Justia Health Law Opinion Summaries

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Once a person turns 65 or has received federal disability benefits for 24 months, he becomes “entitled” to Medicare Part A, 42 U.S.C. 426(a)–(b) benefits. Not all patients who qualify for Medicare Part A have their hospital treatment paid for by the program; a patient’s stay may exceed Medicare’s 90-day cap or a patient may be covered by private insurance.Medicare pays hospitals a fixed rate for in-patient treatment based on the patient’s diagnosis, regardless of the hospital’s actual cost, subject to the “disproportionate share hospital” (DSH) adjustment, which provides higher-than-usual rates to hospitals that serve a higher-than-usual percentage of low-income patients. The DSH adjustment is calculated by adding the Medicare fraction (proportion of a hospital’s Medicare patients who have low incomes) and the Medicaid fraction (proportion of a hospital’s total patients who are not entitled to Medicare and have low incomes). A 2004 HHS regulation provides: If the patient meets the basic statutory criteria for Medicare, that patient counts in the denominator and, if poor, in the numerator of the Medicare fraction. The Ninth Circuit declared the regulation invalid.The Supreme Court reversed. In calculating the Medicare fraction, individuals “entitled to" Medicare Part A benefits are all those qualifying for the program, regardless of whether they receive Medicare payments for a hospital stay. Counting everyone who qualifies for Medicare benefits in the Medicare fraction—and no one who qualifies for those benefits in the Medicaid fraction—accords with the statute’s attempt to capture, through separate measurements, two different segments of a hospital’s low-income patient population. Throughout the Medicare statute, “entitled to benefits” is essentially a term of art meaning “qualifying for benefits” and coexists with limitations on payment. View "Becerra v. Empire Health Foundation, For Valley Hospital Medical Center" on Justia Law

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Mississippi’s Gestational Age Act provides that “[e]xcept in a medical emergency or in the case of a severe fetal abnormality, a person shall not intentionally or knowingly perform . . . or induce an abortion of an unborn human being if the probable gestational age of the unborn human being has been determined to be greater than fifteen (15) weeks.” The Fifth Circuit affirmed an injunction, prohibiting enforcement of the Act.The Supreme Court reversed, overruling its own precedent. The Constitution does not confer a right to abortion; the authority to regulate abortion belongs to state representatives. Citing the “faulty historical analysis” in Roe v. Wade, the justices concluded that the right to abortion is not deeply rooted in the nation’s history and tradition; regulations and prohibitions of abortion are governed by the same “rational basis” standard of review as other health and safety measures. The justices analyzed “great common-law authorities,” concerning the historical understanding of ordered liberty. “Attempts to justify abortion through appeals to a broader right to autonomy and to define one’s ‘concept of existence’ … could license fundamental rights to illicit drug use, prostitution, and the like.”Noting “the critical moral question posed by abortion,” the justices compared their decision to Brown v. Board of Education in overruling Plessy v. Ferguson, which “was also egregiously wrong.” Roe conflated the right to shield information from disclosure and the right to make and implement important personal decisions without governmental interference and produced a scheme that "looked like legislation," including a “glaring deficiency” in failing to justify the distinction it drew between pre- and post-viability abortions. The subsequently-described “undue burden” test is unworkable in defining a line between permissible and unconstitutional restrictions. Traditional reliance interests are not implicated because getting an abortion is generally an “unplanned activity,” and “reproductive planning could take virtually immediate account of any sudden restoration of state authority to ban abortions.” The Court emphasized that nothing in this opinion should be understood to cast doubt on precedents that do not concern abortion.Mississippi’s Gestational Age Act is supported by the Mississippi Legislature’s specific findings, which include the State’s asserted interest in “protecting the life of the unborn.” View "Dobbs v. Jackson Women's Health Organization" on Justia Law

