Justia Health Law Opinion Summaries

Hospitals and hospital associations filed suit challenging HHS's decision to reduce the reimbursement rates for 340B hospitals. The district court held that the rate cute exceeded HHS's statutory authority to adjust specified covered outpatient drugs (SCOD) rates.After determining that it had jurisdiction, the DC Circuit proceeded to the merits and held that HHS had statutory authority to impose its 28.5 percent cut to SCOD reimbursement rates for 340B hospitals. The court held that HHS reasonably interpreted 42 U.S.C. 1395l(t)(14)(A)(iii)(II)'s adjustment authority to enable reducing SCOD payments to 340B hospitals, so as to avoid reimbursing those hospitals at much higher levels than their actual costs to acquire the drugs. Applying Chevron deference, the court held that, at a minimum, the statute does not clearly preclude HHS from adjusting the SCOD rate in a focused manner to address problems with reimbursement rates applicable only to certain types of hospitals. View "American Hospital Ass'n v. Azar" on Justia Law

Federal regulations require commercial truck drivers to undergo annual physicals to be “medically certified as physically qualified." A driver is not physically qualified if he has a clinical diagnosis of a respiratory dysfunction likely to interfere with his ability to drive a commercial motor vehicle safely. Respiratory dysfunction includes sleep apnea.Allman was diagnosed with apnea after a sleep study and was instructed to wear a CPAP machine when sleeping in his truck. Allman complained about the device, which was remotely monitored. Allman was suspended twice for noncompliance. Allman independently completed a second sleep study, which showed that Allman did not have sleep apnea. Allman stopped wearing the CPAP and obtained a new DOT certification card without another examination. Walmart instructed Allman to participate in another sleep study because the doctor who performed Allman’s independent study was not board certified. A third study resulted in a second diagnosis of sleep apnea. Allman refused to wear the CPAP machine. Rather than taking the conflicting sleep studies to a DOT medical examiner, Allman resigned and filed suit, asserting discrimination based on perceived disability and retaliation under Ohio law.The Sixth Circuit affirmed the rejection of both claims. Walmart offered a legitimate, nondiscriminatory reason for its CPAP requirement; Allman failed to rebut that reason as pretextual. Walmart’s CPAP requirement was not an unsafe working condition but was a disability accommodation meant to promote public safety and to ensure compliance with federal law. View "Allman v. Walmart, Inc." on Justia Law

After the Medical Center suspended plaintiff's medical privileges, plaintiff filed suit against the Medical Center, an injunction against the suspension, and a declaration that the Health Care Quality Improvement Act provided no immunity from damages to the Medical Center.The Eleventh Circuit vacated the district court's judgment and remanded with instructions to dismiss plaintiff's complaint for lack of subject matter jurisdiction. Plaintiff contends only that federal question jurisdiction exists over his suit, but a request for declaratory relief that a federal law does not entitle the opposing party to a defense ordinarily does not raise a federal question under 28 U.S.C.1331. The court explained that, because the Declaratory Judgment Act does not enlarge the court's jurisdiction, plaintiff must still assert an underlying ground for federal court jurisdiction. In this case, plaintiff's complaint does not establish that the Medical Center could file a coercive action under federal law. Furthermore, a plaintiff cannot create federal question jurisdiction by seeking a declaration that a federal defense does not protect the defendant. Therefore, plaintiff's request for declaratory judgment does not establish federal question jurisdiction. View "Patel v. Hamilton Medical Center, Inc." on Justia Law

