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International Lawyers Network

The International Lawyers Network (ILN) is a leading association of 91 high-quality, full-service independent law firms.

Since 1988, the ILN has helped its members keep pace with today’s global economy, through access to the tremendous strength and depth of the combined expertise of 5,000 lawyers in 66 countries on six continents.

ILN member firms are among the most respected and most experienced counsel in their jurisdictions. Clients’ increasing need for reliable foreign counsel is well-met by the personalized, high-quality and cost-effective legal services provided by ILN member firms. Unique to the ILN are the strong personal and professional relationships among its members and their clients developed over the past 30 years. Far from a mere directory, the ILN is an affiliation of lawyers who gather on a regional and worldwide basis annually and work routinely with each other to address client requirements and needs.

Each of the ILN’s member firms is international in outlook and staffed by highly trained senior attorneys, who are experts in a broad range of practice areas. ILN members have demonstrated experience in working successfully with international companies. They are independent, mid-sized firms within their jurisdictions, and are committed to the focus of the International Lawyers Network, admitted to the Network only after a rigorous application process. The ILN provides clients with high-quality service from experienced local counsel who work in firms that maintain excellent reputations in their own countries. This means that clients have immediate access to attorneys who are native, both linguistically and culturally, to the country of interest.

The ILN’s international directory app is available for iPhone, Android and BlackBerry smartphones. To access the app, click here or log on to ILNmobile.com from your smartphone.

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CHRONIC Care Act, Title III of the Bipartisan Budget Act of 2018, Signals Meaningful Change for Medicare Advantage Plans and Telehealth Coverage

Our collegues Helaine Fingold, Daniel Kim, and Amy Lerman at Epstein Becker Green have a post on the Health Law Advisor blog that will be of interest to many of our readers: “CHRONIC Care Act, Title III of the Bipartisan Budget Act of 2018, Signals Meaningful Change for Medicare Advantage Plans and Telehealth Coverage.”

Following is an excerpt:

“…[T]he [Bipartisan Budget Act of 2018 (BBA)] includes certain provisions taken from the CHRONIC Care Act that will provide a needed expansion of Medicare [fee-for-service] coverage for certain telehealth-based chronic care services. The BBA preserves many of the telehealth-focused aspects of the original 2017 bill equivalent and, seemingly, reflects a commitment by the federal government to improving access to telehealth services for qualified Medicare beneficiaries and further integrating these services into the U.S. health care system.”

Read full post here.

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ILN Today Post

Digital Media, Technology & Privacy Alert >> With GDPR Deadline Looming, Ad Tech Community Proposes Collaborative Industry Solution

With only a few months to go before the European Union’s General Data Protection Regulation becomes enforceable, the Interactive Advertising Bureau’s Technology Laboratory (IAB Tech Lab) has published an advisory that seeks to explain how ad tech companies can comply with the new rules through a collaborative information sharing process.

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CHRONIC Care Act, Title III of the Bipartisan Budget Act of 2018, Signals Meaningful Change for Medicare Advantage Plans and Telehealth Coverage

On February 9, 2018, President Trump signed into law the Bipartisan Budget Act of 2018 (“BBA”). Among the most notable changes that will occur with the enactment of the BBA is the inclusion of certain provisions taken from the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (“CHRONIC”) Care Act of 2017 bill (S.870) which the Senate passed in September 2017. Among other things, the CHRONIC Care provisions will have the effect of redefining new criteria for special-needs plans (“SNPs”), in particular the special-needs Medicare Advantage (“MA”) plans for chronically ill enrollees. The CHRONIC Care provisions also will expand the integration and coverage under Medicare for certain telehealth-based chronic care services.

Impact on MA Special Needs and Other MA Plans

The BBA includes provisions taken from the CHRONIC Care Act that largely affect MA SNPs, though other types of MA plans may also be affected by the enacted changes.

