August 2026, CAP Today, All About HR (Titus) - Putting It Together

 The August 2026 issue of CAP TODAY headlines Homologous recombination, issues and dilemmas.  We put that together with a 2022 review in The Oncologist and a 2042 review in CAP TODAY.

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The central lesson from CAP Today in 2026

Karen Titus’s 2026 article is best understood as an update on a problem that the 2022 Friends of Cancer Research paper hoped the field would solve but has not yet solved: HRD is clinically important, but it is not a single analyte with a standardized measurement system.

“HRD testing” can mean at least three different things:

1. Finding a possible cause of deficient repair, such as a pathogenic BRCA1/2 alteration.

2. Measuring the accumulated consequences of deficient repair—LOH, telomeric allelic imbalance, large-scale state transitions, and related genomic scars.

3. Determining whether the tumor is functionally HR-deficient now, at the moment treatment is being considered.

Current NGS-based clinical testing does the first two reasonably well under favorable conditions. It does not necessarily answer the third. Titus’s deeper message is therefore not merely that HRD testing is technically difficult. It is that the laboratory is being asked to turn several biologically related but nonidentical measurements into a binary clinical answer.

The article the file labels as “2025” was actually published by CAP on May 29, 2024. The January 1, 1970 date on the article page is a website artifact; CAP’s Precision Medicine article index gives the correct date.

A useful teaching framework: cause, scar, and current function

Clinical question	What is measured	Principal strength	Principal limitation
What may have caused HRD?	Germline or somatic BRCA1/2 and other HRR-gene alterations; potentially methylation	Identifies a specific biological lesion; BRCA findings may have hereditary implications	A mutation in an HRR-associated gene does not invariably establish an HRD phenotype; methylation, large deletions, and some copy-number losses may be missed
Has the tumor experienced HR failure?	LOH, TAI, LST, or composite genomic-instability scores	Captures HRD beyond BRCA and other readily identifiable causal variants	Genomic scars are historical, persistent, continuous, spatially heterogeneous, and assay-dependent
Is the tumor HR-deficient today?	Potential functional assays such as RAD51 foci	Conceptually closest to the current drug-sensitive phenotype	Not yet established as a practical, broadly validated routine assay
What broader biology surrounds the result?	Comprehensive genomic profiling: CCNE1, RB1, HRR genes, resistance alterations, MSI/TMB, and other biomarkers	Can help interpret borderline or biologically contradictory results	Much of this contextual interpretation remains exploratory rather than part of a validated HRD classifier

This distinction is already explicit in the 2022 Oncologist paper, which separates potential “causes” of HRD from their genomic “consequences.” Titus makes the distinction more clinically vivid: the scar is evidence that homologous recombination failed, but the scar itself neither causes PARP sensitivity nor proves that the repair defect is still present.

The principal problems identified in Titus 2026

1. HRD is not one measurement

BRCA1/2 alterations remain the strongest and best-understood causal biomarkers. But BRCA testing alone misses tumors that have acquired an HRD phenotype through other mechanisms. Conversely, merely finding an alteration in PALB2, CHEK2, ATM, BRIP1, RAD51C, RAD51D, or another nominal HRR gene does not mean that every alteration has the same penetrance, produces biallelic loss, creates the same degree of genomic instability, or predicts the same treatment benefit.

Titus quotes Kyle Strickland bluntly: “just looking at the genes that are altered is not a good way to evaluate HRD.” That is an important correction to the simplistic equation:

HRR-panel mutation = HRD-positive.

Gene testing and genomic-scar testing provide complementary information. Neither automatically subsumes the other.

2. The clinical-trial evidence does not use a uniform biomarker

The major PARP-inhibitor trials differ simultaneously in drug, treatment setting, combination therapy, enrolled population, biomarker definition, and numerical cutoff:

• SOLO1 was overwhelmingly a BRCA-mutated population.

• PRIMA defined HRD through a deleterious BRCA alteration or a genomic-instability score of at least 42.

• PAOLA-1 also used 42, but studied olaparib combined with bevacizumab.

• VELIA used a cutoff of 33.

Thus, 33 versus 42 is not merely an analytical disagreement that laboratories can settle by choosing the statistically “best” threshold. The cutoffs are embedded in particular trial designs and treatment claims. A result cannot be interpreted independently of the assay, cancer population, therapeutic regimen, and validation study that produced the cutoff.

This was already one of the 2022 paper’s central concerns: different assays and thresholds can produce different HR-status calls and consequently different treatment decisions. Titus shows that this remains a live clinical problem in 2026. The CAP Today article summarizes these trial and cutoff differences directly.

3. A continuous, heterogeneous signal is forced into a binary result

Clinicians understandably want “HRD positive” or “HRD negative.” But genomic instability is measured on a continuous scale. The cutoff converts that continuous measurement into a category for a specific clinical purpose; it does not establish a natural biological border.

Titus provides an especially useful example: different regions of the same heterogeneous ovarian carcinoma can fall on opposite sides of the threshold. A tumor tested four times might be classified as deficient three times and proficient once. A score of 41 is analytically reported as negative under a cutoff of 42, but it is not biologically the opposite of a score of 42.

This raises several unresolved questions:

• Should there be a formal indeterminate or borderline interval?

• Should another tumor block be tested near the cutoff?

• How much movement results from true intratumoral heterogeneity versus analytical variation?

• Should a borderline score be interpreted alongside BRCA and other genomic findings?

• Is a cutoff validated in one therapeutic context transportable to another?

Titus does not supply definitive answers. Her point is that the clean binary result received by the oncologist conceals a substantial gray zone.

4. The specimen can determine the answer

The article gives preanalytics unusual prominence, and rightly so. Ovarian cancer patients may receive neoadjuvant chemotherapy before debulking surgery. Treatment can eradicate or greatly reduce viable tumor, forcing the laboratory back to a small pretreatment biopsy.

The requirements are particularly demanding for copy-number loss. Strickland says that accurate detection of BRCA1/2 copy-number losses may require approximately 50 percent tumor content on the slide. Small biopsies, treated tumors, low tumor fraction, necrosis, and limited tissue can therefore affect the component of HRD testing that depends on allelic imbalance and copy-number architecture—even when SNVs and small indels remain technically detectable.

“We can do a lot with a little, but we can’t do everything with a little” is more than a memorable quote. It captures an assay-design issue: a panel can have excellent small-variant sensitivity while remaining vulnerable in LOH, large deletion, copy-number loss, and genomic-scar reconstruction.

