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Scientists Pursue Anti-Ageing Treatments

In September life-science company Calico, which was set up by Google last year to investigate the aging process, joined with U.S. drugmaker AbbVie in committing an initial $250 million apiece to developing cures for age-related diseases. Away from the limelight, however, Switzerland’s Novartis and Denmark’s Novo Nordisk are already testing new roles for existing drugs, which could keep people alive for longer, as they look to cater to the ever larger numbers living into their 80s and beyond. “Everybody now is talking about the aging population and how to have a healthy old age,” said Mads Krogsgaard Thomsen, Chief Science Officer at Novo Nordisk.

The goal is not to create some “elixir of life” pill to help people live ever longer, but rather to maximize healthy lifespan and reduce the period of end-of-life sickness and dependency.Alex Zhavoronkov, chief executive of Baltimore-based biotech company Insilico Medicine, believes shifting healthcare spending from treatment to prevention will be central to this.

Research into anti-ageing drugs has historically received little attention from Big Pharma, given the difficulties of running clinical trials to prove such an effect. Moreover, companies have been deterred by regulators in the United States and Europe who will only approve medicines for specific illnesses and not for something as broad as aging, which is not in itself defined as a treatable disease. Despite these obstacles, Novartis has completed a successful pilot trial examining its cancer drug everolimus as a potential treatment to reverse immunosenescence, or the gradual deterioration of the immune system that occurs with age and is a major cause of disease and death.

Encouraged by studies showing that the closely related drug rapamycin extended the lifespan of worms, flies and mice, Novartis looked for ways to assess whether everolimus could have a similar effect in humans. The hurdles were high. Aging is a gradual, decades-long process making it impractical to assess directly in clinical trials. “For aging you have to pick a target system that can be investigated in months or years, not decades,” said Novartis’s head of research Mark Fishman. The company’s work-around is to focus on immunosenescence. It gave 218 people aged over 65 a six-week course of everolimus followed by a regular flu vaccine after two weeks.

Results showed that taking the drug improved the immune system response by more than 20 percent compared to placebo, potentially opening the door to use it as a treatment to increase the efficacy of vaccines and help stave off the infections associated with old age. While Fishman stresses the research is still early-stage, Novartis’s work highlights the growing interest in aging as a biological process that can be manipulated, treated and delayed.

Given the regulatory barriers, experts believe re-purposing existing treatments in new indications will likely be the fastest way to get drugs with an anti-ageing benefit to market, since these medicines have already been proven safe. A study published in the journal Neuropharmacology this week found lixisenatide, a drug sold as Lyxumia by Sanofi to treat type 2 diabetes, could slow nerve cell damage in mice with some of the hallmarks of Alzheimer’s disease. Other diabetes drugs may have a similar effect. Imperial College London is currently recruiting around 200 patients with mild Alzheimer’s for a study with Novo Nordisk’s diabetes drug liraglutide, or Victoza. “It would be fantastic if we were able to take a safe and simple type 2 diabetes medicine and use that in Alzheimer’s,” said Novo’s Thomsen.

The Danish company, which is the world’s biggest maker of insulin, is also working with academics at the University of Oxford, the Karolinska Institute and the University of Copenhagen on a new project looking at healthy aging. Its interest in the field has a scientific logic, since some of the genes that researchers are now exploring as factors in healthy aging have links to the body’s insulin pathways.

Once again, scientific developments have to be considered when calculating long term claim reserves in life pension cases, and life time medical awards. The future is sure to be full of surprises.

New California Law Follows WHO Naloxone Guideline to Reduce Opioid Deaths

Opioids are potent respiratory depressants, and overdose is a leading cause of death among people who use them. Worldwide, an estimated 69 000 people die from opioid overdose each year. Among people who inject drugs, opioid overdose is the second most common cause of mortality after HIV/AIDS. A recent rise in opioid-overdose deaths in a number of countries is associated with an increase in the prescribing of opioids for chronic pain. In 2010, an estimated 16 651 people died from an overdose of prescription opioids in the United States of America alone.