The critical issue Congress finally settled through the enactment of the BBA is the long-term status of the MA SNP Program (the “Program”).  Congress created the Program through the Medicare Modernization Act of 2003 (enacted Dec. 8, 2004).  However, the Program was time limited, with a scheduled end date of December 2008.  The Program has since been extended a total of 7 times, with Congress generally pushing out the Program’s end date by a year or two but never giving stakeholders a clear signal of support for the Program, leaving many stakeholders hesitant in making large investments in a program that was scheduled to terminate.[1]

The amendments made by the BBA have provided not only a more secure future to encourage plan sponsors and other stakeholders to further invest in the Program, but have also made changes to strengthen these programs. With respect to those SNPs targeting the dual eligible population (“Dual SNPs”), statutory changes provide for:  increasing integration through use of mechanisms to better coordinate contact with and information dissemination to State partners; requiring the Secretary to develop a unified grievances and appeals process for Dual SNPs to implement by 2021; and imposing more stringent standards to demonstrate integration. With respect to those SNPs focused on serving the chronically ill (“Chronic SNPs”), the BBA broadens the definition of beneficiaries who qualify to enroll in a Chronic SNP, imposes more stringent care management standards, and authorizes Chronic SNPs to provide certain Supplemental Benefits. The BBA further amends the Social Security Act to authorize the Secretary to require quality reporting at the plan level for SNPs, and, subsequently, for all MA plan offerings.

Impact on Accountable Care Organizations

The BBA makes several statutory changes impacting Accountable Care Organizations (“ACOs”) and beneficiary participation in such entities. Specifically, under the terms of the Act, fee-for-service (“FFS”) beneficiaries will be able to prospectively and voluntarily select an ACO-participating professional as their primary care provider and for purposes of being assigned to that ACO. The BBA further authorizes ACOs to provide incentive payments to encourage fee-for-service beneficiaries to obtain medically necessary primary care services.

Expansion of Medicare FFS Telehealth Coverage for Chronic Care Services

Additionally, the BBA includes certain provisions taken from the CHRONIC Care Act that will provide a needed expansion of Medicare FFS coverage for certain telehealth-based chronic care services. The BBA preserves many of the telehealth-focused aspects of the original 2017 bill equivalent and, seemingly, reflects a commitment by the federal government to improving access to telehealth services for qualified Medicare beneficiaries and further integrating these services into the U.S. health care system. For example, with the enactment of the BBA, Medicare coverage of telehealth services will be expanded to include services provided at home for beneficiaries dealing with end-stage renal disease (“ESRD”) or those being treated by practitioners participating in Accountable Care Organizations (“ACOs”). Additionally, with the enactment of the BBA, some of the geographic requirements traditionally required by Medicare’s coverage rules for telehealth services (e.g., originating sites, rural health professional shortage areas, counties outside Metropolitan Statistical Areas) will be lifted if such telehealth services are rendered to beneficiaries with ESRD, or who are being treated by ACO practitioners, or who are being diagnosed, evaluated, or treated for symptoms of an acute stroke. There are some important caveats to these changes in the coverage rules. For example, for ESRD beneficiaries who utilize telehealth services from their homes, an in-person clinical assessment will be required for such beneficiaries every month for the first 3 months and then once every 3 months thereafter. Likewise, payments will not be made for any telehealth services rendered by ACO practitioners to beneficiaries in their homes if such services typically are furnished in inpatient settings (e.g., hospitals).

As part of increasing benefits offered to special needs MA plan enrollees (as discussed above), the enactment of the BBA also will allow MA plans to offer more telehealth services to its enrollees, including services provided through supplemental health care benefits, starting in the year 2020. However, this provision requires that the same types of items and services an MA plans offers to its enrollees via telehealth are also offered to enrollees in-person. CMS is required to solicit public comments regarding this particular provision by November 30, 2018.

*          *          *

With the BBA establishing a long-term MA SNP Program, we are more likely to see increased investment into the Program by stakeholders and plan sponsors, thus growing and strengthening the Program. But, as explained above, the BBA also introduces several amendments that will certainly affect Dual and Chronic SNP standards, benefits, and coordination of care.  Although CMS has not formally solicited public comments regarding implementation of the referenced changes to SNP requirements, stakeholders and plan sponsors may want to consider the impact these changes may have on them and their industry and submit comments and input to help CMS in developing its proposed regulations.

