Wednesday, November 25, 2015


USA Today published a piece on whether or not physicians should be forced to check a prescription database before writing opioid prescriptions. In Massachusetts Governor Charlie Baker proposed measures to obstruct physicians from prescribing these medications. Among the irresponsible provisions recommended for this purpose, one was to limit opioid prescriptions to 72 hours.  In all but the most emergent situations this rule would prevent patients from getting their prescriptions for more than three-days. 

Meanwhile, in California, Senator Lara submitted legislation, SB 482, that would require physicians to rely on a statewide data base known as CURES that does not yet exist before prescribing Schedule II or III medications. Failure to do so would make the physician subject to discipline by the state's medical board. This bill is currently on hold and awaits the 2016 legislative season that begins in January.  In the meantime, Gov. Brown signed off on AB 679 (Allen) which was chaptered on 11 October 2015 and extends the deadline for mandatory enrollment in the CURES system from 1/01/16 to 7/01/16. 

California also has Utilization Review (UR) obligations that primary treating physicians (PTPs) are obliged to accept. It works like this: physicians may prescribe diagnostic studies,  treatment programs, even medications, including non-opioid, or ask for consultations. Instead of complying with same, the patient is hung out to dry by the insurance company which says it is obliged to submit all such requests to UR before the prescription or treatment can be "authorized." Never mind that the doctors belong to MPNs or Medical Provider Networks and have already been approved by the insurance company. In many cases patients are kept in pain because the treatment they're seeking -- and that has been properly prescribed -- is being withheld by the insurance company.

There is an appeal process. If UR doesn't reverse its denial of care in timely fashion based upon an initial complaint by the treating doctor, the decision is passed over to an Independent Medical Review agency which may employ doctors who are out-of-state and whose names are concealed by the insurance companies from the patient and the actual treating doctor. Statistics show that the vast majority of cases denied by UR get denied again by IMR.

Under these circumstances, many physicians including the most prestigious simply refuse to accept industrial or workers comp cases -- injured workers who get injured on the job expect that they'll get authorized treatment from their industrial carriers. Strike one occurs when their access to treatment is delayed. Strike two occurs when UR denies care that had previously only been delayed. Strike three occurs when IMR goes along with UR and gangs up to deny care again. There's a 4th strike that occurs when the likes of Governor Baker, Governor Brown, and State Senator Lara help insurance companies and corporate interests shirk their obligations to provide timely medical and surgical care. 

Stanford Hospital and Clinics knows what to do. In a letter to a California physician, July 24, 2014, Stanford refused to provide neurosurgery consultation to an injured worker. The letter from Stanford gave the following reason: "We don't take WC cases."

Thursday, October 15, 2015


Governor Brown in his veto message of AB 1542 (Mathis & Cooley) said "this bill undermines the Division of Workers Compensation's authority ... when it determines eligible medical specialties ... that power resides with the physician's licensing board. If the Board of Psychology believes there is value in recognizing neuropsychology as a subspecialty, it should do so."

It turns out that the Governor knowingly acted on an incorrect opinion from the Department of Industrial Relations (DIR) and from Christine Baker in particular. It seemed lost on the Governor that AB 1542 was supported by the California Psychology Association and by the Board of Psychology. It was well known to Governor Brown, or should have been, that the Board of Psychology does not formally recognize or enfranchise subspecialties. However, the Board of Psychology does recognize the American Psychological Association (APA) of which it is a member. The subspecialty of clinical neuropsycholgy is in fact recognized by the the APA, a fact that the Governor, in his zeal to support Christine Baker, ignored. By his veto  Governor Brown evidently felt he was supporting "the Division of Workers Compensation's authority." Regrettably, the reverse is true now that NeuropsychologyQMEs have been relegated to the basement of medical and psychological evaluation and treatment for injured workers with traumatic brain injuries (TBIs). These injured workers will no longer have the direct access to NeuropsychQME evaluation as they have had for the last 22 years. Employers will find that assigning TBI patients to appropriate return-to-duty status has just been made more difficult. Trades where head injuries are more common, e.g., construction, working at heights, or around heavy equipment, have just been made more risk laden by Governor Brown's arbitrary veto. 

By contrast Governor Brown signed AB 2127 (Cooley) last year so that high school athletes who sustain TBIs can get direct access to health care providers. These health care providers are supposed to be trained to recognize and evaluate concussions and TBIs. It looks like Gov. Brown feels that injured workers do not need the same access to first level responders as do high school athletes who get hurt playing football, or soccer. 

We understand that the underpinnings of the Governor's veto was his desire to support DIR Christine Baker and the Division of Workers Comp as seen through her eyes. What's too bad is that in this effort the injured workers who do construction and other risky jobs have been short-changed, actually, to put it bluntly, they've been torpedoed. 

