AB 72 (Bonta) targets physicians but leaves insurance companies and MPNs unscathed

Governor Brown signed AB 72 (Bonta) to put a stop to "surprise billing" but he left intact the ability of Medical Provider Networks (MPNs) and insurance companies to skimp on medical coverage, for instance, by not retaining enough specialists. When the MPN's patients then need the specialist that the MPN can't provide, "out-of-network" specialists are summoned. The "out-of-network" physicians, since they're not in-network, may bill at higher rates than the MPNs -- this practice has resulted in unpleasant surprises to patients when they learn that the medical bills they're getting are higher than expected because the specialist called in at the last minute was "out-of-network." This practice ends with Bonta's legislation which targets doctors but spares MPNs. Here's the scoop: the MPN purposefully retains too few doctors, especially specialists, in order to avoid paying "in-network" specialists. This desultory practice is known as "network contraction" or "in-network sharing." It allows more of subscribers' premium payments to be used for increased executive compensation instead of for patient care. Bonta's bill could have fixed this aspect of the problem along with the smack-down on "surprise billing." Only Bonta didn't want to ruffle the feathers of the insurers and MPNs. This writer recommends for legislative year 2017 that CMA, CSIMS, CNS, and UAPD seek legislation requiring MPNs to field fully staffed networks so that "out-of-network" doctors are no longer needed. The legislation needed would require that MPNs be fully  staffed or else -- the or else would be dissolution of the MPN for non-compliance.

IS MANDATORY MALPRACTICE ORDERED TO BEGIN ON TUESDAY, 1 SEPTEMBER 2015?

According to workcompcentral's newsletter, 2015-08-27, California's Division of Workers Compensation has ordered that as of 1 September 2015 "clinical neuropsychology will no longer be a recognized medical specialty." This decision by DWC was approved by the Office of Administrative Law on 8/12/15. The ruling means that "the elimination of the specialty designation for clinical neuropsychology" goes into effect on September 1st. 

Clinicians, particularly psychologists with specialized training in neuropsychology, will at first blush be astonished that the authority of the DWC can be used to ease the way for medical malpractice. On second look clinicians have observed that the workers comp system is rigged against fair hearings for injured workers, for instance, nearly 90% of Utilization Review (UR) denials are upheld by anonymous Independent Medical Reviewers (IMRs). 

Keep in mind that MPNs (Medical Provider Networks) pre-select their own clinicians and then step aside as disproportionate numbers of their own clients get denied treatment by the mandatory UR panels created by SB 863 and which usually have links to insurance companies. The MPNs step aside when IMRs such as Maximus slavishly confirm the treatment denials. 

In the case of neuropsychology, we know that psychologists with special training in traumatic brain injury (TBI) are uniquely qualified to make diagnostic and treatment decisions about TBI. In fact, Assemblyman Devon Mathis, R-Visalia, co-author of AB 1542 along with Assemblyman Ken Cooley, D-Rancho Cordova, testified in favor of AB 1542 before the Senate
Committee on Labor and Industrial Relations to the effect that while general psychologists deal with mental injuries neuropsychologists are specially educated and trained about TBI.

Assemblyman Mathis' credentials include a Purple Heart for TBI sustained during an IED attack in Iraq in 2008. The point of Mathis' testimony is that the best recommendations for diagnosis and treatment for him and for injured workers who sustain TBI on-the -job is through adequate diagnosis and work-up that requires TBI expertise. Anything else, in this writer's opinion, amounts to inferior treatment. It can now be argued with reasonable medical probability that DWC has in this case imposed a restriction that arguably can be stated to suborn malpractice by advocating and in fact eliminating NeuropsycheQME as a separate and distinct clinical specialty. 

That is why it's obligatory to make sure that AB 1542 which would protect neurospsyche as a designated specialty makes it through the legislature where it's already passed the Assembly 79 to 0 and then persuade the the governor to  sign the bill into law. 

