AO on MCED Testing with Paid Screening (e.g. CRC) - Longer AI Essay

 See the original blog here:

https://www.discoveriesinhealthpolicy.com/2026/06/hhs-oig-releases-legal-viewpoint-on.html

Here is a longer Chat GPT opinion.

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OIG Advisory Opinion 26-11: 

Why the Free MCED Report Survived, and Where the Reasoning Could Fail

OIG Advisory Opinion 26-11 is important less because it “approves free testing” than because it shows how carefully OIG will parse a free molecular diagnostic add-on when the add-on is investigational, clinically plausible, non-billed, and tightly tethered to a separately covered screening test. The opinion should not be read as a general permission slip for laboratories to bundle free molecular information with federally reimbursed testing. OIG expressly found that the arrangement implicated both the Anti-Kickback Statute and the Beneficiary Inducements CMP. The favorable result came only after OIG concluded that the specific facts made the fraud-and-abuse risk sufficiently low.

The arrangement involved a precision oncology company offering a Medicare-covered, FDA-approved blood-based colorectal cancer screening test. Using the same blood sample, the company also ran an algorithmic multi-cancer detection analysis and furnished a free supplemental report to consenting patients. The supplemental report identified positive or negative signals for multiple cancers, including cancers for which there is no broadly recommended screening modality. The multi-cancer detection test was investigational, CLIA-validated, under development for FDA submission, and not separately reimbursed.

The threshold legal problem was straightforward. A free supplemental report is a thing of value. OIG emphasized that the report was valuable in part because the company hoped it would become reimbursable in the future. It could influence a beneficiary to select the company’s colorectal cancer screening test over other CRC screening modalities and thereby select the company’s laboratory. It could also create downstream billable physician visits or referrals. Thus, the arrangement created remuneration under the AKS framework and generated prohibited remuneration under the Beneficiary Inducements CMP. OIG also found that no AKS safe harbor applied. Nor did the preventive-care exception save the arrangement, because neither the CRC blood test nor the multi-cancer detection test was listed in the USPSTF Guide, even though CRC screening itself is broadly recommended.

The opinion therefore turns on enforcement discretion, not formal exemption. Several factual “locks” made the arrangement tolerable.

First, OIG relied heavily on the preexisting, independent clinical order. The supplemental report was available only where the patient already had a valid order for the Medicare-covered CRC screening test from an independent, non-affiliated physician who would use the results in patient management. This reduced the risk that the free report itself was the engine of utilization. The Medicare-paid service was not open-ended; it was a CRC screening test covered no more than once every three years for eligible beneficiaries.

Second, the supplemental analysis used the same specimen. There was no additional blood draw, procedure, or separately reimbursed laboratory service. This mattered because the free item did not create an additional claim to Medicare. OIG accepted that follow-up visits after a positive result might occur, but treated them as clinically grounded in the information returned rather than as utilization inappropriately caused by the free add-on.

Third, the report sat in a clinically meaningful gap. OIG noted that several cancers included in the MCD report lack USPSTF-recommended screening tests. This did not create a preventive-care exception; legally, that exception failed. But it mattered to OIG’s risk assessment because the free report could provide information not otherwise broadly available through recommended screening.

Fourth, the company avoided referral-linked provider economics. Physicians were not compensated for ordering the CRC test or for opting in to receive the supplemental report. The supplemental report was available regardless of the physician’s volume or value of referrals for the CRC test, the MCD test, or other company products. This is a critical guardrail. Had physicians received fees, data-collection payments, consulting opportunities, or other benefits tied to ordering or opting in, the opinion’s logic would likely deteriorate quickly.

Fifth, marketing was constrained. The company did not actively market the supplemental report as a provider benefit, did not conduct targeted or incentivized marketing for the report, and did not engage in direct-to-consumer promotion of the free supplemental report. Educational materials were pre-approved, neutral, and objective, and disclosed performance limitations. OIG also noted social-media controls, including instructions to physicians not to post about the free report and monitoring for third-party promotion. This is not cosmetic. In OIG’s analysis, restrained communication helped distinguish informed clinical availability from a promotional inducement.

