New England AADMINISTDMINISTRRAATTOORR District One March “I have never let my schooling interfere with my education..” 2021 -Mark Twain American College of Health Care Administrators

THE TECHNOLOGY ISSUE

PLUS: Pioneer Bob “Mr. Maine” Armstrong Loneliness and aging • Everyone I know is dead The C.A.R.E. Expert • The Marketing Guru The Legal Perspective

THE C.A.R.E. EXPERT The TB12 Method: Top 12 Most Important Things to Know by Kris Mastrangelo, that can help our senior popu- peak performance. He debunks OTR/L, MBA, LNHA lation live healthier longer many training methods in the and Savannah James lives. athletic sphere and recom- mends his regimen to athletes Fun fact: This applies to all The majority of New England and people of all levels and of us! Patriots fans rooted for Tom ages. Many rumors surround- Brady in LV be- Below is the article written ing Brady’s neurotic methods tween the Tampa Bay Bucca- by Savannah James: are also confirmed or denied. neers and . I certainly did while wearing a Does Brady eat strawberries or other nightshades? No. TB12 T-shirt and displaying a If you are a football fan, odds Does he sleep in bioceramic cardboard cutout of the former are you have a strong opinion pajamas that release far in- Patriots’ . Brady’s about the newly crowned frared rays? Yes. Is success is impressive, unfath- Super Bowl LV champion, as neurotic and disciplined as omable, and piques everyone’s Tampa Bay’s starting quarter- Kris Mastrangelo people say he is? Absolutely. curiosity about his methodol- back Tom Brady. Many Jets ogy. fans and Colts fans hate Brady, Here are 12 things you need they supposed to maintain citing the infamous incidents to know about the TB12 peak performance? According Back in 2017, Savannah of “spygate” and “deflate- Method developed by Brady to Brady, without pliability, it is James outlined the 12 points gate.” Other fan bases share and body coach and former not possible to have a level of on being healthy from Tom this hatred for similar or differ- teammate Alex Guerrero. performance that endures over Brady’s book. While the read- ent reasons. If you are from time. ers are interested in his secrets New England, Brady is most Pliability to athletic success, many Holistic and likely your hero, your G.O.A.T. The TB12 Method is centered healthcare providers may want integrative training (Greatest of All Time), or your on muscle pliability, which is to apply his methodology to favorite athlete of all time. something that is not included This one is simpler and less increase the quality of life of in most performance training news-breaking. Brady outlines Regardless of where you nursing home residents. routines. As defined by Brady, these 12 methods and claims come from or what team you The mantra of Harmony “pliable muscles are long, soft, they must be practiced in con- root for, some small part of Healthcare International (HHI)– and capable of full muscle junction to be effective. Is this a you must be a little curious as It’s not ok to decline in function pump function.” marketing ploy? Maybe. Brady to how Brady continues to suc- once a patient is admitted to a also emphasizes the importance ceed despite his advanced The TB12 Method focuses nursing home–reinforces that of detail: Every single aspect football age. At the old age of on “prehab” instead of it is the responsibility of the from your sleepwear to how 43, Brady holds the record for “rehab,” so injury prevention nursing home to: “Maintain much water you drink must be the most Super Bowl wins is of the utmost importance: each resident’s practical state analyzed and optimized for the (seven), the most Super Bowl Keeping muscles long and soft of physical, mental, and emo- needs of your body. appearances (10), and the increases blood and lymph cir- tional well-being… (OBRA Balance and moderation most division titles (17). He culation, preventing injury. 87’)” in all things currently just finished playing When muscles are denser Savannah’s article demon- in his 20th season with aspira- and harder, the majority of Again, this is a concept many strates that aging does not tions to play until he is 45. If he heavy lifting is transferred to are already aware of. Balance need to correlate to functional accomplishes this, he will top bones and joints, which cause and moderation are important decline. There are methods the current record holder for injury. in everything you do, espe- the oldest quarterback to play cially eating and athletic train- Brady endorses pliability in the NFL, Steve Deberg, who ing. training, which is deep-force played until the age of 44. muscle work combined with Conditioning for Quarterback and kicker George contracting and relaxing the endurance and vitality Blanda technically holds the muscles. If your muscles are record for the longest NFL ca- The TB12 Method is not just trained to be loose and for optimizing athletic perform- reer, although he spent a large stretched, you are much less portion of his career as a ance, but also overall energy likely to suffer an injury upon and health. If applied properly, kicker. Brady could potentially impact. this method could increase top both players to clinch the your overall quality of life. record. Many athletes–especially at the professional level–cannot In his book, “The TB12 compete for the full length of Continued on page 17 Method,” Brady shares the their season because of injury. training and eating regimen If athletes are constantly strug- that allows him to maintain his gling with injuries, how are PAGE 3 THE MARKETING GURU How digitization leads to democratization Book review: “The Patient Will See You Now” by Eric Topol by Irving L. Stackpole, RRT, MEd It’s hard to conceive of a book about healthcare, which fea- tures the actress, Angelina Jolie, and besieged entrepre- neur, Elizabeth Holmes. Yet the autonomy with which Jolie evaluated the information about her risk for cancer, made the decision to have surgery, and went public with that deci- sion define a new type of healthcare consumer. In pub- lishing her story, Topol says, Jolie “symbolized the new era of medicine, whereby access to critical information about oneself–in this case genomic swiftly. In 2019 Holmes was information–leads to the indi- ousted as CEO, and faces sig- vidual’s empowerment to nificant jail time for “massive of Medicine Is in Your Hands.” that patients control their data, make a pivotal choice that de- fraud.” In 2015, Topol de- Topol urges readers to make the author argues, the safer termines one’s fate.” scribed the experience of hav- use of technology, digital and more individualized med- ing a droplet of blood taken ical care can become. This is Holmes, the founder of Ther- know-how and entrepreneurial painlessly from his finger: the premise underlying the anos, which sought to revolu- creativity to learn as much as “Over fifty tests were ana- vital importance of technology tionize the technology of blood they can about their health, to lyzed...and I got the results for quick and accurate access tests, is another kind of hero– know it all, own it all, and man- back in just a matter of min- to patients’ own information the technological visionary age it on their personal de- utes.” and place it–literally–in the who finds new, digitally based vices. “For just as Gutenberg democratized reading, so there hands (or handhelds) of those ways to surmount traditional Topol, a cardiologist and a is the chance that smartphones seeking medical care, and not roadblocks to medical testing pioneer in genetics and tech- will democratize medicine. just in computers of the doc- and get patients their results nology, builds on the argu- That will ultimately be tors and others in long white ments of his earlier book “.” achieved when each individual lab coats. He argues that it is critical for has unfettered, direct access to people to know as much as “The Patient Will See You all of their own health data and possible about their bodies Now” is full of innovative information.” and their health, from their ge- thinking. Readers learn about netic codes to the moment-by- And the obstacle? What devices that can measure body moment information that stands most in the way, ac- chemistry, organ function, or implanted sensors might trans- cording to Topol, is an en- medical risk; integrate that in- mit about their bloodstreams, trenched culture of medical formation instantly into a pro- their airways and their hearts. paternalism, which goes back file of their health; and offer While some find the prospect to the original Hippocratic answers to questions they did- of fully empowered consumers Oath. And for the most part, it n’t even realize they ought to be asking. Topol’s argument is thrilling, most of my col- is this paternalism that he that these devices and this leagues who practice medicine blames for problems large and small, from the long waits for kind of patient involvement are wary. A few even see it as medical appointments, to the have the potential to revolu- a dystopian future, auguring barriers that divide people tionize the practice of medi- badly for medicine. Irving L. Stackpole from their own lab results and cine, eliminating many of the The book is written in an ex- medical records, to the med- abuses of medical paternalism hortative, urgent voice; as the ical errors that endanger pa- PAGE 4 subtitle suggests, “The Future tients in hospitals. The more Continued on page 7

