Monday, September 11, 2017

More Unfinished Business: AB 1048 (Arambula):opioid prescribing

It's no secret that that the State of Opioids in California and elsewhere is a mess. In 1999 the Orgeon medical board sought to discipline a physician because it was claimed that he hadn't prescribed enough pain medicine. In 2001 the State of California made page one of The Washington Post when a patient's family sued because they said the doctor hadn't prescribed enough pain medicine. Now the shoe is on the other foot and doctors everywhere are beleagured for prescribing opioids to relieve pain. Comes now to the mini-partial rescue, Dr. Arambula, whose bill would allow pharmacists as of 07/01/18 to dispense Schedule II controlled substances as a partial refill if asked to do so by the patient or the prescriber. As of this writing the bill is on the Senate Floor where it is being sponsored by the CMA and guided by Alecia Sanchez from CMA's legislative office. This publication favors the bill -- a phone call or fax from you to your state senator advising an aye vote is our recommendation.

The matter will not be settled by this vote. It will continue to be an issue and will be the CME topic for the Union of American Physicians and Dentists at their meeting on October 28th (Marriott, Los Angeles airport). Contact UAPD for more information. 

Late Flash: AB 1048 cleared the state senate on 09/13/17, by 40 to zero. On 9/15/17 it was designated as "enrolled." 

Updating: AB 1048 is now on the Governor's desk according to the CMA Hot Lists dated 9/29/17 and 10/03/17 (that means the bill awaits the governor's signature). Phone calls, faxes, or e-mails intended to influence this legislation should go directly to the governor's office, 916-445-2841, 916-558-3160 (fax), or


"Opioid prescribing and panic," WORKCOMPCENTRAL, 08/15/17

See previous post this date (9-11-17) for current status of MOC and how ABMS boards profit from it (at members' expense, of course). 

UNFINISHED BUSINESS: first, the boards, MOC, and rapacious financial conduct

Under Unfinished business we wryly observe that MOC (Maintenance of Ceritification) remains viable and unwell. We now know without doubt that ABMS specialty board physicians and executives are profiting from MOC fees which, allegedly, are supposed to support the not-for-profit educational mission of our traditional (since 1922) specialty boards. In fact, reasonable argument can be made that the original not-for-profit motif of the boards has been converted into one of personal gain that belies the legal enablement of the boards under 501(c)3 rules and regulations. What is called for now is an investigation by the FTC (for possible restraint of trade) and by IRS (are the boards conducting themselves in conformity with the law governing 501(c)3 organizations)? 

Here's some grist from the mill, in this case, from the 990 Form filed by the American Board of Psychiatry and Neurology (ABPN) in 2015:

The MD president was allocated $613,314 as "reportable income from the organization (W-2/1099-MISC)." In addition his "estimated amount of other compensation from the organization and related organizations" was $322,686.

Four ABPN Directors are listed as having received "reportable compensation" ranging from $175,947 to $246,012. In addition, the same four got additional "compensation from the organization and related organizations" ranging from $73,914 to $83,546.

Two managerial remunerations were reported as $111,661 (with an additional $50,351 listed as "other compensation") and $106,552 (with an additional $37,608 listed as "other compensation").

The VP of Research came in for $286,384 plus $99,668 for "other compensation"). 

Other remunerations were equally fat.

Here's the point: if a 501(c)3 organization has high enough expenses including salaries it is obvious that it can't make a profit if all of the money it takes in gets distributed to private hands inside the organization in the form of expenses. In this way, a not-for-profit organization can make more money for its officers, directors, trusteee, and others than can a true for-profit business.

Is this the way we want our ABMS boards to function?


"Specialty Boards Profiting from Physician MOC Fees," MEDSCAPE, 08/01/2017

"Medical Staff Votes Against Mandatory MOC," WORKCOMPCENTRAL, 01/22/2016

Form 990 (2015), Part VII, Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees, page 8.

