Monday, April 17, 2017

SENATE BILL 562 (INTRODUCED BY LARA & ATKINS): A PR0P0SAL FOR SINGLE-PAYER THAT INCLUDES PROVISION FOR COLLECTIVE BARGAINING


Senate Bill 562 enjoys the nickname of The Healthy California Act because it is intended to offer comprehensive health-care coverage to all residents of California -- it would be innovative as a single-payer plan for Californians. All the same the California Medical Association (CMA) is opposed.

By contrast the Union of American Physicians and Dentists (UAPD) holds a more guarded position and currently is "watch" on this bill although it is widely thought that the majority of its physicians who are employed or salaried favor SB 562. 

The reasoning goes like this: California already has a state-wide program called Medi-Cal (the stateside version of Medicaid). This program is administered by DHCS (Department of Health Care Services) and is largely governed and funded by the federal program, Medicaid. SB 562 purportedly would expand this program to cover all residents of California. 

The chief argument in favor of SB 562 is that it would cut out the meddlesome middleman, namely, the insurance company. Supposedly so doing would reduce costs; however, there is nothing in the law that mandates passing on these costs reductions to the patient. More likely the savings in costs would find their way into the pockets of the corporate overseers in the form of increased corporate compensation. 

The argument stumbles on, akin to the United States Postal Service whose rates have gone up while its efficiency has not. What is more likely than not is that the single-payer system would simply declare certain expensive services out of bounds as was done in the summer of 2015 when cardiac pacemakers were put on a rationing status by requiring conditions beyond what most cardiologists would require, e.g., Big Gubbamint decided that Mobitz Type II syndrome did not require a pacemaker.

How about rationing? Under the Affordable Care Act (ACA), popularly known as Obamacare, Sections 3403 and 10320 are especially relevant -- these sections set up how a public policy committee will be set up within the ACA to keep costs down. 

The method used for Obamacare was to appoint a committee,  the Independent Payment Advisory Board (IPAB) whose job it would be to decide, once costs got too high, which services should  be curtailed. The IPAB as envisioned in the ACA will not report to Congress. The salary is expected to be about $165,000 each for 15 appointees (none will be elected). 

Trouble is that SB 562 envisions a similar mechanism, namely, "a public advisory committee to advise the board on all matters of policy for the program." The members of this committee would include 4 physicians (one must be a psychiatrist) appointed by the Governor, Senate Rules Committee, and two by the Assembly Speaker. It doesn't get more political than that, does it!?

Two appointees would be registered nurses appointed by the Senate Committee on Rules. One would be a dentist appointed by the Governor. One representative would be from the private hospital sector, also appointed by the Governor. Another appointee would be a representative of the public hospital system, appointed, wouldja' believe, by the Governor. Another would be a representative of an integrated health care delivery system, no surprise by now, also appointed by the Governor. There would also be other representatives appointed by the Governor, the Assembly Speaker, and the Senate Committee on Rules. 

So instead of a science-based advisory board, we'll be offered a "public advisory" board steeped in political intrigue. 

Under Chapter 2, Governance, we learn that there will be "Appointments to the board by the Governor, the Senate Committee on Rules, and the Speaker of the Assembly," to wit 

(A) "At least one representative of a labor organization representing registered nurses,"

(B) "At least one representative of the general public,"

(C) "At least one representative of a labor organization,' 

(D) "At least one representative of the medical provider community."

Does it escape anyone's notice that the first dictum above guarantees appointment of two RNs and that none of the provisions guarantees the appointment of an MD? The closest it comes to that is the statement about someone from "the medical provider community" but not necessarily an MD.

Notice also how the provisions outlined above tilt to labor, e.g., the two RNs are to be from "a labor organization representing registered nurses" AND "at least one representative of a labor organization" which makes at least three appointees from Big Labor. Not, come to think of it, that the insurance companies haven't earned this shift in appointee preference!

In referring to a piece done by the undersigned for the Indiana Daily Journal in 2009 it was mentioned that "the trap to avoid is restrictive utilization review such that we get Rationing Coupons as opposed to access to care." When this comment came to the attention of Stuart A. Bussey, MD, JD, UAPD president, he stated that "we will follow this bill 562 and suggest safeguards to avoid restrictive utilization."

Finally, that brings us to why unions might be interested in SB 562. On page two of the current draft still in committee, we read that "the bill would authorize health care providers, as defined, to collectively negotiate rates of payment for health services." 

We will no doubt continue this discussion as SB 562 walks, runs, or stumbles its way through the legislative process. 

