Monday, November 20, 2017

When an employee requests a religious accommodation, take it on faith that his belief is sincere



I’m not sure what the employer was thinking, with this one. The case had drawn considerable attention because the facts were novel. And as religious accommodation cases go, the employer’s defense was novel, too.

The employer had just implemented a new biometric hand scanner system to better track its employees. A devout Evangelical Christian with 40 years at the company told his supervisor that he could not use the hand scanner. As he understood the Book of Revelation, the Mark of the Beast brands followers of the Antichrist, allowing the Antichrist to manipulate them. Use of a hand-scanning system would result in being so “marked,” he feared, “for even without any physical or visible sign, his willingness to undergo the scan … could lead to his identification with the Antichrist.” Because using the hand scanner would violate his sincerely held religious beliefs, he asked for a religious accommodation, some alternative means by which the company could follow his comings and goings.

’m not sure what the employer was thinking with this one. The case had drawn considerable attention because the facts were novel. And as religious accommodation cases go, the employer’s defense was novel, too.

The employer had just implemented a new biometric hand scanner system to better track its employees. A devout Evangelical Christian with 40 years on the job told his supervisor that he couldn’t use the hand scanner. As he understood the Book of Revelation, the Mark of the Beast brands followers of the Antichrist, allowing the Antichrist to manipulate them. Use of a hand-scanning system would result in being so “marked,” he feared, “for even without any physical or visible sign, his willingness to undergo the scan … could lead to his identification with the Antichrist.” Because using the hand scanner would violate his sincerely held religious beliefs, he asked for a religious accommodation, some alternative means by which the company could follow his comings and goings.

But the employer was adamant. It was armed with written assurances from the scanner’s manufacturer that the system did not detect or place a mark, including the Mark of the Beast, on a person’s body. The manufacturer also offered its own interpretation of “the Scriptures,” explaining that because the Mark of the Beast “is associated only with the right hand or the forehead, use of the left hand in the scanner would be sufficient to obviate any religious concerns regarding the system.” But that was not the employee’s interpretation. And, faced with the employer’s insistence that he would be subject to discipline if he did not use the scanner (with his left hand, as the manufacturer recommended), the employee retired instead.

It’s unclear why the employer dug in its heels here, especially since, as the employee later discovered, the company had provided an alternative to the hand scanner for two employees with hand injuries. They simply had to enter their personnel numbers on a keypad attached to the system—a bypass that came at absolutely no cost or hardship to the company.

Because the employer refused to provide this accommodation for the employee’s religious beliefs, the EEOC brought a Title VII constructive discharge suit on his behalf, and won a jury verdict in his favor. The district court denied the employer’s motion for judgment as a matter of law. Affirming, the Fourth Circuit, in EEOC v. Consol Energy, Inc., upheld the verdict, ruling there was sufficient evidence from which the jury could find a conflict between the employee’s bona fide religious belief and the requirement that he use the hand scanner.

Management lawyers typically advise employers: Never doubt the sincerity of an employee’s religious belief. Instead, focus on whether the religious accommodation that the employee has requested would be an undue hardship for the company. In this case, the employer didn’t doubt the sincerity of the employee’s belief. Where it went wrong, though, was in insisting that his religious belief was mistaken. In the employer’s view—which essentially relied on the scanner manufacturer’s interpretation of scripture—allowing the employee to scan his left hand instead of his right hand was enough to avert any potential religious conflict. In fact, at oral argument, the employer cited scripture passages “purporting to demonstrate that the Mark of the Beast can be imprinted only on the right hand.”

That the employer thought the employee’s religious beliefs were unfounded was beside the point, the appeals court explained. Nor did it matter that the scanner manufacturer, or even the employee’s own pastor, did not share his view. The jury specifically found that the employee’s religious belief was sincere, and that was all that mattered. As the appeals court pointed out, it wasn’t the employer’s place—or the court’s—“to question the correctness or even the plausibility of [the employee’s] religious understandings.”

Again, in religious accommodation cases, the dispute usually centers on the “undue hardship” question. Here, though, once the “sincerely held belief” issue was resolved, this was an easy case, the appeals court noted, because the employer conceded it would pose no additional burden on the company to have honored the employee’s religious belief. Indeed, that much was obvious, since the employer had readily granted an accommodation to other employees.

All that was left to make out a constructive discharge case was for the EEOC to show that the employee was put in such an intolerable position that he had no choice but to quit. And the appeals court affirmed: Demanding that an employee use a scanner that he “sincerely believed would render him a follower of the Antichrist, ‘tormented with fire and brimstone,’” was objectively intolerable.

Consequently, the employer was left to pay nearly $600,000 in damages, and learned a costly lesson: Courts (and juries, it seems) are quite deferential to employees’ asserted religious beliefs. Rather than debate scripture with an employee, take it on faith that his views are sincere, regardless of whether you deem them theologically sound.

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A Dozen Steps to Successfully Appeal Denied Claims


Appealing denied claims used to be a simple process. A biller working with a physician's office would stamp "APPEAL" in big red letters on a photocopy of the claim, and mail it back to the insurance company. These days, you’d be wise to put the cost of that postage in the bank, and throw away both the APPEAL stamp and its red ink stamp pad. This sort of knee-jerk response won’t even make it past the insurance company's initial computer screening; they’ll likely toss such “appeals” into the trash and you’ll never hear anything back from them.



To successfully appeal denied claims, you need to get your “A-game” on; otherwise, you won’t see a penny for your efforts.

Follow these steps to effectively appeal denied claims.


1. Recognize denials. Insurance companies don’t print the word “denied” in big letters across the top of the claim form. In fact, the word “denied” may never appear at all. The insurance company simply declares the reimbursement amount to be “$0” and enters an adjustment reason code next to the amount paid. The key is to identify it as separate and distinct from a contractual adjustment, which is – and should be – a write off.