Sunday, August 13, 2017


   The mechanism of opioid action
is through a receptor mechanism that we all have, namely, mu, delta, and kappa receptors. Human opioid receptors are endogenous (meaning that their mechanism comes from within the system and does not require an external source) and can be activated by endogenous peptides such as the enkephalins, dynorphins and endorphins. These substances are released by neurones and are made available for pain modification. Endogenous opioid peptides comprise a class called endorphins.  

  This class of neurochemical stimulation is available to injured persons and can be mobilized into action without prescribing the likes of vicodin, oxycodone, oxycontin, or similar controlled substances (or illegal non-controlled substances). This level of neurochemical stimulation can be triggered to release endogenous substances in the human body that relieve pain.  For instance, physical therapy, aquatic therapy, or massage can have this favorable effect. When this method doesn't work, analgesic medication including opioids may then  be prescribed.

  The trouble is that in the case of injured workers covered by workers comp, these alternative methods to opioid prescribing are often rejected by Utilization Review (UR). Then that rejection by UR gets rubber-stamped by anonymous Independent Medical Review (IMR) doctors whose prejudices cannot be addressed since their names are kept secret. When the PTP or Primary Treating Physician's attempt to prescribe an alternative to analgesic relief is denied authorization, the next step is pharmacological, usually NSAIDs (non-steroidal anti-inflammatories), then opioids if the NSAIDs fail. That's when the bureaucratic howling begins. What should happen instead is that the UR and IMR doctors who denied treatment by physical therapy or massage should be relieved from duty. 

"Turn the Tide," a publication of The Office of the Surgeon General, discloses resources for the proper prescribing of opioids for pain, chronic pain in particular. For instance, once opioids are prescribed, they should only be continued if "meaningful improvements in pain and function without significant risks or harm" can be documented. Interestingly, the brochure distributed by The Office of the Surgeon General, states in red capital letters, "Start Low and Go Slow."

In fact, in The Weinmann Report, 6/26/17, "Opioid Denials and Obstruction of Alternative Treatments," we discussed how The Washington Post in 2001 made a front-page headline about a doctor in California who was being sued for not prescribing enough pain medication. Two years earlier the Oregon Medical Board actually disciplined a physician for not prescribing enough medication to relieve pain. We also cited a peer-reviewed reference from HEADACHE that stated that opioids were useful in pain management but that that its use had to be slow, slow, slow -- this advice was 17 years ahead of "Turn the Tide" and 10 years before Paduda's original article. 

In a panic-ridden piece entitled "Narcotic use is rampant in workers compensation," we are told that "the problem is showing up in a doubling of emergency room admissions due to prescription drug abuse, driven primarily by oxycodone, methadone, and hydrocodone." This particular article makes no reference to the Utilization Review denials for physical therapy, massage, and alternative treatments that force patients into the pharmaceutical stream.

On the contrary, Dr. John Torres recommended massage therapy on MSNBC with moderator Craig Melvin on August 1st, 2017. It isn't clear whether or not Dr. Torres knew he was recommending a treatment often rejected by workers comp Utilization Review. Since we  had the privilege of evaluating just this kind of patient recently, we'll see what happens if and when the PTP asks for overturn of the denial of massage therapy.

Readers should not be surprised. Since the emphasis now placed on evidence-based-medicine, the reliance on the winds of fashion and bureaucracy has increased. Discipline for not providing enough pain medication has been supplanted by a new chorus chanting for discipline for doctors who provide too much.  


The Weinmann Report, 6/26/17, "Opioid denials and obstruction of alternative treatments"

"Controversies in headache medicine," summer, 2000, HEADACHE, V. 11, # 2, Lawrence Robbins, MD (opioids can be used:  "when they are not overused, the opioids are a safe medication")

"Doctor's  duty to ease pain at issue in Calif. lawsuit," Susan Okie, Washington Post, 05/07/2001

"Oregon Board disciplines doctor for not treating patient's pain,"  New York Times, 09/04/99

"Narcotic use is rampant in workers compensation," Joseph Paduda, October, 2010

"Prescribing Opioids for Chronic Pain," TURN THE TIDE, Office of the Surgeon General, CDC

