Monday, September 29, 2014


It  is not commonly realized by participants in health care plans sponsored by health insurance exchanges derived from the Affordable Care Act (ACA) that these plans are subject to changes allowed under the law.  The meaning is that a plan purchased this year may have been compliant with the ACA (Obamacare) at the time of purchase but may not remain compliant with changes that the ACA allows these plans to make (including the annual premium which may be raised annually if that's what the executives of these plans want). 

We understand that the ACA and the exchanges have dealt death blows to many longterm relationships between patients and their doctors.  It is not uncommon to see posters in clinics that state that the clinic and its doctors do not accept Covered California subscribers. 

Take a look at what it means to buy into a Bronze, Silver, Gold, or Platinum Plan. These plans reflect "actuarial values" which means the percentage of the covered benefits that each of the plans is expected to pay, e.g., Bronze Plan subscribers pay the least in annual premiums while paying the highest co-pays. Conversely, Platinum Plan subscribers pay the most for their annual premiums and in return pay the lowest co-pays. 

Currently, the Bronze Plan covers about 60% of health care costs. The Silver Plan covers about 70%. The Gold Plan covers about 80%. The Platinum Plan covers about 90%. The unpaid gap is the subscriber's co-pay, highest for patients who are strapped for cash and are obliged to purchase the lowest price plan, lowest for patients who can afford the Platinum Plan. That means that doctors, clinics, and hospitals who have a high percentage of Bronze Plan participants are most likely the ones who'll be stiffed on required co-pays. 

Here's the rub: each of the plans has a range that it's supposed to cover, e.g., at the time of this writing the Bronze Plan is reported to cover from 58 to 62 percent. It is expected that as time marches on there will be changes, even favorable changes in these plans. Because of how the ACA is written and because of how the exchanges function, a Bronze Plan that now covers 60 percent may at some time in the future cover 65%. The rub is that the next step up in the ACA division is the Silver Plan which starts coverage at 68 percent which means that your Bronze Plan no longer qualifies as a Bronze Plan but also doesn't qualify as a Silver Plan. So your plan is no longer valid under the ACA. 

What may be even harder to understand is that the Platinum Plan also has limits. It cannot cover more than 92 percent. So doing is not legal under the ACA.

So where does Proposition 45 which is on the November ballot in California fit in? Proponents of the ACA or Obamacare fear that passage of Proposition 45 could prove harmful to the ACA since the Covered California exchange recently negotiated a rate increase for its over one million plus enrollees. 

The ACA makes purchase of healthcare insurance mandatory but does not regulate premium prices. Covered California, like other insurers, does not want to have rate increases it can currently negotiate subject to being rescinded by an insurance commissioner. Proposition 45 would  empower the insurance commissioner to do just that. The Insurance Department in California is reported to have found that rate increases from 2013 to 2014 are from 22 to 88 percent (the Covered California board has not voted a position one way or the other on Propostion 45 as of the date of this article).  

References for this piece: 

1) THE HILL Newspaper,  Washington, D.C., "What Obama should've said about healthcare reform," 9/16/09, by Robert L. Weinmann, MD;
2) POLITICO, "GOP govs could gum up Obamacare," 2/10/10 ("I will ensure that no government bureaucrat gets between you and the care you need"), by Robert Weinmann, MD; 
3) John C. Goodman ( Goodman, 9/23/14 ("if you like your insurance you can keep it");
4) SAN JOSE MERCURY NEWS, "Measure creates odd alliances," Tracy Seipel, 9/26/14;
5) Editorial, Robyn G. Young, MD, President, CALIFORNIA NEUROLOGY SOCIETY, 9/17/2014 ( these three points are emphasized:
  a) Prop 45 will require public disclosure of hearings re health inssurance rates;
  b) Prop 45 will require approval of changes in health insurance rates by the California Insurance Commissioner;
  c)  Prop 45 will require sworn statements about the accuracy of information submitted to the insurance commissioner to justify proposed rate changes.

  Comment: Prop 45 proposes transparency that the ACA (Obamacare) has consistently denied, e.g., Pelosi's laughable comment that the ACA had to be passed so we could see what's in it and then an Independent Payment Advisory Board (IPAB) that by law need not include even a single physician. The Covered California board likes the murky mists of non-transparent legislation. THAT is what Prop 45 seeks to change. THAT scares insider deal-moguls to their very core of existence.  

Thursday, September 18, 2014


From the Association of American Physicians and Surgeons, AAPS News, September, 2014, we learn that the Florida Medical Association passed the following resolution, namely, "that the FMA advocates that the lack of specialty board recertification (italics added) should not restrict the ability of the physician to practice medicine in Florida." 

