Category: Daily News

In research published in the medical journal Brain, Saint Louis University researcher Daniela Salvemini, Ph.D. and colleagues within SLU, the National Institutes of Health (NIH) and other academic institutions have discovered a way to block a pain pathway in animal models of chronic neuropathic pain including pain caused by chemotherapeutic agents and bone cancer pain suggesting a promising new approach to pain relief.

The scientific efforts led by Salvemini, who is professor of pharmacological and physiological sciences at SLU, demonstrated that turning on a receptor in the brain and spinal cord counteracts chronic nerve pain in male and female rodents. Activating the A3 receptor — either by its native chemical stimulator, the small molecule adenosine, or by powerful synthetic small molecule drugs invented at the NIH — prevents or reverses pain that develops slowly from nerve damage without causing analgesic tolerance or intrinsic reward (unlike opioids).

Pain is an enormous problem. As an unmet medical need, pain causes suffering and comes with a multi-billion dollar societal cost. Current treatments are problematic because they cause intolerable side effects, diminish quality of life and do not sufficiently quell pain. The most successful pharmacological approaches for the treatment of chronic pain rely on certain “pathways”: circuits involving opioid, adrenergic, and calcium channels.

For the past decade, scientists have tried to take advantage of these known pathways — the series of interactions between molecular-level components that lead to pain. While adenosine had shown potential for pain-killing in humans, researchers had not yet successfully leveraged this particular pain pathway because the targeted receptors engaged many side effects.

In this research, Salvemini and colleagues have demonstrated that activation of the A3 adenosine receptor subtype is key in mediating the pain relieving effects of adenosine. “It has long been appreciated that harnessing the potent pain-killing effects of adenosine could provide a breakthrough step towards an effective treatment for chronic pain,” Salvemini said. “Our findings suggest that this goal may be achieved by focusing future work on the A3AR pathway, in particular, as its activation provides robust pain reduction across several types of pain.”

Researchers are excited to note that A3AR agonists are already in advanced clinical trials as anti-inflammatory and anticancer agents and show good safety profiles. “These studies suggest that A3AR activation by highly selective small molecular weight A3AR agonists such as MRS5698 activates a pain-reducing pathway supporting the idea that we could develop A3AR agonists as possible new therapeutics to treat chronic pain,” Salvemini said.

A workers’ compensation fraud defendant was sentenced to six years of local custody after being convicted by a jury of 12 felony counts including perjury and insurance fraud for her role in defrauding her employer out of more than $300,000 over a seven-year period. Golnaz Gholipour, 35, was sentenced to three years in local prison and three years of mandatory supervision. A restitution hearing will be held at a future date to determine how much she will pay in restitution to Sharp Healthcare for costs they incurred in handling her fraudulent claim.

Gholipour was a nurse at Sharp Hospital who initially told her doctors in January 2007 that she injured her back while waking up from a nightmare. She first filed for state disability benefits, but after learning that the most she could receive from state disability was $4,515 based on the fact that she’d only been employed in California a few months, she filed for workers’ compensation benefits.

All of the defendant’s medical expenses were covered and she received more than $88,000 for the two years she claimed she could not work after her injury. In May 2010, after all conservative care was exhausted, Gholipour had back surgery. By April 2013, when Ghoilpour continued to claim she was worse off than before the surgery, the insurance company hired a private investigator.

The defendant was filmed on several occasions in a normal state with no apparent injuries. Only when she was going to doctor’s visits or attending legal meetings did Gholipour appear hurt and in need of a walker. At her deposition, Gholipour testified that she lived with her parents and that her mother had to bathe her and help her get dressed. She claimed to need to use the walker at all times, that she was depressed, had not gone out on any dates and was not involved in any relationships. She also said she had significant gastro-intestinal problems and generally stayed at home groggy from her medications.

After her deposition, Gholipour was filmed over an eight-hour period as she went shopping, dined at restaurants, and moved about in a normal fashion without any sign of pain or discomfort and without a walker. On another occasion, she was filmed during a 12-hour period during which she moved potted plants on her balcony, went shopping, walked several hundred yards to go to a picnic and back and went to a movie. In the videos, she was observed with the same man who is now her husband and they appeared to be living together.