New World Health Organization (WHO) guidelines, released this month aim to reduce the number of deaths from opioid overdose globally by providing evidence-based recommendations on the availability of naloxone for people likely to witness an opioid overdose along with advice on the resuscitation and post-resuscitation care of opioid overdose in the community. The guidelines recommend countries expand naloxone access to people likely to witness an overdose in their community, such as friends, family members, partners of people who use drugs, and social workers. In most countries, naloxone is currently accessible only through hospitals and ambulance crews who may not manage to get help to the people who need it fast enough

According to the Guideline, people dependent on opioids are the group most likely to experience an overdose. The incidence of fatal opioid overdose among opioid-dependent individuals is estimated at 0.65 per 100 person years. Non-fatal opioid overdoses are several times more common than fatal ones.Although people taking prescribed opioids are at lower risk of overdose than people using unprescribed opioids. The high number of people receiving prescribed opioids in many countries mean that they constitute a significant proportion of opioid overdose deaths, if not the majority. Risk factors for overdose in people taking prescribed opioids include higher prescribed dosage, male gender, older age, multiple prescriptions (including benzodiazepines), mental health disorders and lower socioeconomic status. The risk of overdose is significantly higher where the prescribed dose is 100 mg morphine equivalents daily or greater.

Opioids depress the respiratory drive and overdose is characterized by apnoea, myosis and stupor. A severely reduced respiration rate results in hypoxaemia, leading to cerebral hypoxia and impaired consciousness. Cardiac arrest is a late complication of opioid overdose and secondary to respiratory arrest and hypoventilation. Prolonged cerebral hypoxia is the mechanism for brain injury and death in opioid overdose, resulting from apnoea or cardiac dysrhythmias and cardiac arrest.

The Guideline concluded that death in opioid-overdose can be averted by emergency basic life support resuscitation and/or the timely administration of an opioid antagonist such as naloxone. Most opioid overdoses occur in private homes, and most of these are witnessed. Close friends, a partner or family members are most likely to witness an opioid overdose. The other key group of individuals likely to witness overdoses are people working with people who use drugs. They include trained health professionals and first responders, such as ambulance, police, fire and drug-treatment workers as well as outreach workers. Naloxone has been used in the management of opioid overdose for more than 40 years. It is a safe drug with a low risk of serious side effects. Any adult capable of learning basic life support can also learn to recognize an opioid overdose, and administer naloxone in time to save lives.

Naloxone is a prescription medicine in almost all countries. In recent years, several countries in different regions have started distributing naloxone to people likely to witness an opioid overdose, initially in pilot programs, but now also in some cases state or national policy, demonstrating the feasibility of this approach and prompting calls for widespread adoption of this approach.

The California legislature passed Assembly Bill No. 1535 this year and it was signed by the Governor on September 15, 2014. The new law adds Section 4052.01 to the Business and Professions Code, relating to pharmacists. Existing law, generally, authorizes a California pharmacist to dispense or furnish drugs only pursuant to a valid prescription except for nicotine replacement products and emergency contraceptives and hormonal contraceptives. The new law would now also authorize a pharmacist to furnish naloxone hydrochloride in accordance with standardized procedures or protocols developed and approved by both the Pharmacy Board and the Medical Board of California, in consultation with specified entities. The new law would authorize the California State Board of Pharmacy to adopt emergency regulations to establish the standardized procedures or protocols that would remain in effect until the earlier of 180 days following their effective date or the effective date of regulations adopted as described above. California therefore will provide non prescription access to naloxone and will be on the forefront of these new WHO Guidelines. Claim examiners may wish to take advantage of this new law in cases where risk factors are high for overdose.

Lake Tahoe Skier Gets One Year Sentence

A former U.S. Postal Service employee from South Lake Tahoe has received a one-year prison sentence for making a false statement to obtain workers’ compensation.