Sixth, the competitive posture was unusual. The company’s laboratory was the only laboratory performing the CRC screening test. Therefore, a patient choosing that CRC test would choose that laboratory even without the supplemental report. This reduced, though did not eliminate, steering and unfair-competition concerns. The arrangement would be much harder to defend if many laboratories offered the same covered primary test and one laboratory used a free multi-cancer add-on to divert volume.

The opinion also contains built-in expiration points. The company certified that the arrangement would continue only until the MCD test received FDA approval as a medical device or was covered by Medicare under an NCD. That is sensible: once the MCD test becomes an approved or covered stand-alone product, giving it away for free beside a paid CRC test looks less like investigational information and more like free commercial value used to obtain federal program business.

The most important lesson is that the AO protects a narrow transitional fact pattern. It could fall through if the supplemental report becomes promotional, if the test becomes reimbursable, if the company adds DTC advertising, if physicians receive compensation or other economic benefits, if the analysis requires additional reimbursed services, if eligibility expands beyond independently ordered covered CRC screening, if performance limitations are obscured, or if the arrangement disadvantages competing laboratories in a more ordinary competitive market.

For molecular diagnostics companies, AO 26-11 is not a broad blessing of “free plus paid” diagnostic bundling. It is closer to a map of conditions under which OIG may tolerate a no-charge investigational add-on: no extra Medicare payment, no provider compensation, independent ordering, careful consent and data collection, neutral education, restrained marketing, and a credible clinical rationale. Remove enough of those conditions, and the same arrangement becomes the familiar fraud-and-abuse problem OIG says it continues to worry about: free items or services used to influence federally reimbursed ordering.

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Key source anchors: OIG states the opinion is requester-specific and fact-bound, and loses force if material facts are omitted, misrepresented, or change. It expressly finds AKS and Beneficiary Inducements CMP remuneration, no safe harbor, and no preventive-care exception. The favorable result rests on the same-sample/no-extra-cost structure, independent physician order, no physician compensation, limited neutral materials, lack of DTC promotion, and reduced steering concerns because only the requester’s lab performs the CRC test. The formal limitations section also confirms that no other party or arrangement may rely on the opinion, and that OIG gives no opinion on Stark, FCA, or other law.

Claude Opus Project: Assesses the CLFS ALM Day

Claude Opus worked from a transcript of the CLFS ALM day, the agenda of 47 speakers or organizations, and the Excel spreadsheet of the circa-110 codes under discussion.

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The frame of the day

What CMS convened on June 10 was not a pricing decision but a price-nomination hearing. Under §1834A(f)(3) of the Social Security Act, CMS has to take public comment before setting a payment basis for new and substantially revised CDLT codes, and this five-hour webinar — the CY2027 Annual Laboratory Meeting — is that statutory forum. 

The opening remarks set the boundaries tightly: every presenter is arguing for one of exactly two outcomes for each code, crosswalk (assign the payment of an existing comparable code) or gap-fill (kick the code to the MACs, who derive a carrier-specific amount over roughly nine months, post it ~April 30, and accept reconsideration). No dollar figures are debated; no policy is entertained. The meeting feeds a separate machine — the CDLT FACA advisory panel on July 14–15, then preliminary determinations in early October, a 30-day comment window, finalization, and a second meeting/panel cycle on September 15–16, with reconsideration rights layered on top.

A few contextual flags from the introduction matter for any expert read. CMS reminded everyone that legislation CAA 2026 §6226 (enacted Feb 3, 2026) revised the PAMA data-reporting requirements and continued to cushion the private-payer-rate phase-in (no more than a 15% annual cut through 2029) — so the rate environment around all of this is still being held artificially flat. They also disclosed, somewhat unusually for an opening statement, that a handful of recently established CPT codes are not on the agenda despite incoming letters and questions, and "will not be discussed." That is a live procedural dispute parked in plain sight.  [BQ: It involves digital pathology codes.]

The code list itself frames the day as much as the agenda does. Of ~110 codes, the overwhelming majority are proprietary (PLA 0xxxU or xxxxU) rather than Category I, and the substantive center of gravity is unmistakable: oncology ctDNA/MRD assays, rare-disease whole-genome and exome sequencing (often proband-plus-comparator trios), transplant rejection signatures, and — the single most conspicuous cluster — a wave of DNA-methylation "positive/negative risk" tests spanning psychiatry, neurology, hepatology, cardiology, and substance use.