To correct this egregious mistake, it would help if the Board of Psychology changed its policy to provide formal recognition to NeuropsychQMEs and if Mathis, Cooley, and others would reintroduce a revised version of AB 1542 in 2016.

Tuesday, September 29, 2015


Governor Brown's healthcare policies are now colliding. In 2014 Governor Brown signed AB 2127 (Cooley) into law. As a result of this decision the California Education Code now requires that high school athletes who have sustained a cerebral concussion, even a mild one, must be evaluated by someone trained to make this evaluation before the athlete can return to play. The idea is to reduce the consequences of traumatic brain injury (TBI) which may follow a cerebral concussion or be delayed until a series of such concussions have occurred. The injured athlete is now required to get written clearance from a licensed health care provider trained in the management of concussions. This legislation is a step in the direction of protecting high school athletes.

Governor Brown now has a chance to sign legislation, AB 1542 (Mathis & Cooley),  that would similarly help injured workers. We have previously recommended that he sign this bill. Nonetheless, the bill remains subject to possible veto. Construction workers, roofers, persons who work at heights, are particularly prone to the type of injury that may cause cerebral concussion and lead to post-concussion syndrome secondary to TBI. California's injured workers deserve protection that is at least as cognizant of their well being as AB 2127 tries to be for high school athletes. That is in part why we ask again that Gov. Brown sign AB 1542, just as he signed AB 2127. In the case of the injured worker trained specialists in the form of NeuropsychQMEs are available and have been for 22 years. It makes no sense to cut this specialty out of the loop. They already are the "licensed health care provider" trained in the management of concussion that is required by law and by common sense. The injured worker who has sustained TBI should have this level of evaluation available.

AB 1542 also looks out for the employer because it provides a sound scientific basis whereby reassignment to modified work or to one's usual and customary job can be made with reasonable medical judgment. It is analogous to deciding whether or not injured athletes can return to play.
In the case of a TBI expertise is also needed for treatment decisions.

A veto of AB 1542 after having signed AB 2127 sends mixed messages on health care. Such a decision would relegate injured workers to a level of healthcare protection below that of injured high school athletes. We do not believe that Gov. Brown wants or needs such a healthcare policy collision.

Wednesday, September 2, 2015

AB 1542 (Mathis and Cooley): DRAMA IN THE CAPITOL

Now that AB 1542 (Mathis and Cooley) has passed the Senate, 39 to 0, having already passed the Assembly, 79 to 0, we have a unique situation wherein the Governor is being pressured by the Department of Industrial Relations (DIR)  to veto a bill that has unanimous bipartisan support. The reason given by DIR Director Christine Baker for public consumption is that "the California  Board of Psychology does not recognize neurospsychology as a subspecialty in psychology." 

On the other hand, the same California Board of Psychology accepts the American Psychological Association's (APA)  recognition of specialists in neuropsychology. In short, the APA recognizes neuropsychologists. Given these facts, it is difficult to fathom why DIR should object to AB 1542 unless there are other reasons we don't yet know about. What we are left with is that a specialty with national  recognition is being denied recognition in California. 

Medical specialists involved in the diagnosis and treatment of traumatic brain injury (TBI) also recognize the specialty role provided by the neuropsychology specialists, for instance, the American Academy of Neurology has published on this matter since 1966. 

In my personal letter to the Governor, I indicated that the DIR position, if the Governor bows to it, is likely to increase litigation since the current easy access to neuropsyche Qualified Medical Evaluations will be impeded. It will then be up to the applicants' lawyers to fight tooth-and-nail for neuropsyche evaluations for their TBI clients and for the defense lawyers to forestall successful litigation by the applicants' lawyers. Lawyers who fail to support their applicants' cases to the hilt may find themselves on the wrong side of a malpractice suit.

The same goes for the physicians who treat and evaluate injured workers. Failure to obtain neuropsyche assessment may be seen as a dereliction of duty by the physician, enough so that the physicians themselves become subject to potential liability or malpractice claims.

Disallowing recognition of neuropsychologists harms brain-injured workers and impairs the ability of the workers compensation system to take care of injured workers with TBI. Employers are also harmed when TBI patients are not properly assessed with reference to return to work status or feasibility for continued employment. 

AB 1542 preserves access of injured workers to neuropsychological expertise. I believe that should be enough reason for the Governor to sign AB 1542 into law.