Commentary by Dr. John Torres, 1 August 2017, MSNBC TV (recommends massage for pain relief) 

Friday, July 28, 2017


Rife predictions of disaster are among us now that Obamacare (ACA) has been defeated in the Senate. Senator Ted Cruz may not be far from the mark when he says that annual increases of $7,000 per year in health insurance premiums should be anticipated since Obamacare was not repealed. On the other hand, the preservation of Obamacare means that coverage for pre-existing conditions will be continued. Medicaid funding (Medi-Cal in California) will be continued whereas under repeal of Obamacare Medicaid would likely be directed to the ashcan of political poverty. Keep in mind that federal legislators and their families have their own healthcare plan and are not dependent on Obamacare or even on any replacement that has been offered to date. That fact alone may explain why so many federal legislators know so little about the ins and outs of Obamacare or, for that matter, Any Care. A solution would be to dissolve the special health care coverage that federal legislators and Congressional staff get for themselves, including admission to military hospitals and clinics. Congress should  have the same healthcare insurance that the rest of us are obliged to get. THAT would perk up Congressional interest. 

Comes now HR 849, the Protecting Seniors Access to Medicare Act. 

HR 849 would repeal sections of the ACA that would implement the Independent Payment Advisory Board (IPAB). The IPAB has been called a "death panel." This columnist, while favoring repeal of the IPAB, doesn't call it that -- here's why: the actual intent of the IPAB is to reduce the costs of Medicare. It is not expected to do that by pulling the plug on individual patients. The expected protocol will be to see to it that in certain situations the plug is never inserted. This issue is already alive and unwell with reference to cardiac pacemakers which The Center for Medicare and Medicaid Services (CMS) has already determined as of 6 July 2015 will be restricted to patients with "non-reversible symptomatic bradycardia." This restriction ties the hands of cardiologists whose medical judgement is herewith cut to shreds. 

In layman's terms, that means that your cardiologist may think you should have a cardiac pacemaker because you have asymptomatic Mobitz Type II Heart Block. THAT is the type of medical decision that the IPAB will be enabled to prevent from implementation. The decision-makers will not be obliged to report to Congress even though the entire panel will be political appointees and even though there is no requirement by law that any of them be a physician. 

Reform of Obamacare is the way to go

It is probably correct Medicare costs are growing -- the constant stream of administrators and bureaucrats that clogs our healthcare systems is largely to blame. The first reform that we should make is repeal of the IPAB (the law as currently envisioned anticipates 15 appointees at $165,000 each). So  let's start the savings by not appointing an IPAB panel and then by repealing the ACA provisions that enable the IPAB. Previously, this writer has stated that the IPAB is "a form of rationing with a special dagger aimed at the hearts of the elderly." 

Implementation of the IPAB could conceivably extend a financial lifeline to the Medicare program while at the same time pulling life preservers away from patients. It has fiscal merit at the expense of the sick and injured whose healthcare needs would be subverted when the money originally intended for their care gets directed other than to patient care. 

Our recommendation is to repeal the IPAB to enable  physicians to provide treatment instead of the shackles favored by regulators who don't take care of patients. 

At this time, there are two ways to repeal the IPAB: my choice is to improve the ACA. The other choice is to pass H.R. 849


"Medicare versus the Independent Payment Advisory Board (IPAB), "The Weinmann Report,, 6/29/15

"Affordable Care Act & the IPAB," The Weinmann Report,, 3/8/12

POLITICO, "I will insure that no government bureaucrat gets between you and the care that you need," 12/17/10

POLITICO, "How to ration care without using the R word," 12/14//10

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

Monday, June 26, 2017


"Doctor's Duty to Ease Pain at Issue in Calif. Lawsuit" was headline news for The Washington Post on 7 May 2001. The story was about how a patient died in pain at age 85 after his  doctor reportedly "discharged him from the hospital with what (his daughter) said was inadequate pain medication."  

