Health care law newsletter最新文献

Given the complexity of federal Medicaid law and the limitations it imposes on state flexibility, it is likely that states will continue to ask the Secretary to grant waivers under Section 1115 to allow them to pursue new approaches to health care reform. The results of currently operational Section 1115 projects involving statewide managed care systems will be useful in evaluating the Medicaid reform measures currently under discussion in other states and at the federal level. In particular, the ability of the states to control Medicaid and indigent care costs and to utilize federal dollars more efficiently should prove important in evaluating a block grant approach to federal Medicaid funding. Moreover, Section 1115 project results that bear on the sufficiency of various Medicaid capitation rate methodologies will also be of value as more states expand the use of managed care arrangements for their Medicaid populations.

As genetic testing becomes more prevalent and the uses for genetic information multiply, we are likely to witness more demand for comprehensive state legislation on the order of the Oregon law regulating the procedures for obtaining and using genetic information. In addition, the United States Senate has expressed an interest in the subject. The Senate Labor and Human Resources Committee reportedly agreed on August 2, 1995 to include in a health insurance reform bill (S. 1028) language prohibiting health plans from using genetic information when determining eligibility, continuation, enrollment, or contribution requirements. 4 BNA's Health Law Rep. at 1218 (Aug. 10, 1995). Insurance companies continue to maintain that genetic test results are simply another factor that should rightfully be used during underwriting, much as age, medical history, and physical examinations are routinely used today. Right to privacy advocates argue that genetic testing provides employers and insurance companies with too much information and offers a great potential for discrimination. As more states wrestle with this issue, these competing interests are likely to be debated in public forums throughout the country.

If not modified or overturned on appeal, the Dal Cielo decision will very likely have a significant negative impact on the ability of California's organized peer review bodies to conduct frank, candid, and confidential peer review. Dal Cielo appears to permit the Board to subpoena committee minutes, physician credentials files, and live testimony whenever it determines that a physician should be investigated. Further, the impetus for the Board's investigation might be little more than a complaint from a single patient or even a disgruntled former employee of the physician or hospital. Regardless of current and future decisions, however, peer review bodies in California and other states operating under similar court decisions still retain at least some limited means to protect the confidentiality of their evaluative work. If, for example, a peer review body can establish that an investigatory subpoena seeks irrelevant information, is based upon little more than unsubstantiated rumor, or that the medical board has made no efforts to obtain information from other available, non-privileged sources, it may be able to convince a court that the subpoena is not supported by good cause. Peer review organizations should thus consider challenging medical board subpoenas in court to narrow their scope or establish that there is sufficient need for them. If any peer review body is served with an investigatory subpoena by a medical board requesting production of peer review information, it should carefully assess applicable state confidentiality protections.(ABSTRACT TRUNCATED AT 250 WORDS)

The Court's decision in Schleier leaves the taxation of recoveries arising out of employment disputes, as well as many other types of disputes, in a state of confusion. To be sure, employers and employees now know with certainty that recoveries under the ADEA are not excludable from income under Section 104(a)(2). Recoveries under other statutes, however, including the Fair Labor Standards Act and the 1991 version of Title VII of the Civil Rights Act of 1964, are altogether unclear after Schleier. In the absence of further guidance, employers should consider adopting a more conservative approach to employment dispute settlements by treating settlement payments as taxable income, subject to withholding and employment taxes.

The joint antitrust enforcement statement for physician networks was designed in part to dispel uncertainty in the physician community about antitrust agency law enforcement intentions. In the two years since its issuance, the antitrust agencies have generally, but not always, been consistent in applying the methodology and standards set forth in their enforcement statement. Even though agency pronouncements like the enforcement statement are not binding on private parties or the federal courts, both the statement and subsequent advisory opinions and business review letters have been exceptionally helpful, if not always encouraging, to health care providers in their antitrust planning efforts.

While there have been no reported cases as yet on the subject of ERISA preemption of claims arising from utilization review decisions by providers, it will unquestionably be a significant issue facing providers that participate in capitated arrangements. If preemption is determined not to be available, providers will be exposed to risks from which health plans are currently shielded. Providers conducting utilization review should be following this issue as it develops, but should also be obtaining insurance for this risk to the extent it is available (e.g., it will not be available for punitive damages). Providers should also consider negotiating provisions in their contracts with health plans to the effect that any utilization review conducted by the provider is on behalf of the health plan and that the provider's utilization review activities will be covered under the health plan's liability insurance.

The new PRM provisions provide helpful guidance to SNFs in submitting requests for exceptions to cost limits. However, they also make the process more rigid and create procedural traps for the unwary. Accordingly, SNFs are advised to study the PRM sections to assure that their exception requests contain the required information. However, they should not feel bound by the limits in the PRM. When submitting requests, SNFs should think creatively about why their facilities are atypical and how to best quantify their higher costs. They should then protect their rights by including these more creative theories or calculations in the materials they submit to the intermediaries.

Timing issues will continue to be at the forefront of insurance coverage disputes for a long time, and may impact not only the question of which insurer is responsible for a particular loss, but also whether any coverage exists at all. For example, if a policyholder has self-insured for any period, the timing issue may well determine whether purchased liability insurance will afford any protection for the loss. Though courts have provided useful guidelines, in order to determine coverage the facts of each case must be carefully examined, particularly the policy language and the nature of the injury on which the claim is founded. When there are difficult timing questions, one viable approach may be for the policyholder to select a "target" insurer to sue for coverage, based in part on the timing analysis, and leave to the targeted insurer the task of seeking contribution from all other carriers potentially responsible for covering the loss.

"No third party beneficiaries" clauses, if drafted with care, can offer some measure of protection to providers. Although courts may give minimal weight to "boilerplate" clauses in determining contractual intent, a more detailed and substantive clause may be more persuasive. In drafting such clauses, however, care should be taken to clearly state the specific intentions of the parties, including the scope and purposes of the contract, the identity of the intended beneficiaries, and the classes of persons that are to be excluded as beneficiaries (e.g., HMO enrollees).