Then we'll need to know whence the misguided direction arose that convinced Director Christine Baker to file a letter in support of eliminating neurospyche as a specialty and to combine it with the more general classification of psychology absent recognition of specialized TBI education and training. One will also need to ask if there is a need for re-education and restructuring within DWC. 

This author previously addressed this issue in an editorial reprinted by workcompcentral, 2015-05-20, "Does Somebody Want to Sabotage Neuropsychological Evaluations?" This issue deserves continuing investigation and reporting. 

References

Workcompcentral, "QME Rules Take Effect Tuesday," 2015-08-27

The Weinmann Report, www.politicsofhealthcare.com, 4/24/2015

CSIMS, "Comments on DIR Director Christine Baker's Opposition to AB 1542, 8/12/2015

Department of Industrial Relations, letter by DIR Baker, 7/29/2015

Voters Injured at Work, Support letter for AB 1542, Jesse Ceniceros, VIAW president

Brain Injury Association, Support letter for AB 1542, 8/03/2015

California Neurology Society, Support letter, Steve Cattolica, Legislative Advocate, 6/04/15

WHEN PATIENTS GET TOO EXPENSIVE TO TREAT

What do insurance companies do when medical expenses get too high for comfort?  How may insurance companies deal with expanding medical costs that lower shareholder return and that may cause reduced executive compensation?

Currently, rituxin is one of the newer agents recommended for the active phase of acute demyelinating disease, multiple sclerosis in particular, but also extending to a complicated condition known as "lupoid sclerosis." Robyn G. Young, MD, Alameda, formely, president of the California Neurology Society,  states that this treatment is a preferred regimen for active system disease. e.g., MS/demyelination accompanying systemic SLE.

However, reluctance on the part of payers to cover this regimen has been noticed by frustrated clinicians whose treatment decisions may be delayed or denied by insurers who may assert that a specific treatment regimen is "experimental" and therefore not eligible for coverage under the plan. If that happens, the patient is then denied insurance coverage and may have to pay for treatment out-of-pocket while the insurance company continues to bill for its alleged coverage, whatever of that remains once what the patient currently needs is denied. 

Insurance companies have other ways of controlling costs. One of these other ways is to limit access to physicians to cover the number of enrolled subscribers. That increases the length of time it'll take to see a physician, especially a specialist, which in turn reduces expenses for the insurance company, which in turn allows more favorable financial quarterly reports to be issued. Another technique is to drop physicians from the MPN (medical provider network) based purely on business reasons -- no allegation of poor medical practice need be made. This latter technique reduces short-term expenses, allows for more favorable financial reports on a quarterly basis, and runs little risk of collectively increased long-term expense because of delays of care. Keep in mind that in workers comp, for instance, Temporary Disability (TD) runs out in two years. 

Doctor Young stated that "our patients should not be the victims of either insurance or pharma greed ... the physician has been devalued while all the other entities with financial interests in rationing patient care have been elevated in control and influence."

That is why some medical organizations seem poised to fight simultaneously for their patients' rights as well as for the rights of member physicians lest the latter become indentured servants dependent either on the corporate mentality that rules Big Biz or the other corporate mentality that rules government. In this regard watch for a likely take-down on an aspect of Obamacare (Affordable Care Act). The case is King versus Burwell, Docket # 14-114, set for SCOTUS argument beginning on 4 March 2015. The case deals with an IRS ruling re availability of federal tax subsidies to persons who bought health insurance on exchanges run by the federal government -- we'll cover more on that in future columns.

In the meantime, Doctor Young's conclusion  that "it is time that we (physicians) took back our role as patient care advocates" should be shouted from physician rooftops everywhere.

References

"Regaining Control of Medical Practice," CLINICAL EEG,  c. 1995, V. 26, #1 (reprints available SSAE upon request to Dr. Weinmann, 2040 Forest Avenue, #4, San Jose, CA. 95128)

"Union head urges reform in health care," THE OAKLAND TRIBUNE,  4 November 1998 (White House press conference with then President Bill Clinton)