2. Understand why the claim was denied. Before you pick up the phone and demand to speak to the claims representative, determine the root cause of the denial. You can’t effectively appeal until you know why payment for the service was denied. In addition to the reason code, there is a remark code. Look up the insurance company's definition of that code to get details about the reason for the denial. WPC maintains a complete listing of standard reason and remark codes, available at www.wpc-edi.com/content/view/711/401/

3. Don't procrastinate. There is often a timeframe in which you can resubmit a claim after it’s been denied. Pull the record, research the code, call the patient, etc., but don’t delay: most insurers only allow a few months to resubmit a claim for reconsideration.

4. Follow the insurance company's rules. Each insurer has an appeal process. The Centers for Medicare and Medicaid Services (CMS), for example, has a form to complete when appealing the denial of a Medicare claim called the "Medicare Redetermination Request Form". (See www.cms.gov/cmsforms/downloads/CMS20027.pdf) Get familiar with the insurer's protocols to understand your options if your first appeal is turned down. Don’t give up; most insurers have multiple levels of appeals and even a grievance process if you disagree with the outcome after you've exhausted the appeals process.

5. Make a compelling case. An appeal means that you disagree with the insurance company's decision, so put your debate cap on and gather supportive evidence to present your case. Perhaps the most important aspect of your claims letter is the content. The letter should go well beyond stating, “please pay my doctor.” Build a compelling case for why the claim should be paid:
• Develop a professional letter that begins by referencing the claim number, date of service and patient; then, briefly describe the particulars of the service in question.
• Use the insurer's own language if possible. For example, to appeal a claim denied because the insurance company claims the treatment was experimental, quote from the insurer's own marketing materials where it declares it seeks to provide the best medical care for its beneficiaries.
• When the insurer questions the necessity or separate payment for a distinct service, the physician should type or dictate a paragraph or two about the benefits of the service to the patient. Seek objective evidence to support your case from your specialty society and medical literature.
• Look to see if Medicare or Medicaid pays for the service; if they do, you can argue that even the government has determined that payment is appropriate.
• Copy and attach sections that support your case from coding manuals, including past issues of the American Medical Association (AMA) CPT Coding Assistant, a periodical that the AMA publishes to clarify CPT codes. (See http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.shtml)
• For appeals that concern clinical issues (for example, medical necessity), send the appeal to the medical director of the insurance company.
• Look at the class action settlements between several large physician organizations and a number of national insurance companies; review those settlements to see if anything in there can support your position. See http://www.hmosettlements.com/for an up-to-date compilation of the settlements, as well as a list of pending lawsuits.

6. Confirm receipt. Don’t just send the appeal and hope for the best. Review your submission online, or call the insurance company to confirm that they received your appeal, noting the name of the operator, extension number, date and time. Place a tickler in your practice management system or Microsoft Outlook to follow up in 30 days.

7. Set boundaries. Although it might make you feel better to fight for every dollar, it doesn’t pay to prepare a third-level appeal of a $2.41 service, particularly if you only perform it once a year. Establish protocols for dollar thresholds that you’ll appeal only once, twice, etc.

8. Don’t go overboard. Avoid fighting for a claim that should have never been submitted in the first place, such as an undocumented service. Your physician may have provided the service and feels there should be some way to get paid, but – as the saying goes – if it wasn't documented, it wasn't done.

9. Carbon copy stakeholders. Your appeal to reverse a denial is a matter between you and the insurance company, but sometimes pulling in other key stakeholders helps. Your first, and most important, advocate is the patient. Although patients may never be held responsible for payment if a denial is ultimately upheld, news of payment disputes certainly get their attention. And the patient’s attention is just want you want. Prompting the patient to contact the insurance company directly to encourage payment doesn’t guarantee payment, but it certainly helps.

10. Develop supportive language in your contract. Your contract establishes the relationship between you and the insurance company. Even though the insurer is the party that typically presents the contract to physicians for their signature, it’s every bit as much your physician's contract as it is the insurer's. Proactively negotiate the inclusion of language that supports your efforts to appeal claims. If you’re frustrated by the appeals process itself or if you keep running into certain problems, such as unfair bundling denials, seek to include clearer definitions of these processes in the contract.

11. Compile appeals. Appealing claims one-by-one may get the results you need, but it is laborious. If you’ve seen the same service denied for the same reason multiple times – or your insurer hasn’t paid in a timely manner, according to your state's prompt payment law – compile your appeals and present them together for reconsideration.

12. Maintain a hassle folder for each insurance company. Keep a record of denied claims – by dollar and type. Measure and compare the data on a quarterly basis. If you negotiated a good reimbursement rate with an insurer, but all of your claims get denied, the “good” rate is meaningless. It pays to maintain a record of reimbursements and denials in order to effectively review your contract for its strategic contribution to the practice’s bottom line.

Preventing denied claims is a key skill of successful billers. But getting some denials will always be a fact of life in today’s complicated physician payment system. Appealing denials is your right: it pays to exercise it.

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Saturday, November 18, 2017

The Trial of Galileo

The debate over whether scientific teaching ought to conform with literalist interpretations of the Bible did not begin, as many assume, with the trial of John Scopes in 1925. Three centuries earlier in Rome, Galileo Galilei faced trial before the Holy Office for promoting in a book his idea that the earth did not sit at the center of the universe--as Pope Urban had concluded through his interpretation of Scripture--but, rather, revolved around the sun. The tragedy of Galileo's trial and sentence to house-arrest is seen by marking the end of the Italian Renaissance.


The trial of Galileo is fascinating both for what it reveals about the very different minds of two remarkable seventeenth-century figures and for what it tells us about the dangers of a bureaucracy intent on preserving its own power.


* * *


In the 1633 trial of Galileo Galilei, two worlds come into cosmic conflict. Galileo's world of science and humanism collides with the world of Scholasticism and absolutism that held power in the Catholic Church. The result is a tragedy that marks both the end of Galileo's liberty and the end of the Italian Renaissance.

