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

Tuesday, July 1, 2014


AB 1805 (Skinner & Pan), which would restore the 10% cut in Medi-Cal reimbursement for Medicaid patients in California, is bogged down, mired in the mud of the Assembly Appropriations Committee where it is being held hostage. The 10% cut was imposed by the state budget in 2011 and recently was denied restoration by Governor Brown's recently revealed budget for 2014. It is clear that the Governor isn't going to do much to help Medi-Cal recipients or their treating doctors. Even if the bill passes, it'll have to survive his Gubernatorial veto. Readers interested in the survival of this bill will be obliged to rely on the democratic process, i.e., they'll need to call their elected state reps.

AB 2400 (Ridley-Thomas), sponsored by the California Medical Association, which would have allowed providers the ability to negotiate changes unilaterally made by health plans and their insurance companies, or to terminate the contract if agreement could not be reached, has bitten the dust. The tilt of the current administration, like the one that preceded it, is towards big business and against hapless patients and their beleaguered providers. This bill was residing uncomfortably in Senate Health Committee. Now it rests in not so peaceful repose. Readers interested in this bill will need to try to restore interest and build a wider coalition in 2015 than they had this year.

SB 492 (Hernandez) which would allow optometrists to practice aspects of ophthalmology that they are not currently licensed for has had better success. This bill passed Assembly Business and Professions Committee. It is opposed  by the California Medical Association, the Union of American Physicians and Dentists, the California Neurology Society, and a host of professional organizations whose weight in this case is negligible since their combined opposition is regarded as turf protection. 

One success is the failure of SB 1215 (Hernandez) to clear the Senate Business and Professions Committee. This bill would have eliminated the in-office exception for specific procedures such as physical therapy and advanced imaging including CAT and MRI scanning, ultrasound, and other procedures, thereby sending patients on a perpetual run-around. Readers can learn  more about this bill on the Advocacy and Legislation sections of the California Neurology Society website. The CMA, UAPD, CNS, et al were opposed and were part of a wide coalition in opposition.

An aulde lesson in these bills is the importance of coalitions not all of whose members need necessarily have a stake in the outcome. Protection of public welfare still plays a role albeit not as much as many of us would like.

ALERT: The trial lawyers' malpractice initiative has now been officially designated as Proposition 46 while the campaign against it, which we support, will be known as the No on 46 Campaign. The idea is to add Proposition 46 to our list of flame-outs lest its carelessness and callousness burn irreparable damage into California's health care.

Monday, June 30, 2014

Malpractice and drug testing: Pee Pee Politics (PPP)

We've been asked several times to provide the dates of our posts on the Pee Pee Wars, namely,  the trial lawyers' attempt to disguise advantageous malpractice reform in their favor while making it seem as though they want to protect the public by testing doctors for drug abuse. The Triple P moniker arises from the method of testing, namely, micturition into little cups. Here's the dates of our posts: 6/25/14. 5/28/14, 4/27/14, and 4/24/14. - RLW, editor

P.S. The trial lawyers' initiative, The Troy and Alana Pack Safety Act,  has now been officially designated Proposition 46. Accordingly, we recommend support for the NO on 46 campaign. - rlw, ed.

Wednesday, June 25, 2014

Interim Bill Review: AB 1340, 2400, 1805, 1886, and the thinly disguised malpractice initiative

This post includes late additions to the original posting

Assembly Bill 1340 (Achadjian) that would establish Enhanced Treatment Programs is a life-and-death issue for nurses, technicians, and doctors who take care of the sickest and the meanest among us. For this privilege the trial lawyers would like to force the doctors, but not themselves, to pee in a cup. That's the program the trial lawyers are hiding behind in their shameless effort to get higher malpractice awards for themselves under the guise of the Troy and Alana Pack Safety Act which has as its most likely main benefit for a family of four the opportunity to pay $1,000 more annually for health insurance.