According to the Sacramento Bee, Mark E. Leung, 60, was sentenced Tuesday in Sacramento by U.S. District Judge John A. Mendez. In addition to the prison sentence, the judge ordered Leung to pay $160,000 in restitution, according to a U.S. Attorney’s Office news release.

Court documents indicate Leung worked for the U.S. Postal Service until 1987, when he claimed he suffered a work-related injury. He never returned to full-time employment with the Postal Service and began receiving workers’ compensation benefits in 1987.

From September 2007 through November 2012, Leung received approximately $160,000 in benefits from the Department of Labor, which administers the program for the U.S. Postal Service, authorities said. To obtain the benefits, Leung submitted an annual certification form and had his medical providers attest that he could not perform any work due to the pain that limited his mobility and range of movement.

But while claiming he was totally disabled for employment, Leung maintained a yearly ski pass for Heavenly Ski Resort, where he regularly skied at least 40 days per ski season, authorities said. In addition, they said, Leung was observed performing arduous physical labor on numerous days.

The case resulted from an investigation by the U.S. Postal Service, Office of Inspector General, and the Department of Labor, Office of Inspector General.

UC Davis Biomedical Engineers Improve Lab-Grown Tissues

Lab-grown tissues could one day provide new treatments for injuries and damage to the joints, including articular cartilage, tendons and ligaments. Cartilage, for example, is a hard material that caps the ends of bones and allows joints to work smoothly. UC Davis biomedical engineers, exploring ways to toughen up engineered cartilage and keep natural tissues strong outside the body, report new developments in the journal Proceedings of the National Academy of Sciences.

“The problem with engineered tissue is that the mechanical properties are far from those of native tissue,” said Eleftherios Makris, a postdoctoral researcher at the UC Davis Department of Biomedical Engineering and first author on the paper. Makris is working under the supervision of Professor Kyriacos A. Athanasiou, a distinguished professor of biomedical engineering and orthopedic surgery, and chair of the Department of Biomedical Engineering.

While engineered cartilage has yet to be tested or approved for use in humans, a current method for treating serious joint problems is with transplants of native cartilage. But it is well known that this method is not sufficient as a long-term clinical solution, Makris said.

The major component of cartilage is a protein called collagen, which also provides strength and flexibility to the majority of our tissues, including ligaments, tendons, skin and bones. Collagen is produced by the cells and made up of long fibers that can be cross-linked together.

Researchers in the Athanasiou group have been maintaining native cartilage in the lab and culturing cartilage cells, or chondrocytes, to produce engineered cartilage. “In engineered tissues the cells produce initially an immature matrix, and the maturation process makes it tougher,” Makris said.

Knee joints are normally low in oxygen, so the researchers looked at the effect of depriving native or engineered cartilage of oxygen. In both cases, low oxygen led to more cross-linking and stronger material. They also found that an enzyme called lysyl oxidase, which is triggered by low oxygen levels, promoted cross-linking and made the material stronger.

“The ramifications of the work presented in the PNAS paper are tremendous with respect to tissue grafts used in surgery, as well as new tissues fabricated using the principles of tissue engineering,” Athanasiou said. Grafts such as cadaveric cartilage, tendons or ligaments – notorious for losing their mechanical characteristics in storage – can now be treated with the processes developed at UC Davis to make them stronger and fully functional, he said. Athanasiou also envisions that many tissue engineering methods will now be altered to take advantage of this strengthening technique.

The plethora of medical developments on the horizon pose a mixed dilemma for workers’ compensation claims administrators when reserving long term medical costs and settlements.  On one hand, the cost of exotic medical care will no doubt drive higher reserve estimates for these procedures in the future.  On the other hand, if these treatments are successful, costs should at some point be reduced to the extent of less effective care that is no longer needed.  An accurate reserve estimate may be somewhat difficult to establish between these forces.