Galileo Galilei was born in 1564--the same year that Shakespeare was born and Michelangelo died. From an early age, Galileo showed his scientific skills. At age nineteen, he discovered the isochronism of the pendulum. By age twenty-two, he had invented the hydrostatic balance. By age twenty-five, Galileo assumed his first lectureship, at the University of Pisa. Within a few more years, Galileo earned a reputation throughout Europe as a scientist and superb lecturer. Eventually, he would be recognized as the father of experimental physics. Galileo's motto might have been "follow knowledge wherever it leads us."

At the University of Padua, where Galileo accepted a position after three years in Pisa, he began to develop a strong interest in Copernican theory. In 1543, Nicolaus Copernicus published Revolutions of the Celestial Orbs, a treatise that put forth his revolutionary idea that the Sun was at the center of the universe and that the Earth--rotating on an axis--orbited around the sun once a year. Copernicus' theory was a challenge to the accepted notion contained in the natural philosophy of Aristotle, the astronomy of Ptolemy and the teachings of the Church that the sun and all the stars revolved around a stationary Earth. In the half-century since its publication, however, Copernicus' theory met mostly with skepticism. Skeptics countered with the "common sense" notion that the earth they stood on appeared not to move at all--much less at the speed required to fully rotate every twenty-four hours while spinning around the sun.

Sometime in the mid-1590s, Galileo concluded that Copernicus got it right. He admitted as much in a 1597 letter to Johannes Kepler, a German mathematician who had written about planetary systems: "Like you, I accepted the Copernican position several years ago and discovered from thence the cause of many natural effects which are doubtless inexplicable by the current theories." Galileo, however, continued to keep his thoughts to a few trusted friends, as he explained to Kepler: "I have not dared until now to bring my reasons and refutations into the open, being warned by the fortunes of Copernicus himself, our master, who procured for himself immortal fame among a few but stepped down among the great crowd."

Galileo's discovery of the telescope in 1609 enabled him to confirm his beliefs in the Copernican system and emboldened him to make public arguments in its favor. Through a telescope set in his garden behind his house, Galileo saw the Milky Way, the valleys and mountains of the moon, and--especially relevant to his thinking about the Copernican system--four moons orbiting around Jupiter like a miniature planetary system. Galileo, a good Catholic, offered "infinite thanks to God for being so kind as to make me alone the first observer of marvels kept hidden in obscurity for all previous centuries." Galileo began talking about his observations at dinner parties and in public debates in Florence, where he has taken up a new post.

Galileo expected the telescope to quickly make believers in the Copernican system out of all educated persons, but he was disappointed. He expressed his discouragement in a 1610 letter to Kepler: "My dear Kepler, what would you say of the learned here, who, replete with the pertinacity of the asp, have steadfastly refused to cast a glance through the telescope? What shall we make of this? Shall we laugh, or shall we cry?" It became clear that the Copernican theory had its enemies.

Galileo's first instinct was turn to acquiring more knowledge for those few open minds he was able to reach--disciples such as monk Benedetto Castelli. Galileo wrote to Castelli: "In order to convince those obdurate men, who are out for the vain approval of the stupid vulgar, it would not me enough even if the stars came down on earth to bring witness about themselves. Let us be concerned only with gaining knowledge for ourselves, and let us find therein our consolation."

Soon, however, Galileo--flamboyant by nature--decided that Copernicus was worth a fight. He decided to address his arguments to the enlightened public at large, rather than the hidebound academics. He saw more hope for gaining support among businessmen, gentlemen, princes, and Jesuit astronomers than among the vested apologists of universities. He seemed compelled to act as a consultant in natural philosophy to all who would listen. He wrote in tracts, pamphlets, letters, and dialogues--not in the turgid, polysyllabic manner of a university pedant, but simply and directly.

The Admonition and False Injunction of 1616

In 1613, just as Galileo published his Letters on the Solar Spots, an openly Copernican writing, the first attack came from a Dominican friar and professor of ecclesiastical history in Florence, Father Lorini. Preaching on All Soul's Day, Lorini said that Copernican doctrine violated Scripture, which clearly places Earth, and not the Sun at the center of the universe. What, if Copernicus were right, would be the sense of Joshua 10:13 which says "So the sun stood still in the midst of heaven" or Isaiah 40:22 that speaks of "the heavens stretched out as a curtain" above "the circle of the earth"? Pressured later to apologize for his attack, Lorini later said that he "said a couple of words to the effect that the doctrine of Ipernicus [sic], or whatever his name is, was against Holy Scripture."

Galileo responded to criticism of his Copernican views in a December 1613 Letter to Castelli. In his letter, Galileo argued that the Scripture--although truth itself--must be understood sometimes in a figurative sense. A reference, for example, to "the hand of God" is not meant to be interpreted as referring to a five-fingered appendage, but rather to His presence in human lives. Given that the Bible should not be interpreted literally in every case, Galileo contended, it is senseless to see it as supporting one view of the physical universe over another. "Who," Galileo asked, "would dare assert that we know all there is to be known?"

Galileo hoped that his Letter to Castelli might foster a reconciliation of faith and science, but it only served to increase the heat. His enemies accused him of attacking Scripture and meddling in theological affairs. One among them, Father Lorini, raised the stakes for the battle when, on February 7, 1615, he sent to the Roman Inquisition a modified copy of Galileo's Letter to Castelli. He attached his own comments to his submission:
All our Fathers of this devout convent of St. Mark are of opinion that the letter contains many propositions which appear to be suspicious or presumptuous, as when it asserts that the language of Holy Scripture does not mean what it seems to mean; that in discussions about natural phenomena the last and lowest place ought to be given the authority of the sacred text; that its commentators have very often erred in their interpretation; that the Holy Scriptures should not be mixed up with anything except matters of religion....When, I say, I became aware of all of this, I made up my mind to acquaint your Lordship with the state of affairs, that you in your holy zeal for the Faith may, in conjunction with your illustrious colleagues, provide such remedies as may appear advisable....I, who hold that those who call themselves Galileists are orderly men and good Christians all, but a little overwise and conceited in their opinions, declare that I am actuated by nothing in this business but zeal for the sacred cause.In fact, Lorini's letter appears more charitable than he in fact was. He would stop at almost nothing to destroy the "Galileists," as is shown from his alteration--in certain key places--of the text of Galileo's Letter to Castelli. For example, where Galileo had written: "There are in Scripture words which, taken in the strict literal meaning, look as if they differed from the truth," Lorini substituted: "which are false in their literal meaning." However unscrupulous his methods, Lorini's denunciation succeeded in setting the machinery of the Catholic Church in motion.