Meanwhile, HEADACHE, Vol. 11, #2, summer 2000, in a series entitled "Controversies in Headache Medicine," published a column on "Long-Acting Opioids as Preventive Medicine for Severe Headaches." The report recognized the risks of opioid medication but opined nonetheless that "when they are not overused, the opioids are safe medication" and that "the doses must be kept low" since "occasionally, the body develops tolerance to the narcotic and the patient needs increasing doses to achieve the same result." The HEADACHE article discussed methods of management. 

Pain management physicians understand these complications while also facing the needs of patients who suffer from chronic pain. That is why physicians try alternative methods to achieve pain relief, for instance, physical therapy, aqua therapy, and other methods not dependent on medications (these alternative methods are felt to induce secretion of endogenous substances that enhance pain relief). The trouble is that injured workers offered treatment under these techniques are likely to have these recommendations denied or delayed by Utilization Review (UR) and Independent Medical Review (IMR). DWC is ultimately responsible for care to injured workers and for the frequent denials and inadequate authorizations of treatment by UR and IMR. These denials then help throw these patients into opioid regimens because alternative treatment has been denied. The usual ruse is to call these treatments "experimental" or "unproved." 

That's when the primary treating physicians (PTPs)  and their consultants inherit the blame. Now that the political winds are against opioid use and physicians try to avoid their use, the ultimate sufferer is the injured worker and chronic pain patient. There is no winner in this sad game. 


HEADACHE, V. 11, #2, Summer, 2000, by Lawrence Robbins, MD ("Long-acting opioids as preventive medicine for severe headaches") 

The Washington Post, May 7, 2001, by Susan Okie ("Doctor's duty to ease pain at issue in Calif. lawsuit")

Workcompcentral, 2016-07-26, by Robert Weinmann, MD ("SB 863 benefits employers, harms injured workers")

Workcompcentral, 2017-01-04, by Robert Weinmann, MD ("Malpractice reform reaches California Supreme Court") 

Saturday, May 20, 2017

Single Payer (Healthy California Act, SB 562, Lara & Atkins) wins Senate Health Committee support

SB 562 or Healthy California Act is better known as the Single Payer Act. Senator Ricardo Lara's position is that "healthcare is not a privilege, it's a human right."

1) SB 562 promises to cover all Californians for "all medical care, including inpatient, outpatient, emergency care, dental, vision, mental health, and nursing home care;

2) Co-pays and deductibles will be eliminated;

3) Californians will choose their doctors from "a full list of health care providers, not a narrow network chosen by insurance companies" (now we'll just have to worry about who makes up these lists of providers -- physicians should now understand why MOC is such a hot potato);

4) Referrals will not be required for members to see "any eligible provider" (shades of 1998: the undersigned spoke on this topic at the White House when President Clinton signed off on allowing federal HMO members to go directly to specialists without having to see a primary care doctor first); 

5) Californians will be covered when they travel;

6) The bill will say that "physicians and nurses will make decisions about care, and have the ability to override computers or clinical practice guidelines in the best interest of the patient" (notice that this provision mentions "physicians and nurses" and avoids designating MDs and RNs); 

7) The bill says that "Healthy California will be governed by a nine-member, unpaid board appointed by the governor and legislature and a public advisory committee (italics added ) of doctors, nurses, other health care providers, and consumers" (in other words, kind of like the Independent Payment Advisory Board of Obamacare).

In fact, SB 562, specifies under Chapter 2, Governance, that one of the board members will be a "representative of a labor organization representing registered nurses." It is proper that Registered Nurses get this recognition.  

It would be a good idea to make sure that physicians and surgeons with MD degrees also get such recognition. Under SB 562 they do not -- in fact, they almost get ignored. SB 562 states that the governing board will include "at least one representative of the medical provider community." The "medical provider" community includes many kinds of providers of services, e.g, physical therapy, massage, non-RN nurses, nurse anesthetists, physician assistants, naturalists, chiropractors, acupuncturists, etc. 