Injured Worker Loses Legal Malpractice Claim

Richard Hamp Sr. worked as a ready-mix concrete driver for Hanson Aggregates Pacific Southwest, Inc. The job includes driving and delivering concrete material. The delivery responsibilities require the driver to load and unload concrete material through heavy chutes that must be removed from the truck frame, attached to the rear of the truck, and then reloaded on the truck after the delivery is complete. In July 2004, Hamp injured his back at work. He filed a workers compensation claim and was on medical leave for the next several years.

Hanson Pacific made a decision to terminate Hamp based on its asserted conclusion that Hamp’s disabilities (as described in its workers compensation carrier’s report) precluded him from performing the key functions of his job (including the heavy lifting and bending requirements). However, Hanson Pacific did not send a letter to Hamp notifying him of this decision. Hamp contacted Hanson Pacific and inquired about his employment status. At that time, he first learned that he had been terminated. The next month, in December 2007, Hanson Pacific wrote a letter to Hamp confirming his 2006 termination and stating that it had been willing to seek to accommodate his disabilities before it terminated him, but Hamp never responded to its inquires and letters. Hamp denied this version of events and maintained that he had asked for accommodations but Hanson Pacific never responded to his requests.

In January 2008, Hamp retained Harry Harrison Esq., to bring a lawsuit challenging his employment termination. During November 2008 and January 2009, Hanson Pacific’s attorneys took Hamp’s deposition over three different days. In his deposition testimony, Hamp acknowledged he still had back problems and never received medical clearance to return to his ready-mix driver job. When asked if he thinks he is “physically capable of returning to work as a ready mix driver . . . ,” Hamp responded: “I can’t answer that. I don’t know.” He said he is not sure whether the problem would “flare[ ] up” if he returns to his job. When Hanson Pacific’s attorney asked Hamp about his PTPs certification to the EDD in June 2007 that he was not capable of returning to work because he could not perform the physical duties of the ready-mix driver job, Hamp indicated he agreed with that statement.

During the lawsuit, Harrison defeated Hanson Pacific’s summary adjudication motion on Hamp’s wrongful termination claim based on evidence showing Hanson Pacific failed to make efforts to accommodate Hamp’s disability. About five or six months later, in February 2010, Harrison wrote an email to Hamp explaining the weaknesses in his case and urged Hamp to accept Hanson Pacific’s $8,000 settlement offer. After Hamp refused to accept this offer, the attorney-client relationship broke down. Several months later, in May 2010, Harrison obtained the court’s approval to withdraw from the representation.

Shortly after, Hamp obtained new counsel, but the court ultimately found in Hanson Pacific’s favor on the accommodation issue and entered judgment for Hanson Pacific. Hamp then sued Harrison, and his firm Harrison Patterson O’Connor and Kinkead alleging breach of fiduciary duty and attorney malpractice. The primary focus of the complaint was on the Third Job Description produced by Hanson Pacific in the underlying lawsuit. Hamp alleged this job description “was entirely fraudulent and was produced . . . to defraud the court and prejudice the proceedings against the interest of [Hamp].” On the malpractice cause of action, Hamp alleged Harrison failed to identify and seek exclusion of the “fraudulent” job description. After considering the papers and conducting a hearing, the court granted Harrison’s summary judgment motion, finding the undisputed facts showed Hamp could not prevail on any of his causes of action. The court also overruled the parties’ numerous evidentiary objections. The dismissal of his malpractice claim was affirmed in the unpublished case of Hamp v Harrison Patterson etc.