Lorini had allies, such as Father Tommaso Caccini. Caccini traveled to Rome to appear before the Holy Office and expose, as he saw it, "the errors of Galileo." Called for examination on March 20, Caccini said that Florence was full of "Galileists" publicly declaring God to be an accident and doubting miracles. Caccini placed full blame for the sorry state of affairs on Galileo. Asked the basis for his report, Caccini credited Lorini and a Father Ximenes. Overall, the condemnation was hardly convincing. Giorgio de Santillana, author of The Crime of Galileo, wrote of Caccini's testimony: "The whole deposition is such an interminable mass of twists and innuendoes and double talk that a summary does no justice to it."

Matteo Caccini, Tommaso's brother, fumed when he learned of his brother's denunciation of Galileo. He described his brother as "lighter than a leaf and emptier than a pumpkin." In an April letter he wrote of his Tommaso's action: "As to F. T., I am so angry that I could not be more, but I don't care to discuss it. He opened up with me in private the other day, and he revealed such dreadful plans that I could scarcely control myself. In any event, I wash my hands of him forever and ever."

Aware of the move against him, Galileo wrote to a friend, Monsignor Dini, asking that his letters be forwarded to the influential Cardinal Bellarmine, the Church's chief theologian, and--if it could be arranged--Pope Paul V. Unfortunately for Galileo, the seventy-four-year old Cardinal Bellarmine "was no friend of novelties" (although, unlike some of Galileo's other detractors, he had at least looked through a telescope and given--in 1611--an audience to Galileo). In his innate conservatism he saw the Copernican universe as threatening to the social order. To Bellarmine and much of the Church's upper echelon, the science of the matter was beyond their understanding--and in many cases their interest. They cared about administration and preserving the power of the papal superstate more than they did getting astronomical facts right.

Bellarmine stated his views on the Galileo controversy in an April 12, 1615 letter to Father Foscarini, a highly-respected monk from Naples. He indicated that Galileo could speak about the Copernican model "hypothetically, and not absolutely." Bellarmine wrote that "to affirm that the Sun, in its very truth, is at the center of the universe...is a very dangerous attitude and one calculated not only to arouse all Scholastic philosophers and theologians but also to injure our faith by contradicting the Scriptures."

With "nineteen centuries of organized thought piling up to smother him," Galileo pleaded--in a powerful summary of thoughts on Scriptural interpretation and the evidence concerning the nature of the universe--his case in his Letter to the Grand Duchess. He asked that his idea not be condemned "without understanding it, without hearing it, without even having seen it." Galileo's eloquent Letter was forwarded to Rome where, in the words of one historian, "it sank out of sight as softly as a penny in a snowbank."

When depositions in the Galileo matter concluded, the Commissary-General forwarded two propositions of Galileo to eleven theologians (called "Qualifiers") for their evaluation: (1) The Sun is the center of the world and immovable of local motion, and (2) The Earth is not the center of the world, nor immovable, but moves according to the whole of itself, also with a diurnal motion. Four days later, on February 23, 1616, the Qualifiers unanimously declared both propositions to be "foolish and absurd" and "formally heretical." Less than two weeks later, Pope Paul V--described by the Florentine ambassador as "so averse to anything intellectual that everyone has to play dense and ignorant to gain his favor"--endorsed the theologian's conclusions. The Pope, according to the Inquisition file, "directed the Lord Cardinal Bellarmine to summon before him the said Galileo and admonish him to abandon the said opinion; and, in the case of his refusal to obey, the Commissary of the Holy Office is to enjoin him...to abstain altogether from teaching or defending this opinion and even from discussing it."

Summoned before Bellarmine on February 25, 1616 and admonished, Galileo--according to a witness, Cardinal Oregius--"remained silent with all his science and thus showed that no less praiseworthy than his mind was his pious disposition." Oregius' account, and Galileo's own writings, indicate that Galileo did not "refuse to obey" the Church's admonition. It is assumed, therefore, that Galileo was not formally enjoined. Yet, surprisingly, in the Inquisition file there appeared the following entry:
At the palace, the usual residence of Lord Cardinal Bellarmine, the said Galileo, having been summoned and being present before the said Lord Cardinal, was...warned of the error of the aforesaid opinion and admonished to abandon it; and immediately thereafter...the said Galileo was by the said Commissary commanded and enjoined, in the name of His Holiness the Pope and the whole Congregation of the Holy Office, to relinquish altogether the said opinion that the Sun is the center of the world and immovable and that the Earth moves; nor further to hold, teach, or defend it in any way whatsoever, verbally or in writing; otherwise proceedings would be taken against him by the Holy Office; which injunction the said Galileo acquiesced in and promised to obey.Many things about the entry are suspicious. It appears in the Inquisition file where one would expect the actual Bellarmine injunction (if it existed) to appear. Moreover, the entry appears on the same page as the entry for the previous day--and every other report, legal act, and entry in the entire file begins at the top of a new page. It is widely believed by historians that the reported injunction of Galileo was "a false injunction": the injunction never happened, but a false report was maliciously planted in the file by one of Galileo's enemies. Seventeen years later, Galileo would stand before the Inquisition charged with violating an injunction that was, in all likelihood, never issued against him.