For telehealth advocates, the inclusion of so many meaningful provisions in the BBA signals a newly energized willingness on the part of policymakers to work to expand use of telehealth services for Medicare beneficiaries, even in an environment where there are financial incentives for providers and health plans to restrain costs. Although lawmakers have historically resisted expanding these types of services in a FFS context, the belief being that doing so would add to (and not replace) services already otherwise being delivered, the enactment of the BBA signals strong potential for change in this regard.  As telehealth integration into various Federal programs increases, the enactment of the BBA being a critical step in this process, stakeholders and plan sponsors may want to consider the various implementation strategies by which telehealth items and services will be offered since each program carries its own set of standards and requirements.

[1] Pub. L. 110–173, §[  ], substituted ‘‘2010’’ for ‘‘2009’’; Pub. L. 110–275, §164(a), substituted ‘‘2011’’ for ‘‘2010”; Pub. L. 111–148, § 3205(a), substituted “2014” for “2011”;  P.L. 112-240, §607, struck out “2014” and inserted “2015”; P.L. 113-67, §1107, struck out “2015” and inserted “2016”; P.L. 113-93, §107, struck out “2016” and inserted “2017”; P.L. 114-10, §206 struck “2017”, inserted “2019″.

 

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What you should consider doing before Canada’s new Trademarks Act comes into force

February 21, 2018 — Almost anything that is related to your company’s or organization’s image — a name, a design, a slogan, a three-dimensional shape — can fall under the scope of the Trademarks Act.

Important changes to this Act will soon be in force: Richard Uditsky explains the impact of some of these changes and how you could save money and frustration in anticipation of the new regime.

Click here to read more (PDF).

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ILN Today Post

Karolis Smaliukas joins TGS Baltic as an Associate Partner

Advocate Karolis Smaliukas has joined law firm TGS Baltic. The lawyer practicing in the area of public procurement for more than ten years has become an Associate Partner of the law firm and he will be responsible for the development of the Public Procurement practice group.

Karolis’ unique experience in the public procurement field will contribute to the development of the Public Procurement practice group of law firm TGS Baltic and the provision of first class services to clients. Market participants commend Karolis Smaliukas for deep expertise and finding of an adequate solution in any situation.

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ILN Today Post

Ny afgørelse fra EU-Domstolen i Max Schrems-sagen

Facebook-brugere kan ikke anlægge massesøgsmål mod Facebook i Wien

Maximillian Schrems, som er østrigsk advokat, forfatter og privatlivsforkæmper, har sagsøgt Facebook ved domstolen i Wien.

I sagen kræver Schrems, på vegne af sig selv og andre Facebook-brugere, erstatning for Facebooks overtrædelse af de persondataretlige regler.

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Medicare Secondary Payer Compliance: Conditional Payments (Part II)

This is our second blog post on compliance with the Medicare Secondary Payer (MSP) law. Over the past three years, enforcement trends have focused attention on this often-overlooked area of law and highlighted why providers and suppliers need to know more about it. In this post, we will discuss Medicare conditional payment and subsequent repayment requirements.

As a general rule, Medicare will make a conditional payment to a beneficiary if there is a delay in payment by the primary payer to keep the beneficiary from experiencing a gap in coverage.[1] Medicare may then pursue reimbursement of conditional payments from:

  • A beneficiary or other party, if both a primary and conditional payment were received;
  • A primary payer, if a conditional payment was made pursuant to liability insurance settlements, disputed claims under group health plans, workers’ compensation plans, or no-fault insurance; and
  • The beneficiary or provider, if the filing of an improper claim resulted in a conditional payment, unless the claim was a result of false information provided by the beneficiary and the provider complied with certain regulatory procedures.

These conditional payments must be reimbursed to Medicare within 60 days of receipt of payment. If a primary payer or provider fails to pay back the conditional payments, CMS may recover double the amount of the Medicare primary payment.[2]

Both beneficiaries and their fiduciary agents, such as attorneys, can be sued for recovery of improper conditional payments. In one recent case, a Medicare Advantage (MA) plan operated by Humana made a conditional payment to a beneficiary injured in a motor vehicle accident.[3] The beneficiary sued several insurance companies for payment, resulting in a settlement and the disbursement of settlement funds to the beneficiary’s attorney. Humana issued a demand letter to the beneficiary seeking reimbursement for its conditional payment, which it alleged was partly contained in the settlement amount. When the beneficiary failed to pay, Humana commenced a lawsuit against both the beneficiary and the beneficiary’s counsel to recover the funds. On a motion to dismiss by the beneficiary’s attorneys, the court ruled that the MSP allowed the MA plan to pursue recovery of conditional payments and double damages against beneficiary’s counsel, as “plain language fails to limit the parties against whom suit may be maintained” and that there is a private right of action that a MA can use to recover conditional payments pursuant to 42 USC §1395y(b)(3)(A).[4]