For laboratories, HRD is therefore a specimen-management service as much as it is an NGS assay. Selection of a larger untreated block, documentation of treatment history, pathologist estimation of tumor content, macrodissection, and an appropriate “quantity not sufficient” or qualified-result policy are central parts of performance.

5. Assays are not interchangeable

The Myriad strategy combines BRCA status with LOH, TAI, and LST. Foundation has historically used an LOH-centered approach. Other assays use different combinations, algorithms, training sets, and proprietary scales. “HRD-positive” on one system is not automatically the same measurement as “HRD-positive” on another.

The 2024 CAP review makes this especially relevant to Thermo Fisher. It describes:

• Myriad GIS, with a clinically used cutoff of 42.

• Foundation LOH, with a cutoff of 16 in the cited setting.

• Oncomine Comprehensive Assay Plus’s genomic instability metric, a different 0–100 construct with a reported cutoff of 16.

• Illumina TSO 500 HRD, which uses licensed Myriad GIS methodology.

• A low-pass WGS/deep-learning approach from Sophia Genetics.

The fact that two metrics both use “16” does not make them comparable. Nor does high analytical concordance with an established assay automatically confer the same clinical validity for a particular drug and indication.

The 2022 paper recommends that publications and reports identify the assay, features measured, continuous score, cutoff, tumor type, and intended-use context. Titus demonstrates why that level of transparency is still necessary.

6. A genomic scar records history, not necessarily present function

This is perhaps the most important conceptual limitation.

Once LOH, TAI, LST, deletions, and chromosomal rearrangements have accumulated, the daughter cells inherit them. But a tumor may subsequently regain homologous-recombination function through a BRCA reversion mutation or reversal of BRCA methylation. The tumor can then become resistant to PARP inhibition while retaining the old genomic scars that produced its HRD-positive score.

A scar assay therefore asks:

Has this tumor lineage experienced HR deficiency?

The therapeutic question is closer to:

Is homologous recombination impaired in the currently dominant tumor population?

Those questions overlap, but they are not identical. This mismatch is particularly important after platinum or PARP exposure, when therapy has selected resistant clones. It also explains why a static, archival-tissue HRD result may become progressively less informative later in the disease course.

7. Epigenetic HRD is undermeasured

BRCA function may be lost through promoter methylation rather than sequence alteration. Many current assays do not directly measure methylation. Moreover, methylation can potentially be reversed, restoring function and producing early recurrence or platinum/PARP resistance despite the genomic-scar result.

Titus treats this as a major knowledge gap: the assay may detect the historical consequences without capturing the epigenetic mechanism or its subsequent reversal. For a sequencing company, this is a reminder that a DNA panel—even a very broad one—is not necessarily a complete HRD assay.

8. “HR-proficient” is becoming its own heterogeneous research category

Historically, most attention went to HRD because it supplied the therapeutic opportunity. Titus suggests that HRP tumors may now become equally important. HRP should not be treated simply as “nothing detected.”

Examples in the article include:

• Strong CCNE1 amplification, associated with replication-fork stress and presented as evidence pointing away from the classic deletion/LOH-rich HRD phenotype.

• RB1 loss in some HRP tumors, which may identify tumors behaving more like HRD tumors.

• HRP tumors retaining RB1, which emerging data suggest may have particularly poor survival.

• Possible differences in immune infiltration and PD-1/PD-L1 biology between BRCA-altered/HRD and HRP tumors.

These observations remain investigational. A CCNE1 amplification or RB1 result should not be promoted as a validated substitute HRD classifier. But they illustrate why comprehensive profiling may ultimately be more useful than an isolated positive/negative scar report.

9. Evidence is strongest in high-grade serous ovarian cancer

The field tends to talk as though HRD were a tumor-agnostic property. Yet both genomic-scar patterns and clinically appropriate thresholds may depend on tissue and histology. The strongest evidence remains in high-grade serous ovarian carcinoma, with some trial inclusion of endometrioid and other nonmucinous epithelial cancers.

Titus points to clear cell carcinoma and carcinosarcoma as areas where interesting cases exist but robust evidence does not. The 2022 paper makes the broader principle explicit: assays and cutoffs should be validated in their intended-use populations because the genomic manifestation of HRD may differ by tumor type.

What has changed from 2022 to 2026?

The 2022 paper described a harmonization problem: inconsistent definitions, different assay components, different thresholds, and inadequate reporting. The 2024 CAP review translated that framework into available laboratory technologies, including Oncomine Comprehensive Assay Plus.

Titus in 2026 shows three important developments:

• The field now has more routine clinical experience, making tissue limitations, borderline scores, and intratumoral heterogeneity impossible to ignore.

• Comprehensive profiling is beginning to place the HRD score in a larger biological context—BRCA and non-BRCA causes, CCNE1 amplification, RB1 status, resistance, and immune biology.

• The static nature of genomic scars is increasingly recognized as a fundamental limitation, particularly after treatment and biological reversion.

In other words, the problem has evolved from “How do we standardize competing HRD assays?” to “Can a single HRD category adequately represent a heterogeneous and changing tumor?”

Some Technologies

 

Roswell Park uses an Oncomine Precision Assay for additional targeted tumor profiling while also relying on Myriad MyChoice CDx and FoundationOne CDx. That is an important distinction: the Oncomine panel can contribute information about HRR genes and wider tumor biology, but its presence in the workflow does not by itself make it interchangeable with the HRD companion diagnostic used in a pivotal trial.

Meanwhile, the article gives a competitor example: Labcorp’s OmniSeq Insight incorporates an optimized Illumina TSO 500 HRD workflow and combines genomic-instability measurement with broad DNA/RNA profiling and PD-L1. The market signal is that HRD is moving toward integrated comprehensive profiling, rather than surviving indefinitely as a narrow standalone score.

The strategic lessons are:

• Do not market HRD as merely another panel output. The platform must distinguish causal HRR variants, genomic-scar measurement, and current functional status.

• Treat the algorithm and clinical evidence as part of the product. Sequencing performance alone does not establish interchangeability with a trial-validated CDx.

• Make preanalytics visible. Tumor fraction, treatment status, tissue area, copy-number confidence, and specimen-selection guidance are critical.

• Retain and report the continuous metric. A binary call should not erase the actual score or its proximity to the cutoff.

• Build a contextual report. BRCA findings, relevant non-BRCA genes, possible biallelic status, genomic-instability components, strong counter-signals such as CCNE1 amplification, and applicable limitations should be separable.

• Validate by tumor type and intended treatment use. An ovarian-cancer threshold cannot simply be carried into prostate, pancreatic, breast, or other tumors because the same biological pathway may leave different genomic patterns.