The Trial of 1633

Galileo's admonition stopped the Copernican movement dead in its tracks. For Galileo, his admonition marked the beginning of a period of silence. He busied himself with such tasks as using tables of the moons of Jupiter to develop a chronometer for measuring longitude at sea. He endured his rheumatism, enjoyed the attention of his daughter, Maria Celeste, and adjusted to a world which elevated mindless conformism over scientific understanding.

In 1623, Galileo received some hopeful news: Cardinal Maffeo Barberini had been elected Pope. Unlike the dull and mean-tempered Pope Paul V, the new Pope Urban VIII held a generally positive view of the arts and science. Writing from Rome, the Pope's private secretary, Secretary of the Briefs Ciampoli, urged Galileo to resume publication of his ideas: "If you would resolve to commit to print those ideas that you still have in mind, I am quite certain that they would be most acceptable to His Holiness, who never ceases from admiring your eminence and preserves intact his attachment for you. You should not deprive the world of your productions."

In the early years of his reign, Pope Urban VIII held long audiences with Galileo. Encouraged by a Pope who seemed open to renewed debate on the merits of the Copernican system (so long as the arguments fell short of purporting to be a definite refutation of the Earth-centered universe), Galileo began work on a book that would eventually prove his undoing, Dialogue Concerning the Two Chief World Systems.

On December 24, 1629, Galileo told friends in Rome that he had completed work on his 500-page Dialogue. The Dialogue has been described as "the story of the mind of Galileo." The book reveals Galileo as physicist and astronomer, sophisticate and sophist, polemicist and polished writer. Unlike the works of Copernicus and Kepler, Galileo's Dialogue was a book for the educated public, not specialists. Although using the form of a debate among three Italian gentleman, Galileo marshals a variety of arguments to lead his readers to one inexorable conclusion: Copernicus was right. The character Salviati, a person of "sublime intellect," clearly speaks for Galileo in arguing for a Sun-centered system. Sagredo is a Venetian nobleman, open-minded and hesitant to draw conclusions--a good listener. Simplico is the straw man of the debate, a stubborn, literal-minded defender of the Earth-centered universe.

Early news from Rome gave Galileo reason for optimism that his book would soon be published. The Vatican's chief licenser, Niccolo Riccardi, reportedly promised his help and said that theological difficulties could be overcome. When Galileo arrived in Rome in May 1630, he wrote: "His Holiness has begun to treat of my affairs in a spirit which allows me to hope for a favorable result." Urban VIII reiterated his previously stated view that if the book treated the contending views hypothetically and not absolutely, the book could be published.

Reading the book for the first time, chief licenser Riccardi came to see the book as less hypothetical--and therefore more problematic--than he expected it to be. Riccardi demanded that the Preface and conclusion to revised to be more consistent with the Pope's position. In August 1630, in the midst of his required revising, Galileo received a letter from his friend Benedetto Castelli in Rome urging him, for "weighty reasons" which he "not wish to commit to paper," to print the Dialogue in Florence "as soon as possible." Galileo's Jesuit opponents in Rome were aiming to block publication.

Riccardi seemed paralyzed with indecision. Caught between two powerful forces, he did nothing as Galileo fretted that his great work might never see the light of day. "The months and the years pass," Galileo complained, "my life wastes away, and my work is condemned to rot."

Finally, reluctantly ("dragged by the hair," according to one account), Riccardi gave the green light. The first copy of Galileo's Dialogue Concerning the Two Chief World Systems came off the press in February 1632. The book, which quickly sold out, soon became the talk of the literary public.

By late summer, Galileo's hopes turned to fears when he learned that orders had come from Rome to suspend publication of his book. On September 5, the full scope of Galileo's problems became clearer when Pope Urban told Francesco Niccolini, who had come to the Vatican to protest the suspension decision, "Your Galileo has ventured to meddle in things that he ought not and with the most grave and dangerous subjects that can be stirred up these days." Jesuit enemies of Galileo had convinced the Pope that the Dialogue was nothing but a thinly-veiled brief for the Copernican model. The Pope complained that Galileo and Ciampoli deceived him, assuring him that the book would comply with papal instructions and then circumventing them. The Pope seemed especially embittered by Galileo's decision to put the Pope's own argument concerning the tides into the mouth of the simple-minded Simplico--an attempt, as he saw it, to ridicule him.

The Pope swung the machinery of the Church into motion. He appointed a special commission to investigate the Galileo matter. Riccardi, the chief licenser, was severely lectured. Ciampoli was exiled to obscure posts, never to return to Rome.

Galileo, too, became angry. His noble goal of spreading scientific awareness to the public was being frustrated by a narrow-minded bureaucracy intent on preserving its own power. He believed he had done no wrong. He had been authorized to write about Copernicanism, had followed the required form, revised his work to meet censors' objections, and obtained a license. What more could authorities expect? How could the law reach him when he had acted with such care?

The water in which Galileo found himself soon became even deeper. The special commission's report to the Pope outlined a series of indictments against Galileo. On September 15, the Pope turned the matter over to the Inquisition. Eight days later, the General Congregation declared--in what would come as a shock to Galileo--that he had violated the 1616 (so-called) injunction against teaching, holding, or writing about Copernican theory.

On October 1, 1632, the Inquisitor of Florence showed up at Galileo's house with a summons to present himself to the the Holy Office in Rome within a month. In despair, Galileo expressed regret for involving himself with the Copernican cause: "I curse the time devoted to these studies in which I strove and hoped to move away somewhat from the beaten path. I repent having given the world a portion of my writings; I feel inclined to consign what is left to the flames and thus placate at last the inextinguishable hatred of my enemies." The fire left his belly. He declined urgings to escape to the Venetian territory and instead asked that proceedings against him be moved to Florence. His request was denied: the Pope insisted that the old man, weak and ill though he was, make the two-hundred mile wintertime journey to Rome.