The take-away from this decision is that all parties involved in the medical treatment and payment process of a Medicare beneficiary, including payers, providers, the beneficiaries, and their counsel, as well as fiduciaries, should be conscious that payment obligations do not end once Medicare has cut a check. Counsel may also want to be aware of Medicare conditional payment obligations in settlement negotiations. For example, in an unpublished opinion, the Third Circuit affirmed a District Court’s ruling that the estate of David Trostle had not exhausted administrative review procedures and therefore the court lacked subject matter jurisdiction. The action was brought after Trostle received the wrong prescription from a pharmacy, causing him to fall gravely ill. While hospitalized, Trostle received a conditional payment, stopping Trostle from experiencing a gap in insurance coverage. As a result of the conditional payment, CMS asserted a lien against any potential recovery Trostle possibly would receive in order to recoup the funds disbursed in the conditional payment. CMS stated that the lien was for $1,212 and reserved the right to adjust the amount if necessary. Trostle’s actual medical costs paid by CMS for a sixty-six day hospital stay was nearly $100,000. Trostle settled the tort claim against the pharmacy which allegedly caused the injury, receiving $225,000 in July of 2014. After Trostle informed CMS of the settlement amount, CMS revised the lien amount substantially upward to $53,295. Trostle challenged the $53,295 lien, arguing that CMS induced Trostle to rely upon the $1,212 lien, a much lower number, when negotiating the settlement.

While the court found it could not assess the claim since Trostle had failed to exhaust all administrative review procedures, and therefore did not reach this issue, the facts of this case demonstrate a potential area of unknown for counsel, beneficiaries, and other fiduciaries who may attempt to secure settlements from NGHP’s without full knowledge of how conditional payments function.[5]

This is part 2 of 7 in the Medicare Secondary Payer Compliance series. Subscribe to our blog for future updates. Part 1 can be accessed here: Medicare Secondary Payer Compliance: An Introduction (Part I)

Andrew Kuder, a Law Clerk (not admitted to the practice of law) in the firm’s Newark office, contributed significantly to the preparation of this post.

[1] 42 USC § 1395y(b)(2)(B); 42 CFR §§ 411.21 & 411.24.

[2] 42 CFR § 411.24(c)

[3] Humana Ins. Co. v. Paris Blank LLP, 187 F. Supp. 3d 676 (E.D. Va. 2016).

[4] Id. at 681.

[5] Trostle v. Ctrs. for Medicare & Medicaid Servs., No. 16-4062, 2017 U.S. App. LEXIS 19431 (3d Cir. Oct. 5, 2017).

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They Giveth and They Taketh Away: CMS Policy Proposals on Supplemental Benefits under MA Plans

The Centers for Medicare and Medicaid Services’ (“CMS”) recently announced its intent to expand what may be considered “supplemental benefits,” broadening the scope of items and services that could be offered to Medicare Advantage (“MA”) plan enrollees over and above the benefits covered under original Medicare. However, in articulating the standards for covering this broadened group of items and services, CMS proposed a new requirement that could greatly limit enrollees’ ability to access all types of supplemental benefits and increase the already substantial burden on MA participating providers; CMS now proposes to require that the supplemental benefits be ordered by a licensed provider.

Under current CMS guidance, supplemental benefits may not be a Part A or Part B covered service, must be primarily health related in that “the primary purpose of the item or service is to prevent, cure or diminish an illness or injury,” and the plan sponsor must incur a non-zero cost for the benefit. Medicare Managed Care Manual, Ch. 4, Sec. 30.1. Within the draft 2019 Call Letter, released on February 1, 2018, CMS proposes to expand the scope of items and services considered “primarily health related” to now include items and services to help maintain health status and not only those that “prevent, cure or diminish illness or injury.” According to CMS, under its new interpretation, in order for a service or item to be primarily health related “it must diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.” Current CMS guidance explicitly excludes from being a supplemental benefit those items or services which are solely for daily maintenance purposes.  CMS’s broadened definition follows medical and health care research studies which have shown the value of certain ‘maintenance’ items and services in diminishing the effects of injuries or health conditions and decreasing avoidable emergency and health care services.