"Reasons to Keep Neuropsychology as a Specialization in QMEs," Hannah Pence, MS, CRP, 09/01/2015;

"Three Comp Bills Left for Final Week of Session," workcompcentral, 09/04/2015;

"Does Somebody Want to Sabotage Neuropsychological Evaluations," workcompcentral, 5/20/2015;

"Neuropsychology Medical-Legal Evaluations (Neuropsyche QMEs): Does Somebody Want to Sabotage Neuropsychological Evaluations," The Weinmann Report,, 4/25/2015;

"Is Mandatory Malpractice Ordered to Begin on Tuesday, 1 September 2015," The Weinmann Report,, 8/27/2015;

"Neuropsychology -- The How and Why," James R. Cole, PhD, QME, California Society of Industrial Medicine and Surgery," 8/18/2015;

Analysis from Assembly Committee on Appropriations, 7/08/2015, Jimmy Gomez, Chair, prepared by Lisa Murawski. 

Thursday, August 27, 2015


According to workcompcentral's newsletter, 2015-08-27, California's Division of Workers Compensation has ordered that as of 1 September 2015 "clinical neuropsychology will no longer be a recognized medical specialty." This decision by DWC was approved by the Office of Administrative Law on 8/12/15. The ruling means that "the elimination of the specialty designation for clinical neuropsychology" goes into effect on September 1st. 

Clinicians, particularly psychologists with specialized training in neuropsychology, will at first blush be astonished that the authority of the DWC can be used to ease the way for medical malpractice. On second look clinicians have observed that the workers comp system is rigged against fair hearings for injured workers, for instance, nearly 90% of Utilization Review (UR) denials are upheld by anonymous Independent Medical Reviewers (IMRs). 

Keep in mind that MPNs (Medical Provider Networks) pre-select their own clinicians and then step aside as disproportionate numbers of their own clients get denied treatment by the mandatory UR panels created by SB 863 and which usually have links to insurance companies. The MPNs step aside when IMRs such as Maximus slavishly confirm the treatment denials. 

In the case of neuropsychology, we know that psychologists with special training in traumatic brain injury (TBI) are uniquely qualified to make diagnostic and treatment decisions about TBI. In fact, Assemblyman Devon Mathis, R-Visalia, co-author of AB 1542 along with Assemblyman Ken Cooley, D-Rancho Cordova, testified in favor of AB 1542 before the Senate
Committee on Labor and Industrial Relations to the effect that while general psychologists deal with mental injuries neuropsychologists are specially educated and trained about TBI.

Assemblyman Mathis' credentials include a Purple Heart for TBI sustained during an IED attack in Iraq in 2008. The point of Mathis' testimony is that the best recommendations for diagnosis and treatment for him and for injured workers who sustain TBI on-the -job is through adequate diagnosis and work-up that requires TBI expertise. Anything else, in this writer's opinion, amounts to inferior treatment. It can now be argued with reasonable medical probability that DWC has in this case imposed a restriction that arguably can be stated to suborn malpractice by advocating and in fact eliminating NeuropsycheQME as a separate and distinct clinical specialty. 

That is why it's obligatory to make sure that AB 1542 which would protect neurospsyche as a designated specialty makes it through the legislature where it's already passed the Assembly 79 to 0 and then persuade the the governor to  sign the bill into law. 

Then we'll need to know whence the misguided direction arose that convinced Director Christine Baker to file a letter in support of eliminating neurospyche as a specialty and to combine it with the more general classification of psychology absent recognition of specialized TBI education and training. One will also need to ask if there is a need for re-education and restructuring within DWC. 

This author previously addressed this issue in an editorial reprinted by workcompcentral, 2015-05-20, "Does Somebody Want to Sabotage Neuropsychological Evaluations?" This issue deserves continuing investigation and reporting. 


Workcompcentral, "QME Rules Take Effect Tuesday," 2015-08-27

The Weinmann Report,, 4/24/2015

CSIMS, "Comments on DIR Director Christine Baker's Opposition to AB 1542, 8/12/2015

Department of Industrial Relations, letter by DIR Baker, 7/29/2015

Voters Injured at Work, Support letter for AB 1542, Jesse Ceniceros, VIAW president

Brain Injury Association, Support letter for AB 1542, 8/03/2015

California Neurology Society, Support letter, Steve Cattolica, Legislative Advocate, 6/04/15

Wednesday, July 29, 2015

Maintenance of Certification (MOC) and the IRS: where money and power meet

We've heard a lot lately about MOC and its finances: in 2012 the president and CEO of the American Board of Internal Medicine (ABIM) pulled down $628,952 and of that amount $465,687 was "base compensation" while $44,742 was "bonus and incentive compensation" These figures come from line (i) of Part II,  Schedule J, re "officers, directors, trustees, key employees and highest compensated cmployees" as listed in ABIM's IRS 990 report, 2012. 

On the same line in Schedule J the president and CEO is listed as having received $83,654 in "retirement and other deferred compensation." We aren't told what type of compensation format comprised this prize, e.g., was it "defined benefit," 401-K, or something else?

To that was added $34,869 in "non-taxable benefits."

The total for Line (i) for 2012 was $628,952.