After a two-week jury trial, the defendant was convicted on eight counts of perjury and four counts of insurance fraud.

The Division of Workers’ Compensation has posted a second 15-day notice of modification to the proposed Medical Treatment Utilization Schedule (MTUS) regulations to the DWC website. Members of the public are invited to present written comments regarding the proposed modification to dwcrules@dir.ca.gov until 5 p.m. on Tuesday, December 9. The proposed modifications include:

1) Re-organization of section 9792.21 to clarify the MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.
2) Addition of a new section, 9792.21.1 – The Medical Evidence Search Sequence. The Medical Evidence Search Sequence was separated from section 9792.21 to clarify the steps required to find medical evidence. Any search for medical evidence begins, and likely ends, with the MTUS. Searching for medical evidence outside the MTUS is limited to situations where a medical condition or injury is not addressed by the MTUS or if the MTUS’ presumption of correctness is being challenged. (Note: A flow chart is included in the Notice of Modification to Text of the Proposed Regulations to provide a visual aid for the Medical Evidence Search Sequence.)
3) Specification that a treating physician who seeks treatment outside of the MTUS bears the burden of rebutting the MTUS’ presumption of correctness by a preponderance of scientific medical evidence.
4) Requirements that shall be included in a Request for Authority, Utilization Review Decision and Independent Medical Review Decision. Any citation provided by a treating physician or medical reviewer shall be the primary source relied upon which contains the recommendation that guides the reasonableness and necessity of the requested treatment that is applicable to the injured worker’s medical condition or injury. If more than one citation is provided, then a narrative shall be included in the three aforementioned documents explaining how each guideline or study cited provides additional information that guides the reasonableness and necessity of the requested treatment applicable to the injured worker’s medical condition or injury but is not addressed by the primary source.
5) Details of the citation format requirements.
6) Revision of The MTUS Methodology for Evaluating Medical Evidence to clarify when it must be applied by a reviewing physician and how to evaluate the quality and strength of medical evidence used to support a recommendation.
7) Amendments to citations in sections 9792.23, 9792.24.1 and 9792.24.3 referencing the sections currently being revised in rulemaking to sections 9792.20 – 9792.26.

The DWC has also prepared a graphical flowchart that depicts the decision making process of a medical treatment review.

The notice and text of the regulations can be found on the proposed regulations page.

Payments for pharmaceuticals and durable medical equipment (DME) in California workers’ compensation continue to increase sharply, adding pressure against the recent reforms to the system according to a new CWCI study that examines medical and indemnity payment trends from accident years (AY) 2002 to 2014.

The study, based on an analysis of 2.1 million claims involving $25.6 billion in benefit payments, breaks out results by accident year, noting average amounts paid for medical services at 3 through 60 months post injury. The latest data show that while average medical payments on lost-time claims in the first two years post injury grew a modest 2.3% between AY 2011 and AY 2012, average amounts paid for pharmaceuticals and DME increased 19.4% to $2,154 — and that came on the heels of a 26% increase in the prior year. Following legislative reforms in 2003 and 2004, pharmaceutical and DME payments declined briefly, falling in both AY 2004 and 2005, but since then they have been the fastest growing medical component in California workers’ comp, increasing more than threefold over the past 7 years. In contrast to the ongoing double-digit increases in pharmaceutical and DME payments, the 2-year data on AY 2011 and AY 2012 claims show medical treatment expenses (i.e., payments to medical providers, hospitals, outpatient facilities, and for ancillary services such as X-rays and MRIs), which accounted for two-thirds of all medical payments on those claims, and medical management/cost containment expenses (i.e., medical bill review, medical case management, utilization review and medical network fees), registered only modest increases, while payments for medical-legal reports declined.

With growth rates varying among the medical subcategories over the past decade, medical treatment declined from 81.7% of all workers’ comp medical payments at 24 months in AY 2002 to 66.6% in AY 2012, while pharmaceutical/DME payments grew from 7.8% to 13.2%. Medical management payments grew from 6.6% to 14.2% over the same period, as those expenses escalated rapidly after AY 2005 as various managed care elements of the 2002-2004 reforms led to increased outlays for medical bill review, medical case management, and medical network access fees, though the 2-year data from AY 2011 and AY 2012 claims indicate they may have leveled off, albeit near record levels.