How speakers typically presented

The format is a near-ritual. A presenter — almost always a VP of Reimbursement, Market Access, or a reimbursement consultant rather than the bench scientist — walks a slide deck through four beats: the clinical indication, the analytic workflow (extraction → library/assay → algorithm → report), the resources required, and then the recommendation with a comparator table. The argument is structured almost entirely as analytic equivalence to a chosen anchor code: same analyte type, same platform, same number of targets, same specimen, same reportable output, therefore crosswalk to code X. Abbott's TBI panel (X300U) crosswalking to 0570U is the canonical clean case — genuinely the same two-analyte immunoassay on a different platform.

Two presentation strategies recur and are worth flagging because they bear directly on valuation:

The first is anchor selection toward the high end — companies pick the most generous defensible comparator. The second, more aggressive, is additive ("stacked") crosswalking: rather than map to a single code, presenters build a price by summing codes. Variantyx recommended trios priced as a base genome code "plus two comparators"; ClearNote built X282U as 0410U + 86301; ACLA constructed its Alport recommendation as a level-8 plus a level-9 sequencing code, notably applying a 0.5 multiplier "to represent the efficiencies" of a single panel — almost the only downward adjustment volunteered all day.

The professional societies (ACLA, AMP, ASM) presented differently from the labs. They tended to recommend gap-fill where novelty is real (the reconsidered carbapenem-resistance code 87183 is the shared example), to coordinate openly ("we are in alignment with ASM/ACLA"), and to flag where AMA descriptor conventions strip methodology out of the code (e.g., GFAP chemiluminescence not appearing in the descriptor). They functioned as the day's only systematic counterweight to anchor-shopping.

The panel's questions: how often, and why

This is where an observer learns the most. The CDLT advisory panel — the same body that meets formally in July — is present and listening, but the questioning is carried by a tiny rotating cast: Joe Lennerz (MGH), a "Dr. Bridges" (CMS), Chris Chong, and Mark Rumpler. Across 47 presentations, only a minority drew any question at all — a rough quarter to a third — and the overwhelming default transition is "any questions from the panel? … okay, thank you," straight to the next speaker. Lennerz and Bridges were the most active and by far the most technical.

The striking thing is the content of the questions: almost without exception they probe the resource inputs that determine whether the proposed crosswalk is honest. Rumpler asked Agendia about the computational burden of 465 housekeeping genes and asked another presenter about batch size. Bridges, who had clearly pre-reviewed Biodesix's 0634U, asked for the validated limit of detection per variant, the limit of blank, crosstalk in the 11-plex design, and concordance against an FDA-approved companion diagnostic on shared samples — and the presenter could only promise to "follow up." Lennerz's exchange with TruDiagnostic is the cleanest illustration of the whole day's tension: he established that the "risk score" for twelve chronic-disease tests is actually a binary output, that sign-out is a pipeline QC check with lab-director review and no molecular pathologist, and that cancer indications (including HCC) are being run on whole blood, not tissue — all while the company seeks to crosswalk to 0020M, a 30,000-locus tumor-tissue methylation classifier.

So the questions, when they come, are doing one job: testing whether "resource equivalence" survives contact with the actual analytic and professional facts. They are not about clinical utility, evidence of benefit, or price level — those are out of scope by design.

What is unusual about the day

Several things should catch an expert's eye:

The methylation-risk-score flood is genuinely anomalous. A single company (TruDiagnostic) brought twelve codes asking to anchor all of them to one oncology tissue classifier on a pure "same array, wet-lab cost dominates" theory; Quantigen brought a parallel set (tobacco, alcohol, lung-cancer hazard ratios from methylation). This is a coordinated attempt to establish a high epigenetic-screening price tier by equating chronic-disease binary screens with cancer diagnostics.

The advocacy asymmetry is structural, not incidental. The applicant supplies the anchor; the panel is mostly silent; ~70% of codes pass with no interrogation at all. Combined with the 10-minute one-way format and no requirement to disclose actual costs, the operative default is "accept the proposed crosswalk unless someone on the panel happens to challenge it."