The land that technology forgot by Al Terego didn’t want to move forward, we simply couldn’t afford it. We could barely afford to When the Editor-in-Chief of The New Eng- put up the shed in the back of the parking land Administrator assigned an article to lot, where we keep 10 years’ worth of writ- me about the use of technology in long- ten records. term care, I thought, this is going to be the shortest article ever, because long-term care We were slow to adopt pagers, electric is the land that technology forgot. beds, defibrillators, and crash carts–not be- cause we lacked vision, but because we had There’s a dearth of useful technology to pay our bills and make payroll. Our busi- within long-term care, and it has been that ness model has been broken for decades. way right from the beginning. We’ve just learned to keep surviving. Keep in mind, after Medicare passed in For many of us, this is how we existed, 1965, people started creating their own right up through the 1980s at least. Since paths in the operation of care homes, which then, we have done what we can to em- eventually led to Mary Adelaide Mendel- brace technology. Slowly, we began to find son’s seminal book, “Tender Loving Greed.” value in call bell systems that help track a It exposed the practices of numerous unsa- lost resident, or that can tell you if an elder vory owners and operators in the unregu- is trying to get out of bed by themselves. lated cottage industry, which led to legislative hearings, which led to laws and Our software systems finally interface regulations, which led to ongoing pain for with each other, so that rehab treatments all operators. can be billed for without manual calcula- Telehealth for mental tions being made by the business office One of the most significant, and confining staff. Our pharmacy systems reduce errors, health services sets of regulations imposed by the govern- ment was the decision to use the JCAH (the waste, phone calls, and repetitive docu- by K.R. Kaffenberger, Ph.D., M.P.H. O was added later) standards for hospitals, mentation. and retrofit them into nursing homes. Thus But there’s so much more that we need. According to the Morbidity and Mortality was born the long corridors, double (or Chronic staffing shortages and increased Weekly Report, a publication of the Centers triple or quadruple) rooms, and nursing sta- clinical challenges are forcing us to be even for Disease Control and Prevention, more tions at the hub. The trappings were laid for more creative in trying to be everywhere si- than a third of the U.S. adult population suf- the institutionalization of our elders. multaneously, to reduce falls, to become fers from identified mental illness. Depres- Nursing homes were built to resemble less reliant on pharmaceutical interven- sion, suicidal ideation, and substance abuse hospitals, but with one big difference: They tions, to increase consumer satisfaction. are prominent, measurable disorders con- were funded more like poor houses, i.e., The care and service our staff members tributing to these statistics. They are also part of the state welfare system. Adminis- provide can never be replaced by robots, among the most common disorders in older trators have evolved to be the most re- and that’s a good thing. But we all need adults. Older adults suffer from these disor- sourceful, creative, inventive, and frugal more people. Technology needs to augment ders in the community, in hospitals, in nurs- business leaders on the planet, but don’t let care, streamline the flow of information, re- ing homes, in assisted living residences, our MacGyver-like qualities confuse you. duce duplicative work, and eliminate ineffi- and in prisons. We’re also caring and compassionate un- ciencies. The availability of services to help with derneath. There are solutions out there, but it will these disorders is often limited. The scarcity We had to get by without purchasing new cost you. of available services, especially psychother- equipment for many years, long past the apy, leaves many people with untreated point where our systems were obsolete. We Al Terego is the pen name of a fellow-administrator who conditions. Others, especially in nursing were one of the last bastions of paper wishes to protect his identity from lurking surveyors and homes, have their conditions managed with records in health care. It wasn’t because we would-be assassins. psycho active medications that in many in- stances have proven to be inappropriate and/or harmful. The most common and expected means of providing psychotherapy has been in- person sessions with a clinician interview- ing individual patients or coordinating group sessions in person. While telemedi- cine has been used to treat acute physical disease in recent years, most psychothera-