References

"Single-payer health plan has its own disadvantages," Indiana Daily Journal, Franklin, Indiana, August 8-9, 2009

"Medicare versus the Independent Payment Advisory Board (IPAB)," The Weinmann Report, www.politicsofhealthcare.com, June 29, 2015














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Monday, March 27, 2017

HOW OBAMACARE'S SURVIVAL MAY ENHANCE UTILIZATION REVIEW DENIALS IN WORKERS COMPENSATION


Sections 10320 and 3403 of the Affordable Care Act (ACA) remain in force thanks to the calamitous Trump-Ryan campaign to repeal Obamacare in its entirety while omitting discussion whenever possible about aspects of the ACA where the Republicans would've been better off with debate and compromise. By not bringing the issue up independently, the Democrats joined hand-in-glove with their Republican opponents.

Sections 10320 and 3403 of the ACA enable a particularly harmful method of disallowing coverage of healthcare known as the Independent Payment Advisory Board (IPAB). The IPAB has often been linked to rationing of healthcare. Here's how it will work once it is installed as allowed by current ACA legislation.


The basic idea of the IPAB is to eliminate services from healthcare once it can be shown that such services are financial encumbrances to the program. In order to decide which diagnostic and treatment protocols qualify under this rubric, a special committee will be appointed. It will not be necessary to be a physician to get appointed, but it will be necessary to get a political appointment. The job is envisioned to pay about $165,000 per year. It will not be required for the committee to report to Congress which will happily divest itself of this controversial oversight. It is expected that the committee will be appointed in 2017 or 2018 or as soon as costs escalate beyond current levels.

An example is the restriction that Medicare recently imposed on cardiac pacemakers. The decision as to which patients should have pacemakers used to be up to one's cardiologist. No more. There is now an impediment, namely, Medicare itself. In the absence of specific findings mandated by administration authorities, pacemaker coverage can now be denied. Not the pacemaker itself, mind you, just its coverage under Medicare -- so, Dear Reader, if you are  among those whose concern about pacemakers is less than theoretical, here is the information you may need when the IPAB nixes your application: cardiac pacemakers cost about $6,000 on the open market. That does not include professional fees and other related costs.

This IPAB program has been called "rationing." It isn't rationing on a per se or individual basis. It is rationing across the board for entire classes of potential recipients. It's purpose is to stretch the ACA dollar since it is expected that the ACA's financial troubles will get worse sooner than expected given recent increases in policy costs and deductibles. This reasoning, cost reduction, is the same as California's approach to Utilization Review (UR) for Injured workers.


Injured workers on the wrong end of Utilization Review (UR) whose rejection of treatment is usually upheld by Independent Medical Review (IMR) will immediately recognize this technique as a denial of care mechanism. In a nutshell, Congress has now extended the ACA'S chief mechanism for "denial of care" and has managed to keep the public in the dark. No more! This writer urges all of us, injured worker or not, to make one's own legislator face this issue.


By way of recent history, the IPAB was initially aimed at Medicare's recipients -- it was called the IMAB (Independent Medicare Advisory Board) then. It got deleted from Medicare when thousands of Medicare recipients protested loudly enough for Congress to hear them.

My recommendation: whether or not one is an injured worker, but especially if one is an injured worker, the time to shout out for repeal of Sections 10320 and 3403 of the ACA has arrived.  This step can be taken without repeal of the entire ACA which would remain a separate issue. 



Tuesday, March 21, 2017

OBAMACARE, TRUMPCARE, OR RYANCARE?


"We own it," that's what Rick Santorum, former presidential candidate and senator said with reference to the on-going Republican  proposed healthcare bill to replace Obamacare.


By now we know what the successful aspects of Obamacare (the Affordable Care Act, ACA) are that reflect the lifeline of the ACA as it now stands. 


The successful parts of the ACA include keeping children insured until age 26 and disallowing the exclusion from healthcare plans of persons with pre-existing conditions. On the other side of the ledger, once President Obama dumped the Public Option from the ACA, the greedy doors of the insurance companies swung open to raises in premiums and deductibles. In turn, as the cost of the ACA goes up, attempts to control costs raise their ugly heads.



Chief among these ugly heads is the Independent Payment Advisory Board (IPAB) which effectively, once it becomes operative, will facilitate the rationing of health care. Review of recent healthcare history shows that there was a predecessor to the IPAB known as the IMAB (Independent Medicare Advisory Board) which was deleted from Medicare because of public opposition by Medicare recipients. Unfortunately, a revised version of the IMAB wormed its way into the ACA as the IPAB -- if the ACA is repealed the IPAB goes down with it, unless, unless it is brought back to life by as yet unknown devotees willing to throw grandma under the bus. 