While broadening the scope of items and services eligible to be considered supplemental benefits, CMS concurrently proposes to add a more stringent standard to an enrollee’s receipt of such benefits. “Supplemental benefits under this broader interpretation must be medically appropriate and ordered by a licensed provider as part of a care plan if not directly provided by one.” Although current guidance specifies medical necessity as a standard for supplemental benefits that extend the coverage of original Medicare, there is no requirement that supplemental benefits be ordered by a licensed provider. Depending upon the nature of the supplemental benefit, such a rule could prevent an enrollee from accessing certain benefits. For example, plan sponsors may provide acupuncture or other alternative therapies as supplemental benefits, but enrollees would only be able to access such services if their provider accepts the value of such services and agrees that they are medically necessary. Given that many in traditional medicine do not support the use of alternative therapies, it is likely that at least some enrollees will be unable to access these benefits under this newly proposed standard.  Also, requiring a provider to review and order other types of supplemental benefits would likely create a paperwork burden with no benefit, including, for example, with respect to a supplemental transportation benefit, fitness benefit or over-the-counter drug benefit.

Although CMS should be applauded for seeking to expand the definition of “health related” in identifying eligible supplemental benefits, its proposal to require that such benefits be ordered by a provider as part of a treatment plan will decrease plan flexibility and increase burden for providers and enrollees alike, with minimal benefit.

CMS is accepting comments on the draft Call Letter through 6pm EST, Monday March 5, 2018.

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Health Plan Insurance on the Blockchain: An Interview with James Schutzer, Vice President, JDM Benefits

James D. Schutzer is the Vice President at JDM Benefits, a consulting group that provides strategic benefits services to small and mid-size employers. His career in healthcare spans over 20 years and has included leadership roles in employee benefits and insurance sales. He spent 10 years working in sales for carriers like Wellpoint and Oxford Health Plans. Jamie frequently presents and lectures to many organizations on the topic of the Affordable Care Act and sat on the New York State Health Benefit Exchange Regional Advisory Council. In addition, Jamie is the Immediate Past President of New York State Association of Health Underwriters (NYSAHU) as well as Legislative Co-Chair, and is an Executive Committee member of the Business Council of Westchester, and currently serves as Treasurer. In December 2015, Jamie was named in the Employee Benefit Adviser as one of the 14 politically active brokers to know across the U.S.

While attempts to fully repeal and replace the Affordable Care Act in 2017 did not come to fruition, several developments are taking on momentum which will surely shape the ability of employers to sponsor insured health plans for their employees in the future. From the repeal of the individual mandate penalty, expansion of association health plans, State proposals to increase taxes on insurers, referenced-based pricing and new “blockchain” models to purchase services directly for employees, the insured markets will be under increasing stress to survive. It is possible that these trends will accelerate the collapse of the insurance markets and usher in a government provided single payer system, and/or self-directed mode of procuring healthcare via blockchain technology.  I recently sat down with James Schutzer to discuss the evolving landscape in employer-provided group healthcare and obtain his insights regarding how these changes will impact costs and the future of employer-provided health insurance.

Michelle Capezza: How do you see the repeal of the individual mandate impacting the insurance markets and the ability of employers to obtain affordable insurance plans for their employees?

James Schutzer: For starters, the individual mandate penalty lacked the teeth from the beginning and I think it is still difficult to ascertain how many people enrolled in health insurance to avoid the penalty. There are different reports out in the market which argue the point from both sides. As an employee benefits advisor, I have seen a slight uptick in enrollment in employer sponsored coverage for the reason that employees want to avoid the individual mandate penalty. Therefore, I do not see the elimination of the individual mandate having a significant impact in the employer sponsored market. Plus, the employer mandate still exists as of this time and Applicable Large Employers are required to offer insurance or pay a penalty.

MC: For employers that seek to utilize the new rules expanding the ability to form association health plans (AHPs), how will this increase the adverse selection issues already straining insurance markets?