Continued on page 16

PAGE 6 Eldercare and the adoption of technology

by Michael R. Carlson

With more than 20 years work- ing within ALF & SNF commu- nities, Radius Executive IT Solutions truly understand the challenges that these commu- nities incur. As the account manager, my focus is on in- creasing technology and pro- ductivity for the staff, The future of medicine is in your hands leadership, and the residents. For this article, I partnered up Michael Carlson Continued from page 4 ing, accumulating and analyz- with Strategic Care Solutions, ing personal medical data by returning information (and LLC, which offer results-driven raises important questions take up the very valuable time the power that it brings) into management solutions for or- about privacy and confidential- the nursing professionals al- the hands of patients. And he ity. Topol acknowledges this ganizations throughout the ready don’t have!” This is also presents many intriguing sce- issue, exploring the problems elder care continuum. I cannot evident within the facility oper- narios in which technological of identity theft and hacking stress enough the importance ators, whether it is financials, creativity offers everything and the question of whether of having an experienced con- building metrics, staffing, and from telehealth–“My (Smart- your insurer should have ac- sulting company and/or IT ven- tracking trends of the building. phone) Doctor”–to cheap, fast cess to all possible medical dor that can help guide your Having multiple applications to skin tests for diagnosing data. He believes that keeping facility in the right direction, as gather data, with downtime malaria. patient records secure is possi- well as help with projects between applications can cre- While Topol’s enthusiasm ble, noting in particular that whether that be adding loca- ate a very unproductive envi- and clear expertise are excit- “anything that will better pro- tions, consolidating locations, ronment. ing, it’s important to keep in tect the genomic privacy of an staffing, or just clinical reim- As we have already learned, mind that devices, tests, and individual should be pursued.” bursement. it can be very cumbersome therapies are all tools, with no But the questions are huge and Now that you know who I and time consuming having to inherent moral code, and that complicated, and if the am, let’s talk about some of the juggle between many applica- one of the recurring lessons of changes that Topol describes challenges within the skilled tions, especially regarding in- medical science is that discov- are coming as quickly as he nursing world that technology formation for the residents, the eries and promising therapies hopes, they’re going to require has been able to overcome. Let facility, and leadership. Imple- can carry dangers and unex- development of new technical us start with some words di- menting web-based dash- pected physical, ethical, and and legal protections so that rectly from an individual who boards for facility data has social outcomes. In addition to we keep ourselves safe and has climbed through the ranks proven to increase productiv- the very real issues of en- healthy in every sense. No- as a skilled nurse! ity. There are a few options trenched paternalism, many tably absent is discussion of I had a brief interview with currently available, including problems that inhibit good pa- the potential applications of Matt Ryan, a registered nurse Microsoft Power BI and tient care reflect the uneasy in- block chain for just this pur- consultant, which was very en- Tableau. Refer to your current tersection of market forces and pose. lightening for me as he is well IT vendor to see which applica- medical practice, from produc- Topol sees a future in which immersed in the SNF world. tion would work best with your tivity pressures applied to doc- “your smartphone will become He said,“Mike, we are all about network. SCS and Radius IT tors by their institutions (see central to labs, physical exams, efficiencies. Slow response are currently in the process of more patients, spend less time and even medical imaging; times while navigating through designing a single dashboard with each one) to paperwork and...you can have ICU-like [in- different applications like Point solution as well. It will be a overload (if you want to pre- tensive-care unit] monitoring Click Care, Optima Health, scribe a drug that will cost us in the safety, reduced expense, Labs, and X-ray website can Continued on page 10 more, we’re going to make you and convenience of your spend a lot of time filling in home.” This is a book full of forms and waiting on hold on technical wizardry and intrigu- the phone). The market plays a ing questions about the na- complicated role here, and ture–and the future–of new products and technolo- diagnosing, monitoring, and gies are not guaranteed to healing. make life easier or more con- venient for patients or doctors. Irving Stackpole RRT, MEd is the Presi- dent of Stackpole & Associates, market- Any discussion of increas- ing, market research and training firm at www.StackpoleAssociates.com. He can be reached directly at: PAGE 7 [email protected]. PIONEERS & ROGUES: Bob Armstrong – “Mr. Maine” The New England Alliance Conference Calendar Every issue we feature a New England individual whose accomplishments– good or bad–have helped to shape our profession. Today we journey north Spring Regional Conference to Maine to recognize an outstanding leader from DownEast. May 26 to 28, 2021 by Bruce Glass, FACHCA,CNHA, Newport Harbor Hotel & Marina CALA, 9 CEUs For those of us who bear the Fall Regional Conference title of “veteran sloggers,” it September 22 to 24, 2021 was too often the story at dis- Portland Regency Hotel trict meetings that the Maine Chapter was moribund. Year after year the report was: For more details: thenealliance.org “Sorry, nothing to report.” Fortunately, more than a decade ago that changed dra- matically. A group of College members not only revived the Maine Chapter, but also built it Loneliness and aging into a powerhouse. Prominent In the latter capacity, Bob among them was Bob Arm- worked closely with John by Sheldon Ornstein Ed.D, RN, strong. Pratt, director and professor of LNHA But that is just one of a long LTC at St. Joseph’s College of list of accomplishments in his Maine to rewrite and update My father-in-law, of blessed illustrious career. the licensing rules for all levels memory, often said, “Loneli- of senior care. An important ness is a fatal disease.” A Bob has been a true leader part of this was establishing a friend of mine once described in the industry–and in many code of conduct. loneliness as “a devastating ill- other aspects of senior care. In 1991, Bob received the ness…more so than physical Starting in, of all places, dis- Secretary of Defense Medal for illness.” Some can overcome a tant rural Aroostook County. Outstanding Public Service in little, but the older an individ- After graduation from recognition of his service on ual is, the more hazardous the UMaine Presque Isle, he be- the Armed Service Retirement loneliness becomes. A hug or came planner for the Aroost- Board, which oversees the U.S. a touch from another becomes ook County Area on Aging. He Soldiers Home in Washington, extremely important. Loneli- then went on to become the D.C. and the U.S. Naval Home ness, according to Louise executive director for the West- in Gulfport, MS. At the same Hawkley, Ph.D, a senior re- ern Maine Area Agency on time he served on the faculty search scientist at the Univer- that unrelieved loneliness is Aging. In that position he of St. Joseph’s and as vice sity of Chicago, “is a universal often accompanied by frequent worked closely with Congress- president, then president of human experience and being mood swings that send an man (later Senator) Bill Cohen the Maine chapter, all while the social animal that we are, older individual to prescriptive to sponsor important legisla- continuing his full-time role as there must be implications medications for relief. tion to benefit Maine’s seniors. an administrator. when those social connections There are others who define are not satisfied.” Next it was a short step into It was at this time he re- loneliness based on statistical the burgeoning field of as- ceived the nickname of “Mr. There is, and will always be, studies. Still others lend cre- sisted living, where he became Maine.” His next venture was a human need to be connected dence to the issue based on executive director of the Clover as Director of Rural Health and integrated into a social brain scans, suggesting a de- Living Center, Maine’s first as- Planning and LTC for Central network. Hawkley further cline in brain functioning as a sisted living connected to a Maine. states, “When social network- reason for that loneliness. And nursing home. ing is absent, the conse- there are still others who be- Between 2001-2013 he quences are all too real in lieve that the individual who He then became administra- turned around numerous prop- terms of one’s mental and suffers fatigue from loneliness tor of a nursing home in Nor- erties, assisted in the creation physical health.” Most of us is based on observable behav- way, Maine. His close of two rural health networks, are intimately familiar with ioral patterns. connection to Governor John and upgraded two rural hospi- only one kind of loneliness–our R, McKernan led to his appoint- tals. Julianne Holt Lunstad, a psy- own. The research has shown ment as a member of Maine’s chologist at Brigham Young Following early “retire- Committee on Aging and Chair University, questions whether ment,” Bob formed Bob Arm- of Maine Nursing Home Ad- PAGE 8 Continued on page 14 ministrator Licensing Board. Continued on page 14