An employee of a federally supported health center failed to properly administer a drug to Alexis Stokes while she gave birth to Baby Stokes. As a result, Baby Stokes suffered from “cerebral palsy and spastic quadriplegia,” along with other disabilities, and his life expectancy was 22 years. The district court awarded damages to Baby Boy D.S. (Baby Stokes) and his parents, Alexis Stokes and Taylor Stokes, (collectively, the Stokes) in this Federal Tort Claims Act (FTCA) action. The government appealed, arguing that the district court erred in structuring damage payments. The Stokes cross appealed, arguing that the district court erred both by miscalculating the present value of a portion of the award and by awarding too little in noneconomic damages. After review, the Tenth Circuit: (1) vacated and remanded the portion of the district court’s order structuring a trust with respect to Baby Stokes’s future-care award, with instructions to fully approximate section 9.3 of the FTCA; (2) vacated and remanded the portion of the district court’s order calculating the present value of Baby Stokes’s future-care award, with instructions to apply Jones & Laughlin Steel Corp. v. Pfeifer, 462 U.S. 523 (1983); and (3) affirmed the portion of the district court’s order regarding noneconomic damages. The matter was remanded for further proceedings. View "Stokes v. United States" on Justia Law

The Supreme Court held that when reviewing a finding that a fact has been proved by clear and convincing evidence, the appellate court must view the record in light most favorable to the prevailing party below and give due deference to how the trier of fact may have evaluated the credibility of witnesses, resolved conflicts in the evidence, and drawn reasonable inferences from the evidence.A probate court appointed limited coconservators for O.B., a young woman with autism. O.B. challenged the order, arguing that the proof did not clearly and convincingly establish that a limited conservatorship was warranted. The court of appeal rejected O.B.'s challenge to the sufficiency of the evidence, concluding that the clear and convincing standard of proof "disappears" on appeal. The Supreme Court reversed, holding that when reviewing a finding of fact that has been proved by clear and convincing evidence, the appellate court must determine whether the record as a whole contains substantial evidence from which a reasonable fact-finder could have found it highly probable that the fact was true. View "In re Conservatorship of O.B." on Justia Law

The parents of a teenage girl (L.M.) sued Premera Blue Cross under the Employee Retirement Income Security Act (ERISA), claiming improper denial of medical benefits. L.M. experienced mental illness since she was a young girl. L.M. was eventually placed in Eva Carlston Academy, where she obtained long-term psychiatric residential treatment. For this treatment, the parents submitted a claim to Premera under the ERISA plan’s coverage for psychiatric residential treatment. Premera denied the claim ten days into L.M.’s stay. But Premera agreed to cover the first eleven days of L.M.’s treatment, explaining the temporary coverage as a "courtesy." The parents appealed the denial of subsequent coverage, and Premera affirmed the denial based on a physician's medical opinion. The parents filed a claim for reimbursement of over $80,000 in out-of-pocket expenses for L.M.’s residential treatment at the Academy. Both parties moved for summary judgment, and the district court granted summary judgment to Premera based on two conclusions: (1) Premera’s decision was subject to the arbitrary-and- capricious standard of review; and (2) Premera had not acted arbitrarily or capriciously in determining that L.M.’s residential treatment was medically unnecessary. The district court granted summary judgment to Premera, and the parents appealed. After review, the Tenth Circuit concluded the district court erred by applying the arbitrary-and-capricious standard and in concluding Premera had properly applied its criteria for medical necessity. Given these conclusions, the Court reversed and remanded the matter back to the district court for de novo reevaluation of the parents’ claim. View "M. v. Premera Blue Cross" on Justia Law

Tiffany O., a woman in her 60s, developed epilepsy early in childhood and suffered from regular seizures. She was also diagnosed with intellectual disability, and was described as "unable to engage in a meaningful conversation." In 2007, Tiffany's daughter Rachel petitioned for the appointment of a guardian for Tiffany. In March 2008, the superior court appointed the Office of Public Advocacy to serve as Tiffany’s public guardian. After a period of working well together, the relationship between Rachel and the public guardian soured. Rachel twice petitioned for review of the guardianship. In June 2011 Rachel was appointed as Tiffany’s guardian. The daughter relied on faith-based medicine to care for her mother, electing to, in one instance, pray over her mother after she became nonresponsive instead of calling emergency services. The superior court ultimately removed the daughter as guardian, finding that her behavior and “intractable belief system” caused her to deprive her mother of appropriate services and care. The Alaska Supreme Court found the superior court did not abuse its discretion when it removed the daughter as her mother’s guardian. The Court also concluded that removing the daughter as guardian did not violate the Alaska Constitution’s free exercise clause because the State possessed a compelling interest in preventing harm to the mother. View "In the Matter of the Protective Proceedings of Tiffany O." on Justia Law