The IPAB's lease on life comes from Sections 3403 and 10320 of the ACA (this writer has sought repeal of both sections for the past 7 years, see articles from The Hill newspaper, 9/16/09, and POLITICO, 12/10/10 and 12/17/10). Once the costs of the ACA reach critical levels, these ACA sections allow the appointment of political operatives whose job will be to regulate costs by deciding which procedures and treatment protocols are too expensive to maintain -- not quite the death panels touted by some ACA opponents but too close for comfort.


At this moment in Congress, the deep divide is how much of Obamacare to keep, if any. It appears that complete repeal without adequate replacement will disenfranchise millions. On the other hand, if Obamacare maintains its lease on life, millions risk losing access to care because they'll not be able to afford the ever rising premiums and deductibles. 


Santorum in Congressional hearings points out that either way the blame or credit will fall upon the Republicans. If the proposed health care law fails, the Republicans risk losing seats in the midterm elections (sad to say how much this aspect rules Congressional thinking). So at the moment here's the scoop: Trump does not want the currently proposed bill to be called Trumpcare since its passage could replace the disastrous aspects of Obamacare with new equally disastrous effects. That's why in the glorious halls of Washington, DC, the current Republican proposal is wryly called Ryancare. 


References


The Hill newspaper,  Washington, D.C.,  "What Obama should've said about health reform," 9/16/09


POLITICO, "How to Ration Care without Using the R Word," 12/14/10

POLITICO, "I Will Insure that No Government Bueaucrat Gets between You and the Care that You Need," 12/17/10 

The Weinmann Report, "Affordable Care Act and the IPAB," 03/28/12,  (www.politicsofhealthcare.com) 




Thursday, February 16, 2017

UTILIZATION REVIEW HYPOCRISY REVISITED -- One Doctor's Answer to Arbitrary Utilization Review Denials


UTILIZATION REVIEW HYPOCRISY IN VELVET GLOVES,
originally published in this blog, 03-18-2014, has met its match in the psych practice of Richard Dorsey, MD. With Doctor Dorsey's permission, we publish his method of dealing with Utilization Review minions.


Doctor Dorsey uses an 866 number going to a 24/7 answering service. This number is used for all UR doctor calls as listed on his RFAs. What this method means is that every UR call gets a live answer, no voicemails. All of his UR calls will be logged in as to date and time. This method allows Dorsey to claim accurately that UR personnel who say they couldn't reach his office are likely lying.

Should odd-hour calls come in, said calls are noticed to Dr. Dorsey by e-mail and are then answered during normal business hours. Dorsey keeps a log for dates and times of the UR doctor calls he actually returns. Dorsey says he'll do two such calls per case. For UR calls that come in during regular business hours, Dorsey's answering service e-mails notification of same upon receipt. Far from creating hostility, this method allows Dorsey to develop his own rapport with the UR doctors such that his rate of  "cases approved" has reached a high level. 

For more about Dorsey's technique, go to dorseypsych.com 

References

Utilization Review: Hypocrisy in Velvet Gloves, politicsofhealthcare.com (The Weinmann Report), 3/18/14, & workcompcentral, 3/26/14

Out-of-State v. In-State Utilization Review, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 01/10/13

Malpractice by Utilization Review? politicsofhealthcare.com (The Weinmann Report), 12/13/14, & workcompcentral, 12/19/14

Malpractice Reform Reaches California Supreme court, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 4 Jan 2017

SB 863 Benefits Employers, Harms Injured Workers, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 7/26/16

Getting to Yes with UR and IMR, Dr. Steven Feinberg, workcompcentral, 02/07/17 (more on this topic in subsequent issues)







Friday, January 20, 2017

WHEN PATIENT CARE INTERFERES WITH REQUIRED DATA INPUT, IT'S THE PATIENT WHO LOSES


First, a word of congratulations to the CEO of the American Academy of Neurology whose reportable compensation from the organization (W-2/1099-MISC) in 2014 was listed as $596,190 and whose estimated amount of other compensation from the organization and related organizations was reported at $35,338 (total of $631,5280).

In 2015 the respective amounts in these two categories grew to $657,503 and $36,142, respectively, an overall increase of  $61, 313 in reportable compensation and an overall increase in both categories of $62,117 (for 2015 the total was $693,645).

Next,  look at the American College of Cardiology (ACC) where the Chairman/president's reportable compensation from the organization was $258,551 and whose "other compensation" was listed as $70,000 (total = $328,551).