Then comes Line (ii): base compensation was $155,229. "Bonus and incentive compensation" was $14,914. "Retirement and other deferred compensation" was $27,885. "Non-taxable benefits" was $11,623. The total for line (ii) was $209,651.

The total for lines (i) and (ii) is $838,603. Not bad, not bad at all for an internist!

Plus there are 15 others at or near or above the $200,000 level. 

Where does this money come from?

One answer is possibly from donors, e.g., in 2012 the ABIM Foundation contributed $245,000. The Joshiah Macy Jr. Foundation contributed $151,632 while the Medical University of South Carolina contributed $62,789.

Another answer is that the majority of the money comes from MOC, testing, courses, and programs put on by non-board independent but nonetheless contingent organizations that charge for course attendance that in many cases contributes to MOC recertification. The point is that MOC in its current format cannot be sustained without MOC fees paid by doctors who submit to the programs as though they were necessary to maintain certification in a country where CME (Continuing Medical Education) is available in all 50 states.

The continuing clamor to set MOC aside in favor of alternative programs such as NBPAS (National Board of Physicians and Surgeons) is growing. It won't be the first time that lust for power and money brought down a financial empire, this time possibly the American Board of Medical Specialties (ABMS) where, not incidentally, the president and CEO took down annual compensation of $779,487 in 2013 (Form 990, Schedule 3, Part II -- Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees). 

In the ABMS case the declared "base compensation" was $681,188 to which was added $12,500 in "bonus and incentive compensation," $71,000 in "deferred compensation," and $14,799 in "non-taxable benefits." The 990 Form doesn't state if the "deferred compensation" is in the form of "defined benefits" or 401-K or other. 

Finally, our observation that some Form 990s don't include all of the officers, directors, trustees, key employees, and highest compensated employees is quizzical. Why not? 

Monday, June 29, 2015


Here is how it works: The Affordable Care Act (ACA) grants coverage to about 15 million persons not previously covered by what passed for health care coverage before passage of the ACA. Trouble is that Covered California and other ACA derived plans have now raised their premiums to cover the influx. But the premiums can't be raised enough to cover this influx. It has been determined that a better way  is to reduce utilization to keep costs below or equal to the pre-ACA expenditure. This method is a form of rationing with a special dagger aimed at the hearts of the elderly. It is called the Independent Payment Advisory Board (IPAB). 

Here's a pre-IPAB example: programs that provide vision care advise patients that refraction is not covered by Medicare or by most commercial PPO plans. Refraction is the method by which corrective lenses are prescribed. Medicare and the commercial PPOs determined that refraction isn't a medical procedure after all. Medicare and the involved PPOs conveniently decided that refractive errors requiring prescribed lenses are a result of changing eye-shape and are not because of disease.  Hence, coverage is denied.  

How about something more current than refraction? Let's take a look at what's happening to cardiac pacemakers. The Center for Medicare and Medicaid Services (CMS) has determined that as of 6 July 2015 coverage for cardiac pacemakers will be restricted to patients with "non-reversible symptomatic bradycardia." This decision means that patients with asymptomatic complete heart block would not be covered and that the exclusion will apply even to patients with asymptomatic Mobitz Type II heart block. So far our information is that the American Medical Association (AMA) has not filed a protest. We're now obliged to ask would-be presidents of AMA and contingent state medical associations where they stand on this matter.

We all recall Sarah Palin's barbs about "death panels" for Medicare. Suddenly, it doesn't seem as though she was all that far off the mark, does it?

That's where the Independent Payment Advisory Board (IPAB) comes in -- the IPAB was formed to manage costs that the ACA might run up due to the influx of previously non-covered patients. The IPAB owes its existence to Sections 3403 and 10320 of the ACA. The official job of the IPAB will be to control and cut Medicare spending. The IPAB according to the ACA will be appointed, not elected, and will not be obliged to report to Congress. In effect this technique will remove Congressional  oversight of Medicare spending. Instead,  unelected IPAB members will have this power. The salary for the 15 IPAB members is proposed to be about $165,000 annually -- once again we see there's money enough for bureaucracy but not for patients and citizens. The IPAB is ripe for repeal before it can do damage.

In the second Obama-Romney debate, Gov. Romney asked President Obama who would be appointed to the IPAB. Obama's answer, and I quote same in toto, was "doctors et cetera."
Although the reply was short, it was also wrong. Trouble is neither Romney nor Obama knew it. The fact is that there is nothing in Sections 3403 or 10320  or in the rest of the ACA that requires even one physician to be appointed to the IPAB. While it's likely that an acquiescent physician can be found, the fact is that there is no legal requirement under the ACA to appoint even one physician to the IPAB. The IPAB should be repealed forthwith -- so doing will improve the ACA by removing what to all intents and purposes looks as close to Palin's death-panels as one can get without handing the IPAB a portable gallows.