• Plan for longitudinal disease. Static scar testing is strongest near diagnosis in untreated tissue. Recurrent, post-PARP, or platinum-resistant disease may require rebiopsy, liquid-biopsy resistance testing, methylation assessment, or eventually functional HR measurement.

• Avoid overclaiming the HRP category. A negative scar score is not proof of homogeneous normal repair biology, and HRP itself may contain clinically distinct subgroups.

A concise teaching conclusion

The cleanest conclusion for the executives is:

HRD testing attempts to infer a dynamic DNA-repair phenotype from a mixture of causal variants and historical genomic damage. The available assays differ in what they measure, how they score it, where they set the cutoff, and the clinical trials to which that cutoff is tied. Tissue quality, tumor heterogeneity, non-BRCA biology, methylation, and acquired BRCA reversions can all separate the reported HRD category from the tumor’s current therapeutic vulnerability. The next generation of testing will therefore need to move beyond a solitary positive/negative scar score toward integrated, tumor-specific, and eventually longitudinal assessment.

That, I think, is the real 2026 CAP Today message: HRD is a valuable biomarker, but “HRD-positive” is still a compressed summary of a much more complicated biological and measurement problem.

Who's Predicting the CRUSH rule?? And, How Does Chat GPT Predict the CRUSH rule?

 https://chatgpt.com/c/6a8da199-c37c-83e8-bbe8-847d54cbe10e

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Who, if anyone, is trying to really predict what will in the actual proposed CRUSH rule?

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The genuine forecasting literature is surprisingly thin. Most coverage simply restates the February RFI. There is no final CRUSH rule: the proposed rule was sent to OMB’s Office of Information and Regulatory Affairs on August 7, 2026, where it remains under review. OMB identifies it as a proposed rule and “not economically significant”; the Unified Agenda tentatively lists publication in October. OMB review docket; Unified Agenda entry.

The useful forecasting literature

Source	What it genuinely adds
Liles Parker, June 5	The most direct forecast. It expects more payment suspensions, automated prepayment controls, enrollment screening, ownership scrutiny and revocations. Its AI emphasis is plausible operationally, although AI may appear more in the preamble than in regulatory text.
Sidley, May 20	Predicts continued use of predictive analytics, enrollment interventions, coordinated “war rooms,” suspensions and state pressure. It forecasts the administration’s enforcement model more than individual CRUSH provisions.
KFF, June 9	Shows where Medicaid policy is already going: accelerated revalidation of high-risk providers, additional attention to providers without NPIs, and continuing federal pressure on states.
Mintz, July 14 and McDermott, July 22	These analyze the July home-health proposed rule rather than CRUSH itself. Nevertheless, that rule is probably the best available predictor because it reveals which CRUSH-style enrollment powers CMS has already converted into actual regulatory language.
MedScout laboratory analysis	One of the few industry pieces to make a substantive laboratory prediction: laboratories should expect more nationally consistent molecular-test rules. Its prediction does not establish that CMS will adopt national MolDX wholesale.
BCBSA recommendations summarized by Becker’s	Particularly useful for predicting how the MA proposal may be narrowed. BCBSA supports real-time notification and coordinated action but cautions that simply transplanting Medicare fee-for-service suspension rules into capitated plans would not work.

The principal conclusion from the search for forecasts is therefore negative. But important: there is no emerging expert consensus based on leaked text or unusually informed reporting. 

The soundest forecast comes from reverse-engineering CMS’s regulatory posture, its actions since February, the July enrollment proposals and the practical constraints that OMB review imposes.

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Chat GPT Steps Into the CRUSH Ring: Forecasting the Proposed Regulation

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What Will Be in the CRUSH Proposed Rule—and What May Have Fallen Off the Truck

The proposed Comprehensive Regulations to Uncover Suspicious Healthcare rule has reached the White House. CMS transmitted the proposal to the Office of Management and Budget on August 7, 2026. No proposed text is public, and no final regulation exists. Nevertheless, the available evidence permits a reasonably discriminating forecast—not simply of subjects that CMS considered in February, but of the provisions most likely to survive the journey from an expansive request for information to an administrable proposed rule.

The February CRUSH request for information, 91 Fed. Reg. 9803, was intentionally panoramic. It raised questions about enrollment, payment suspensions, Medicare Advantage, Part D, laboratories, DMEPOS suppliers, artificial intelligence, claim-filing deadlines, surety bonds, beneficiary solicitation, Medicaid, CHIP and the insurance Exchanges. An RFI can afford to be panoramic. A proposed rule cannot. Its provisions must have statutory authority, workable regulatory language, defensible burden estimates and a plausible implementation path.

OMB’s characterization supplies the first clue. CRUSH is classified as “other significant,” but not major or economically significant. It is also listed as having no federalism, unfunded-mandate or international impact. Those labels are preliminary rather than binding, but they make a massive redesign of every CMS program less likely. They point instead toward a package of administrative enforcement tools—rules that expand CMS discretion, allow faster intervention and concentrate burdens on providers or services classified as high risk.

Enrollment will be central—but much of the first tranche has already appeared

CRUSH will almost certainly contain provisions making it easier to deny, deactivate or revoke the enrollment of providers and suppliers considered high risk. Enrollment has become the administration’s preferred gatekeeping mechanism because it allows CMS to prevent payments without first completing a conventional fraud case. It also produces immediate, visible results: an entity can be kept out, removed or disconnected from Medicare billing before the government has paid years of questionable claims.

But some of the most important enrollment provisions may have “fallen off the CRUSH truck” for an unusual reason: CMS has already placed them in another proposed rule. The CY 2027 Home Health PPS proposed rule, 91 Fed. Reg. 41216, 41285–41327, contains program-wide Medicare enrollment provisions that go well beyond home health.

Among other things, CMS has proposed to loosen the existing standards for revoking enrollment based on abuse of billing privileges; revoke providers based on excessive geographic concentration and perceived fraud risk; propagate a denial or revocation across a provider’s other enrollments; reach parties with business or financial relationships to an applicant; make many revocations retroactive; extend reapplication bars; and reduce the post-revocation claim-submission period from 60 days to 15 days. The proposal frequently avoids fixed numerical thresholds and reserves case-specific discretion to CMS.

This is probably the clearest preview of CRUSH’s drafting philosophy. The agency appears more interested in removing limiting factors from its existing authority than in creating a highly prescriptive new fraud code. CRUSH may add a second enrollment tranche—more frequent revalidation, stronger deactivation authority, elevated screening of newly identified high-risk categories and improved propagation of adverse actions across programs—but it need not repeat every provision already riding in the home-health rule.