The study also offers a first view of medical experience for 2014 injury claims, showing total medical payments at 3 months post injury averaged $3,809, up 12% from $3,400 in the prior year, but such outcomes should be treated as preliminary as early treatment patterns often change due to market and regulatory factors. In addition to identifying medical payment trends, the Institute study also provided new trend data on indemnity benefits and length of temporary disability. Among the key findings at 24 months, total indemnity costs per claim for injury year 2012 were up 5.9 percent to $12,923. At 24 months, average temporary disability payments increased by 5.5 percent and paid temporary disability days increased by 2.9%.

The CWCI Research Update report, “California Workers’ Compensation Medical and Indemnity Benefit Trends, AY 2002 – 2014,” is posted on the Institute’s website, and is available to CWCI members and Research subscribers who use their passwords to log in to the site.

Yeh Juin Tung hired Michael Waller, who owned Waller Tree Care, to perform services that included removing one tree and trimming four others. The price for the work was $400. Tung was unaware that Waller was not licensed; he knew only that Waller had advertised on Yelp.com as being bonded and insured. Waller did not have workers’ compensation insurance at that time.

On October 6, 2008, Waller appeared at Tung’s property to do the work. He was accompanied by Jose Luis Escalera. Escalara leaned a ladder against a tree and climbed up about 10 feet. As he began to cut branches with a handsaw, he fell. He did not know why he fell; as he stated in his deposition, “All I know is that the ladder went to one side and I wasn’t able to hold on.”

Escalara filed a civil action in December 2009, alleging negligence against both Waller and Tung.

Tung moved for summary judgment, contending that plaintiff was not his employee but an employee of Waller, an independent contractor. He also disputed plaintiff’s negligence claim “because there is no evidence of any breach of any duty or any causation by Mr. Tung.” In his opposition, plaintiff agreed that Waller was an independent contractor, but he raised the “peculiar risk” doctrine to argue that Tung was liable whether or not he was personally negligent, because plaintiff was performing “inherently dangerous work,” and Tung must bear responsibility for all risks of injury to a worker, “regardless of fault.” The parties debated the applicability of the exception to the peculiar-risk doctrine expressed in Privette v. Superior Court (1993) 5 Cal.4th 689.

The superior court ruled in Tung’s favor. Addressing plaintiff’s assertion that Tung was vicariously liable because Waller had not procured workers’ compensation insurance, the court reasoned that “an employee of a negligent contractor can recover under the workers’ compensation system even if the contractor is uninsured.” As plaintiff had not established a triable issue under the peculiar risk doctrine or supported a theory of direct liability, Tung was entitled to summary judgment. From the ensuing judgment on July 13, 2012, plaintiff brought an appeal. The Court of Appeal affirmed the dismissal in favor of the homeowner in the unpublished case of Escalera v. Tung.

On appeal, plaintiff does not suggest that he was Tung’s employee under the workers’ compensation system; he acknowledges that the Workers’ Compensation Act (§ 3200 et seq.) is inapplicable because he worked less than 52 hours on Tung’s property. Plaintiff does, however, assert that Tung was his employer for purposes of civil tort liability under section 2750.5. Plaintiff cites the undisputed facts that “Waller was a contractor who did not have a contractor’s license,” that “Waller advertized [sic] his tree care business on Yelp, and that he did not state in his advertisement that he was not licensed under the contractors’ licensing law.” From those facts plaintiff asserts that Waller is “conclusively presumed to be Tung’s employee” under labor code section 2750.5.

Under this statute Waller would be presumed to be an employee of Tung by performing a service for which a license was required, and plaintiff, by working for Waller, would then also be deemed an employee of Tung. A license is not required, however, for small jobs costing the hirer less than $500. (Bus. & Prof. Code, § 7048.) It was undisputed that the contract price for the tree trimming was $400; accordingly, the presumption would not have applied.