On February 13, 1633, Galileo completed his twenty-three day trip to Rome and took up lodging in the Florentine embassy. It was not a good time. The Grand Duke reported that Galileo "for two nights continuous...cried and moaned in sciatic pain; and his advancing age and sorrow." His only consolation during his stay at the embassy seemed to be that soon he would finally have a chance to defend his science and theology.

On April 8, Niccolini informed Galileo that he would stand trial before ten cardinals. A more difficult chore for Niccolini was to break the news to him that the merits of his case--as a practical matter--had been decided already; all he could do was submit.

Four days later, Galileo officially surrendered to the Holy Office and faced Father Firenzuola, the Commissary-General of the Inquisition, and his assistants. Firenzuola informed Galileo that for the duration of the proceedings against him he would be imprisoned in the Inquisition building. After putting Galileo under oath, the Commissary deposed Galileo concerning meetings he held with Cardinal Bellarmine and other church officials in 1616. Galileo seemed to have trouble remembering who might have been present with Bellarmine on that fateful February day seventeen years earlier, as well as exactly what restrictions--if any--had been placed upon him. Firenzuola told Galileo that he had been commanded to "neither hold, defend, nor teach that [the Copernican] opinion in any way whatsoever." Galileo quibbled with the language--suggesting "I do not remember...the clause "in any way whatsoever"--, but accepted most of what the Commissary said. After a series of questions concerning the licensing of the Dialogue, Galileo signed his deposition in a shaking hand.

Three counselors to the Inquisition, driven especially by Galileo-hating Melchior Inchofer, prepared a seven-page evaluation of the Dialogue. The report concluded that in the book Galileo taught, defended, and showed that he held Copernican theory, and that--while claiming to discuss world models hypothetically--he gave the Copernican model "a physical reality."

Weeks past as internal debates raged over what the Inquisitors should do with their old scientist. Finally, Cardinal Francesco Barberini, a moderating influence on the panel of ten judges deciding Galileo's fate, persuaded the Commissary to meet with Galileo and convince him to admit error in return for a more lenient sentence. In a letter written by the Commissary (and not discovered until 1833), Firenzuola described his April 27 discussion with Galileo: "I entered into discourse with Galileo yesterday afternoon, and after many arguments and rejoinders had passed between us, by God's grace, I attained my object, for I brought him to a full sense of his error, so that he clearly recognized that he had erred and had gone too far in his book."

Some historians have seen Galileo's decision to admit error as a "final self-degradation." Others, including Giorgio de Santillana, have seen it as the only rational move open to him: "He was not a religious visionary being asked to renounce his vision. He was an intelligent man who had taken heavy risks to force an issue and to change a policy for the good of his faith. He had been snubbed; he had nothing to do but pay the price and go home. The scientific truth would take care of itself."

The trial by the Congregation moved to its conclusion. Several of the ten cardinals apparently pushed for Galileo's incarceration in prison, while those more supportive of Galileo argued that--with changes--the Dialogue ought to continue to be allowed to circulate. In the end, a majority of the cardinals--rejecting much of the Commissary's agreement with Galileo--demanded Galileo "even with the threat of torture...abjure in a plenary assembly of the Congregation of the Holy Office...[and] then be condemned to imprisonment at the pleasure of the Holy Congregation." Moreover, the cardinals declared, the Dialogue "is to be prohibited."

The grand play ran its course, with the Pope insisting upon a formal sentence, a tough examination of Galileo, public abjuration, and "formal prison." Galileo was forced to appear once again for formal questioning about his true feelings concerning the Copernican system. Galileo obliged, so as not to risk being branded a heretic, testifying that "I held, as I still hold, as most true and indisputable, the opinion of Ptolemy, that is to say, the stability of the Earth and the motion of the Sun." Galileo renunciation of Copernicanism ended with the words, "I affirm, therefore, on my conscience, that I do not now hold the condemned opinion and have not held it since the decision of authorities....I am here in your hands--do with me what you please."

On the morning of June 22, 1633, Galileo, dressed in the white shirt of penitence, entered the large hall of the Inquisition building. He knelt and listened to his sentence: "Whereas you, Galileo, the son of the late Vincenzo Galilei, Florentine, aged seventy years, were in the year 1615 denounced to this Holy Office for holding as true the false doctrine....." The reading continued for seventeen paragraphs:
And, so that you will be more cautious in future, and an example for others to abstain from delinquencies of this sort, we order that the bookDialogue of Galileo Galilei be prohibited by public edict. We condemn you to formal imprisonment in this Holy Office at our pleasure.

As a salutary penance we impose on you to recite the seven penitential psalms once a week for the next three years. And we reserve to ourselves the power of moderating, commuting, or taking off, the whole or part of the said penalties and penances.

This we say, pronounce, sentence, declare, order and reserve by this or any other better manner or form that we reasonably can or shall think of. So we the undersigned Cardinals pronounce.Seven of the ten cardinals signed the sentence.


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2018 MACRA Update for Small Practices

Earlier this summer, CMS released the proposed rule for the 2018 Quality Payment Program. As we move into the fall and the final months of recording 2017 data, let’s take another look at the proposed rule for next year and see how practices can prepare for the changes that may come in the second year of the program. Below is a set of key points that summarize the proposal.

1. The QPP is alive and growing


There are significant changes in the new proposed rule relative to the 2018 plans laid out in the final rule governing the 2017 performance year, but the majority of the program is the same. Core program elements, such as performance categories and the structure of the program tracks, remains unchanged. Future program requirements look to be ramping as expected, as discussed below.

What does this mean for the small practice? MIPS has a definite and accelerating path, and now is a good time to get comfortable as the program ramps up the requirements over the next few years.

2. Cost category not included in your final score in 2018


CMS has proposed that cost will again account for 0% of the composite performance score in 2018 and not impact payments in 2020. While this is still not the final rule, it has momentum, and CMS is requesting feedback before the final rule is published. Based on this information the category weights would stay the same in 2018 as they did in 2017, with Quality counting for 60%, Advancing Care Information counting for 25%, and Improvement Activities counting for 15%.