The presence of professional reimbursement intermediaries fronting multiple clients is notable — McDermott+ presented for Abbott, for the Point of Care Testing Association, and for the Coalition for 21st Century Medicine in the same day. That is normal in this world but worth naming: the "public" comment is substantially a managed-advocacy exercise.

Finally, the "missing codes" disclosure and the fact that one presenter (One Lambda's X253U) explicitly invoked a prior panel vote ("nine to one to crosswalk") as precedent both reveal how path-dependent and quasi-adjudicative this nominally informational meeting actually is.

How the day shapes valuation — rational, fair, or skewed

The honest answer is that the format pushes simultaneously toward both poles.

It promotes rational, data-based valuation in real ways. Everything is on the record and the code list is published in advance. Panel members pre-review specific codes (Bridges: "I reviewed this code") and ask exactly the questions that separate a fair crosswalk from a borrowed one — LOD, professional interpretation, batch economics, concordance. The societies inject an independent voice for gap-fill where novelty is genuine. And the architecture gives multiple deliberative bites: this meeting, then the FACA panel, then comment, then reconsideration. The resource-equivalence framing, at its best, is a disciplined cost-based logic that resists paying for marketing claims.

But the same architecture skews in predictable directions. Because applicants nominate their own anchors and the dominant move is crosswalk rather than gap-fill (crosswalk references outran gap-fill roughly four-to-one), the process systematically imports the price of yesterday's most generous comparable into today's test — and additive stacking lets a presenter manufacture a price larger than any existing single code. The "resource equivalence" standard, taken literally, deliberately excludes clinical value, evidentiary rigor, and indication from the pricing conversation, which is precisely how a whole-blood binary screen can argue for parity with a tissue tumor classifier. And because only a minority of codes are questioned, the quality control is a spotlight, not a floor: a code gets rigor if Lennerz or Bridges happens to pull the thread, and a pass if they don't.

The net effect is a process whose rationality is real but conditional — conditional on a handful of expert panelists having the bandwidth and pre-reading to contest self-interested anchors across 47 presentations in five hours, and conditional on the July panel and the comment cycles correcting what June lets through. For the codes that get interrogated, the day works as designed; for the long tail that does not, valuation is effectively set by the applicant's slide deck.''

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###  SIDEBAR ONE

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Crosswalk vs gap-fill tally

Classifying each of the 47 agenda slots by what the presenter clearly advocated (noting that several multi-code presenters split their recommendations):

• Clearly favored crosswalk (every code presented was a crosswalk request): ~34. This is the bulk of the day — essentially all the single-product labs (Abbott, CNSide, Agendia, Biodesix, Mayo, Guardant, Veracyte, TruDiagnostic's full set of 12, Variantyx, Natera, Castle, BillionToOne, Quantigen, GeneDx, and so on).
• Clearly favored gap-fill (every code was a gap-fill request): 4. Virant (0604U, 0605U), Pairidex (0644U, 0645U), ID-Fish (0580U, 0615U), and IGeneX (0636U–0639U). Notably, three of these four are rare-disease / tick-borne immunoblot or personalized-MRD assays whose sponsors argued no comparable code exists.
• Mixed — recommended gap-fill for some codes and crosswalk for others: ~8–9. This is where almost all the gap-fill advocacy lives, and it is concentrated in the multi-code society and coalition presentations: AMP, ASM, ACLA, the Coalition for 21st Century Medicine (9 crosswalks + 1 gap-fill), Thermo Fisher (0648U crosswalk / X269U gap-fill), POCTA, Genomic Health (X278U gap-fill / X294U crosswalk), Labcorp Oncology PGDx (gap-fill for the 0646U baseline, crosswalk for the rest), and AdvaMedDx (predominantly crosswalk, with one ambiguously worded code).

The headline is the asymmetry: crosswalk advocacy outnumbered clean gap-fill advocacy by roughly 34 to 4, and even the mixed presentations leaned crosswalk. Gap-fill was pushed mainly by the professional societies (where it reflects a principled "no true comparator exists / let the MACs cost it" stance) and by a handful of genuinely novel assays — almost never by a single-product lab that had a usable anchor available.

