Author: WorkCompAcademy

Republican Robert Howell will face Democratic incumbent Ricardo Lara in the race for insurance commissioner after edging Democratic Assemblyman Marc Levine for the second spot on the November ballot.

Howell, a cybersecurity equipment manufacturer, bills himself as a “Reagan Republican,” and has pledged if elected to “serve as your personal watchdog guarding against waste, fraud, and abusively inflated premiums.”

No Republican has won statewide office in California since 2006 when Arnold Schwarzenegger was re-elected as governor and Steve Poizner was elected as insurance commissioner.

During the primary campaign, Lara touted his work related to wildfires, including helping create the first “Safer from Wildfires” framework and issuing regulations requiring insurance companies to use the framework in pricing.

“There’s nothing that substitutes for the experience I have in this position working directly with consumers and wildfire survivors,” said Lara, California’s first openly LGBTQ+ statewide elected official.

Levine conceded Wednesday, acknowledging on social media, “there simply aren’t enough uncounted ballots left to change the outcome of the election.”

Howell entered Wednesday’s resumption of the count of unprocessed ballots with a 4,921-vote lead and increased the lead to 6,393, according to figures released Wednesday morning by the Secretary of State’s Office.

Each year, Merative 15 Top Health Systems conducts a rigorous analysis of US health system performance based on metrics aggregated from individual hospital data. The result is a list of the top performing US health systems in the nation – based on a balanced scorecard derived from publicly available clinical, operational and patient experience data.

This year Scripps Health has been named one of the top five medium-sized health care systems in the nation by Merative and the only health provider all of California to be included among a broader list covering the top 15 large, medium and small systems across the United States.

The systems were chosen by Merative from among 2,604 hospitals that were evaluated for their quality of care, operational efficiency and patient experience. They were announced in the online edition of Fortune magazine.

Merative evaluated 349 health systems and 2,604 hospitals that were members of those systems. The research was based on Medicare cost reports, Medicare Provider Analysis and Review data and data from the Centers for Medicare and Medicaid Services Hospital Compare website.

Hospitals included among the 15 best systems achieved better patient outcomes, fewer complications, shorter lengths of stay, lower readmission rates, fewer healthcare-associated infections, lower inpatient expenses, and higher ratings from patients.

Health systems do not apply for this annual listing, and winners do not pay to market the honor. Prior to 2018, the listing was produced by Truven Health Analytics.

Based on the research, the care delivered by the 15 best systems resulted in:

– – 16,000 additional lives saved
– – More than 17,000 additional patients being complication-free
– – A 5% reduction in healthcare-associated infections
– – Patients being discharged a half-day sooner

“Scripps is honored to receive this prestigious recognition once again and to be recognized as a top health system in the nation,” said Scripps President and CEO Chris Van Gorder. “This is the direct result of a constant effort by our physicians, nurses and employees to make sure the care we deliver to patients is the best available.”

The honor comes after more than two years of coping with a wide range of difficulties posed by the ongoing COVID-19 pandemic, noted Ghazala Sharieff, MD, MBA, Scripps corporate senior vice president and chief medical officer for acute care operations and clinical excellence. “We are particularly proud of this achievement considering the unprecedented challenges that we have faced recently. It’s a testament to Scripps’ long legacy of providing outstanding patient care.”

A federal judge rejected claims that the three largest US opioid distributors ignored warning signs when they sent millions of pills to a West Virginia community, handing a rare trial win for companies linked to the drug epidemic.

US District Judge David Faber said in an opinion Monday McKesson Corp., Cardinal Health Inc. and AmerisourceBergen Corp. didn’t create a public nuisance in Cabell County, West Virginia, and its largest city, Huntington. The plaintiffs alleged between 2006 and 2014, the companies delivered more than 127 million painkillers to pharmacies in the county — or about 142 pills annually for each man, woman and child in the area.

The judge concluded the local governments didn’t prove the distributors failed to put in place “effective controls” against opioids being diverted to illegal uses and couldn’t properly hold the companies accountable for billions of dollars in harms tied to the painkillers under state law.

The federal judge conceded in his 184-page ruling that the “opioid crisis has taken a considerable toll on the citizens of Cabell County and the City of Huntington, And while there is a natural tendency to assign blame in such cases, they must be decided not based on sympathy, but on the facts and the law.”

In the Cabell County case, lawyers argued the distributors ignored warning signs about excessive opioid orders from West Virginia pharmacies.

“We are deeply disappointed personally and for the citizens of Cabell County and the city of Huntington,- lawyers for the West Virginia local governments said in a statement. “We felt the evidence that emerged from witness statements, company documents, and extensive datasets showed these defendants were responsible for creating and overseeing the infrastructure that flooded West Virginia with opioids.”