What does this mean for the small practice? While not directly responsible for cost outcome, it is a good idea to monitor and understand the process and your data now, expect inclusion of Cost in your Composite Performance Score in 2019.

3. There will likely be more flexibility for small practices


CMS is proposing to increase the planned thresholds for low volume exclusions in 2018. The 2017 thresholds, where clinicians or groups with ≤$30,000 in Part B allowed charges or ≤100 Part B beneficiaries. CMS is proposing thresholds of ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries to qualify for exclusion in 2018.

What does this mean for the small practice? Low volume Medicare Part B practices may be excluded in 2018, to a larger degree than in 2017. All low volume practices should check their Medicare Part B metrics to determine their status.

4. Bonus points proposed


CMS has proposed adding additional bonus points to increase flexibility and reward clinicians and groups who have more difficulty scoring well in MIPS:
Proposed: Up to 10 percentage points available for performance improvement in the Quality category. This bonus will be based on the rate of improvement in the Quality category score between the 2017 performance year and the 2018 performance year.

Proposed: Additional bonus of up to 3 points available for eligible clinicians based on the medical complexity of patients they see. The assessment of medical complexity may be based on the average Hierarchical Conditions Category (HCC) risk score.

Proposed: A bonus of 5 points automatically awarded to any eligible clinician or group in a small practice with 15 or fewer clinicians.

What does this mean for the small practice? Small practices now have an added handicap that allows them to score bonus point to offset their small size, complex patient population and relative improvement in MIPS performance.

5. Virtual MIPS Groups are proposed


Virtual Groups will be comprised of eligible clinicians in solo practices or groups of 10 or fewer clinicians who elect to jointly participate in MIPS. By doing so small practices can offset low scores with other practices that may have high scores and improve both practices overall performance. The group as a whole reports the combined score which is attributed to each practice in the virtual group.

What does this mean for the small practice? Identifying your practice's areas of high and low MIPS performance and joining a Virtual Group to offset each other will lead to much better MIPS scores for all the practices in the Virtual Group. You will need to elect to participate in a Virtual group in 2018 prior to the start of the 2018 performance period.

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Friday, November 17, 2017

LGBT Activist files federal lawsuit challenging Tennessee therapist law


An LGBT rights activist filed a federal lawsuit [complaint, pdf] Monday challenging a Tennessee law [text, pdf] that allows counselors to refuse to serve clients based on religious views.


The law, signed in April 2016 [JURIST report] by Tennessee Governor Bill Haslam[official website], allows therapists to refuse to treat patients based on religious objections, when that patient's "goals, outcomes or behaviors" conflict with the counselor's "sincerely held principles."


The lawsuit was filed by activist Bleu Copas, a former Arabic translator and linguist for the US Army, who was honorably yet involuntarily discharged [AP report] in 2006 pursuant to the military's former Don't Ask Don't Tell [JURIST backgrounder] policy. Since his discharge, he has sought mental health services, and as the suit notes, "desires to re-engage in therapy, but fears that a therapist will refuse to treat him because of his sexuality."


The suit states:


The Bill's authors intended for the Bill to empower certain people to discriminate against members of the LGBT community. In an attempt to camouflage their intent, the authors drafted a bill that allows for all types of discrimination.



The suit argues that the Tennessee law violates the Equal Protection Clause of the Fourteenth Amendment and the First Amendment's Establishment Clause [text], which prohibits governments from establishing or protecting only one religion, or enacting any "law respecting an establishment of religion."


Copas filed a similar lawsuit last year in Chancery Court for Anderson County, Tennessee.




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Transgender woman sues Massachusetts Department of Corrections for treatment in male prison

An unnamed transgender woman being held in an all-male prison in Massachusetts filed suit[complaint, PDF] Wednesday alleging unfair treatment.


The lawsuit, filed by GLAD Legal Advocates and Defenders [advocacy website] in the US District Court for the District of Massachusetts [official website], names the Massachusetts Department of Correction, Commissioner Thomas A. Turco III, MCI-Norfolk [official website] Superintendent Sean Medeiros, Americans with Disabilities Act Coordinator James M. O'Gara Jr., and Assistant Deputy Commissioner of Clinical Services Stephanie Collins.

Jane Doe's claim alleges that defendants have violated the Americans with Disabilities Act (ADA), the Rehabilitation Act, and the Equal Protection and Due Process clauses of the Fourteenth Amendment [text] through discriminatory actions, failure to accommodate, and irrational explanations of her treatment in the Norfolk institute. Jane Doe asserts that she has been diagnosed with Gender Dysphoria, which requires a specified treatment plan to cope with the difficulties of being born one gender, while having experiences of another. The ADA and Rehabilitation Act require the correction institute to not only provide proper treatment plans, but to also adhere to them. The corrections institute does, however, have the ability to deny requests and treatments based on "rational reasoning." According to Jane Doe and her attorneys, Norfolk irrationally failed to provide this specified treatment or allow Jane Doe to attempt treatment for her medical diagnosis.

According to Jane Doe, her experiences at the corrections institute have fallen short of her desired treatment plan, where she gives testimony of daily interactions with inmates and officers. GLAD asserts,
They have traumatized her by forcing her to live in a male correctional facility, subjecting her to strip searches by male correctional officers, forcing her to shower in view of male prisoners who inappropriately comment on her female breast development and otherwise harass her, and refusing to address or refer to her using female pronouns.Through events mentioned above, GLAD claims that this is in full violation of Jane Doe's treatment, which requires she have the opportunity to live life as a female, especially considering she has undergone reconstructive surgery and now appears as a woman. Accordingly, GLAD provides other claims where Norfolk had previously accepted the requests and treatments of Jane Doe by allowing her to shower with other transgender inmates, yet these actions have been denied since then and she returns to the public showers with other men.



