Abstract

Excerpted From: William M. Sage and Keegan D. Warren, Swimming Together Upstream: How to Align MLP Services with U.S. Healthcare Delivery, 51 Journal of Law, Medicine & Ethics 786 (Winter 2023) (75 Footnotes) (Full Document)

Medical-legal partnership (MLP) is an established and successful model for delivery of healthcare in the U.S. Yet, it is not commonly found in the healthcare vernacular, even among medical professionals and policymakers dedicated to improving the health of vulnerable communities and populations. Consider, for example, that MLP is absent from most governmental healthcare frameworks. The Health Resources and Services Administration (HRSA) stands alone in clearly, expressly incorporating legal care into its conceptualization of health services--and it did so only in 2014. Even with the current proliferation of standards for entities to engage in remediating social determinants of health or improving health equity--goals that MLP demonstrably achieves one accrediting body has included integrated legal services as a mandate, or even a suggestion.

The overtly legalistic phrase “health justice”--which both of us consider a more accurate description of the necessary restructuring and advocacy than “determinants,” “disparities,” or even “equity”--may eventually lead MLP to a more prominent position in health system improvement, but it has yet to do so. As we discuss below, there are both discordances and concordances between how MLP thinks of itself as a field and how the health care system operates.

In this article, we consider how attention to aligning the MLP model with traditional medical care financing and delivery might make more prominent the value of lawyers as onsite healthcare practitioners. Following a brief description of the professional resonance between MLP and the established medical sector, we organize the article around three themes: the way professionals move (clinical alignment); the way data move (informational alignment); and the way money moves (payment alignment).

Taken together, these forms of alignment represent levers to increase the sustainability and prominence of medical-legal partnership.

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For MLP advocates, as for others pursuing fundamental aspects of health system improvement, success will not come without “constancy of purpose.” Greater clinical, informational, and financial alignment between legal and medical services can help MLP become a widespread, recognized, and sustainable aspect of healthcare delivery, and can reduce the risk that the larger movement in support of health justice and health equity turns out to be transitory or ineffective. But long-term incorporation of MLP into professional norms and patient expectations is essential as well.

One of the most significant recent developments in the MLP service model has been the greater involvement of academic health centers (AHCs), health professional training programs, universities, and graduate schools of law, social work, and other fields. Without idealizing academic medicine's historical role in defining U.S. health care, this trend seems promising not only for MLP, but also for health justice, health equity, and the broader public interest.

Emerging generations of physicians, nurses, and other health professionals appear receptive to making the health care system operate more ethically, and promoting change from within AHCs using the MLP model places health justice prominently in health professions training. In addition, clinical care (with its associated revenue) is the life-blood of AHCs as well as non-academic health systems, so teaching the MLP model helps build interprofessional collaboration and change workflow within established institutions, which in turn reduces the harms caused by prior care practices and enhances the measurable benefits of attention to health equity. Finally, interdisciplinary research in AHCs can be expected to expand and improve the evidence base not only for MLP, but also for other methods of engaging communities and addressing health-harming needs without unduly medicalizing social problems. The strong commitment to justice as well as science among students and trainees today is an encouraging sign.

Note

The authors have no conflicts to disclose.

William Sage, M.D., J.D.,is a tenured professor in Texas A&M's medical and law schools and a professor by courtesy in the Bush School of Government & Public Service. Dr. Sage is an elected member of the National Academy of Medicine, for which he recently completed terms of service on the Board on Health Care Services and the Committee on the Future of Nursing 2020-2030, and is an elected member of the American Law Institute.

Keegan Warren, J.D., LL.M.,is Executive Director of the Institute for Healthcare Access at Texas A&M University. A Federally Qualified Health Center (FQHC) director with two decades of senior management experience spanning health and human services, she is a national expert on integrating medical and social services through medicallegal partnership.