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SIDEBAR TWO

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The four presentations that drew the most questions

Counting distinct questions put to each presenter, three incidents stand clearly above the rest, and the fourth slot is a tie among several two-question exchanges, of which Castle Biosciences is the most substantive. The four:

Incident	Code(s)	# Q's	Questioner(s)	What was probed	Presenter's response
Thermo Fisher (Dumanois)	0648U	~5	Bridges (CMS) alone	Content completeness: which guideline biomarkers are covered by tumor type, MSI/TMB reporting, additional CDx indications + on-label vs RUO claims, RNA-fusion sensitivity/DV200/failure rate, concordance vs larger panels	Deflected nearly everything to written follow-up
Biodesix (Pascal)	0634U	4	Bridges (CMS) alone	Analytic validation: LOD per variant, limit of blank, crosstalk in the 11-plex, concordance vs an FDA ESR1 companion Dx, justification of rarer variants	Partial answers (3–4 copy LOD, 100% concordance vs Guardant360), exact data promised later
TruDiagnostic (Mallon)	0616U–0627U	4	Rumpler + Lennerz	Crosswalk justification: do loci differ by indication or is it one array; what the "score" actually outputs; molecular-pathologist sign-out vs pipeline QC; confirm whole-blood (not tissue) even for the cancer indications	Answered directly — and the answers undercut the equivalence claim
Castle Biosciences (Goldberg)	0635U	2	Rumpler + a second panelist	Crosswalk magnitude: 487 genes vs a 50–100-gene anchor — is a 1:1 crosswalk appropriate; does the larger panel consume more material/sequencing/reagents	Held firm, refused to concede, repeated "gene count reflects analytic content, not resource burden"

(The fourth position is genuinely a tie: CNSide 0640U, Precision Medicine 0628U, Pairidex 0644/0645U and Theranostix X258U each also drew two questions. Castle is the most useful to profile because it crystallizes the same dispute TruDiagnostic raised.)

Differences among the four incidents

The cleanest axis of difference is what kind of doubt the questions expressed. Thermo and Biodesix were both interrogated by Bridges, who had pre-reviewed the codes, and her questions were about the test itself — Thermo's were content/coverage questions (is this panel under-covering guideline biomarkers, is it missing MSI/TMB), and she even volunteered that the crosswalk looked reasonable; Biodesix's were pure assay-performance questions (LOD, limit of blank, crosstalk, concordance). Those two incidents exposed data gaps — facts that simply weren't in the room and had to be sent later.

TruDiagnostic and Castle were different in kind: the questions weren't fishing for missing data but pressing a conceptual dispute about the crosswalk anchor. Both presenters were arguing that a large, algorithm-driven test should be priced at a smaller-content comparator because the wet-lab work is equivalent, and in both cases a panelist pushed on exactly that move — Lennerz establishing that TruDiagnostic's "score" is a bare binary with pipeline QC and no pathologist sign-out (while still seeking the price of a 30,000-locus tumor-tissue classifier), and Rumpler pushing Castle on whether 487 genes really equate to a 50–100-gene anchor. The presenters' postures diverged sharply: TruDiagnostic conceded the distinguishing facts; Castle refused to concede and repeated its framing.

Secondary differences: Thermo and Biodesix were single-code, single-questioner (Bridges) episodes; TruDiagnostic and Castle were multi-panelist, and TruDiagnostic uniquely carried twelve codes onto one anchor.

Commonalities

All four were crosswalk requests — not one gap-fill among them — so every one of these exchanges was, functionally, a stress-test of a crosswalk justification. All four were probed by the same three-person technical core (Bridges, Rumpler, Lennerz) and by no one else; there were no peer-lab or public questions in any of them. Every question stayed strictly on analytic and resource inputs — assay performance, sequencing depth, professional review, loci counts — and none touched clinical utility or the dollar level, consistent with Lennerz's explicit instruction elsewhere in the meeting that utility and cost paradigms "are not factors we can take into account." And in all four, the presenter could not fully close the question in the room; each ended with a promise to respond in writing — which maps onto the chair's closing note that several presenters were asked to submit follow-up answers by June 17.

"The Coverage Myth in Diagnostics"

In an interview, I was asked, "What's the biggest myth you hear repeated?'  That led to the (AI assisted) essay below.  For entry points, here, here, here.