THE LIGHTER TOUCH Adopting technology at SNFs by Ralph Peterson Continued from page 7 times a day. The entire facility was being run of a web-based app that will give a 100MBPS/20MBPS broadband Recently I was going through Everyone snapshot of financial info, connection. To put this into an old file box that I have been staffing information, and perspective, most households lugging around for years. It is trends in the facility, i.e., com- I know nowadays run off of a 300- full of articles, ideas, and mus- mon ailments, new residents ings. As a writer, I keep every- 600MBPS broadband connec- coming in, as well as the loss is DEAD. tion. They had 100MBPS thing. For a long time, I had a of current residents. This will running an entire facility. This practice of writing every idea be a truly catered application is a very easy fix that can be or thought I had on a sticky for skilled nursing staff, which cost effective and make a huge note. Then I would place the is what they have been asking cooking, and paying bills, all difference in overall facility sticky note on the wall of my for. office, or on my computer by himself… until he fell. performance. A new concern that the pan- monitor. Still, his biggest accomplish- In conclusion, a facility is demic has brought to our at- ment was being alive. only as good as its people. The Of course, as my sticky note tention is getting skilled nurses, executive direc- collection grew, I would have I think my favorite part of communications out to resi- tors, administration staff, and to take some down, and con- meeting Mr. Reynolds, and in- dents that cannot leave their the facility managers all must solidate them. Sometimes, if I deed, the reason I am sharing rooms. With a lack of access to work together in harmony to was lucky, an idea or phrase I this story, is because of what Wi-Fi or an internet connection keep the show alive. Technol- wrote down would turn into a he did for me. He changed my in general, residents and staff ogy and management compa- story idea or an article. Most of perspective. must rely on physical flyers, nies are there to compliment them, however, would end up communication from nurses, I used to think people came the staff. When the technology in a box. or conference calls. This takes to nursing homes to die. I starts working against the facil- “Everyone I know is dead.” a lot of time for skilled nursing thought it was the last stop. The ity, it is time to contact your IT staff to facilitate. We have de- This phrase is written on a place everyone goes–like a wait- vendor or start looking for a veloped a less intrusive yellow sticky note, stuffed in a ing room–before they move on. new one. process of bringing in a wire- Ziploc bag full of sticky notes. Mr. Reynolds, however, had less solution to these facilities. Thank you for taking the For some reason, this one is no intention of moving on. In It opens the ability to bring in time to listen to my story. I on top and visible, and reading fact, all he wanted to do was more forms of communication hope if anything, this provides it again makes me think of the keep living. He was always up to our residents, such as a you with a reference for com- person who said it to me, Mr. early and ate his meals in the tablet solution or smart TV mon questions or even a solu- Reynolds dining room. He always in- with digital signage for events tion to a problem that has He was 92 when I met him, sisted on being fully dressed, and alerts in the facility. We been avoided for some time and one of the first things he even though getting dressed have also found that having a now. said to me was, “Everyone I was both exhausting and robust internet connection know is dead.” painful. He chatted up every- readily available greatly in- one who came to his room. He He wasn’t complaining. In creases productivity with the joined in activities and volun- CONTINUING CARE fact, he was bragging. He had staff. Faster communication teered to help with anything RETIREMENT just moved into the nursing translates directly to more pro- and everything. CENTERS home I was working in, and he ductivity. IN was counting his blessings. In short, he did not come to The last and most important NEW ENGLAND Not only had he outlived the nursing home to die. For piece is looking at the overall everyone he knew, but up to him, it was simply a new place IT infrastructure, including the that point, he had also re- to live. components that are currently mained independent. He was It was such an important les- in place and the Internet con- State Facilities still driving, shopping, bathing, son for me, and one that I am nection. We also look at the always reminding my man- transport type: fiber, broad- CT 17 agers to consider. Most of our band, DSL, or T1. Having the residents do not move into our right transport type for the homes because they have right applications is impera- ME 3 given in or given up. They tive. move in to live. Radius IT recently took over MA 27 Our job is to make sure they a new facility, and during my do. discover walk through, I kept

hearing common concerns: NH 10 Ralph Peterson Ralph Peterson is a three-time best-sell- slow response times; my email ing author and a leading expert in man- takes forever; our system agement development in the long-term crashes all the time; I have to VT 1 PAGE 10 care industry. [email protected] restart my system multiple WEWE AREARE BACKBACK OldOld isis newnew againagain

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BOOK REVIEW “Hallowed Ground: Stories of Succesful Aging” by Julian Rich, FACHCA, CNHA he served for close to 20 years and profoundly influenced the When I finished reading “Hal- quality of life of thousands of lowed Ground,” I called Larry patients, residents, family Minnix to congratulate him on members, and staff members, writing the ultimate reference as well as health leaders, legis- for professionals and non- pro- lators, and others who were fessionals–if not anyone and fortunate enough to meet him. everyone who chooses a ca- reer in aging services. Maybe Like few before him, he cap- senior care organizations tures that aging services, sen- should give out the book to ior care, or however one every new employee as re- references our field, is an emo- quired reading. Granted, it’s a tionally charged environment, plug for Minnix, but there is and that emotion impacts the truth in that statement. The au- mission and the day-to-day op- thor is kind enough to want to erations and management of convey the wisdom, knowl- any senior care organization in edge, and understanding that ways that are hardly scientific he gained from his rich and re- but require sensitivity, empa- warding personal and profes- thy, and, of course, a sense of sional life to our benefit. humor and wisdom. These are the major lessons of “Hal- Minnix was the CEO of Lead- ing Age, formerly the Ameri- lowed Ground.” can Association of Homes and Services for the Aging, where Continued on page 15