The record of the underlying action shows Harrison’s litigation strategy was to acknowledge that Hamp was disabled and could not perform the ready-mix job without accommodation, and to use these facts to support the theory that Harrison considered the strongest: Hanson Pacific breached legal duties by failing to engage in the legally-required interactive process to identify a position that would accommodate Hamp’s disability. Under this strategy, the difference between the First Job Description and the Third Job Description was not material. Even assuming Hamp could not return to the ready-mix driver job, there is California law supporting that an employer must engage in an interactive process to determine whether any reasonable accommodation is possible. (See Wysinger v. Automobile Club of Southern California (2007) 157 Cal.App.4th 413, 424-425.) Whether Harrison’s strategy was a competent one is not a matter of common knowledge. An expert witness was necessary to evaluate whether this litigation strategy was within the range of reasonable tactical decisions, particularly given Hamp’s concessions at his deposition and his prelitigation admissions that he could not engage in the heavy lifting or repeated stooping and bending required for the job. Hamp did not present any expert evidence to support his theory that Harrison breached his duty by failing to challenge the Third Job Description. Generally, expert witness testimony is required in a professional negligence case to establish the applicable standard of care, whether that standard was met or breached by the defendant, and whether the defendant’s negligence caused the plaintiff’s damages.

Details Emerge About Fake Spinal Screws

Spinal Solutions founder. Roger Williams spent 16 years in the orthopedic sales business with his father before he went out on his own. He started Spinal Solutions in 1999 and launched a firm selling knee and hip implants three years later. From nothing, he built an $18 million-a-year business based in Murrieta, California. Williams and his wife had a BMW, a Mercedes-Benz, a yacht named “Spare Change” and a 6,300-square-foot Murrieta home, according to court records and interviews. He ordered his seven-seat jet painted with stripes of Lakers purple and gold, and he and his wife sat courtside among celebrities at Laker games, according to interviews with former employees.

But Spinal Solutions also racked up big debts with hardware manufacturers and then refused to pay, according to industry executives and lawsuit allegations.The company increasingly relied on Lenders Funding LLC, a firm that fronted cash at an interest rate of 35 percent. By 2013, the company owed the lender about $35,000 per month – solely in interest payments – and imploded in debt.

Spinal Solutions could not have raked in millions or spread its products across the U.S. if not for doctors eager to do business. Roger Williams allegedly lured them with private plane rides, generous consulting contracts and even cash. Williams made it clear the consulting deals and free flights were tools to keep doctors hooked on his products, said Quin Rudin, a businessman who poured money into the company when it hit a cash crunch in 2012. “He said that many times. ‘In order to do business with these guys, I gotta take care of them,’ ” Rudin recalled from behind thick glass in a downtown Oakland jail, where he landed after pleading guilty in an unrelated fraud case.

Although the true extent of the caper remains buried in the necks and backs of people scattered around the U.S., it began to unravel in 2009 when evidence of the scheme landed in the receiving room of Ortho Sol, a surgical supply firm in South Africa. Ortho Sol makes precision screws for the most delicate of construction projects: spinal fusion. The company had repossessed some of its screws after Spinal Solutions LLC stopped paying its bills. Nestled with the returns, the brighter yellow luster of a few screws caught Richard Walker’s eye. Testing confirmed his fears. Some were not made of his firm’s medical-grade titanium. Their uneven threads showed potential for backing out or breaking, he said. He feared the laser-etched markings intended to make them look authentic could be toxic to patients.

More evidence – Derika Moses hefted a case of 2-liter soda bottles while setting up a grocery store display in 2007. Nothing helped. In desperation, Moses opted for spinal fusion surgery.The procedure offered little relief. Five years later, she had most of her spinal hardware removed, convinced that the erector set of metal in her spine was the source of ongoing problems. Attorneys contacted Moses after finding her name among Spinal Solutions’ sales records. CIR showed photos of Moses’ hardware to U and I, the South Korean company whose logo was etched on it. Company engineers noted the finishes and lot numbers on some of Moses’ screws and connectors did not match their product. But the dead giveaway was the logo, they said, which lacks the firm’s signature forward-leaning font. During an interview at the company’s U.S. office in Orange County, California, General Manager Sung Hwang identified three of Moses’ four screws as fakes. “This is obviously not what we did,” Hwang said. “I feel sorry because (patients) got the surgery with improper devices, so they might suffer from it.”