This approach also continues a much older progression. CMS created the modern Part 424 enrollment framework in the 2006 enrollment rule, 71 Fed. Reg. 20754. It added risk-based screening, fingerprinting, temporary moratoria and payment-suspension provisions in the 2011 program-integrity rule, 76 Fed. Reg. 5862. The 2019 program-integrity rule, 84 Fed. Reg. 47794, enlarged affiliation disclosure and denial and revocation authorities. CRUSH is likely to be another turn of that ratchet, but with a stronger emphasis on rapid, data-triggered intervention.

Payment suspension and prepayment review should be the rule’s center of gravity

The strongest candidate for a leading role in CRUSH is expanded authority to stop money before it leaves the government. That is the operational meaning of the administration’s promised transition from “pay and chase” to “detect and prevent.”

In traditional Medicare, CMS already can suspend payments when it possesses reliable information concerning an overpayment or a credible allegation of fraud. It can also impose prepayment medical review and automated claim edits. CRUSH could make these tools easier to initiate, maintain or coordinate by revising evidentiary standards, broadening the information that CMS may consider, removing procedural impediments, or explicitly connecting analytics-generated risk signals to medical review and payment action.

The administration’s behavior strongly favors this prediction. CMS reports billions of dollars in suspended payments and repeatedly publicizes moratoria, payment holds, site visits and enrollment removals. Sidley’s May analysis similarly expects continued reliance on predictive analytics, payment and enrollment suspensions and coordinated enforcement teams. These are tools the agency already understands, and expanding them can produce immediate results without waiting for criminal or False Claims Act litigation.

The more difficult question is whether CMS will require Medicare Advantage and Part D plans to suspend payments whenever CMS directs them to do so. Some version of cross-program coordination is highly likely. A provider suspended in traditional Medicare should not be able simply to redirect the same activity to Medicare Advantage. Plans therefore may be required to screen against CMS data, receive suspension information in real time and take specified action against revoked, precluded or suspended parties.

A wholesale transplantation of fee-for-service suspension rules into MA and Part D is less likely. As the Blue Cross Blue Shield Association observed, plans operate through capitation, provider contracts and different payment systems. Questions also arise concerning beneficiary liability, continuity of care, contractual appeals and the treatment of clean claims unrelated to the suspected conduct.

The likely compromise is a graduated system: immediate notification of plans; mandatory screening and internal suspension policies; required action against providers subject to defined CMS sanctions; and possibly CMS-directed suspensions in specified high-risk circumstances. CMS could pilot the broader authority or initially apply it to DMEPOS suppliers and other sectors where the risk of billing migration is especially apparent.

Identity proofing and ownership scrutiny are highly likely to survive

Enhanced identity verification is another strong candidate for inclusion. Modern fraud schemes frequently use stolen identities, nominal owners, rapidly changing corporate shells, shared addresses and individuals who appear on paper while someone else controls the operation. Identity proofing addresses the actor before CMS must adjudicate the validity of thousands of individual claims.

CRUSH therefore is likely to enlarge the circle of persons subject to verification. Owners with meaningful interests are obvious candidates, but CMS also may reach managing employees, authorized officials, directors, compliance personnel and selected affiliated parties. Higher-risk individuals could face fingerprints, criminal-background checks, address verification and confirmation of banking or tax information. CMS could also require more rapid reporting when these parties change.

The July home-health proposal supports this prediction. It would clarify the scope of managing employees, reach a wider range of associated parties and expand ownership-related enrollment reporting. CMS also has proposed to deny enrollment based on misuse of another person’s identity. These are concrete indications that the agency wants to look beyond the billing entity to the people and organizations surrounding it.

A categorical requirement that every person holding a 5% ownership interest be a United States citizen or lawful permanent resident is less likely to survive intact. Such a rule would affect legitimate international ownership structures, invite questions about statutory authority and potentially create consequences far beyond high-risk providers. OMB’s designation of no international impact is another reason for caution. CMS is more likely to require fuller disclosure of foreign or nonresident owners, a verifiable domestic responsible party, an agent for service and reliable financial and location information.

Claim deadlines, bonds and solicitation restrictions will probably be narrower than advertised

The RFI’s proposal to shorten the ordinary Medicare claim-filing period to 90 or 180 days has intuitive political appeal: fraudsters should not be allowed a long period in which to manufacture or warehouse claims. But a universal deadline has a weak connection to the identity of the biller or the medical necessity of the service. It also can penalize legitimate providers dealing with corrected claims, delayed documentation, coordination of benefits or enrollment problems.

For those reasons, a universal 90-day limit appears unlikely. CMS may propose 180 days, incorporate exceptions, or apply a shorter period only to selected suppliers and services. Another possibility is that CMS will use special deadlines after a revocation or other adverse event. The home-health rule’s proposed reduction of the post-revocation filing window from 60 days to 15 days demonstrates that CMS is willing to shorten deadlines when it can connect the change directly to an identified program-integrity risk.

Surety bonds present a similar pattern. CMS already has experience with bonds for DMEPOS suppliers, where inventory, ownership turnover and rapid billing can create collectability risks. An increased DMEPOS bond or a risk-adjusted bond tied to billing volume is plausible. A general bond requirement for laboratories, physicians and institutional providers is less likely. It would require difficult decisions about bond amounts and could restrict legitimate market entry without reliably distinguishing honest providers from fraudulent ones.

Beneficiary-solicitation rules also are likely to be targeted. CMS can plausibly update the DMEPOS prohibition on unsolicited telephone contacts to encompass texts, email, social media and third-party lead generators. But the RFI itself recognized that extending the statutory DMEPOS prohibition to entirely different provider classes may require legislation. The proposed rule may therefore focus on modern communications and indirect marketing within CMS’s existing authority, leaving a general health-sector solicitation ban off the truck.

Laboratories are likely to be visible, but a national MolDX regime is not inevitable

Laboratories—especially genetic and molecular laboratories—are unusually likely to receive their own section. Most of the regulatory history is program-wide; CRUSH may be the first major enrollment and program-integrity package to identify molecular laboratories so prominently as a distinct target.

CMS has a substantial enforcement record on which to draw. A Florida laboratory owner was convicted in a scheme involving approximately $463 million in claims and $187 million paid. In 2026, federal prosecutors in Texas alleged that two laboratories had billed roughly $65 million and received more than $43 million for genetic testing associated with kickbacks and medically unnecessary orders. Those cases make laboratory oversight politically conspicuous and give CMS a clear rationale for action.