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The Coverage Myth in Diagnostics

There is a comforting myth in diagnostics reimbursement: that coverage is a rational contest, conducted by serious people, in which the best evidence wins. In this myth, the startup publishes several good papers, writes a strong PowerPoint deck, secures a payer medical-director meeting, brings along one or two respected KOLs, and the payer thoughtfully concludes that the test is clinically valuable and should be covered.

That world may exist in pitch decks. It rarely exists in real reimbursement.

The reality is far more institutional, slower, and less responsive to scientific persuasion than investors want to believe. In molecular diagnostics, the practical route to coverage usually requires one of two things: either the lab benefit manager decides to approve the test, or major clinical guidelines make the test effectively required. Both pathways are very slow. Both are opaque. Neither is well suited to a startup running on a finite cash runway.

The problem is not that evidence does not matter. Evidence matters a great deal. But evidence is not self-executing. A publication does not automatically become a policy. A favorable KOL quote does not become a claims edit. A well-designed clinical utility study does not force a lab benefit manager, MolDx, a MAC, a commercial payer committee, or a guideline panel to move on a venture-backed timeline.

This is where investors often misprice diagnostics. They build reimbursement timelines as if each step takes six months: six months for coding, six months for evidence, six months for payer engagement, six months for coverage. But novelty does not move through the system like a Gantt chart. Novelty gets bogged down. Two or three years is not a disaster scenario; it may be the optimistic scenario. Five years is not unheard of. For some technologies, the system simply times out again and again.

Examples are everywhere. An improved test for osteoporosis and bone-density screening became tangled in CMS processes for years. National coverage decisions can sit for three, four, or more years. MolDx and other MAC processes, including Noridian, can take years to resolve novel technologies. The automated retinal imaging code 92229 illustrates the same pattern: coding arrived in 2019, publication followed in early 2021, but payment and RVU issues dragged on because software novelty did not fit comfortably into existing physician-fee-schedule machinery. The test may be useful, the clinical logic may be strong, and the code may exist — yet the reimbursement system can still stall.

The same warning now applies to computational pathology. For stakeholders in this vibrant new field, AMA CPT appeared to impose what felt like a moratorium on new codes for two years or more. Then, instead of continuing the earlier PLA-code pathway used by some whole-slide imaging and digital pathology tests, CPT shifted new computational pathology services into Category III codes. That may be defensible as coding policy, but from a business-planning perspective it leaves companies in limbo. CMS pricing is still up in the air: will these services be paid on the Clinical Lab Fee Schedule, through physician-fee-schedule RVUs, through contractor pricing, or through some future software-specific payment system? For a startup, that uncertainty is not an academic detail. It can determine whether the product is commercially viable at all.

The deeper lesson is that coverage is not merely an evidence review. It is an operating system. It includes coding, payment, benefit-category logic, medical-necessity language, claims edits, utilization management, guideline incorporation, payer committee cycles, lab benefit managers, MAC jurisdictional variation, and sometimes CMS national policy. Any one of those components can delay or defeat a test.

This makes the standard market-access fairy tale dangerous. It encourages startups to believe that if they are scientifically right, the system will eventually recognize them in time. But “eventually” is not a business model. A company with $10 million, or even $30 million, may not have enough runway to survive a multi-year reimbursement slog, especially if the product requires continued evidence generation, field sales, KOL cultivation, coding work, payer engagement, and operational claims support.

The most important reimbursement question for a diagnostics investor is therefore not simply, “Is the test good?” It is: “Who has to say yes, through what mechanism, on what timeline, and can the company survive until then?”

In diagnostics, the best test does not always win. The test that wins is the one that becomes operationally unavoidable — through guidelines, through lab benefit manager approval, through entrenched clinical workflow, or through a payer system that finally knows how to pay for it.

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tagmyth

AI Essay v JAMA-Sutton - ver 5 (where Claude edits Chat GPT 4 from 7000 to 5000 words)

 

ACCESS, Chronic Care, and the CMMI Savings Paradox

When Better Care for Under-Managed Patients May Cost More

CMS’s ACCESS model is a serious attempt to modernize Medicare payment for technology-enabled chronic care. Rather than paying for visits, devices, app clicks, or care-management minutes, ACCESS pays organizations for measurable improvement in chronic disease outcomes — an elegant and potentially important idea. But it also exposes a deeper CMMI paradox: under-managed Medicare patients may need more care, not less. Better management can mean more drugs, physical therapy, behavioral health, monitoring, labs, and specialist follow-up. Judged too narrowly on savings, ACCESS may reward low-cost metric improvement while discouraging the costly care activation patients actually need.