The screws, real or fake, all funneled into what lawsuits claim was a larger scheme to bilk California’s workers’ compensation system. Some hospitals billed insurance carriers as much as $12,500 a screw before a 2012 change in state law shut down the astronomical markups. From that, Spinal Solutions stood to reap several thousand dollars from the sale of a single screw.

The source of the counterfeits, plaintiffs’ attorneys allege, was 85-year-old machinist William Crowder. He owns a small office park machine shop in Southern California’s Inland Empire. He had experience working on parts for boats, planes and, it appears, the human body. In an interview with CIR, Crowder said Spinal Solutions’ operations manager, Jeff Fields, gave him professional-looking medical screws and asked for exact copies. “He might want 50 of this size and 40 of these,” said Crowder, who has been named as a defendant in dozens of lawsuits. Plaintiffs’ attorneys believe that thousands of counterfeit screws went into unsuspecting patients, though Crowder testified in a recent deposition to making “maybe 500.” Crowder also said he didn’t etch anything on the screws he made for Spinal Solutions. Instead, that trail seems to lead to another Spinal Solutions contractor, Ryan Zavilenski. On his YouTube page, Zavilenski boasts of owning a laser engraver. He also posted photos of spinal implants on his photo-sharing website. From behind the screen door of his Santa Rosa, California, apartment, Zavilenski confirmed to CIR that he did laser engraving for Spinal Solutions several years ago. He said he engraved only a few screws, however, which he called prototypes.

DWC Adjusts Outpatient Hospital and ASC Fee Schedule

The Division of Workers’ Compensation (DWC) has posted adjustments to the hospital outpatient departments and ambulatory surgical centers section of the official medical fee schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1. The changes take effect December 1, 2014.

L.C. 5307.1(g)(1)(A)(i) provides that the annual inflation adjustment for outpatient hospital facility fees shall be determined solely by the estimated increase in the hospital market basket. Thus, in lieu of using the Medicare 2014 rates to determine the updated OMFS amounts, the estimated increase in the hospital market basket was applied to the 2013 OMFS rate. The 2013 unadjusted conversion factor was $70.761. The estimated increase in the market basket is 2.5%. The revised unadjusted conversion factor under the OMFS is $72.530 ($70.761 x 1.025).

Section 9789.34 Table A sets forth the wage index values and adjusted conversion factors that are applicable to ASCs. These conversion factors would also be applicable to any hospitals that are not in Table B (section 9789.35). Section 9789.35 Table B sets forth hospital-specific wage index values and adjusted conversion factors for services rendered on or after December 1, 2014. Table B reflects the additional 7.1% payment adjustment for services rendered by rural sole community hospitals and EACHs.

More information and the adjustments to the hospital outpatient departments and ambulatory surgical centers section of the OMFS can be found on the DWC OMFS page

San Gabriel Physician Faces 339 Years for Drug Trafficking

A San Gabriel Valley doctor has pleaded not guilty to federal drug trafficking charges that allege he illegally distributed drugs that include the powerful and addictive painkiller oxycodone. Dr. Daniel Cham, 47, was arraigned on a 31-count indictment and a trial was scheduled for December 16. Bond was set at $140,000, and Cham was ordered to serve home detention while free on bond and was prohibited from practicing medicine. If convicted of the 31 counts in the indictment, Cham would face a statutory maximum sentence of 339 years in federal prison.

The indictment, which was returned by a federal grand jury on October 7 and unsealed when the defendant was arrested, charges Cham with drug trafficking, money laundering, fraud and making false statements to federal authorities. The indictment focuses on prescriptions Cham wrote at various locations, including his medical offices in La Puente and Artesia. The drugs involved in the allegedly illegal prescriptions include oxycodone (a powerful narcotic painkiller best known under the brand name OxyContin), hydrocodone (a narcotic painkiller often sold under the brand names Vicodin and Norco), alprazolam (commonly known by the brand name Xanax), and carisoprodol (as muscle relaxer best known as Soma).