But “molecular testing” is not synonymous with fraud. Genomic and biomarker testing has become central to precision oncology, helping identify therapeutic targets, inherited risk and, increasingly, early-detection signals. The National Cancer Institute’s explanation of biomarker testing illustrates how closely testing can be integrated with treatment selection. A rule that treats rapid expenditure growth as proof of abuse would risk obstructing one of medicine’s most consequential areas of development.

The most plausible CRUSH response is therefore targeted rather than categorical. CMS could designate certain laboratory profiles or molecular services as higher risk; require additional enrollment screening or accreditation; intensify prepayment review of outlier codes; verify ordering-provider relationships; collect information about marketers, specimen arrangements and referral entities; and require clearer identification of the particular test being billed. Test-specific identifiers or registration could be attractive because generic CPT codes sometimes aggregate heterogeneous assays and make claims analytics less informative.

Nationwide adoption of MolDX as a unified coverage and payment system is less certain. Supporters argue that MolDX-style registration and technical assessment would give CMS better visibility and more consistent medical-necessity rules. Opponents, including the American Clinical Laboratory Association, warn about duplicating CLIA oversight, prolonged technical-assessment delays and barriers to coverage for new tests. Nationalizing MolDX would also be a substantial coverage-administration project, not merely an anti-fraud control.

Consequently, CRUSH may borrow selected MolDX features without nationalizing the program. Registration of certain high-risk molecular tests, unique test identifiers, uniform data elements or a limited demonstration are more likely than immediate nationwide transfer of molecular coverage authority. CMS also could solicit further comment, establish contractor performance standards or move broader MolDX policy into a separate rulemaking.

Medicaid provisions will emphasize revalidation and federal visibility

The Medicaid portion is likely to focus on tools that CMS can describe as minimum program-integrity standards rather than on a wholesale federal takeover of state operations. Likely provisions include accelerated or off-cycle revalidation of high-risk providers, more consistent risk categorization, improved use of NPIs, reporting of ownership and adverse actions, and faster exchange of suspension and termination information among states and CMS.

That prediction is consistent with current practice. CMS has asked states to revalidate high-risk providers and prepare broader two-year revalidation strategies. KFF’s review identifies high-risk classification, providers without NPIs, state capacity and the public availability of revalidation results as important unresolved questions.

More sweeping Medicaid financing proposals are less likely to be central to CRUSH. Intergovernmental transfers, state-directed payments and eligibility verification involve different legal and policy structures. They also create obvious federalism and economic consequences, whereas the Unified Agenda identifies CRUSH as having no federalism impact. The administration can continue pursuing state-specific deferrals and compliance actions without placing every dispute into this rule.

Artificial intelligence may power the rule without becoming much of the rule

Artificial intelligence will be prominent in speeches, press releases and the preamble. It is less certain that CRUSH will contain extensive binding AI regulations. CMS already can use predictive models and claims analytics to select providers for review. It does not need a new regulation every time it changes an algorithm.

Detailed AI rules for Medicare Advantage coding would raise difficult questions about model validation, explainability, clinical review, performance measurement, proprietary information and appeal rights. Those questions are real, but they could slow a rule centered on immediate enforcement authority. CMS may instead state that data analytics can support payment, medical-review and enrollment decisions while reserving specific AI governance for guidance, contracts, audit protocols or a later rulemaking.

This distinction matters. Operationally, providers may encounter much more automated scrutiny even if “artificial intelligence” appears in few operative provisions. The legally significant change may be the consequence attached to an analytic flag—prepayment review, a site visit, revalidation or suspension—rather than the model that generated the flag.

What probably fell off the truck

The provisions least likely to emerge intact are a universal 90-day filing deadline; a general surety-bond requirement across provider classes; an across-the-board citizenship requirement for owners; immediate nationwide MolDX coverage administration; comprehensive regulation of AI coding tools; and a direct transplantation of traditional Medicare suspension procedures into every MA and Part D payment system.

Marketplace provisions also may have receded. Although the February RFI discussed federal and state-based Exchanges, the later Unified Agenda abstract describes Medicare, Medicaid and CHIP but does not mention the Marketplace. That omission may be accidental, but it is one more sign that the proposal reaching OMB is narrower than the original questionnaire.

Some enrollment concepts may be absent for the opposite reason: CMS has already proposed them elsewhere. The July home-health rule has become a vehicle for broad Medicare enrollment changes, including retroactive revocations, associated-party scrutiny and new risk-based authorities. Those provisions did not necessarily lose favor; they may simply have left the CRUSH package early.

The likely shape of the proposed rule

The most probable CRUSH proposal is a concentrated package built around four ideas. 

• First, CMS will acquire or clarify authority to stop suspicious payments earlier, with greater use of prepayment review and some form of required coordination by MA and Part D plans. 
• Second, enrollment will become more dependent on verified identity, ownership, management, location and affiliation information. 
• Third, Medicaid agencies and managed-care organizations will face stronger revalidation, screening and information-sharing expectations. 
• Fourth, CMS will establish targeted controls for conspicuous high-risk sectors, with molecular laboratories and DMEPOS suppliers likely to receive particular attention.

The rule’s practical significance may exceed its formal economic designation. A regulation need not impose a universal multibillion-dollar compliance system to have enormous consequences for an individual provider. A payment suspension, retroactive revocation or enrollment denial can be existential.

The central forecast is therefore not that CRUSH will create an entirely new program-integrity system. It will make the existing system faster, more interconnected and more discretionary. The 2006, 2011 and 2019 rules constructed the enrollment and screening architecture. CRUSH is likely to give CMS more ways to act on the signals that architecture produces—and to act before suspicion has matured into a completed fraud case.

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Sidebar:  Re ownership idenity, I asked a follow-up.   Is it really that they don't know the owners, they used fake IDs, or is it that the money wired at midnight to the Cayman Islands and the owners are in Macedonia?

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Honestly, the Cayman Islands and Macedonia comments are closer to the mark. FBI and DOJ can often identify the real participants eventually. The problem is that CMS may not know—at enrollment and payment time—whether the reported owner is the actual controller, a straw owner, a stolen identity, or merely the domestic face of a foreign organization. By the time investigators reconstruct that structure, Medicare has paid and the proceeds have been layered through shell companies and a chain of domestic and foreign banks.

The schemes fall into three overlapping categories:

• False identity: stolen or fabricated identities are used to establish providers, order services or supply beneficiary data.

