Monday, June 27, 2011

US HealthWorks and the RBRVS


SB 923 (De Leon) will increase fees to primary treating physicians while reducing payment to specialists. The sponsor of the bill is USHealthWorks (USHW). Ron Kent, MD, neurologist, spoke at the Insurance Committee hearing and said that close to 80% of neurologists stopped treating injured workers in states that adopted the RBRVS schedule. Stuart Bussey, MD, JD, primary practice physician, speaking at the same committee hearing, said "Even though I'm a primary care doctor and I would get a boost from this, losing access to orthopedic surgeons, neurologists and cardiologists, I'll be cutting my own throat." Bussey then pointed out that without access to specialists the primary treating physician could find himself holding the malpractice bag.

By contrast, workcompcentral reported that Andy Parker, MD, Vice President of USHW, reported that he has not seen any access issues because of the RBRVS fee schedule. Did Dr. Parker pay attention when Dr. Kent and Dr. Bussey testified or did he ignore their testimony?

A further question that merits investigation is the extent to which non-physician corporate ownership, even if only partial, dictates how USHW functions as an entity providing medical care to injured workers. My understanding is that there are two entities, a management company and a medical group. One of the non-physician owners of the management company is Daniel Crowley.

PTPs or primary treating physicians are responsible for getting specialty consultation and care for injured workers, but, as Dr. Bussey indicated, that can't be done if they've left the program. It can't be done, as Dr. Kent indicated, if the majority of neurologists and other specialists quit accepting injured workers as patients.

The extent to which non-physician corporate ownership through the management company plays a role in how the medical group dispenses services is a reasonable area to explore further.

Tuesday, June 21, 2011


Senate Bill 923 (De Leon) is supposed to assist injured workers by increasing access to care. More likely, if it gets signed into law, it'll protect them out of much of the care they currently get.

As if Utilization Review by doctors without licensure in California weren't bad enough, we now have another opportunity to stick it to injured workers by making them subject to the Medicare RBRVS fee schedule. This schedule was tried in Hawaii and in Texas. Both states lost the participation of so many specialists that both states had to increase the conversion factor to keep their specialists in the system. With this dismal record well known in healthcare circles, it remains a wonder that the good Senator De Leon wants to try it out again with injured workers in California as the latest guinea pigs.

The current method of reimbursement to physicians who treat injured workers in California follows the Office Medical Fee Schedule (OMFS) which currently pays doctors some of the lowest reimbursement rates in the USA. If that's so, then how could the RBRVS be worse? The answer is that the Medicare RBRVS is geared to the elderly and provides largely geriatric care whereas the OMFS is geared to injured workers so they can return to work. The RBRVS is supposed to provide care although at the present time even that is in danger because of Section 10320 of the Affordable Care Act and the directive to establish an unelected Independent Payment Advisory Board (IPAB) whose primary purpose is to cut costs to Medicare. Installing the Medicare RBRVS system into workers comp and replacing the OMFS with it only shows that the researchers for SB 923 didn't do enough homework.

If the RBRVS is inserted into the system, we can count on many specialists including surgeons to withdraw from workers comp and industrial medicine. When the injured workers discover as a community that they've been shortchanged -- such discoveries take a few years -- the politicians who put the screws to them will have left office and gone to greener pastures, e.g., some will be working for insurance companies. The legacy they leave if SB 923 gets signed into law will be one of deprivation and denial of care.

Our advice: since SB 923 is expected to be heard in the Assembly Insurance Committee on June 23rd, there's still time to tell 'em what you think by faxing the committee at 916-319-2086 and its Chair, Assemblyman Jose Solorio, 916-319-2169.

Aside from Texas and Hawaii, the RBRVS has been tried in other states, e.g., Florida, Massachusetts, and Maryland, all without success. In this report we've named five states in which the RBRVS failed. The RBRVS should not be foisted upon our injured workers in California. SB 923 (De Leon) desrves to be soundly defeated, badly enough so that it won't come back for a long time.

Wednesday, June 1, 2011

Assembly Bill 584 (Fong): stops the unlicensed practice of medicine

AB 584 (Fong) is an important step in the right direction and should be supported by physicians and by all of their organizations.

As matters stand now, injured workers may legally be denied access to diagnostic tests and treatment needed to diagnose and treat their injuries even when properly prescribed by duly licensed California doctors.

The legal maneuver used to deprive injured workers of indicated and necessary treatment is based on the Schwarzenegger adaptation of utilization review. Utilization review is required by California law -- it's supposed to be a way to supervise treating doctors and prevent overutilization of services. It is primarily a cost control measure.