THE LEGAL PERSPECTIVE

Legal risks of health care technology: Learning from the $18.25M Athenahealth, Inc. settlement by Lawrence W. Vernaglia and Stephanie J. payment reductions as part of the pro- Schwartz grams. With more financial arrangements be- UPSET YOU DIDN’T GET TAKEN TO THE SUPER BOWL BY tween providers and third parties comes YOUR VENDORS THIS WINTER? MAYBE YOU SHOULD BE greater risk of conduct that potentially vio- GLAD YOU DIDN’T. lates federal law, including the Anti-Kick- back Statute (“AKS”) and the False Claims arrangements that allegedly violated the Long term care facilities and their owners Act (“FCA”), the violation of which could re- AKS, the Vendor and its clients would have and managers face risks when accepting sult in significant fines, civil monetary submitted (or caused to be submitted) gifts, trips, benefits, or other perks from cur- penalties (“CMPs”), and exclusion from par- claims to a federal health care program (i.e., rent or potential vendors. ticipating in the federal health care pro- claims for enhanced payments under the The January 2021 settlement of $18.25 grams (among other consequences). EHR incentive programs and MIPS) in viola- million paid to the federal government by 3 The AKS, 42 U.S.C. § 1320a-7b(b), pro- tion of the FCA. Below, we will discuss Athenahealth, Inc. (the “Vendor”), a Massa- hibits the knowing and willful solicitation or these alleged marketing programs and the chusetts-based electronic health records receipt of any remuneration, in cash or in conduct that was argued to have rendered (“EHR”) developer, is one of the more re- kind, in exchange for referrals or the pur- them illegal, to provide a view of the key cent examples of how sales and marketing chase of items or services for which pay- risks to consider when entering into arrangements can be viewed negatively by ment may be made in whole or in part arrangements with third-party vendors, in- enforcement authorities. While this case under a federal health care program. An cluding health care technology companies. was brought against a health care informa- AKS violation results in a felony conviction The first program that the government al- tion technology vendor (thus coming within that brings with it a maximum fine of leged violated the AKS was the Vendor’s the scope of this issue of New England Ad- $100,000 or a maximum prison sentence of “Concierge Event” program. Through this ministrator), the case offers a broader cau- 10 years (or both), as well as the potential incentive program, the Vendor “provided tionary tale for providers entering into imposition of a CMP of up to $104,330 (as existing potential clients with all-expense- business arrangements with third-party adjusted for inflation, effective January 17, paid trips to sporting, entertainment, and vendors and of when sales strategies can 2020, see 45 C.F.R. § 102.3 (2019) (citing 42 recreational events.”4 The Vendor allegedly get parties in trouble. C.F.R. § 1003.310(a)(3) (2019))). The FCA, 31 provided these gifts to executives, The allegations against the Vendor in- U.S.C. §§ 3729-33, imposes liability where a providers, and other stakeholders in order volved three marketing arrangements in person “knowingly presents, or causes to to induce them to purchase the Vendor’s which the company allegedly engaged be- be presented, a false or fraudulent claim for EHR products. The exchange of in-kind re- 1 tween January 2014 and September 2020. payment or approval” (among other types muneration (with no demonstrated educa- These schemes, detailed below, allegedly of conduct). Significantly, the standard to tional component) for the purchase of a involved illegal kickbacks paid to potential establish intent (i.e., “knowingly”) under product that would be used to attest for clients, existing clients, and competitors in the FCA includes “reckless disregard” for EHR incentive programs was argued to be a exchange for referrals to and/or continued the truth or falsity of the claim, which has violation of the AKS. business with the Vendor. These allegedly proven to be a rather low bar. Each claim illegal kickbacks were alleged to have re- that violates the FCA results in a civil The second Vendor program that al- sulted in false or fraudulent claims (because penalty between $11,665 and $23,331 per legedly violated the AKS was the Vendor’s they were tainted by the kickbacks) that claim (as adjusted for inflation, effective “Client Lead Generation” program, which were ultimately submitted by the Vendor’s June 19, 2020, see 28 C.F.R. § 85.5 (2020)), was in place from January 2014 to Septem- clients to federal health care programs— plus three times the amount of damages ber 2020. Under this program, the Vendor specifically, the EHR incentive programs the federal programs sustain. Providers allegedly induced its existing clients to refer provided under Medicare and Medicaid. may also be excluded from participation in new clients by offering and making pay- the federal health care programs, for a pe- ments for each referral. The payments in- EHR incentive programs were first estab- riod of time or permanently, and may face cluded (but were not limited to) $200 for lished under the Health Information Tech- CMPs of up to $20,866 (as adjusted for infla- meetings with prospective clients that arose nology for Economic and Clinical Health Act tion, effective January 17, 2020, see 45 from a referral, $3,000 per doctor referred (“HITECH Act”) and, with the passage of the C.F.R. § 102.3 (2019) (citing 42 C.F.R. § after a successful referral of an ambulatory Medicare Access and CHIP Reauthorization 1003.210(a)(1))). practice, and $10,000 for each referred inpa- Act of 2015 (“MACRA”), were replaced by tient hospital program. the Merit-based Incentive Payment System It is often alleged that it is a violation of (“MIPS”), which analyzes several quality the civil FCA to submit a claim that has The third program addressed in the com- measures in determining Medicare pay- been rendered illegal because it resulted ment adjustments.2 Health care providers from an AKS violation, even when the un- Continued on next page attest to using certified EHRs to satisfy derlying conduct is not charged criminally. these programs’ requirements, in order to Here, the government alleged that by en- PAGE 13 receive incentive payments and/or avoid gaging in conduct under its three marketing Older individuals can combat loneliness