Faber’s ruling reinforces arguments Cardinal Health’s lawyers made, Eric Timmerman, a company spokesman, said in a statement. The judge found the firm properly provides a “secure channel to deliver medications of all kinds from manufacturers to our thousands of hospital and pharmacy customers that dispense them to their patients based on doctor-ordered prescriptions.”

“Pharmaceutical distributors like AmerisourceBergen have been asked to walk a legal and ethical tightrope between providing access to necessary medications and acting to prevent diversion of controlled substances,” Gabriel Weissman, a company spokesman, said in a statement. “Today’s ruling will help enable our company to do what we do best — ensuring that health care facilities like hospitals and community pharmacies have access to the medications that patients and care providers need.”

The case is City of Huntington v. AmerisourceBergen, 17-cv-1362, US District Court, Southern District of West Virginia.

Bloomberg News reports that  West Virginia has been among the hardest-hit states in the opioid epidemic, with Cabell County’s overdose death rate more than five times the national average during the period covered by the suit, according to researchers. West Virginia officials opted out of a settlement with the distributors last year, arguing it didn’t provide for their local governments still battling the scourge.

In that settlement, McKesson, based in Irving, Texas, Cardinal Health, of Dublin, Ohio, and AmerisourceBergen, of Conshohocken, Pennsylvania, agreed to pay $21 billion to settle the vast majority of the thousands of opioid lawsuits filed by states and local governments across the US.

The strategy of suing opioid companies by alleging public nuisance has had a mixed track record. An Orange County Superior Court Judge, in November 2021, ruled in favor of four pharmaceuticals (including Endo and Teva) after a bench trial in a lawsuit brought by the counties Santa Clara, Los Angeles and Orange and the city of Oakland. That same month, an Oklahoma Supreme Court overturned a $465 Million ruling against Johnson & Johnson, rejecting the public nuisance argument.

However, juries that heard cases have backed nearly identical allegations in New York state court against opioid maker Teva Pharmaceuticals and in federal court in Ohio against pharmaceutical chains including CVS Health Corp.

San Francisco’s opioid lawsuit against Walgreens and a number of pharmaceutical companies commenced a court trial at the end of April, 2022. Lawyers for San Francisco claims that Anda, Allergan, Teva and Walgreens promoted and distributed the powerful painkillers in ways that created a public nuisance that endangered the health and safety of the city’s residents. The case is still underway as of the end of June, 2022.

Consumers, employers, and just about everyone else interested in health care prices will soon get an unprecedented look at what insurers pay for care, perhaps helping answer a question that has long dogged those who buy insurance: Are we getting the best deal we can?

As of July 1, health insurers and self-insured employers must post on websites just about every price they’ve negotiated with providers for health care services, item by item. About the only thing excluded are the prices paid for prescription drugs, except those administered in hospitals or doctors’ offices.

The federally required data release could affect future prices or even how employers contract for health care. Many will see for the first time how well their insurers are doing compared with others. The requirements stem from the Affordable Care Act and a 2019 executive order by then-President Donald Trump.

And according to Kaiser Health News, the new rules are far broader than those that went into effect last year requiring hospitals to post their negotiated rates for the public to see. Now insurers must post the amounts paid for “every physician in network, every hospital, every surgery center, every nursing facility,” said Jeffrey Leibach, a partner at the consulting firm Guidehouse.

“When you start doing the math, you’re talking trillions of records,” he said. The fines the federal government could impose for noncompliance are also heftier than the penalties that hospitals face.

Federal officials learned from the hospital experience and gave insurers more direction on what was expected, said Leibach. Insurers or self-insured employers could be fined as much as $100 a day for each violation, for each affected enrollee if they fail to provide the data.

Entrepreneurs are expected to quickly translate the information into more user-friendly formats so it can be incorporated into new or existing services that estimate costs for patients. And starting Jan. 1, the rules require insurers to provide online tools that will help people get upfront cost estimates for about 500 so-called “shoppable” services, meaning medical care they can schedule ahead of time.

Everyone will know everyone else’s business: for example, how much insurers Aetna and Humana pay the same surgery center for a knee replacement.

“These plans are supposed to be acting on behalf of employers in negotiating good rates, and the little insight we have on that shows it has not happened,” said Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, an affiliation of employers who offer job-based health benefits to workers. “I do believe the dynamics are going to change.”

“Maybe at best this will reduce the wide variance of prices out there,” said Zack Cooper, director of health policy at the Yale University Institution for Social and Policy Studies. “But it won’t be unleashing a consumer revolution.”