JS: One concern related to AHP’s is that they can possibly siphon off the “perceived” good risk leaving the older and sicker members in the small group market. This will certainly create a death spiral. Another concern is that employers can jump in and out of the small group market based on medical needs. I believe the proposed regulations try to address and prevent this type of behavior. I know the National Association of Insurance Commissioners has come out in opposition to AHP’s.

MC: How do you see these developments impacting an employer’s decision to sponsor a high deductible health plan with access to a health savings account for its employees versus self-funding a plan? Are these still viable modes of delivering employer-sponsored health coverage to employees?

JS: High deductible health plans with a health savings account are still growing but I have seen the pace slow down the last couple of years. One important piece which is still not readily available is the price transparency tools which enable people to be better healthcare consumers. On the other hand, we are seeing more employers testing the waters with partially self insured plans. There are many benefits to this strategy but it does come with risks. It is critical that the employer completely understands the inner workings of being partially self insured. Picking the right individual and aggregate stop loss, provider network, pharmacy benefit manager among other things is vital to the success of the plan.

MC: What is your view regarding the viability of referenced-based pricing models for employer-provided health insurance?

JS: Referenced based pricing (RBP) is a newer concept that is starting to break into the Northeast. This market is generally slower to adapt to change but RBP is proving to save employers money in other parts of the country. Hospital and major surgical costs have exploded and RBP is trying to tackle this issue head on by identifying the true cost basis and providing payment based on this data. Employers with a partially self funded plan rely on a “leased” network for their discounts when their employees utilize healthcare. This contracted rate is what the employer is responsible to pay (outside of the employee’s copay, deductible, etc). RBP looks to further peel back layers of hospital and high cost surgical claims and offer a more “fair” payment. In return, the employer’s costs are lowered. The one challenge to RBP is the potential for balanced billing but there are RBP vendors employers can work with to assist in defending the payment.

MC: Given the complexities of these markets and programs, it is no wonder blockchain is being applied to healthcare, and household name employers are beginning to develop models to contract directly with healthcare service providers and pharmaceutical companies and use their own technology to administer claims. It seems that if more transparency in pricing can be obtained, this would lend itself to blockchain purchases. How do you see this evolving, and do you think an AHP could operate this way?

JS: Yes, the blockchain phenomenon is creeping into healthcare. As I mentioned before, transparency is so badly needed in healthcare and blockchain might be the right conduit to deliver it. Healthcare is the only area I can think of where you do not know the cost of the service until after it has been performed. Although some progress has been made over time, there is still plenty of work to be done. Can you imagine needing a hip replacement and having the ability to price out the surgery in advance? But something which cannot be overlooked are the outcomes and the data to support this is sorely needed as well. Blockchain can definitely have an impact here as well as data can be easily accessible.

MC: As more individual data is collected via electronic medical records, and through direct blockchain purchasing developments, and other technology based tracking and healthcare delivery systems, do you see such Big Data being collated, analyzed and utilized to drive value based pricing initiatives and influence certain healthy behaviors?

JS: As I mentioned above, data is a key to bending the healthcare cost curve. I recently bought a new television and the research I was able to do online was remarkable. Brand, dimensions, reviews, prices…all at my fingertips. It would be a game changer if this type of data becomes available in the healthcare industry.

MC: Given these developments, do you see a potential for the pendulum to swing to a U.S. government-provided system of healthcare, requiring all employers and individuals to pay into such a system with increased payroll and income taxes, and perhaps requiring individuals to use blockchain technology to self direct their allotted government healthcare dollars to purchase healthcare services?

JS: I believe we must leave healthcare in the hands of the free market system as opposed to the government. I believe we are in the very early stages of a sea change in the healthcare industry. The current system is just not sustainable in the long run and although we can put band aids on the problem ultimately, there must be some major changes in the delivery system. We have the tools….now we have to figure out how to use them to our advantage.

MC: Thank you. Clearly there are many approaches to providing and obtaining health insurance. As cost pressures increase and the desire for transparency rises, it will be important to monitor which path stands.

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ILN Today Post

Credit union consolidation gains steam in West Michigan

The consolidation trend among Michigan credit unions remained strong in 2017, leading to a further reduction in the number of institutions in the state.

Many of the deals that closed last year involved some of the state’s smallest credit unions merging into a larger organization.

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