In a feisty letter-to-the-editor, Ellen McKnight, MD, Pensacola, writing over the title, "FMA Passes Anti-MOC Resolution,"  stated that "hospital employed physicians should immediately use this to remove MOC requirements from hospital medical staff bylaws."

In a previous editorial in this blog, "How Physicians Eat Their Young," 2/12/14, we showed how the specialty boards use MOC and  re-credentialing to convert their previously august and professional objectives into money-making opportunities for themselves. We recommended taking a look at each board's IRS Form 990, not only for what is reported, but also for what is not reported, e.g., individual compensation arrangements.

We provided references for interested parties. Among the juice-laden items we revealed was that as of 2011 the American Board of Internal Medicine reported total assets of $57, 586, 843 -- so what, dear reader, for what purpose do you think ABIM needs nearly $60 million? 

We informed our readership that as of 2011 the ABIM board chair was remunerated about $800,000. We revealed that recertification costs for an allergist were $2,700 and that MOC costs for an allergist were $2,850. 

Do not think for a moment that FMA's resolve to reduce the necessity for recertification will go unnoticed by the boards -- the huffing and puffing are still to come. We await and expect similar resolutions from other state medical associations, unions, and professional societies. 

Peer-reviewed journal  references are appended to our 12 Feb 14 editorial entitled "How Physicians Eat Their Young." 

Thursday, September 11, 2014


The Los Angeles Times Data Desk report on 61 closed California hospital emergency rooms is ominous. Some hospitals closed altogether, e.g, Saint Louise Mental Health Center in 1999, San Jose Medical Center in 2004, and Martin Luther King Jr -Harbor Hospital in 2007

Now we're waiting to see if a similar fate will overtake Doctors Medical Center in Contra Costa County. A Contra Costa Times editorial dated 8/28/14 provided a dismal outlook and, said, yes, it was the fault of the "nurses and physicians." The newspaper's editors said the nurses and physicians were "more concerned with protecting unsustainable jobs than ensuring adequate emergency service." The nurses and doctors were at fault because they were trying to maintain the hospital as a "full-service hospital." 

The newspaper, in a masterpiece of misunderstanding, opined that keeping a full-service hospital wasn't "realistic." On its side, the paper was able to state that "the district borrowed to keep Doctors running the past few years." The editors said that this effort was burying West County taxpayers deeper in debt." The editors didn't mention that this effort also saved countless lives over the years and if properly funded would continue to do so. 

But, then, the CCTimes is no friend of the hospital. In 12/01/13 the editors opined that "death for Doctors Medical Center is only a matter of time" and that the emergency room service at DMC was already on life-support. The editorial board opined that DMC wouldn't make it past the Spring of 2014. While matters are still rough at DMC, the editors should take note that the Harvest Moon Festival from The Fall of 2014 is already behind us and the medical and nursing staffs are still soldiering, still doing good for many, and even saving lives.

The issue is whether or not patients come first, or profits. 

The main problem according to  CCT is revenue shortfall (that's the lingo financial people use for going broke). CCT pointed out that in 2011 the West Contra Costa Healthcare District which operates the hospital won a $47-per-house tax increase. Declining hospital inpatient volume was and is a serious problem. What do do?

Richard Stern, MD, DMC Chief of Staff, issued a statement wherein he said that "the county's effort to support the medical needs of West County residents has been the equivalent of providing ... fire extinguishers. This will not help when the next Chevron fire ignites homes and there is no infrastructure to fight the fire." Stern has a point when he says "it is time for the politicians to respond to the needs of the entire county and for the Contra Costa Times editorial staff to educate itself on the real issues here and its role in fomenting this human tragedy." 

Tuesday, August 12, 2014

"Medical Board decides it does have authority to discipline utilization review physicians"

In a press release from the California Medical Association (CMA) dated June 25, 2013 the Medical Board of California was reported to have  concluded that the medical board "agreed that physicians conducting worker's compensation utilization review were indeed engaged in the practice of medicine and subject to review by the board." The release also stated that "the board does not, however, have jurisdiction over out-of-state physicians performing utilization review in California." The release explains that Governor Brown vetoed AB 584 (Fong) in 2011 "which would have required worker's compensation utilization review physicians to be licensed in California." The release stated that "CMA supported the bill ... to require that all utilization review be done by California-licensed physicians in order to ensure that there is a disciplinary pathway for the medical board in case an injured worker is unduly hurt by a utilization review-based modification or denial of care."