In May 2014, investigators executed federal search warrants at 13 locations, including Cham’s residence and medical offices. According to the affidavit in support of the search warrants, which was unsealed at Cham’s arraignment, the doctor often saw patients between 8 p.m. and 2 a.m. on Fridays, Saturdays and Sundays, and he post-dated prescriptions to make them appear to have been written on weekdays. In the year that ended in March 2014, Cham issued more than 5,500 prescriptions for controlled substances – primarily for oxycodone, hydrocodone, alprazolam and carisoprodol – and he issued more than 42,000 such prescriptions since July 2010, according to the affidavit.

The affidavit also discussed how an undercover officer made three visits to Cham’s La Puente office earlier this year, and how Cham wrote prescriptions for controlled substances in exchange for $200 or $300 in cash or money orders. As discussed in the affidavit, Cham issued a prescription for oxycodone even though the undercover operative said he “had been high and drunk while receiving controlled substance prescriptions” previously from Cham. On another occasion, Cham prescribed oxycodone even though the undercover law enforcement officer presented, in lieu of photo identification, a written notice that his license had been suspended for driving under the influence.

In addition to counts related to the undercover operation, the indictment charges Cham with fraudulently issuing prescriptions for controlled substances to Tracy Townsend, who used at least five false identities. Townsend, 51, of Studio City, is also charged in the indictment, but his whereabouts are currently unknown.

An investigation by IRS – Criminal Investigation and the Drug Enforcement Administration’s Financial Investigation Group showed that Cham used at least four bank accounts to launder the proceeds of his illegal prescriptions. The indictment charges Cham with concealing proceeds derived from the undercover visits by depositing them into an account held in the name of a separate business.

The investigation into Cham was conducted by the Drug Enforcement Administration, IRS – Criminal Investigation, the Los Angeles County Sheriff’s Department’s Health Authority Law Enforcement Task Force, the Federal Bureau of Investigation, the California Medical Board and the Los Angeles Police Department.

JPA Association Speakers Discuss Study on Quality Care

Early, proactive care from high-performing physicians produces superior outcomes at lower costs, according to information presented at the 2014 California Association of Joint Powers Authorities Conference held last month in Lake Tahoe, Calif.

The report in the Claims Journal says that speakers Gregory Moore, M.P.H., president and CEO of Harbor Health Systems, a One Call Care Management company, and Douglas Benner, M.D., chief medical officer of EK Health, presented both data and best practices to the audience of insurance-based risk sharing pool executives.

“The purpose of our study was to determine whether claims outcomes were impacted by delays in care, and whether accelerating care created unintended consequences,” said Moore. “The message here is that claims operations leaders need to look at practices or inefficiencies that are delaying care delivery and consider the financial impact of those delays. We feel strongly this opens further conversation around the evidence that identifying high-performing doctors and letting them practice assertive medicine produces the best outcomes, lowers costs and shortens claims duration.”

The findings demonstrated that the more aggressive approach to care by high-performing physicians had significant reductions in claim duration, indemnity costs and a lower incidence in litigation:

1) Reductions in claim duration from 13 – 20 percent;
2) Reductions in indemnity costs from 19 – 61 percent;
3) Reductions in litigation from 7.2 – 16 percent.

The following best practices should be followed to realize those benefits from proactive, early care:

1) When you can, identify providers that have a trusted track record and treat claims aggressively in order to decrease claim duration and total claim costs. Data shows that the longer the delay in care, the longer the claim duration and cost.
2) Integrate best-in-class physicians with the use of evidence-based guidelines in outcomes-based networks. Remember, guidelines are not absolute barriers on whether to approve care earlier – the key is to understand the patient and not delay care that is already identified as needed.
3) Break down the barriers involved in care coordination for efficiency, better results and faster return-to-work.