An additional amendment this writer recommends is that SB 562 should require that "at least two California licensed representatives will be medical physicians/MDs, one surgeon and one internist or family physician."

As for the public advisory board, it will also be obliged to meet certain statuatory requirement, it would be required of the board "to seek all necessary waivers, approvals, and agreements to allow various existing federal health care payments to be paid to the Healthy California program which would then assume responsibility for all benefits and services previously paid for with those funds." 

In the words of too many pundits to count, SB 562 still needs work.


"SB 562," 17 April 2017, The Weinmann Report, 

Monday, May 15, 2017

Senate Bill 790 (McGuire): Me too legislation on gifts and benefits

Once again we see a loose cannon approach to limiting gifts and benefits from manufacturers of prescribed products or distributors of medical devices to health care providers. Physicians are the main target of this legislation despite the authors' unctuous assertion that "the vast majority of medical professionals in California do their job well and put the needs of their patients first."

Nonetheless, Sen. McGuire finds that "current voluntary efforts are not enough to ... protect patients from overpriced prescriptions. SB 790 will restrict pharmaceutical gifts and help control drug costs."

On this basis Sen. McGuire seeks to regulate food and beverages served by pharmaceutical companies at meetings of medical professionals -- these meetings are usually dinnertime functions with educational presentations by prominent and respected physicians. It is correct that the participants dine at the expense of the sponsoring company. The pitch in favor of the bill is that "SB 790 gives California an opportunity to put patient care and drug affordability before corporate profits. The bill would significantly restrict the manufacturer (of a prescribed substance or device) from offering or giving gifts and incentives such as travel and lodging, consulting fees and expensive meals and alcohol to health care providers." Sounds good, doesn't it?

There are problems with this expansive bill. For instance, physicians know that the speakers at these commercial enterprises are actual clinicians with field experience, physicians whose lectures are known to be knowledgeable and reliable. Thanks to the pharmaceutical companies we don't have to buy risky tickets on airlines that routinely overbook. Education is brought to our doorsteps. These benefits would be thrown out with the dish water were SB 790 to become law. 

This bill will redistribute the wealth so that medical centers and health plans will still be allowed to put on seminars, dinner and wine included, in other words, will be allowed to advertise their own clinical services while foisting lower level and comparatively inexperienced faculty on attendees, e.g., it is not unusual for medical centers to put on these dinner meetings and draft junior faculty as speakers. The idea is to have attendees at such symposia use the sponsors' hospitals, clinics, and healthcare plans. THAT is not precluded by SB 790  which actually plays into their hands.

Actually, there is an approved exception: conferences or seminars accredited by the Accreditation Council for Continuing Medical Education (ACCME)  or comparable organizations would be allowed to offer these conferences provided the sponsor is not the manufacturer of prescribed products. In other words, courses given by the American Boards or their separate but contiguous professional associations or academies would be exempt (compare our previous items on Maintenance of Certification or MOC and rue the day you left the hen-house for protection by the fox). 

Finally, many of the physicians who attend dinner-meetings put on by pharmaceutical companies do not use or prescribe the products discussed: they come to hear experts discuss the mechanism of action of new medications and techniques and to enjoy the company of colleagues in an environment where there's no "911" calls. 

Where this battle needs to be fought is in the courts and in Congress which so far have allowed Medicare and other entities to avoid negotiating with suppliers for better prices. 

As written, SB 790 also shows flagrant ignorance on how drug profits are actually made, e.g,, Senator McGuire's press release from 4/25/17 says that the current "interaction with the pharmaceutical industry is associated with negative consequences that includes unnecessary drug prescriptions, drug cost increases borne by the patient and less availability of generic drugs (italics added)."

What the authors fail to mention is that the mark-up or profitability of generics is often more than trade name medications. That is because the so-called "filler molecules" entailed in their making are less regulated since they're not the active substance. In other words, generic drugs are not by definition  "bioequivalent" to their brand name counterparts but may be more profitable nonetheless. 

Our suggestion to McGuire and Monning: try again, without grandstanding.