Assembly Bill 2400 (Ridley-Thomas) would level the playing field so that Big Biz insurance companies would not be as able as they are now to drive down access to care for patients with chronic and expensive illnesses. For this privilege the trial lawyers want the doctors to pee in a cup. The trial lawyers who have even gone so far as to concoct bogus statistics actually are the ones who should pee in cups. Their campaign cited a report from March of 2000 by the California Medical Board which said "many believe" that 15% of the general population has problems with substance abuse and that among health care professionals the lifetime level might even be 18%. This rough estimate was a supposition, not a researched statistic. Moreover, this lifetime risk translates to no more than 2% at any one time. The trial lawyers' addled research team that thought this one up should pee in as many cups as can be distributed as quickly as possible.

As for the convicted drunken driver who fled the scene  after running down 10 year old Troy and 7 year old Alana Pack,  it is known that she had three drunken-driver convictions before the accident.  Because she fled the scene and evaded the authorities for two days, a timely blood alcohol test was not obtained. While she was on the run, her apartment was searched. Cocaine was found. She eventually told police she'd taken vicodin prescribed by her treating doctor. Her legal defense at trial was that it was her doctors' fault because they prescribed the medicine for pain relief. She did not assert that they also told her to drive under the influence. Her sentence: 30 years in prison.

Our reward, as doctors whose duty includes the relief of pain, is now supposed to be to pee in cups while prosecutors who get wrongful convictions because they withheld exculpatory evidence from the defense booze it up when what they deserve is to pee in cups and then serve out the time they foisted upon defendants who've since been released because of wrongful convictions. It's a logical next step to have every lawyer,  as he passes through security to enter the courthouse, pee in a cup.

Late flash: the trial lawyers' initiative has been officially designated Proposition 46. The campaign against it will be known as the No on 46 campaign. We support the No on 46 Campaign.

Medi-Cal: we support AB 1805 (Skinner and Pan) which would restore the 10% cut in Medi-Cal remuneration that was installed by the State Budget Act of 2011.  It isn't lost on us that devoted  doctors who take care of the sickest and poorest among us would also be obliged to pee in the trial lawyers' cups. Of course, some might say that Gov. Brown already did that for them when he sent through his recent budget bill which managed once again to give the short end of the stick to the doctors who care for Medi-Cal patients. His having done so raises the ugly spectre of  a possible veto of the Skinner-Pan bill even if it passes handily.

AB 1886 (Eggman): Its original aim, while modified pursuant to amendments obtained by the CMA, remains unchanged, e.g., indefinite posting of disciplinary actions, civil judgments, and arbitration awards against doctors, just enough to make sure that good doctors who  run afoul of one or another disciplinary board become persona non grata to whatever managed care, HMO, or PPO organizations that want to use even minor misdemeanor convictions to ruin careers. It's all about the control and humbling of what used to be an honored profession. Doctors need to learn to say "no" to their would be overseers.
So here are our recommendations: yes on AB 1340, yes on AB 2400, yes on AB 1805, and no on AB 1886 and no, no, no on the Troy and Alana Pack Patient Safety Act, now officially designated as Proposition 46. Accordingly, we urge support for the No on 46 Campaign.


www.politicsofhealthcare.com, 4/29/14, Oppose AB 1886 (Eggman) Unless Amended, and California Medical Association Legislative Hot List, 6/02/14 (author accepted CMA's amendments , CMA now neutral);
www.politicsofhealthcare.com, 6/24/14, AB 2400 (Ridley-Thomas), Deserves Support plus an amendment;
www.politicsofhealthcare.com, 6/23/14, AB 1340 (Achadjian), Deserves Safe Passage;
www.politicsofhealthcare.com, 6/18/14, AB 1805 (Skinner & Pan), Supporting Medi-Cal and 6/16/14, Medi-Cal Patients Snubbed by State Budget;
www.politicsofhealthcare.com, 4/24/14, Random Drug Testing for Lawyers and 5/28/14, Drug Testing for Lawyers and Pharmaceutical Executives