Presumably, the MBC still holds to this view. Likewise, we believe that other organizations aside from the CMA still hold to this view, e.g, the Union of American Physicians and Dentists, the American Federation of State, County and Municipal Employees (AFSCME, AFL-CIO), and the California Society of Physical Medicine and Rehabilitation (CSPMR).

That is why we're surprised to understand that at the present time the MBC reportedly does not feel this issue merits priority action. 
Perhaps we'll learn we're not on target in this understanding when the MBC meets this autumn in San Diego. 

Monday, August 11, 2014


The Medical Board of California is not at this time placing high priority on reform of either Utilization Review (UR) or Independent Medical Review (IMR).  

UR is required before Primary Treating Physicians (PTPs) or consultants can initiate diagnostic studies and/or institute treatment. UR physicians can deny or modify diagnostic or treatment requests by treating doctors. For instance, in one case we're studying, an orthopedic surgeon asked for authorization to do a preliminary treatment and if that treatment failed to go ahead with a fusion. The UR consultant authorized the preliminary treatment, not the fusion. Trouble is the authorized preliminary treatment failed. Since the request to do a fusion should the preliminary fail was denied, this injured worker will now go without the recommended follow-up fusion advised by the expert opinion of the evaluating orthopedic surgeon. The inherent absurdity in the program is that the UR doctor did not interview or examine the patient and reviewed only whatever records were given him by the insurance company. 

A current case that has come under our review concerns a patient who has lifetime medical care and who from time to time when symptoms recur gets physical therapy -- not this time, though! The request for physical therapy, reviewed by Doctor Unctious (his real name is kept secret by the Independent Medical Review Service run by Maximus) denied the request for physical therapy. The treating doctor won't be able to quiz Doctor Unctious because his real name is "protected" by Maximus. This kind of secret denial harkens back to the French Revolution when secret "lettres de cachet" filed by nobles enabled imprisonment of named victims without having to disclose who wrote the "lettre de cachet" in the first place. Perhaps it's better that Untious' real name isn't known. So far our review suggests that Dr. Unctious' professional conduct deserves disciplinary review by the Medical Board.

Aye, but there's the rub! Unctious does not have a California license and under California law does not need to be licensed in this state to practice UR in California. He is free to deny or modify care without a California  license to practice medicine. The official letter denying care trumpets that Unctious is licensed in Ohio and Texas, but those boards can't review Unctious' clinical conduct because those boards don't have jurisdiction in California. 

The California legislature has passed three bills requiring UR doctors to be licensed in California. All were vigorously  protested by the insurance industry. All three bills were vetoed, twice by Schwarzenegger (no surprise) and once by Brown (big surprise). The meaning of this quirk is that non-California licensed doctors do not come under the jurisdiction of the MBC whereas the  PTPs who  are left holding the bag when treatment isn't authorized remain subject to discipline by the MBC.

Texas requires doctors who do UR on Texas patients to be licensed in Texas.  The upshot is that Texas doctors may do UR in California without being licensed in this state whereas California doctors who want to do UR in Texas must first get a Texas license.

So here's how the "double whammy' works: first, UR denies treatment. Then, instead of judicial review by the WCAB, the case gets turned over to Maximus with its cadre of anonymous doctors who have in common with their UR counterparts that they also don't have to be licensed in California.

Epilogue: In the case at hand the patient is getting the P.T. he needs. He's just paying for it himself.  We regret that the Medial Board of California doesn't see enough inequity in this desultory situation to demand that UR and IMR doctors be licensed in California.

Monday, July 21, 2014


"California cuts number of uninsured" was the headline for the San Jose Mercury News Editorial on July 15, 2014." The editorial iself stated that California "has cut the percent of residents without health insurance in half since last summer, from 22 percent to 11 percent of the population." The editorial then blurts out that "the percentage of uninsured Americans has dropped from 18 to 13.4 percent in the same time"and "would have dropped even more if all the states were taking advantage of the Affordable Care Act's health exchange program."

Comment: these statements show how correctly quoted statistics can cause misunderstanding and to all intents and purposes lie outright. I personally queried ten doctors at a local hospital. It turns out that none of them accept Covered California since the plan sticks it to them

Sunday, July 13, 2014



So far we've put our focus on legislation with numbered bills, e.g., AB 1340 or SB 1215, and on the Troy and Alana Pack Safety Act, the malpractice initiative now known as Proposition 46, which is expected to galvanize autumn politics in California. We also recently spent nearly a full day attending hearings in Sacramento on healthcare politics and funding, now coming home to roost in California as Proposition 45. Watch for our stories on Proposition 45 which also promises political fireworks.  . -- Robert L. Weinmann, MD, Editor