Friday, October 31, 2014

Will Proposition 46 suffer from an over-the-top advertising debacle?

A recent advertisement for Proposition 46 depicts a purported doctor in white coat adorned with casually strewn stethoscope over his shoulders sitting at a bar while ordering a drink, presumably other than ginger ale, while his pager goes off -- he's being called to the emergency room, no matter if he's in a drunken stupor. 

With this final flailing effort, Consumer Watchdog appears to have hurled its last lightning bolt in support of Proposition 46, the initiative to raise trial awards for pain and suffering in malpractice suits from $250,000 to $1.1 million. Consumer Watchdog, down to its last one million dollars, reportedly wagered the entire store on this last-ditch effort. It's a gamble that may have misfired.

While consumers are not as mesmerized by physicians as once they were, they're still not at a level where they believe that doctors in general have sunk to this level.  Physicians are still generally admired by the public. Physicians who fall short of public expectations suffer mightily in the court of public opinion and are subject to discipline by the medical board.  The public, more sophisticated than Consumer Watchdog realizes, are not easily misled. 

This latest ad depicting a presumably inebriated doctor on his way from the saloon to the emergency room may have overshot the mark and turned undecided Proposition 46 voters into NO votes on 46.  Consumer Watchdog reportedly depleted its campaign funds with this desperate advertisement and along with it sacrificed its own credibility.

Wednesday, October 8, 2014


Enter now Paul Y. Song, MD, into the Proposition 45 debate. Actually, he's been there all along, has already appeared in my edits, testified at the all day hearing on 45 before it was known as Proposition 45,  and is said by some to be a prospective candidate for insurance commissioner.

In his editorial entitled "Why Are CA Doctors Breaking Their Hippocratic Oath on Prop. 45," Song asserts that the doctors and nurses opposed to 45 are protecting the insurance industry. He says "it is unconscionable." His main point seems to be that there is no conflict with the "independent commission" whereas "Covered California is actually run by purely political appointees." THAT is no news to us -- we don't know of any commission where prospective appointees are required to pass achievement tests and demonstrate that they know anything other than how to make political contributions. Song points out that some of the Covered California persons "have a long cozy history with the private insurance industry." Song points out with some relish that "it is the private health insurance industry and their administrators, many of whom have never cared for a patient, who are denying care, while telling doctors what treatment and drugs they can provide."

Song says that Prop. 45 "would simply apply the same regulatory framework to health insurance which has proven so successful regulating auto, home, and medical malpractice insurance in California." He likens Prop. 45 to Prop. 103 vis-a-vis auto insurance rates.

The juicier parts of Song's editorial include his telling certain persons and groups to "stop spreading ... lies." Take a look at it, and Young's editorial, and Bussey's. In many ways Prop. 45 is more substantial as important legislation than Prop. 46.

Our point is that while Prop. 45 if it passes will have the bite of law, its eventual teeth will be in the rules and regulations that follow. The proponents will need to make sure that the rules and regs are composed by forces that want it to succeed. Are they ready and prepared for the job?


You can follow Paul Y. Song on Twitter at; Bussey's editorial is referenced in our previous post & appears in UAPD Pulse; Young's editorial is referenced in our two previous posts and on the website for the California Neurology Society 

Monday, October 6, 2014

Proposition 46 -- last word, well, almost!

Proposition 46, most voters have figured out, is about raising the limit on "pain and suffering" from $250,000 to $1,100,000 if not more. This amount would be in addition to unlimited economic damages which is already the law. In other words, a cadre of lawyers whose specialty is medical malpractice would be emboldened to sue in circumstances where they might otherwise decline. Ask yourself what would be the consequence of so doing according to Proposition 46?

1) Most likely, insurance companies will raise their annual premiums for a family of four by about $1,000 to $1,250.

2) State and county hospitals, supported by tax dollars, often get virtually hopeless accident cases where medical error may occur even in the hands of the most skilled surgeons. To cover the costs of increased malpractice payouts it is likely that state and county taxes will go up. 

3) What about the system whereby physicians would be obliged to find out what drugs their patients were on before prescribing analgesics for pain. Truth is, I personally called into the system months ago to ask about a patient. That was before Proposition 46 was known. Nobody was home. I was advised that although the program existed in theory it wasn't funded well enough to have full time staff with telephone exchange and answering services. Not to worry, increased taxes should take care of that deficiency. But isn't this system the one we depend upon for privacy about our medical prescriptions? Additional safeguards will be needed. Not to worry about that, either -- increased taxes should pay for enhanced privacy protection, shouldn't it?  

Conclusion: the trial lawyers didn't do a scholarly enough job in putting Proposition 46 together. As written Prop. 46 puts ordinary citizens at risk for increased costs for health insurance premiums, for increased state and county taxes, and for invasions of privacy. It should be defeated. Vote No on 46.

Thursday, October 2, 2014

Proposition 45: pro and con

Robyn G. Young, MD, president, California Neurology Society, presents her case for Prop. 45 in her editorial available on (it is also summarized in our previous blog in the end-of-article listing of references).

Now comes Stuart A. Bussey, MD, JD, president, Union of American Physicians and Dentists, who writes in the "The UAPD Pulse" why Prop. 45 does not deserve passage.

Bussey's piece makes these points:

1. Prop 45 would shift regulatory authority from an independent commission to one political figure who would then become a "pressure point" subject to special interests.

Comment: the independent commission is also subject to special interest pressure, but it's more difficult to get to an entire committee than one person. On the other hand, commissioners get their jobs by appointment, political appointment, not by scoring well on achievement tests.

2. Bussey points out that under the ACA administrative costs are limited to 20% -- anything over that "must revert back to patient services."

Comment: Trouble is that the insurance companies often try to sneak administrative costs into the "patient services" sector. Example are utilization reviews requested by insurance companies that seek to disguise them as "consultations."

3. If  Prop. 45 passes a likely revenge step the insurance companies will take will be to slash provider reimbursement. Agreed, that's what they'll do, not that they don't already do it. The independent commission has not roared its disapproval of provider abuse.

Comment: It's also likely that the insurance companies and MPNs (Medical  Provider Networks) will jettison hundreds of doctors as a way to reduce expenses (not that that hasn't already been done). That in turn will force the remaining doctors to see more patients faster (the short visit you get now will be made even shorter).

My opinion: if Proposition 45 passes, the next step will be the implementation of rules and regulations. Proponents should be ready to take that matter on from Day One. That means day-to-day readiness to participate in the regulatory process. Proponents feel they have a better chance at fair regulation with Proposition 45 than without it. Opponents are skeptical, and with good reason, e.g., the unions bent over backwards to get Brown elected Governor only to find out yesterday that he vetoed all three of their bills. Would a single insurance commissioner be different?

The latest re the ACA: a laboratory in San Jose has just  billed a doctor's office for laboratory work done for Medicare patients. The lab in question said that changes in the Affordable Care Act made in January of 2014 allows them to do so. We'll look into this matter and see what the current insurance commissioner wants to do --  it'll be a prelude to what he'd do were Proposition 45 to pass.

In our next blog, we're planning on a few parting shots re Prop. 46,

Question: When should lawyers be tested for drugs?

Answer: When they're awake.

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 the very core of their 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."