Why is ACC financially outstripped by AAN when it reports about 49,000 members to AAN's 30,000?

Neither organization has committed to full scale opposition to MOC or EHR with its attendant penalties for non-compliance. 

AAN, meanwhile, in its December 2016 issue of AAN News, proudly announced that "AAN Lobbying Helps Ease Impact of MACRA Changes on Neurologists" -- a "new program involves a two-track system for Medicare reimbursement"-- actually, what members really want is a Zero Track System -- THAT is what AAN and ACC should be using its net assets to acccomplish.


Both organizations in the opinion of this writer are applying their assets to greasing through MOC, EHR, and similar programs desired by government and/or insurance companies. Both organizations give pricey seminars, continuing educational course, and examinations to members. The need for enhanced organizational income is real.

Dues alone will not pay for the high level of staff and CEO remuneration that have now replaced clinical devotion as the hallmark of the medical profession. This writer's opinion is that the boards and their financial allies can derive mutual income benefit if they can dominate CME (Continuing Medical Education) by making their courses and programs mandatory.  


The net result is less time spent with patients, more time spent doing computer input for EHR to avoid financial penalties for non-compliance, and time actually taken away from true Continuing Medical Education (CME) which produces real benefits for patient and physician alike. 

Patients may not see these issues straight away: what they see are doctors whose focus is on a near-by computer screen during what they thought was going to be a personal medical visit

References

AAN News (American Academy of Neurology), V. 30, # 12, December 2016

ACC website (American College of Cardiology, Official site, www.acc.org)

"Maintenance of Certifcation (MOC): a rising business opportunity," 15 May 2015, The Weinmann Report (www.politicsofhealthcare.com) 

IRS Form 990 for 2014 & 2015, AAN, and 2015, ACC

"Medical Staff Votes Against Mandatory MOC (Maintenance of Certification Requirements)," 16 January 2016, The Weinmann Report (www.politicsofhealthcare.com) 

"Medical staff votes against Mandatory MOC, Workcompcentral. 22 Jan 2016




Monday, January 2, 2017

MALPRACTICE REFORM MAKES IT TO CALIFORNIA SUPREME COURT


The late and illustrious David J. DePaolo was on target in "Out of State UR" published on 4 January 2013 when he wondered why it should make any difference whether or not Utilization Review (UR) physicians were in-state residents or not. He summarized my own argument at the time by quoting the following: "Because reviewing doctors out of state can't be controlled by California licensing authorities, insurance companies are then free to 'scour the country' for doctors who are willing to to give favorable reviews to insurers." My conclusion at the time, and still is my conclusion, is that "in-state licensure should be required, not in-state residency."

The entire issue has now hit the proverbial fan. UR is now before the California Supreme Court. Fourteen and counting organizations have asked to file amicus curiae briefs. All of of them focus on a combination of clinical matters and legal issues over which looms the spectre of money.

The case at issue is  King v. CompPartners. In January of 2016 the 4th District Court of Appeal issued a ruling that UR physicians have an obligation to apply ordinary care and diligence in their provision of medical opinions with reference to the reasonableness of treatment for injured workers. The clinical issue had to do with the sudden discontinuation of klonopin without having taken due regard of risks, namely, that abrupt discontinuation of this medication is associated with epileptic seizures. This unfortunate situation befell Kirk King when the UR physician reviewing his treatment recommendation in turn advised discontinuation of the medication. The clinical argument is that the UR physician assumed responsibility for the patient when he made a recommendation that directly contradicted the treating doctor's treatment plan and thereby harmed the patient.

One of the organizations filing an amicus curiae brief is the California Applicants' Attorneys Association (CAAA). Their argument is that King is simply asserting his "common-law right to bring a lawsuit against someone ... who may have caused injury." In this writer's opinion, that is precisely what the UR physician did when the insurance company adopted his fallacious opinion and discontinued an indicated and necessary medication.

Not surprisingly, organizations that provide UR physicians are up to their necks in legal riposte. Coventry and Examworks provide UR physicians. These two organizations, among others, argue that UR doctors play only limited roles and as such should not be exposed to malpractice liability. They have the effrontery to argue that UR doctors do not interview or examine the patients so shouldn't be held to the same clinical standard as treating physicians.

They don't remind us about the corporate interests that supported SB 863 which established the misguided public policy allowing legal largesse to UR physicians and their Independent Medical Review (IMR) counterparts -- UR and IMR physicians are not required by law to be licensed in California although both are allowed under SB 863 to provide treatment directives such as the one that discontinued Kirk King's medication and brought the current case to the California Supreme Court.