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The Supreme Court reversed the judgment of the trial court permanently enjoining the Texas Department of State Health Services from enforcing a new Texas law that prohibited the processing and manufacturing of smokable hemp products, holding that Plaintiffs were not entitled to relief.In their complaint, Plaintiffs - Texas-based entities that manufacture, process, distribute, and sell hemp products - argued that Tex. Const. art. I, 19 invalidated the challenged law and sought an injunction prohibiting Defendant from enforcing the law. The trial court declared that Tex. Health & Safety Code 443.202(4) violated the Texas Constitution and that 25 Tex. Admin. Code 300.104 was invalid in its entirety and enjoined Defendant from enforcing the statute or the rule. The Supreme Court reversed, holding that Plaintiffs' complaints did not assert the deprivation of an interest substantively protected by the Texas Constitution's due course clause. View "Texas Department of State Health Services v. Crown Distributing LLC" on Justia Law

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St. Vincent Hospital adopted a COVID-19 vaccine requirement. Employees had until November 12, 2021 to get vaccinated unless they received a medical or religious exemption. In reviewing exemption requests, St. Vincent considered the employee’s position and amount of contact with others, the current health and safety risk posed by COVID, and the cost and effectiveness of other safety protocols. Dr. Halczenko treated gravely ill children, including those suffering from or at risk of organ failure.St. Vincent denied Halczenko’s request for religious accommodation on the ground that “providing an exemption to a Pediatric Intensivist working with acutely ill pediatric patients poses more than a de minim[i]s burden to the hospital because the vaccine provides an additional level of protection in mitigating the risk associated with COVID.” Halczenko and four other St. Vincent employees filed an EEOC complaint. The others—a nurse practitioner and three nurses, including two in the pediatric ICU—were granted religious accommodations. St. Vincent terminated Halczenko’s employment. Halczenko attributes his lack of success in finding new work to his non-compete agreement with St. Vincent, his preference not to move his family, and the limited demand for an unvaccinated physician in his specialty. In a purported class action, the Seventh Circuit affirmed the denial of preliminary relief, concluding that Halczenko had shown neither irreparable harm nor an inadequate remedy at law. View "Halczenko v. Ascension Health, Inc." on Justia Law

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Zelda Sheppard appealed a superior court’s affirmance of an Industrial Accident Board (“IAB” or “Board”) decision granting Allen Family Foods’ (“Employer”) Petition for Review (“Petition”). The IAB determined that Sheppard’s prescribed narcotic pain medications were no longer compensable. Sheppard sought to dismiss the Petition at the conclusion of Employer’s case-in-chief during the IAB hearing, arguing that the matter should have been considered under the utilization review process. After hearing the case on the merits, the IAB disagreed, holding that Employer no longer needed to compensate Sheppard for her medical expenses after a two-month weaning period from the narcotic pain medications. On appeal, Sheppard argued the IAB erred as a matter of law when it denied Sheppard’s Motion to Dismiss Employer’s Petition because Employer failed to articulate a good faith change in condition or circumstance relating to the causal relationship of Sheppard’s treatment to the work injury. Accordingly, Sheppard argued that the Employer was required to proceed with the utilization review process before seeking termination of her benefits. The Delaware Supreme Court determined the IAB’s decision was supported by substantial evidence, therefore the superior court’s decision was affirmed. View "Sheppard v. Allen Family Foods" on Justia Law

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The Supreme Court reversed the judgment of the court of appeals dismissing as moot S.A.M.'s appeal of the order extending his voluntary commitment (recommitment) and affirmed the recommitment order, holding that the appeal of the expired recommitment order was not moot and that S.A.M.'s due process and insufficiency of the evidence claims were without merit.Sauk County successfully petitioned to have S.A.M. involuntary committed to its care for compelled treatment. Before the initial commitment order expired, the County petitioned to extend S.A.M.'s commitment. After a trial, the circuit court found grounds for a recommitment order. S.A.M. appealed, but the court of appeals dismissed the appeal because the recommitment order expired before the court could decide the merits of the appeal. The Supreme Court reversed, holding (1) two collateral consequences raised here rendered the appeal of the expired recommitment order not moot; but (2) on the merits, S.A.M.'s arguments were unavailing. View "Sauk County v. S.A.M." on Justia Law