GLAD also noted that Jane Doe has been experiencing Gender Dysphoria since she was a child, where she received diagnosis as a teenager and then maintained family support through adhesion to the proper treatment plans provided by the World Professional Association for Transgender Health (WPATH), the American Medical Association (AMA) and the American Psychological Association (APA) [advocacy websites]. Jane Doe claims that she has undergone proper treatment for at least four decades, but her treatment in the Norfolk corrections facility has been abandoned and she now fears future mental and physical harms.

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Assistance Resources to Share With Patients


The Go Practice blog has been covering important topics around the increase of patient financial responsibility and how medical practices can respond in order to thrive financially and to address patients’ challenges with empathy. Here are a few examples:

The Changing State of Patient Collections (Infographic)
Patient Collections Boot Camp (Guide)
4 Ways to Add Empathy to Patient Collections

In addition to having the policies in place to clearly communicate and collect patient financial responsibility, it’s a good practice to offer your patients information about assistance resources for health services. In doing this, you show your understanding of their situation and are also helping to make sure they get the support they need to receive quality care. Here is a selection of resources you can share with patients.

General Services


Government Benefits


Benefits.gov will help you find government benefits to which you may be entitled. A short online questionnaire will help direct you toward benefits you can apply for, including those that help with healthcare and childcare. You can also check a box at the bottom of the list to find out what benefits you could qualify for in every category.

You’ll need to have information about your income and any benefits you receive ready. The form goes through several pages, but you can click “View Benefits Results” at any time. The more information you put in, however, the more accurate and extensive the programs suggested will be for your particular situation.

The United Way


The United Way has a broad reach into each community and can provide you with information about medical assistance in your particular area. Dial the three-digit number 211 to talk to a referral specialist in your community, or go to 221.org. They can give you information on anything from drug and alcohol treatment to community clinics. The referral specialists can also help connect you to health services and senior services in your area.

Free Clinics


Many communities have free clinics that can help with medical or dental needs. Search for a clinic near your zip code at the National Association of Free & Charitable Clinics’ website. You'll find detailed information, including directions to clinics and the services offered by each one. The services provided vary with each clinic, but generally can include medical services and treatment, including lab work and access to free or greatly discounted prescription drugs. Vision care, dental care, and mental health services are also sometimes included.

State-Sponsored Programs


Each state has programs to help with financial assistance for medical care, health insurance, prescription assistance, medical supplies and equipment, respite care, disease screening, and more. Search by state at NeedyMeds.org for details about what’s available where you live. For example, Alabama has 21 programs offering help with everything from HIV/AIDS to breast cancer.
Pregnancy Related Services

Department of Health and Human Services programs


The U.S. Department of Health and Human Services can refer you to free or low-cost services for pregnant women and their babies in your community. Call 1-800-311-BABY (1-800-311-2229). For information in Spanish, call 1-800-504-7081. The agency can refer you to your state or community’s Healthy Start program to help improve your health before, during and after pregnancy. Healthy Start also helps families care for babies through their first two years. They can refer you to newborn health screenings and a home visit program to help ensure a safe, healthy environment for you and your baby.

Healthcare Centers


The U.S. Department of Health and Human Services also has healthcare centers that provide a wide variety of services, including complete care when you’re pregnant. They’re located in most cities and rural areas. You pay only what you can afford. You can also receive checkups, treatment for illnesses, immunizations and checkups for your children, dental care for your family, prescription drugs, and mental health and substance abuse care if needed.

Planned Parenthood


Planned Parenthood has over 600 health centers located across the country. The organization helps provide pregnancy testing and general healthcare to women (and to men as well). Check online to find the closest Planned Parenthood clinic in your area. The list specifies the services offered, and you can check to see when appointments are available and make one online.

Medicaid


Medicaid covers other conditions as well, but it also helps finance 40 percent of all births in the U.S. Coverage for pregnant women includes prenatal care through pregnancy, labor, delivery and for 60 days after you deliver. Medicaid is administered by individual states, so income levels can vary. Some states have also loosened income eligibility for pregnant women, especially if your healthcare expenses are sufficiently high. Babies born to pregnant women who are receiving Medicaid are automatically eligible to receive Medicaid until their first birthday. Citizenship documentation is not required.


Medicaid helps finance 40 percent of all births in the U.S. And over 8.1 million children get healthcare coverage through CHIP.

Children


Children’s Health Insurance Program (CHIP)


If you have children, you may be able to get healthcare coverage for them through the Children’s Health Insurance Program (CHIP). Over 8.1 million children are enrolled in the program, which is administered by individual states. Coverage varies from state to state, but all cover check-ups, immunizations, hospitalizations, dental care, lab services and x-rays.

Children and Youth with Special Health Care Needs (CYSHCN)


If you have a child with disabilities, the costs for his or her treatment can be daunting. Even if you are uninsured or underinsured and don’t qualify for Medicaid, you may be able to get healthcare assistance through Children and Youth with Special Health Care Needs (CYSHCN). Your child must have special needs in order to qualify. These needs must be serious, long-lasting disabilities, including physical, behavioral or emotional issues. Eligibility varies according to your income, your child’s age and health condition, and the state in which you live. Services include assistive technology, early intervention and screening for health risks, and family support. Visit FamilyVoices.org and click on the state map for more information about your state’s particular programs. You can also contact your state’s Department of Health & Human Services for more information. The program’s name can vary from state to state.

Prescription Assistance


GoodRx


When you prescribe medications, you can now educate and empower your patients about finding affordable prescription prices and saving money. This free program lets patients compare prices online, print coupons and save up to 80% at almost every U.S. pharmacy. 

Pharmaceutical Companies


Skipping needed medication can lead to even more serious health problems. Many pharmaceutical companies have programs to provide medication for free or at a reduced cost. Research what help is available for your specific medications at RXAssist.org or the Partnership for Prescription Assistance. Your doctor may have to fill out or send in forms on your behalf. Each program has its own requirements, but generally, you’ll need to have no prescription insurance coverage, meet income guidelines, and be a U.S. citizen or legal resident.

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