Continued from page 8 long term illness.” loneliness may be due to peo- In several studies on the ple becoming socially discon- value of animals as pets, espe- nected in a variety of ways. cially with older individuals, it She describes loneliness as “a was suggested that the most subjective feeling or sensation common reasons why people that tests one’s health risks.” love having a pet was to com- bat feeling lonely and to add Simply living alone or in a quality to family life. For the state of isolation can also be as isolated, pets hold an even harmful to one’s health as just greater importance for the plain feeling lonely. elder’s mental state. One can Hawkley asks, “At what always rely on a pet to always point do you say that some- be available and non-judgmen- body is lonely? A teenage boy, tal. Pets are considered, by alone on a Saturday night may many owners, as members of experience a very different kind a family and can play a major of loneliness than does an eld- part in an older person’s exis- erly man without a spouse or tence. partner to communicate with, A final thought: I realize that nor hasn’t spoken to anyone feeling good may be the last for days.” Loneliness can mean thing on our minds as the pan- different things to different demic grinds on in America. people, whether young or old. Countless researchers say pur- Scientists need to measure suing happiness and a happy the condition known as loneli- outlook can give us the re- ness in an encompassing way silience to get through it. where they can define it as ei- ther slightly, moderately, or ex- According to the researcher tremely lonely and as a way of Laura Santos, professor of psy- Health care technology’s legal risks clarifying its treatment plan. chology at Yale University, Continued from preceding page The researcher Sheldon, offers “We need to focus on happi- demonstrates the department’s several correlates on loneli- ness, more now, not less.” plaint as a potential AKS viola- continued commitment to ness that can be identified as Therefore, when you are feel- tion was the Vendor’s “Conver- holding EHR companies ac- psychologic, economic, and ing sad and lonely, try singing sion Deals” program. countable for the payment of physiologic, and that con- my favorite Beatles song, Conversion Deals were alleged unlawful kickbacks in any tributes heavily to loneliness in “Here Comes the Sun.” arrangements entered into by form.” the adult population. He fur- the Vendor and competitor en- New technology is increas- ther clarifies how “the in- Bob Armstrong terprises that were terminating ingly important in the delivery firmed, the widow, and the their EHR offerings. In ex- of health care services. How- Continued from page 8 single man over eighty and liv- change for payments from the ever, as this settlement demon- ing alone are highly prone to strong Consulting, and as- Vendor, these competitors strates, it is just as important experiencing loneliness.” sumed receivership of six fail- would allegedly refer its clients to know the legal risks of en- ing assisted housing facilities. to convert to the Vendor’s Those who are well enough gaging with third-party tech- Three years of that and Bob products. to live without assistance for nology vendors and to was truly ready for retirement. The United States’ allega- performing their activities of recognize aspects of these tions toward the Vendor led to daily living were, surprisingly, Now Mr. Maine lives in arrangements that should be negotiations that ultimately re- most lonely. Others who may Georgia, but certainly has left avoided. Payments in cash or sulted in the $18.25 million be bedfast and who have a his mark in the Pine Tree State in kind that are offered in ex- (plus interest) settlement an- caregiver to help tamp down and in New England. Bob is a change for referrals or pur- nounced on January 28, 2021. the sense of isolation may do Certified Fellow of ACHCA, and chases present severe risk of In the settlement, the Vendor better. has been a proud College being viewed by the govern- neither denied the United member for over 30 years. ment as in violation of the A reprint letter dated 1859 States’ claims nor admitted AKS, and senior care providers and written by Florence W. Bruce Glass, FACHCA, CNHA, CALA wrongdoing. In the Depart- should conduct careful analy- Nightingale, said that “pets are is licensed for both nursing homes and ment of Justice (“DOJ”)’s ses before entering arrange- excellent companions for assisted living in several New England press release announcing the ments to avoid the significant those who are confined with states. He is currently principal of Bru- settlement, Acting Assistant consequences associated with Jan Management, an independent con- Attorney General Brian Boyn- such violations. sulting firm. He can be reached at ton for the DOJ’s Civil Division PAGE 14 [email protected]. declared that “[t]his resolution Continued on page 18 Minnix book chronicles stories of successful aging

Continued from page 11 reflects the necessary Carson was Examples of his lesson component of senior care, discussing plans: i.e., emotion, which dis- aging with tinguishes our field from George Burns · He is a master storyteller, any other. and asked which not only adds an him about the · The titles of his chapters, element of readability but last time he including “Attitude,” “In- evokes experiences that had sex, timacy,” “Whether to we know and understand. Burns looked Laugh or Cry,” “Dying at his watch– · Personal experiences and Death,” and “Retire- a classic. mold us, and Minnix is ment,” suggest that he able to present the good, has injected a sense of re- Bless you Larry, bad, and ugly of his own ality that impacts and can for taking the time life to the benefit of his override the all-too-essen- and making the ef- readers. His relationships tial regulatory, financial, fort to write this and experiences with his and other management book, which I en- aging parents, relatives, issues. Over and over, he thusiastically rec- and friends translate into writes that we cannot for- ommend. You will principles and secrets of get that we are dealing smile, laugh, cry, the aging experience that with the quality of the and have an en- enlighten, teach, and en- lives of those we serve, lightened appreci- tertain. which challenges us but ation of our world. Check out “Hal- · One of his favorite ex- also creates rare opportu- involved in the field as a consultant, in- lowed Ground” (available on pressions, “organ nities for self-actualiza- terim executive, and expert witness. He Amazon)–please! recitals” (now one of tion. can be reached at 508-361-4799 or mine!), refers to the ban- · He reminds us that humor Julian Rich, FACHCA, CNHA, is a long- [email protected] ter that requires our undi- adds a dimension to wis- term member of ACHCA and has been vided/divided attention dom. For example, he active since 1978. He is the founder of J PAGE 15 and tests our patience but notes that when Johnny RICH SOLUTIONS and continues to be Telehealth is a viable way to deliver mental health services Continued from page 6 Israel Hospital in Boston and Danvers State Hospital to use pists have been reluctant to telehealth to provide psy- use distance treatment tech- chotherapy to serious felons niques. Until quite recently, re- housed at Danvers. A link was imbursement was also a established between the two serious barrier to the use of hospitals and the psychiatrists telehealth for the provision of conducted their individual psy- psychotherapy services. chotherapy sessions over Mental health providers slow-scan TV. Though this have begun to provide some early pilot was not a full re- telehealth services in recent search effort, the psychiatrists years, including substance involved declared the experi- abuse support services. Some ment a success. The subjects reimbursement paths also were more at ease and more opened for these services. responsive through the cool Much more recently the limita- TV medium than they were tions on personal contact cre- during in-person sessions. licensed clinical social workers. The Joint Commission has ated by the COVID-19 public Setting up the technology to Insurance coverage varies. recognized telehealth as a health emergency have led to source of mental health and conduct this pilot project was Cathy Pemberton is a con- dramatically increased avail- behavioral services. Its Behav- expensive and complex. The sulting social worker based in ability of reimbursement and ioral Health Care Standards medium was intrusive, the Cambridge MA. She feels that services for psychotherapy and Sampler is easily available on- screens only put up a new telehealth can be a useful and other mental and behavioral line. While these standards are image every 10 seconds or so, powerful tool for extending health services to be provided applied to in-person service and you could see the image mental health and behavioral by telehealth. providers the Joint Commis- emerging. Sound was only fair. services but warns about over- sion has accredited distance Notably, Medicare has al- Today, much better technology extending. Some people and services providers using the tered its reimbursement prac- through cell phones and/or some kinds of treatment may tools outlined in this docu- tices for more than three conventional computers is eas- work very well as distance ment. dozen psychiatric, psychologi- ily available in most settings. services. However, there are cal, and behavioral health These tools produce images clinicians, patients, diagnoses, Telehealth or distance provi- billing codes. They now accept and sound of high quality in and services that may not work sion of mental and behavioral audio-only encounters as a real time. as well as others. She does ex- health services has been going means of service delivery. Martha Seagrave, associate pect to see telehealth expand on for some time. The public Some of these are said to be professor in the Department of as a service tool for some be- health emergency has vastly only for the duration of the Family Medicine of the Univer- havioral and mental health is- extended reimbursement for public health emergency. Oth- sity of Vermont’s Larner School sues. In her conversation, she and use of these services. ers are longer lasting. of Medicine, is the director of highlighted the availability for While the end of the public All New England states’ its medical education pro- reimbursement that is becom- health emergency may end Medicaid programs cover tele- grams. Students from the de- ing much more common. some provisions that have made these services more health services for mental partment fan out across much As a decades-long mental available, we will not return to health and/or behavioral serv- of New England for some as- health care manager and li- the past. The efficiency and ef- ices. All but Massachusetts pects of their training, so dis- censed nursing home adminis- fectiveness of telehealth serv- have parity laws, which equate tance training, services, and trator, it was interesting for me ices guarantee that they will distance services with in-per- communication are not new to to see a blog post by a com- continue and expand as time son services. All but Massa- them. mercial company called MediT- chusetts have private payers goes on. Seagrave reports that tele- elecare. It provides mental who reimburse for some or all health is an excellent way to health and behavioral support This is the 21st century and such services. The Northern receive mental health support. services in skilled nursing facil- we can now provide a much New England states of Ver- The clinician providing serv- ities and other settings. Their broader range of psychothera- mont, New Hampshire, and ices needs to be licensed in the psychiatrists, psychologists, peutic services to our older Maine are party to the inter- state where the client is sitting and nurse practitioners pro- customers than we have in the state medical licensing com- when services are provided. vide distance services in many past by using telehealth. pact which makes it easier for Classes of clinicians eligible to high-risk elder care communi- physicians such as psychia- provide services can vary from ties. They emphasize their suc- K.R. Kaffenberger, PhD is a lecturer in trists to practice across state state to state. Most states ac- cess in not only caring for their aging aervices and fellow of the Geron- lines through telehealth tech- cept psychiatrists and psychol- patients but in doing so while tology Institute. niques. ogists as appropriate reducing the use of high risk, Many years ago, I helped clinicians. Other states include often psychoactive, medica- support an effort between Beth advanced practice nurses and tions. PAGE 16 Bioceramic sleepwear, hydration, and other Brady recommendations