• Nominee (nominal) ownership: the enrolled “owner” is a real, identifiable person but is not the true operator or beneficiary. Fingerprinting confirms who the nominee is; it does not establish who controls the nominee.

• Offshore control and dissipation: the real operators are abroad, while proceeds pass rapidly through money launderers, shell companies and foreign accounts, making asset recovery and extradition difficult.

The enormous 2025 “Operation Gold Rush” case illustrates the combined model: DOJ alleged a foreign-based organization, foreign straw owners, stolen identities and an international money-laundering network. More recent prosecutions describe proceeds moving through global banks, a New Zealand shell company and even construction of a Philippine resort. DOJ’s Operation Gold Rush announcement; 2026 national takedown.

CMS essentially says this explicitly in the CRUSH RFI, 91 Fed. Reg. 9803: it describes opaque ownership, foreign-resident owners and actors beyond the practical reach of American law enforcement. Thus, “identity proofing” is partly an imprecise label for the larger problem of determining beneficial ownership, actual control and collectability before money is released.

But that rationale should not be overgeneralized to laboratory fraud. Many Texas and Florida genetic-testing cases involved perfectly identifiable domestic laboratory owners, marketers and telemedicine participants. Their identities were not the principal mystery; the failures involved kickbacks, medically unnecessary orders, weak prepayment controls and Medicare’s inability to stop aberrant billing quickly. A citizenship rule or more fingerprints would not have prevented most of those claims.

The most effective CRUSH package would therefore combine identity verification with beneficial-ownership disclosure, validation of the receiving bank account, scrutiny of marketers and affiliated entities, and rapid payment holds when billing suddenly becomes aberrant. Fingerprinting alone solves yesterday’s “Who is this person?” problem. The more serious contemporary question is: Whose business is this really, who receives the money, and can the government still reach either one tomorrow morning?

OIG and Medicare Fraud: Recent Years and 2026

 Yes. There are two genuinely important new OIG Work Plan items in 2026, and one is exactly the MolDX-versus-non-MolDX comparison you heard about. I find no separate OIG project on prior authorization for genetic testing.

The headline findings

1. OIG is formally asking whether MolDX jurisdictions look different

On June 15, 2026, OIG added an active project titled Trends and Vulnerabilities in Genetic Tests Covered Under Medicare Part B (OEI-09-26-00270).

OIG will:

• Identify genetic tests potentially vulnerable to fraud, waste, and abuse.

• Analyze trends among laboratories.

• Examine geographic variation, “particularly between jurisdictions that do and do not participate in the Molecular Diagnostic Services Program.”

So your description is fair: OIG intends to test whether the MolDX states have fewer—or at least different—genetic-testing vulnerabilities. OIG does not quite promise to calculate a “fraud rate”; it will probably compare utilization, spending, provider concentration, per-beneficiary testing and conspicuous outliers. But the policy question could hardly be clearer: does MolDX’s test identification, Z-code system, coverage apparatus and claims editing suppress the nonsense seen elsewhere?

This is probably the most consequential federal evaluation of MolDX since the program began.

2. OIG has separately opened an audit of expanded pathogen panels

Four days earlier, on June 11, OIG announced Medicare Payments to Providers for Selected Expanded Laboratory Panels (OAS-26-09-071).

OIG defines expanded panels as tests detecting six or more pathogens, contrasts them with targeted panels of five or fewer, and says there are concerns that providers are using the expensive expanded panels when a targeted panel would suffice. This will be an actual compliance audit against Medicare and MAC medical-necessity requirements.

Although OIG does not name 87798 in the project description, this is plainly aimed at the same ecosystem: large respiratory, urinary, wound and other infectious-disease PCR panels, including panels assembled through numerous units of nonspecific organism codes.

The 81408-to-87798 succession is real—with one coding correction

The code was 87798, not 87789. There is also a nomenclature distinction:

• 81408 is genuinely a Tier 2 molecular-pathology code.

• 87798 resides in CPT microbiology: nucleic-acid detection of an infectious organism, NOS, amplified-probe technique, each organism.

• Beginning with the latest annual report, OIG classifies human and pathogen nucleic-acid testing together as “genetic tests.” Thus, 87798 is molecular testing but not “molecular pathology” in the CPT-section sense.

The progression is remarkable:

Claims year	Code and OIG result
2021	81408 generated $282.2 million for 141,146 units at $2,000—seventh among every CLFS code and the largest-spending genetic code. Meanwhile 87798 was already at $213.7 million. OIG 2021 annual analysis
2023	87798 reached $292.4 million, ranking fifth overall, on 8.5 million units at $35.09. OIG 2023 analysis
2024	87798 exploded to $442.5 million, up 51%, and became the single highest-spending code on the entire CLFS. OIG 2024 analysis

There is a terrific hidden clue in the latest report. OIG gives the median 87798 payment per claim line as $447.05. The underlying rate was approximately $35.09 per organism:

[
13 \times $35.09 \times 98% = $447.05
]

That means the reported median corresponds exactly to 13 organisms—the full longstanding MUE—after 2% sequestration. In other words, this was not principally a $35 test becoming number one through legitimate single-organism volume. At least half of the relevant claim lines appear to have been billed at the 13-unit ceiling. It is almost a statistical fingerprint of panel unbundling.

What OIG previously established about 81408

The definitive 2023 audit, CMS’s Oversight of Medicare Payments for the Highest Paid Molecular Pathology Genetic Test Was Not Adequate, found:

• $888.2 million paid for 450,795 units of 81408 during 2018–2021.

• Two of seven MACs accounted for 97%—$865.7 million—of the spending.

• Four MACs had mechanisms to identify the actual gene being tested; their combined payments accounted for only 3%.

• 80% of affected beneficiaries lacked an established relationship with the purported ordering provider, using OIG’s definition.

• Five MACs prohibited or limited 81408; the two high-paying MACs had essentially no diagnosis limitations until late 2021.

• After those two MACs changed their articles, payments had disappeared by December 31, 2021.

That is already a strong natural experiment suggesting that granular test identification and restrictive local controls matter. The new 2026 MolDX project scales that question from one grotesque code to the entire genetic-testing sector.

Two other precursor reports matter:

• OIG’s 2021 genetic-testing trends report found payments quadrupled from 2016 through 2019, 20 laboratories received 73% of all payments, more than 67,000 beneficiaries received at least 10 genetic tests, and MAC coverage guidance varied dramatically.

• Its 2022 COVID add-on testing report identified 378 laboratories with questionably high billing for respiratory, allergy or genetic add-ons and referred them to CMS.