In 1998, Pennsylvania and 45 other states entered into a settlement agreement with certain cigarette manufacturers, who agreed to disburse funding to the states to cover tobacco-related healthcare costs. Pennsylvania’s 2001 Tobacco Settlement Act established the "EE Program" to reimburse participating hospitals for “extraordinary expenses” incurred for treating uninsured patients according to a formula. The Department of Human Services (DHS) determines the eligibility of each hospital for EE Program payments. The Pennsylvania Auditor General reported that for Fiscal Years 2008-2012, some participating hospitals received disbursements for unqualified claims, and recommended that DHS claw back funds from overpaid hospitals and redistribute the money to hospitals that had been underpaid. DHS followed that recommendation for fiscal years prior to 2010 but discovered methodological discrepancies and discontinued the process for Fiscal Years 2010-2012.Plaintiffs, on behalf of all “underpaid” hospitals, sued an allegedly overpaid hospital, alleging conspiracy to defraud the EE Program in violation of RICO, 18 U.S.C. 1961–1964. The plaintiffs alleged that the defendants submitted fraudulent claims for reimbursement, in violation of the wire fraud statute, 18 U.S.C. 1343 (a RICO predicate offense). The Third Circuit reversed the dismissal of the claims, finding that the theory of liability adequately alleges proximate causation. No independent factors that accounted for the plaintiffs’ injury and no more immediate victim was better situated to sue. View "St. Lukes Health Network, Inc. v. Lancaster General Hospital" on Justia Law

On appeal from a federal appellate court's decision that the Federal Medicare scheme prohibits State Medicaid agencies, including MassHealth, from receiving funds from Medicare, the Supreme Judicial Court ordered that this case be remanded for modification of the declaratory judgment, holding that MassHealth demonstrated a sufficient change in circumstances to warrant modification to allow MassHealth to seek reimbursement where the liable third party is Medicare.In Atlanticare Medical Center v. Commissioner of the Division of Medical Assistance, 439 Mass. 1, 3, 5 (2003) (Altanticare I), the Supreme Judicial Court concluded that the Federal Medicaid scheme tasked the State Medicaid agency, not individual providers, with seeking reimbursement from liable third-party insurers, including Medicare. When the Center for Medicare & Medicaid Services (CMS) refused to issue reimbursements from Medicare to MassHealth, MassHealth brought suit. In 2011, the United States Court of Appeals for the First Circuit held that the Federal Medicare scheme prohibited MassHealth from receiving funds from Medicare. Therefore, a Federal Medicare regulation was amended to acknowledge the practice of State Medicaid agencies obtaining Medicare reimbursements through providers, rather than seeking such reimbursements directly from Medicare. MassHealth sought to modify the declaratory judgment and restore its ability to obtain reimbursements from providers, rather than liable third parties. The Supreme Judicial Court remanded the case for modification of the judgment, holding that changed circumstances required modification. View "Atlanticare Medical Center v. Division of Medical Assistance" on Justia Law

A mental health patient lived in a forty-unit apartment building and repeatedly told his doctors and therapists he would kill an unnamed “neighbor.” He ultimately carried out his threat, killing an individual who lived in his building, a few doors away from his own apartment. In subsequent wrongful death litigation filed by the victim’s mother, the providers argued they had no duty to warn anyone about their patient’s threats because he never expressly identified a specific victim. The trial court rejected this argument and denied the providers’ motion for summary judgment, allowing the case to proceed to trial. On appeal, the Superior Court agreed, and finding no reversible error, the Pennsylvania Supreme Court affirmed. View "Maas v. Univ. of Pittsburgh Med. Ctr." on Justia Law