Continued from page 3 harder to maintain it. Accord- ing to Brady, cell oxygenation One of the greatest of all No-load strength training is a key component to main- time doesn’t lift weights. Here is where it gets interest- taining pliability and decreas- ing: Brady doesn’t lift weights. ing inflammation. How does 90 percent of his training is he do this? With his pajamas. tion, something all athletes are practices such as eating as with resistance bands. One of No, really. Brady and the TB12 aware of. Everyone in the ath- local as you can, eating veg- the greatest quarterbacks, sta- Method team have developed letic sphere knows how impor- etables and avoiding refined tistically, of all time, doesn’t lift a line of functional bioceramic tant it is to drink water. A carbohydrates, dairy, salt, caf- weights. Brady disagrees with sleepwear. nuance in the TB12 Method, feine, and alcohol. many standard practices in however, is when to drink or Bioceramic is a material cre- The method also has some athletic training. Typically, ath- not to drink water. The method ated by heating a combination nutritional caveats. Brady does letes train with strength and has analyzed all aspects of di- of 20 different ceramics and not eat nightshades for undis- conditioning. gestion as well, and it claims mineral oxides to three de- closed reasons. Nightshades that drinking water and eating Strength training involves grees. The material is then in- are darker plants or foods in- meals simultaneously is not weightlifting with machines, serted into the sleepwear. Far cluding mushrooms, eggplant, good for optimal digestion. free weights, and body weight. infrared rays from the vibra- potatoes, and bell peppers. The lifting changes and in- tion frequency of the bioce- The recommended proce- The method also emphasizes a creases in volume and inten- ramics penetrate the skin 1.5 dure is to drink water exactly balance between alkaline or sity, while rest periods inches. The infrared rays then half an hour before eating a anti-inflammatory foods and between repetitions decrease. stimulate the bones, muscles, meal and an hour afterwards. If acidic or inflammatory foods. eating and drinking simultane- Conditioning involves aerobic and tendons to increase cell These foods balance pH in ously cannot be avoided, Brady exercise and movements that oxygenation and muscle repair the body and the ratio between suggests only drinking minimal imitate real-life motions with while decreasing inflammation these foods should be 80/20 al- amounts during the meal. the purpose of elevating heart and pain. kaline to acidic. This aids di- rate and breaking a sweat. Proper hydration Healthy nutrition gestion by neutralizing acids in the body. Many vegetables are Brady cites a common mis- The TB12 Method also talks Again, the TB12 Method goes alkaline while many fruits, conception in the athletic about the importance of hydra- over better-known nutritional sphere: that when athletes get nuts, and some fish and meats injured, it is because they are are acidic. not strong enough. After Supplementation rehab, they continue with the strength and conditioning This principle of the TB12 model, once again leaving out Method talks about supple- pliability and continuing to menting your diet with pro- damage their bodies. This is a teins and vitamins. He vicious cycle that leads to the promotes his line of TB12 pro- further unbalancing of muscles tein powders, probiotics, and and more and more injuries. electrolytes. Promote anti-inflammatory Brain Exercises responses in the body This principle stresses the im- Brady stresses avoiding in- portance of neuroplasticity and flammation of the mind, body, mindset. The brain must be and spirit. Muscle dehydration trained as much as the mus- decreases muscle pliability, as cles and body. Brady is an ad- inflamed muscles are less able vocate of mental toughness, a to lengthen and soften. Dehy- positive mindset, and medita- dration, inadequate nutrition, tion. Meditation is important and inadequate recovery con- and a great way to center the tribute to inflammation or stiff mind and body. muscles. Brain rest, re-centering, Promote oxygen-rich and recovery blood flow Recovery is the final principle Younger athletes naturally of the TB12 Method, where have muscle pliability. It de- sleep and diet are emphasized creases as they grow older, again. Brady has a rigid sleep and older athletes must work schedule, from 9 p.m. to 6 a.m. In addition to his fancy paja- Kris Mastrangelo’s game day accessories. PAGE 17 Continued on next page Be aware of health care technology’s legal risks Brady’s TB12