What about “OIG, prior authorization and genetic testing”?

I cannot find such an OIG Work Plan project.

The current Work Plan contains prior-authorization studies involving Medicare Advantage post-acute care and Medicaid managed care, but none pairs prior authorization with genetic or molecular testing. The June genetic-testing project never uses the term “prior authorization.”

The likely conflation is MolDX itself. MolDX requires advance test registration, a unique Z-code and, for many tests, a successful technical assessment before routine payment. That resembles product-level preclearance, but it is not beneficiary-by-beneficiary prior authorization in the ordinary payer sense.

OIG could eventually recommend prior authorization or prepayment review, but it has not announced that as the study’s objective.

Finally, the reported 2026 collapse in 87798 payment appears real but contractor-driven: laboratories report that non-MolDX MACs are increasingly paying only two units and denying additional units with N35 program-integrity edits. I found no published national CMS policy replacing the 13-unit MUE. Thus, I would currently describe it as a sharp, multi-MAC program-integrity clampdown rather than a formal national prior-authorization policy.

The annual 2025 CLFS report is already active on OIG’s Work Plan, but it will cover 2025 claims. The full effect of the 2026 87798 shutdown will not appear in the statutory annual series until OIG analyzes 2026 claims.

The Half-Working Capital Shift Key: Fixed

 For months, my left capital shift key on my favorite keyboard worked poorly.   To get a few words in capitals, rather than use Shift Lock, I would hold down Capital Shift with my left little finger.  Only partial and erratic capitalization resulted, even if I pressed firmly.

Chat GPT suggested thoroughly spraying with a pressurized computer air can.    This seems to have helped a lot.   See illustration. Ten or fifteen seconds from every angle.  If possible, have a second person tap the key while you spray the heck out of it.

Chat GPT did NOT recommend attempting to take off, clean, and replace the key on my model keypad.

ENVY Apples and the Hyposmic Male

I have hyposmia and perhaps diminished taste. I've noticed I gravitate to more flavorful foods and I am displeased with bland ones. For example, a tasty highly garnished and seasoned pizza is much prefered to a bland one with white cheese and a few bland sausage morsels. Interestingly, ENVY apples seem much better to me than Honeycrisp. Are some types of apple, "apple-i-er"?? If so, is ENVY a good choice.

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Yes. “Apple-ier” is a real sensory phenomenon, although it actually has two components: how intense the flavor is and how strongly it evokes the particular aroma we recognize as “apple.”

With hyposmia, this distinction becomes especially noticeable. Much of what people casually call taste is actually retronasal olfaction—volatile molecules traveling from the mouth up to the olfactory epithelium while chewing. In Parkinson’s, retronasal as well as ordinary orthonasal smell can be substantially impaired. True gustatory perception—sweet, sour, salty, bitter, umami—can also be reduced, although usually the olfactory loss contributes enormously to the sense that food has become bland. (PubMed)

So your pizza observation makes complete sense. A white-cheese pizza with mild sausage may deliver mainly fat, salt and texture; a heavily garnished pizza generates acid + salt + umami + herbs + browned flavors + pungency + texture + multiple aromas. There are many more signals left for a partially impaired sensory system to grab onto.

And Envy is a particularly interesting apple for you

Envy is the cultivar Scilate. In a recent controlled consumer/sensory study, Scilate was associated with sweet, fruity, tropical and pear-like flavors, as well as descriptors including intense, complex and powerful. It was substantially preferred to Gala and Red Delicious in that experiment. (ScienceDirect)

That strikes me as almost a laboratory explanation for why you prefer Envy. It isn't merely sweeter. It apparently throws a fairly large and complex sensory signal.

Honeycrisp is certainly aromatic—it contains numerous esters, aldehydes and other volatiles, with hexyl 2-methylbutyrate identified experimentally as an especially important contributor to its characteristic fruity aroma. (ScienceDirect) But a major part of Honeycrisp's fame is its extraordinary juiciness and crisp texture, not necessarily maximal aromatic intensity. USDA sensory work, for example, found Honeycrisp particularly outstanding for crispness and juiciness. (ARS) Thus someone with normal smell might find Honeycrisp spectacular, while your sensory weighting could favor Envy's concentrated sweetness/aromatic complexity.

And apples differ enormously in their volatile chemistry. Cultivar, maturity and storage conditions can all change the aromatic profile significantly. Even within Scilate/Envy, modern storage methods measurably affect volatile compounds. (ScienceDirect)

I would absolutely keep buying Envy. Your preference is not at all peculiar; it may actually be giving us information about what penetrates your hyposmia.

I'd also experiment with Pink Lady/Cripps Pink, Jazz/Scifresh and Braeburn. Rather than asking simply “Which apple tastes best?”, I'd score each one on two separate 0–10 scales:

FLAVOR INTENSITY — How much do I perceive?
APPLE-NESS — How unmistakably apple-like is what I perceive?

I wouldn't be surprised if you discover that those are quite different rankings—and that Envy wins Bruce's Apple Area under the curve / auc.

##

I also prefer fresh squeezed OJ !

##

Exactly. Fresh-squeezed orange juice is almost a hyposmia-friendly sensory bomb: strong citrus volatiles, sweetness, acidity, slight bitterness, pulp/texture, and often a little peel-oil aroma all arrive together.

Pasteurized bottled OJ can preserve the basic sweet–acid taste pretty well, but processing and storage reduce or alter some of the volatile compounds that make a freshly cut orange smell so vividly orange. So with diminished smell, the difference between “orange-flavored liquid” and freshly squeezed ORANGE may actually become more important, not less.

This also suggests a broader pattern in your food preferences: you may increasingly favor foods with multiple overlapping sensory channels—acid, spice, salt, umami, temperature, texture, pungency, and strong aroma—because they remain vivid despite the weakened olfactory channel.

YES, AND: AN INTERVIEW WITH AN IMPROV HISTORIAN

YES, AND: AN INTERVIEW WITH AN IMPROV HISTORIAN

An interview with Barry Wexler, performer, historian, and author of Accept the Premise: Improv Comedy from Commedia dell’Arte to Corporate Retreats.

INTERVIEWER: I understand that you’re not only an improv performer but also a historian of improv.

WEXLER: Yes, and it’s not my first profession. My first job was wrestling alligators at a theme park in Florida.

INTERVIEWER: Wrestling alligators?

WEXLER: Yes, and also manatees, Burmese pythons, and, briefly, a giant squid.

INTERVIEWER: There was a giant squid at a Florida theme park?