Still, the biggest value of the July data release may well be to shed light on how successful insurers have been at negotiating prices. It comes on the heels of research that has shown tremendous variation in what is paid for health care. A recent study by the Rand Corp., for example, shows that employers that offer job-based insurance plans paid, on average, 224% more than Medicare for the same services.

Tens of thousands of employers who buy insurance coverage for their workers will get this more-complete pricing picture – and may not like what they see.

“What we’re learning from the hospital data is that insurers are really bad at negotiating,” said Gerard Anderson, a professor in the department of health policy at the Johns Hopkins Bloomberg School of Public Health, citing research that found that negotiated rates for hospital care can be higher than what the facilities accept from patients who are not using insurance and are paying cash.

That could add to the frustration that Mitchell and others say employers have with the current health insurance system. More might try to contract with providers directly, only using insurance companies for claims processing.

Other employers may bring their insurers back to the bargaining table.

“For the first time, an employer will be able to go to an insurance company and say, ‘You have not negotiated a good-enough deal, and we know that because we can see the same provider has negotiated a better deal with another company,’” said James Gelfand, president of the ERISA Industry Committee, a trade group of self-insured employers.

The consolidated cases filed by Javier Espino against Fullerton Foods for 2001 injuries to his back, knees, right shoulder, pysche, sleep, and gastrointestinal system, were resolved by a July 28, 2015 C&R approval. The settlement left open the issues of medical treatment and lien of his daughter, Belinda Espino for the home health care she provided.

The parties proceeded to trial over the issue of the entitlement to home health care, both retroactively and prospectively, as provided by Ms. Espino. The defendant’s contended there was no request for authorization for home health care prior to June 21, 2016.and this was submitted to UR.

The WCJ awarded the disputed home health care. Reconsideration was denied in the panel decision of Espino v Fullerton Foods, ADJ326655-ADJ439309 (June 2022).

In resolving the contentions of the parties, the WCAB panel discussed significant procedural errors. It noted that the June 21 2016 UR determination did not specify that applicant’s attorney’s office was served although it was addressed to applicant at the address for his attorney’s office. And subsequent 2017 UR determinations were not served on his attorney as well.

In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298, 1299 (Appeals Board en banc) (Dubon II), the Appeals Board held that if UR is untimely the determination of medical necessity for the treatment requested may be made by the Appeals Board.

An employer has the duty to provide reasonable medical treatment upon learning of the need. (Lab. Code, § 4600). This was made clear by the California Supreme Court in Braewood Convalescent Hospital v. Workers’ Comp. Appeals Bd. (Bolton) (1983) 34 Cal.3d 159, 165 [48 Cal.Comp.Cases 566]. The Supreme Court wrote that “Section 4600 requires more than a passive willingness on the part of the employer to respond to a demand or request for medical aid. – This section requires some degree of active effort to bring to the injured employee the necessary relief” (Citations omitted.)

The WCAB panel noted another procedural error when it said that “It does not appear that defendant investigated applicant’s need for home health care or provided it pursuant to the opinions of the AME and Dr. Sohn despite its duty to expeditiously and actively investigate.”

Although the AME stated that applicant needed home health care for eight weeks in 2002, the record does not reflect that defendant provided it or investigated applicant’s need. Instead, post-surgery care was provided by applicant’s daughter. In his January 22, 2008 report, Dr. Sohn prescribed home health care, eight hours weekly, which was open-ended and did not limit the duration that applicant would need these services.

Because defendant did not take an active role in providing the needed medical treatment, it “becomes liable for the reasonable value of self-procured medical treatment.” (Bolton, supra, at p. 165.)

The WCAB panel noted another procedural error at the beginning of its option when it wrote “our review of the record is complicated by defendant’s failure to comply with WCAB Rule 10945(b), which provides, in relevant part: ‘[e]very petition for reconsideration …. shall support its evidentiary statements by specific references to the record.'”

It went on to write that “Here, defendant has violated Rule 10945(b), has failed to support its arguments with specific citations, and has not cited to the record as required. Defendant cannot evade this responsibility and place the burden on the Appeals Board to discover where the evidence supporting its petition can be found.”

And finally, the panel noted another procedural error when it wrote “Defendant has filed a Response to Applicant’s Answer to Petition for Reconsideration, without our permission and in violation of Workers’ Compensation Appeal Board (WCAB) Rule 10964. Although defendant should have complied with Rule 10964 and requested permission, we accept defendant’s supplemental pleading and include it in our deliberations.”

The takeaway from this case is that the WCAB is clearly urging practitioners – and the parties they represent – to strictly comply with the procedural requirements of the statutes and regulations that apply. In some cases, such as in the Utilization Review process, the failure to comply even with details of the service of documents can be a costly mistake.