There is history on this matter that turns out to  have been prescient, maybe even predictive:

In "Malpractice by Utilization Review?" (The Weinmann Report, www.politicsofhealthcare.com, 13 December 2014), this author described a case wherein lyrica was improperly suspended from an injured worker who had had a three-level cervical fusion (the medication was eventually restored by a California licensed physician). This case and the King case have in common that the UR physicians asserted clinical opinions that harmed the lives of patients dependent upon them for good faith judgments. I understand this argument to be the crux of the case being brought by Attorneys Law, Falcioni, and Lockwood on behalf of King.

In "Utilization Review Hypocrisy in Velvet Gloves" (workcompcentral.com, 26 March 2014), we pointed out more reason why the defective UR program should be replaced.

Finally, we mention again that former Medical Board of California (MBC) president Dr. Frantozzi long ago submitted opinion that UR is an aspect of medical practice and that UR physicians should be licensed in California. The underlying fault is inherent in SB 863 which provides the legal basis that allowed for the wrongful discontinuation of lyrica in the case of the patient with the the three-level cervical fusion and klonopin in the case of Kirk King.  

King's case should be sustained by the California Supreme Court. SB 863 should be repealed. The two situations are analogous: without SB 863 the cavalier determinations by  the UR doctors vis-a-vis one patient's lyrica and another patient's klonopin would not have taken place. 

References


"Supreme Court Gets Additional Amicus Briefs for UR Doctor Malpractice Dispute," workcompcentral, 2016-12-29;

"Supreme Court Gets Amicus Briefs in UR Doctor Malpractice Dispute," workcompcentral, 2016-12-16;

"Malpractice by Utilization Review?" The Weinmann Report, www.politicsofhealthcare.com, 2014-12-13

"Utilization Review Hypocrisy in Velvet Gloves," workcompcentral, 2014-03-26;

"Medical Board Asserts Jurisdiction over Utilization Review," workcompcentral, 2013-06-12;

"Out-of-State v. In-State Utilization Review," workcompcentral, 2013-01-10.


Monday, December 5, 2016

The R & R Ride for SB 1160 (Mendoza)

Now that Governor Brown signed SB 1160 (Mendoza) into law, it's time for the bill to enter the "rulemaking" phase. That's when legislation either gets its teeth or gets its teeth kicked in. The Rules and Regulations (R&R) Ride for SB 1160 (Mendoza) starts at the Hiram Johnson State Office Building at 455 Golden Gate Avenue, San Francisco, 10 AM, 4 January 2017. Public testimony is supposedly limited to 10 minutes per speaker. The subject will be Title 8, CCRs, Section 10770 (amended) and 10770.7 (newly adopted).

Here is our opinion: implementation of SB 1160 (Mendoza) needs to be far more friendly to injured workers than it currently is. The Rules and Regulations (R & Rs) as proposed will implement a lien process that may be expanded in the sense that it will apply not only to doctors who accept liens but also to any physician or other provider who runs into snags with payment so that the only way remaining to proceed with an unpaid claim is through the lien process. That means if the lien process becomes the only viable option for a delayed or denied payment for medical or other service it will be necessary to file a lien under new R & Rs. That means increased crunch and grind especially for small offices. In turn that means progressive reduction in access to care for injured workers.  

We also believe that a hint of hypocrisy persists in the process. Here's how: supposedly, treating doctors will get the first 30 days of treatment unimpeded by Utilization Review. Not quite. Not all procedures will be removed from the UR Cauldron of Dismissal: MRI scanning will remain off limits. So will non-formulary medications and durable medical equipment costing over $250. Psychological treatment will remain on the proscribed list (remember in 2015 that Neuropsych QME was unilaterally and arbitrarily canceled by the Director). 

Surgery will still require prior authorization by UR. 

For these reasons, we urge participants with a stake in this process to file statements:

By mail, Workers Comp Appeals Board, Annette Gabrielli, Regional Coordinator, P.O. Box 429459, San Francisco, CA. 94142-9459

By delivery service or personal delivery, WCAB, Annette Gabrielli, Regional Coordinator, 455 Golden Gate Avenue, 9th floor, San Francisco.

By Fax, 1-415-703-4549.

Have fun over the New Year's Holiday but keep your fingers crossed. We give you two references, see below.

References

"Weinmann: Now Comes SB 1160: Unreasonable Denials," www.workcompcentral.com, 2016-08-23;

"SB 1160 (Mendoza): anti-fraud legislation aimed at physicians permits MPN fraud," www.politicsofhealthcare.com, 2016-08-06.