WEXLER: Yes, and she was shop steward for the aquatic performers.

INTERVIEWER: I’m not sure giant squid can—

WEXLER: That’s a classic improv mistake.

INTERVIEWER: What is?

WEXLER: Denying the reality your scene partner has established.

INTERVIEWER: So improv is basically “Yes, and.”

WEXLER: Yes, and you don’t literally have to say “Yes, and.”

INTERVIEWER: Of course.

WEXLER: You just did.

INTERVIEWER: Let’s talk history. How far back does improv go?

WEXLER: At least to ancient Greece. Socrates was essentially an improviser.

INTERVIEWER: Socrates?

WEXLER: Yes, and Plato was the guy in the audience writing everything down and later claiming it was philosophy.

INTERVIEWER: That’s a somewhat unorthodox interpretation.

WEXLER: Yes, and Aristotle founded the first training center, the Lyceum.

INTERVIEWER: The Lyceum wasn’t an improv school.

WEXLER: You’re fighting the scene very hard.

INTERVIEWER: Most people associate modern improv with Chicago.

WEXLER: Yes, and Chicago itself began as an improv exercise. One settler said, “What if we build a city here?” Another said, “Yes, and make the winters punitive.”

INTERVIEWER: And then?

WEXLER: A third said, “Yes, and put the airport forty-seven miles from everything.”

INTERVIEWER: What actually makes someone good at improv?

WEXLER: Listening. Beginners think it’s about being funny. It’s really about hearing what the other person gives you and building on it.

INTERVIEWER: That sounds almost profound.

WEXLER: Yes, and I charge corporations four thousand dollars an hour to tell them that.

INTERVIEWER: Corporations hire you?

WEXLER: Constantly. Last month I taught senior executives at a pharmaceutical company to embrace uncertainty.

INTERVIEWER: How did that go?

WEXLER: They raised the price of insulin.

INTERVIEWER: I’m not sure that demonstrates—

WEXLER: They committed to the choice.

INTERVIEWER: Is there anything you shouldn’t agree to in improv?

WEXLER: Certainly. Improv requires judgment, boundaries, and trust. For example, if someone says, “You are the King of Belgium,” you should accept that.

INTERVIEWER: I’m not the King of Belgium.

WEXLER: Your Majesty, we talked about this.

INTERVIEWER: There is no Belgium in this scene.

WEXLER: That explains your approval rating.

INTERVIEWER: Do you ever say no?

WEXLER: No.

INTERVIEWER: You just did.

WEXLER: Yes.

INTERVIEWER: That wasn’t “Yes, and.”

WEXLER: And?

INTERVIEWER: Oh, God.

WEXLER: Now you understand the deeper level.

INTERVIEWER: I think we should finish.

WEXLER: Yes, and before we do, my new book comes out Tuesday.

INTERVIEWER: Of course it does.

WEXLER: Yes, And Then What? How Improvisation Can Transform Your Career, Your Relationships, and NATO.

INTERVIEWER: NATO?

WEXLER: Yes, and the foreword is by the giant squid.

INTERVIEWER: The one you wrestled?

WEXLER: We prefer the term “scene partner.”

INTERVIEWER: Are we done now?

WEXLER: Yes.

INTERVIEWER: Thank God.

WEXLER: And—

#

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Prompt.  we will write a humorous/satirical column, in which a journalist interviews an expert, in this case, an improv comedy expert.  Famously, improv skits always pivot on theidea, Yes, AND.   So of course, we start to realize, this is the structure of the interview.   i'll give some examples but I want you to write a humorous mock interview, such as for SHoUTs and muRMers 9which expects the audience to get all of its meta jokes) at Nyer.   for example, "i understand that you are not only a performer, but a historian of Improv.'    B;  'Yes, and it's not my first job.  my first job was wrestling gators at a theme park in florida."  'wrestling gators?'  B:  Yes, and not only gaters, but also manatees and giant squid.  (etc)  that wasn't necessarily brilliantly funny, but you see the idea.  go ahead !

An AI Bio of Fr Luke Dysinger OBS

 From Chat GPT, 8/2026

https://stjohnsem.academia.edu/LukeDysinger/CurriculumVitae

(Full CV above)

(AI report below)

Fr. Luke Dysinger is an unusually accomplished combination: Benedictine monk and priest, retired family physician, Oxford-trained scholar of early Christianity, and Catholic bioethicist.

• He earned a BA in religion from USC in 1974 and an MD there in 1978. He completed family-medicine training through UCLA and Antelope Valley Hospital, became board-certified, and practiced medicine until 1994.

• He joined St. Andrew’s Abbey at Valyermo in 1980, made solemn profession in 1985, and was ordained in 1986. He has served as novice master, junior master, prior, librarian and cantor. He says he entered because the community made common liturgical prayer its “central and most important work.” St. Andrew’s Abbey biography

• At Oxford he received a theology certificate and later a DPhil in theology/patristics in 2000.

• He is professor of Church History and Moral Theology at St. John’s Seminary in Camarillo and has chaired its theology department. He has also taught biomedical ethics and served for many years on the Antelope Valley Hospital bioethics committee. St. John’s Seminary biography

His principal scholarly specialty is Evagrius Ponticus, the psychologically perceptive fourth-century Desert Father whose “eight tempting thoughts” eventually evolved into the Seven Deadly Sins. Dysinger’s substantial Oxford University Press monograph, Psalmody and Prayer in the Writings of Evagrius Ponticus (2005), examines chanting and memorized Scripture as spiritual medicine. In 2024 he was one of five scholars responsible for a major new Oxford translation, Evagrius of Pontus: The Gnostic Trilogy—a genuine scholarly achievement, presenting the whole trilogy from surviving Greek and Syriac versions. 2005 book · 2024 Oxford volume

His other major field is Catholic medical ethics—end-of-life care, assisted suicide, reproductive ethics, sexuality and celibacy. His published positions are squarely within Catholic moral teaching, but informed by actual medical training and clinical experience. One example is his discussion of sterilization in the AMA Journal of Ethics.

He also maintains an enormous, decidedly old-fashioned but remarkably rich online collection of courses and primary texts, much of it freely available. He regularly leads Abbey retreats on lectio divina, the Desert Fathers and Mothers, Benedictine spirituality and contemplative practice.

In short, he appears to be a serious and respected scholar—not merely a retreat lecturer—with an especially rare capacity to connect medicine, psychology, bioethics and ancient monastic spirituality. “Physician–monk–Oxford patristics scholar” is a fairly remarkable résumé.