human Services (HHS). Furthermore, this article will consider the lack of available remedies and narrow measures taken by HHS, and will instead advocate for mediation as the best means of easing the backlog. While the delays also directly affect Medicare beneficiaries, this article will limit its discussion to the backlog in relation to providers and suppliers.

Covering The Care: Health Insurance Coverage In New Hampshire, Jo Porter, Lucy Hodder

Law Faculty Scholarship

the first in a series of data and policy briefs that seek to inform the current conversations about health reform happening across the state. The first brief uses data from the American Community Survey to provide information about the health insurance coverage landscape in NH.

Healthism, Intersectionality, And Health Insurance: The Compounded Problems Of Healthist Discrimination

Marquette Benefits and Social Welfare Law Review

Healthism can identify situations where a person is subject to a particular form of bigotry based on their individual health status. In health insurance, some forms of healthism are unavoidable due to the very nature of health insurance structures. However, when analyzing health insurance programs, particularly those that are funded through government, it is possible to utilize a healthism framework to, first, recognize and minimize and potentially ameliorate the worst effects of healthism combined with intersectionality. This Essay analyzes these issues as they relate to health insurance, Medicare, and the potential role of the Independent Payment Advisory Board.

When Is Competition Not Competition: The Curious Case Of Medicare Advantage, Robert A. Berenson

Saint Louis University Journal of Health Law & Policy

Policymakers routinely assume that Medicare Advantage plans and the traditional Medicare program compete for beneficiaries. Yet the District of Columbia federal district court blocked the proposed Aetna and Humana merger, finding that for purposes of antitrust analysis Medicare Advantage plans and traditional Medicare are effectively in different product markets. That is, they do not compete. This article reviews the basis for the court decision, which relied to a large extent on information that Medicare beneficiaries select their insurance coverage based on durable preferences either for the Medicare Advantage or the traditional Medicare option.

The article explores whether the apparently durable …

Macra And Stark: Strange Bedfellows At The Heart Of Health Care Reform, Rebecca Olavarria

Journal Publications

The enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was well-received by all as it repealed Medicare’s Sustainable Growth Rate and, in its place, mandates the implementation of a new system for health care delivery and payment. Under MACRA, health care providers are expected to work together and coordinate their efforts with the goal of improving patient outcomes and controlling costs. For the first time ever, federal reimbursements will be tied to quality of care and improved cost efficiencies. However, as a new law, MACRA’s potential for success needs to be measured in terms of its …

Federalism And Health Care In Canada: A Troubled Romance?, Colleen M. M. Flood, William Lahey Prof., Bryan P. Thomas

Articles, Book Chapters, & Popular Press

Canadian federalism fragments health system governance. Although the Constitution has been interpreted as providing shared jurisdiction over health generally, with respect to health care, the courts have interpreted it as giving direct jurisdiction to the provinces. The federal role in health care is therefore indirect, but nevertheless potentially powerful. For example, the federal government has used its spending powers to establish the Canada Health Act (CHA), which commits funding to provinces on condition they provide first-dollar public coverage of hospital and physician services. However, in recent times, as federal contributions have declined, the CHA has been weakly enforced. …

Health Information Equity, Craig Konnoth

Publications

In the last few years, numerous Americans’ health information has been collected and used for follow-on, secondary research. This research studies correlations between medical conditions, genetic or behavioral profiles, and treatments, to customize medical care to specific individuals. Recent federal legislation and regulations make it easier to collect and use the data of the low-income, unwell, and elderly for this purpose. This would impose disproportionate security and autonomy burdens on these individuals. Those who are well-off and pay out of pocket could effectively exempt their data from the publicly available information pot. This presents a problem which modern research ethics …

Disparities In Private Health Insurance Coverage Of Skilled Care, Stacey A. Tovino

Scholarly Works

This article compares and contrasts public and private health insurance coverage of skilled medical rehabilitation, including cognitive rehabilitation, physical therapy, occupational therapy, speech-language pathology, and skilled nursing services (collectively, skilled care). As background, prior scholars writing in this area have focused on Medicare coverage of skilled care and have challenged coverage determinations limiting Medicare coverage to beneficiaries who are able to demonstrate improvement in their conditions within a specific period of time (the Improvement Standard). By and large, these scholars have applauded the settlement agreement approved on 24 January 2013, by the U.S. District Court for the District of Vermont …

The Uncharted Waters Of Competition And Innovation In Biological Medicines, Erika Lietzan

Faculty Publications

In 2010, Congress fundamentally changed how federal law encourages the discovery and development of certain new medicines and for the first time authorized less expensive “duplicates” of these medicines to be approved and compete in the marketplace. The medicines at issue are biological medicines, generally made from, or grown in, living systems. Many of the world’s most important and most expensive medicines for serious and life–threatening diseases are biological medicines.

We have a profound interest in understanding and evaluating the impact of this legislation on innovation and competition. Scholars and courts considering this question may be tempted to reason from, …