Continued from page 14 So if you watched the Super though “syringes are typically not Continued from page 18 Bowl from your living rooms separately reimbursable by a federal Under the statute, AKS viola- (like we did), don’t feel bad. It health care program and… hospitals mas, Brady sleeps with the tions may be asserted against are reimbursed for providing a serv- room temperature at exactly might have saved you a lot of ice, not for the equipment included in recipients, as well as offerors, trouble! 65 degrees Fahrenheit to pro- doing so,” this “does not foreclose a of improper remuneration. showing that ‘payment may be made’ mote recovery. Providers should be cautious Lawrence W. Vernaglia is a partner in under a federal health care program” The book also contains pho- about accepting benefits from and that the OIG could seek enforce- the Health Care Industry Team at Foley & tos and explanations of pliabil- vendors or potential vendors ment action under the AKS. Med- Lardner. He has represented providers ity exercises and an extensive in connection with sales and Pricer.com, Inc. v. Becton, Dickinson and vendors in the long term care indus- & Co., 240 F. Supp. 3d 263, 273-74 (D. collection of recipes. While marketing activities. This case try for more than 25 years. Conn. 2017). “The TB12 Method” was writ- stands for the proposition that ten in a vernacular, conversa- the DOJ is willing to proceed Stephanie J. Schwartz is a health care Common examples of arrangements involving products that contribute to tional style with some blatant in a case where the alleged regulatory and business lawyer with Foley & Lardner LLP and counsels clients a provider’s overhead costs and are promotion of other related kickbacks related to the pur- not separately reimbursable concern in the health care, telehealth, and med- TB12 products, the actual chase of an “overhead” tech- medical devices used during proce- ical device industries with respect to a method itself holds a consider- nology. Would the government dures. While the purchase and sale of able amount of useful informa- wide range of regulatory compliance and these products do not involve sepa- have proceeded against the tion about overall health and vendor in the absence of the transactional matters. rate reimbursement under the federal health care programs, improper re- performance. EHR Incentive that provided Endnotes muneration may still result in severe enhanced government com- 1Complaint at 2, United States v. consequences. One case, concerning Kris Mastrangelo, OTR, MBA, NHA, is pensation when the vendor’s athenahealth, Inc., Nos. 17-cv-12125- conduct in 2017, involved the sale of president and CEO of Harmony Health- technology was utilized? The ADB, 17-cv-12543-ADB (2021). implantable devices to be used in sur- geries; although the claims resulted care International and is a nationally- technology in question was 2Complaint at 3, athenahealth, Inc., in a settlement of the allegations and recognized authority of Medicare issues. not separately reimbursable by Nos. 17-cv-12125-ADB, 17-cv-12543- no admission of liability, the settle- She is a regular contributer to the New a federal healthcare program, ADB; Quality Payment Program ment agreement recognized that but there were special govern- Overview, Quality Payment Program, where the purchase or use of the de- England Administrator. Contact Kris : https://qpp.cms.gov/about/qpp- mental payment incentives to vices themselves is not submitted for 800-530-4413. harmony-healthcare.com overview (last visited Feb. 21, 2021). using such technology. reimbursement, the arrangement 3It is important to note that arrange- may nonetheless be considered a vio- Savannah James, a previous editor at the The broad language in the ments that violate the AKS and result lation of the AKS that could also con- Tufts Daily, is the founder and CEO of complaint and settlement sug- in significant fines, penalties, and tribute to various false claims. Hopforce, which is known for its wildly Settlement Agreement at 2, United gests that flashy sales strate- other consequences do not necessi- successful PDPM Calculator. The calcula- gies may be targeted for tate that a given vendor’s products be States v. Asfora, No. 4:16-cv-04115- separately reimbursable or separately LLP (D.S.D. 2019). tor explains the impact of the new Pa- enforcement activity in other covered. That is, an arrangement in- tient-Driven Payment Model that governs 4 Complaint at 2, athenahealth, Inc., scenarios as well. Providers volving kickbacks for a product that Nos. 17-cv-12125-ADB, 17-cv-12543- Medicare Part A reimbursement for who may be on the receiving relates only to overhead costs for the ADB. skilled nursing facilities. end of offers of entertainment, provider (rather than claims for reim- travel, or cash from vendors bursement submitted to the federal should carefully consider the health care programs) may violate the AKS just as the arrangement dis- potential reach of these laws in cussed in this Article allegedly did. New England Administrator prohibiting such activities. In a 1999 Advisory Opinion written by Many providers have estab- Published online quarterly by District One of the the Office of Inspector General lished policies prohibiting ac- (“OIG”), the OIG stated that in decid- American College of Healthcare Administrators. ceptance of gifts or trips from ing whether to prosecute arrange- Matt Lessard, CNHA, FACHCA, District Director vendors. Others have estab- ments that potentially violate the [email protected] lished more nuanced rules, al- AKS, it considers a variety of factors, lowing limited meals and including whether the items pur- chased are separately reimbursable W. Bruce Glass, FACHCA,CNHA, CALA, Editor business courtesies, including under the federal health care pro- [email protected] allowing participation in sport- grams. Advisory Op. No. 99-3 (U.S. ing or recreational activities, Dep’t of Health & Human Servs., Of- Richard E. Gamache, FACHCA Assistant Editor where meaningful business fice of the Inspector Gen. (1999)). [email protected] discussions and relationship- There is greater risk of a kickback vio- lation when separately reimbursable Julian Rich, FACHCA, Advertising Manager building take place. Such en- items are involved in an arrange- [email protected] counters are not inherently ment, but the risk of violation and en- unlawful, but settlements such forcement is not forgone when the Lori Pomelow, Treasurer as this one show that the gov- product involved solely contributes to [email protected] providers’ overhead costs rather than ernment takes a hard line Designed and produced by The ART of Communications when it believes that the sales toward claims for reimbursement. See id. For example, in a case con- Arthur Levine techniques may influence cerning an arrangement involving sy- [email protected] • 978-927-5343 health care purchasing deci- ringes, the District Court for the sions. District of Connecticut found that al-