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.

Thursday, April 27, 2017


Scandalous overreach by the proponents of Maintenance of Certification (MOC) invites investigation by the Federal Trade Commission (FTC) and by Internal Revenue Service (IRS). 

FTC should determine whether or not trade is being or is likely to be restricted by the tenets of MOC doctrine and its financial operatives. IRS, meanwhile, should examine whether or not the ABIM Foundation meets IRS 501(C)3 requirements. The question is whether or not there is reliable evidence that MOC revenue is being diverted into the pockets of selected individuals.

Many observers think that is the case and that the amount of money paid out in personal remunerations seems exorbitant. This finding forces the question, namely,  to what extent the ABIM Foundation is a charitable organization or a well heeled 501(c)3 enterprise. 

Here are some facts and figures:

The president & CEO of ABMS (American Board of Medical Specialties), according to IRS Form 990, received total compensation of $779,487 for tax year 2013;

The ABPN (American Board of Psychiatry and Neurology) CEO in 2012 received total compensation of $843,591 -- according to IRS Form 990 for that year;

The ABIM (American Board of Internal Medicine), schedule J, Form 990, for 2012, reports base compensation for the president-CEO as $628,952;  

Reported base compensation for Senior VP/COO, ABIM, was $464,747;

Base compensation for the Sr. VP/CIO, ABIM, was $382,092;

Base compensation for the Senior VP/COO,  ABIM, was $326,520;

Base compensation for Senior VP/CFO,  ABIM, was $452,630.

-- not too shabby especially when one keeps in mind that these figures do not include income from what IRS refers to as "related organizations". In order to see this additional money jockeying, just go to Schedule J, IRS Form 990, and look at lines i and ii -- add 'em up and weep. Not to worry. Increased fees down the road re MOC will take care of any shortfalls. 

Readers are invited to check out this data by looking up Form 990 information. We expect to add to this report from time to time so stay tuned.  These figures show why MOC will not be easily vanquished -- the stakes are too high.

Monday, April 17, 2017


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. 


"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,, June 29, 2015