In 2005 the Schwarzenegger administration persuaded the Office of Administrative Law to agree that utlization review wasn't medical practice and, therefore, did not require California state licensure. Never mind that the Medical Board of California stated that utilization review was certainly an aspect of medical practice. Once the leash was relaxed on the insurance companies, several insurance groups and their management cohorts hired doctors for utilization review who were not licensed in California and who would not, therefore, be required to take the special 12-hour course in pain management that is required of California licensed doctors.

The upshot is that under current law utilization review doctors who are not licensed in California are allowed to overrule California doctors who are licensed in California.

These non-California licensed doctors are not responsible for their mistakes before the Medical Board of California because they're not licensed in California. They're also not responsible to the medical boards of the states in which they are licensed because those states don't have jurisdiction in California.

The non-California licensed doctors are also not obliged to pay licensure fees to the Medical Board -- they get a free ride while their licensed colleagues are obliged not only to pay for licensure but also for a mandatory pain management course.

Injured workers in California are subjected to delays and denials of treatment by doctors who should not have been allowed to practice in California in the first place.

The Schwarzenegger workers comp policy has caused innumerable delays and denials of treatment and has caused countless workers to lose out on the treatment that could have returned them to work.

Physicians in California should reach out in support of AB 584 (Fong). The bill has already passed the Assembly. It should clear the Senate. Then Gov. Brown should sign it into law.

Senate Bill 866 (Hernandez) re prescription drug benefits

SB 866 (Hernandez) will facilitate the efforts of physicians to care for patients. It will ease the burden of prior authorization and utilization review. It will cut down on wrongful delays and denials of treatment.

This bill is analogous to AB 584 (Fong) in that it reduces how utilization review obstructs the practice of medicine. Here are the essential points: only one universal form will be required for prior authorization. The form is supposed to be limited to two pages; however, there's nothing in the bill that specifies font size (rumors that the insurance companies are shopping for microscopic print fonts are probably exaggerated). The information is then supposed to be electronically available and transmissible. Most important, the company has 48 hours to reply. After that, in the absence of a reply, automatic approval of the physician's prescription ensues (even though I can think of a way around that). All the same, the bill is unequivocal in its support of patients and their doctors.

Support can be expected from the pharmaceutical industry which stands to benefit from reduced prior authorization. Opposition can be expected from the insurance industry which benefits from as much utilization review and prior authorization as it can foist on the public and the healthcare profession generally. Practicing physicians should support SB 866.

Assembly Bill 369 (Huffman) re "stepwise" prescriptions

AB 369 (Huffman) will put the brakes on a favored method insurance companies use to control prescriptive medication. The method is "stepwise" prescribing and works like this: doctor Kindguy wants to prescribe the medication he believes will most likely relieve his patient's pain but finds that he is obstructed in so doing by the patient's insurance company which requires the doctor to try at least two lesser level, that is, cheaper medications, first. Doctors will be obliged to follow this pathway even against their own medical judgment and will retain medical liability while the lesser level medications are foisted upon hapless patients.

Huffman's bill will authorize physicians to decide how long a lesser level drug should be used and would restrict the insurance company from requiring patients to try more than two such medications. Insurance companies want to increase profits without increasing premium costs. This way allows them to shift the cost burden to medications. Pharmaceutical companies object because it makes their best, and sometimes their most expensive, medications less accessible. Physicians should be supportive of the legislation because it'll dispense with still another layer of utilization control.

This writer call the office of Speaker Perez and asked that AB 369 be sent to the floor for a vote.

Assembly Bill 310 (Ma) re "tiered pricing" of medications

Assembly Bill 310 (Ma) would put a stop to so-called "tiered pricing" of medications. Currently, an insured person may be required to make co-payment for prescribed medication. Usually the payment will be a fixed amount, that is, a fixed-dollar amount. Insurance companies want patients to pay more for some medicines than others, that is, not a fixed-dollar ammount, but a percentage of the cost. That means patients will pay more for certain medications than for others despite being insured. The percentage may rise or fall at the pleasure of the insurance company which may use this method to delay or defray outright raises in insurance premiums. AB 310 will limit the amount of co-payment that the insurance company can force subscribers to pay. At the time of this writing this legislation would target medications costing more than $150 per month.

Pharmaceutical companies favor the bill because it'll make their medications, especially the expensive ones, more accessible. Physicians should favor the bill because it'll remove one more layer of bureaucratic utilization control. Currently, physicians may prescribe the best medication for their patients only to find out that the insurance company for the patient has put the medication out of reach. Meanwhile, the physician retains medical liability.

Assemblywoman Fiona Ma previously carried AB 245 which would have required government agencies including the medical board to expunge unproved allegations against accused physicians from government websites. That bill did not pass. This one should.

This writer called Speaker Perez's office to request that AB 310 come to the floor for a vote.