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Defendant and several others were indicted on various healthcare fraud offenses stemming from a scheme in which Defendant and others would pay TRICARE beneficiaries to order certain creams and vitamins. At a jury trial, Defendant was convicted of one count of conspiracy to commit health care fraud, one count of receiving an illegal kickback payment, and six counts of making illegal kickback payments. The District Court sentenced Defendant to 240 months imprisonment.On appeal, Defendant challenged, among other things, the sufficiency of the evidence pertaining to his convictions for paying illegal kickbacks. The Fifth Circuit agreed with Defendant's reasoning that he did not "induce" TRICARE beneficiaries to order the substances by paying them because the substances were for their own use. Thus, the court reversed Defendant's convictions for paying illegal kickback payments. The court affirmed Defendant's other convictions and remanded for resentencing. View "USA v. Cooper" on Justia Law

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Lash, a 60-year-old, obese man with a remote history of smoking and high blood pressure, was traveling when he experienced shortness of breath and chest discomfort. He went to Sparta hospital. An EKG, blood work, and a chest x-ray revealed no signs of a previous heart attack, but his white blood cells and blood sugar were slightly elevated, suggesting a cardiac event. Dr. Panico identified mild congestive failure and an enlarged right hilum, a part of the lung. He recommended a CT scan to rule out a mass. Dr. Motwani, the main physician responsible for treating Lash, diagnosed an “anxiety reaction” and prescribed medications. Lash was not informed of his congestive heart failure nor that an enlarged right hilum could mean heart failure or cancer. One nurse mentioned only that Lash was seen for an “anxiety reaction.” The next evening, Lash went into cardiac arrest. He was taken to the emergency room, where he was pronounced dead.In a malpractice suit by Lash’s estate, the district court granted Sparta hospital summary judgment. Motwani settled the case and was dismissed from the lawsuit. The Seventh Circuit affirmed. . The Illinois Tort Immunity Act provides that “a local public entity,” such as Sparta, is not liable for an employee’s negligent “diagnosis.” Lash never received any treatment, so no doctor could have failed to disclose information that might have changed his decisions. View "Lash v. Sparta Community Hospital" on Justia Law

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The employer-sponsored group health plan offers all of its participants the same limited coverage for outpatient dialysis. A dialysis provider sued the plan, citing the Medicare Secondary Payer statute, which makes Medicare a “secondary” payer to an individual’s existing insurance plan for certain medical services, including dialysis, when that plan already covers the same services, 42 U.S.C. 1395y(b)(1)(C), (2), (4). To prevent plans from circumventing their primary-payer obligation for end-stage renal disease treatment, a plan may not differentiate in the benefits it provides between individuals having end-stage renal disease and other individuals based on the existence of end-stage renal disease, the need for renal dialysis, “or in any other manner” and may not take into account that an individual is entitled to or eligible for Medicare due to end-stage renal disease. The Sixth Circuit ruled that the limited payments for dialysis treatment had a disparate impact on individuals with end-stage renal disease.The Supreme Court reversed. The plan's coverage terms for outpatient dialysis do not violate section 1395y(b)(1)(C) because those terms apply uniformly to all covered individuals. The statute prohibits a plan from differentiating in benefits between individuals with and without end-stage renal disease; it cannot be read to encompass a disparate-impact theory. The statute simply coordinates payments between group health plans and Medicare without dictating any particular level of dialysis coverage. The plan does not “take into account” whether its participants are entitled to or eligible for Medicare. View "Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc." on Justia Law

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The Supreme Judicial Court affirmed the judgment entered by the district court extending a weapons restriction placed on J because J presented a likelihood of foreseeable harm, holding that there was no error in the proceedings below.While J was in protective custody for threatening behavior a doctor concluded that J was a mentally ill person within the meaning of Me. Rev. Stat. 34-B, 3801(5) and that he posed a likelihood of foreseeable harm within the meaning of Me. Rev. Stat. 34-B, 3862-A. The court subsequently prohibited J from possessing dangerous weapons pending a judicial hearing. After a hearing, the court entered a written order extending the restriction for one year. The Supreme Judicial Court affirmed, holding (1) section 3862-A neither violates Me. Const. art. I, 16, nor is it unconstitutionally vague; (2) the extension of the weapons restriction was supported by competent evidence; and (3) the prosecutor did not commit misconduct during closing arguments. View "In re Weapons Restriction of J." on Justia Law