The presentation included data from a Harbor Health Systems study on the impact of aggressive care. The study reviewed information for more than 700,000 claims for four procedures: ACL (anterior cruciate ligament) repair, knee menesectomy, shoulder rotator cuff repair, and carpal tunnel injuries.

A free white paper highlighting the impact of aggressive medical care in workers’ compensation is now available.

WCAB Affirms WCJ Order For Lien Claimant to Appear

Ana Diaz filed an Application for Adjudication of Claim for injuries allegedly sustained to her right shoulder, right arm, right hand fingers, and lower back. Some of the alleged injuries were accepted by Zenith Insurance Company as industrial, and her claim was resolved by Compromise and Release approved on April 30, 2014.

Several outstanding lien claims remained unresolved, and the matter was set for lien conference on August 6, 2014. Hearing representative Javier Jimenez appeared at the lien conference on behalf of lien claimant California Imaging, who filed a lien for photocopying services. Zenith contended that California Imaging was not a properly licensed professional photocopier as required by the Business and Professions Code.

Hearing representative Javier Jimenez was unable to respond to defendant’s contention and unaware of lien claimant’s licensing status; was unable to explain billing characterized by the WCJ as “less than clear”; and was generally unable to respond to inquiries regarding the issues in dispute and appeared unfamiliar with the file. Mr. Jimenez advised the WCJ that his only authority .was to set the matter for lien trial. When asked by the WCJ to identify the person most knowledgeable at California Imaging regarding. ‘the licensing and billing issues, Mr. Jimenez named Maria Rubio Trujillo, and further stated that Trujillo advised him that the “proper” name of lien claimant California Imaging is actually San Diego Imaging.

The WCJ then continued the lien conference to August 22, 2014, and ordered Trujillo to personally appear “in order to explain lien claimant’s billing, address the licensing issue, and explain the relationship between California Imaging and San Diego Imaging to determine the true identity of the lien claimant.” Trujillo’s petition for reconsideration and for removal followed.

Trujillo contends in her petition that she has unspecified personal and family responsibilities as well as work duties that would be “severely and unreasonably impacted” in unspecified ways by her personal appearance in Oxnard, and contends in essence that the Order was an abuse of discretion and a product of bias against her and/or lien claimant California Imaging by the WCI.

The WCAB dismissed the petition for reconsideration as there was no final order subject to reconsideration, and denied removal in the case of Diaz v Sambrailio.

The Workers’ Compensation Appeals Board and individual WCJs have broad power to do all things necessary or convenient to fully adjudicate the disputed issues and to ascertain the substantial rights of the parties and carry out justly the spirit and provisions of the Labor Code. This includes the inherent power to control the WCAB’s practice and procedure to prevent frustration, abuse, or disregard of its processes which in tum includes the power to order the personal appearance of parties at hearings (Rule 10240( d); Henkel v. State Comp. Ins.Fund (2010) 38 Cal. Workers’ Comp. Rptr. 218 (ADJ4197101, Appeals Board Panel Opinion)).

Rule l 0770.1 subdivision (e), provides in relevant part. that every party or representative appearing at a lien conference or lien trial “shall have sufficient knowledge of the lien dispute(s) to inform the Workers’. Compensation Appeals Board as to all relevant factual and/or legal issues in dispute.” As explained by the WCJ in his Report, the representative for lien claimant California Imaging was unable to respond to reasonable inquiries regarding the licensing issue, nor was he able to provide more basic information such as an explanation or clarification of the disputed billing. Because the representative was unable to comply with Rule 10770.1 (e), the WCJ was unable to meaningfully discuss the issues with the parties or determine whether there were disputes that required a lien trial. It was within the WCJ’s discretion to continue the matter to another date and to require lien claimant’s person most knowledgeable to appear, so that a meaningful conference could be held. The Order for Trujillo to personally appear was not arbitrary, capricious, unreasonable, or improperly motivated.