Bruce Quinn Associates LLC  ·  June 8, 2026

CMS’s ACCESS model is one of the most intellectually coherent CMMI models in recent years, and one of the most revealing. On its surface it is a voluntary Medicare demonstration for technology-supported chronic care, creating new payments for organizations that manage common chronic conditions: hypertension, dyslipidemia, obesity, prediabetes, diabetes, chronic kidney disease, atherosclerotic cardiovascular disease, chronic musculoskeletal pain, depression, and anxiety.

Destinations: Where "Road to Wigan Pier" Continues "To the Finland Station"

 Two Journeys into the Political Imagination

To the Finland Station and The Road to Wigan Pier: Two Journeys into the Political Imagination

Certain political books are remembered not only for their arguments, but for the destinations embedded in their titles. The destinations themselves become symbolic geography. In the case of To the Finland Station and The Road to Wigan Pier, the titles evoke movement toward places that are simultaneously real and metaphorical. Neither Finland Station nor Wigan Pier matters chiefly as physical location. Each is instead a staging ground for a meditation on socialism, modernity, and the moral condition of Europe in the age between the world wars.

Between Two Ferns, PhD

 

The Dialectics of Hostile Hospitality:
A Comparative Media Analysis of Jiminy Glick and Between Two Ferns

The contemporary faux-interview format occupies a peculiar and revealing niche within American comedic discourse. Neither fully parody nor fully journalism, the genre derives its power from the unstable relationship between interviewer and guest, authenticity and performance, aggression and conviviality. Two of the most influential exemplars of this form are Martin Short’s Jiminy Glick and Zach Galifianakis’s Between Two Ferns. Though often grouped together as adjacent species of anti-talk-show satire, the two projects embody profoundly different theories of embarrassment, celebrity, and conversational collapse.

At first glance, Jiminy Glick and Zach Galifianakis appear to employ identical tactics: inappropriate questions, grotesque non sequiturs, narcissistic interruptions, and a studied disregard for the comfort of celebrity guests. Yet beneath these surface similarities lie radically distinct comedic architectures. Jiminy Glick operates within the tradition of baroque excess, while Between Two Ferns belongs to the aesthetic of deadpan minimalism. One is centrifugal and overpopulated; the other is austere and claustrophobic.

Dept of Education Final Loans Rule, and NP's, PA's. Next steps.

• ED’s final loan rule narrows “professional degree” status, leaving many NP and PA students at lower graduate borrowing limits after Grad PLUS is eliminated. 
• The best argument against ED is statutory: Congress incorporated the older, broader professional-degree definition, which arguably already covered licensure-linked PA/NP programs. 
• ED’s defense is that “professional” must remain a narrow category like MD/JD/DDS, not all graduate clinical credentials. 
• The PA lawsuit has a serious but uncertain APA claim. 
• Congress could fix the issue cleanly by expressly including accredited NP/APRN and PA programs as professional degrees for loan-limit purposes, ideally through a narrow health-workforce amendment. 

Bottom line

As public policy, your instinct is strong: NPs and PAs are exactly the kind of high-social-value workforce Congress should want to expand, especially in primary care, rural care, behavioral health-adjacent care, and underserved settings. But the litigation is not mainly about whether that is good policy. It is about whether the Department of Education had statutory room to narrow “professional degree” so sharply after Congress cross-referenced the pre-existing 34 CFR § 668.2 definition.

My read: the challengers have a real, non-frivolous APA/statutory argument, especially on the claim that the Department converted an “include but are not limited to” professional-degree definition into a constrained doctoral/CIP-code/supervision framework. But success is not assured, because the Department wrote the rule with a litigation defense in mind: it argues that the old list was not meaningless, that “professional” must be narrower than “graduate,” and that Congress intended higher caps only for a bounded class of traditional professional degrees.