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Category: Daily News

UCLA Patients Infected by Deadly CRE Bacteria

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CRE or Carbapenem-Resistant Enterobacteriaceae is the new and frightening “superbug.” The bacteria can kill up to half of patients who get bloodstream infections, a rate much higher than other resistant infections such as MRSA or Clostridium difficile. The bacteria are also sometimes referred to as the “nightmare bacteria”

According to a report in USA Today, the deadly pattern of illnesses began to emerge in 2012 at hospitals in Seattle, Pittsburgh and Chicago. CRE is perhaps the most feared of superbugs, because it resists even “last defense” antibiotics. And in each hospital case, investigators identified the same source of transmission: a specialized endoscope, threaded down the throat of a half-million patients a year to treat gallstones, cancers and other disorders of the digestive system. They found that the devices, often called duodenoscopes, accumulate bacteria that are not always removed by conventional cleaning, so infections can pass from patient to patient.

CRE has now infected patients closer to home. The Los Angeles Times reports that nearly 180 patients at UCLA’s Ronald Reagan Medical Center may have been exposed to potentially deadly bacteria from contaminated medical scopes, and two deaths have already been linked to the outbreak. The Times has learned that the two people who died are among seven patients that UCLA found were infected by CRE – a number that may grow as more patients get tested. UCLA said it discovered the outbreak late last month while running tests on a patient. This week, it began to notify 179 other patients who were treated from October to January and offer them medical tests. By some estimates, if the infection spreads to a person’s bloodstream..

UCLA said it immediately notified public health authorities after discovering the bacteria in one patient and tracing the problem to two of these endoscopes. The university said it had been cleaning the scopes “according to standards stipulated by the manufacturer,” and it changed how it disinfects the instruments after the infections occurred. Dale Tate, a university spokeswoman, said “the two scopes involved with the infection were immediately removed and UCLA is now utilizing a decontamination process that goes above and beyond the manufacturer and national standards.”

Yet neither the scopes’ manufacturers nor the Food and Drug Administration, which regulates them, have publicized or offered guidance on the problem. So, many doctors who use the scopes – and most of the patients they treat – don’t know the risks. Nor do they know that steps can be taken to cut those risks dramatically. “Most hospitals that do these procedures are not even looking for this problem, or they may not be aware, and that’s got to change,” says Jeffrey Duchin, a physician who heads communicable disease control at the Seattle and King County Public Health Department.

The FDA says in a written statement to USA TODAY that it is “aware of and closely monitoring” the infection risks associated with the scopes. “Some parts of the scopes may be extremely difficult to access and clean thoroughly,” the agency adds, “and effective cleaning of all areas of the duodenoscope may not be possible.” The agency is studying the problem and working with manufacturers to determine whether new cleaning protocols should be mandated or the scopes should be redesigned entirely. Meanwhile, the scopes’ “lifesaving” ability to detect and treat potentially fatal digestive disorders outweighs their infection risks, the statement adds. “It (is) important for these devices to remain available.” Few dispute the scopes’ importance.

But public health officials and endoscopy experts who have studied the problem believe the FDA and scope manufacturers have been slow to bring attention to the infection risks and publicize steps hospitals can take to reduce them dramatically. “It’s fair to ask whether the FDA could have been doing more to regulate these devices and significantly reduce the risk of patient harm,” says Lawrence Muscarella, a biomedical engineer and independent consultant who advises hospitals on endoscope safety. “Patients have died, and the agency seems to be moving slowly.” .

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Salinas Pain Doctor Faces Discipline and Drug Investigation

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As authorities conducted a drug raid on Salinas’ Chinatown last Thursday, a second set of federal officers searched a Salinas doctor’s office and home in connection with an alleged fraud case.

The Californian reports that Dr. Steven Mangar, who runs Pacific Pain Care Institute, was arrested on Valentine’s Day last year on suspicion of driving under the influence of methamphetamine. A California Highway Patrol officer stopped 44-year-old Mangar at Highway 101 and Sanborn Road. But, prosecutor Ed Hazel said the U.S. Department of Justice crime lab in Sacramento is so backed up, Mangar’s toxicology report was not available until last month. Mangar was charged Jan. 21. He was ultimately arraigned 364 days after his arrest. Mangar’s arraignment in Monterey County Superior Court followed a day after federal agents swooped down on his West Alisal Street office and his home on Madeira Avenue in Salinas. Authorities with the Monterey County District Attorney’s Office’s Health Care and Workers’ Compensation fraud units served the search warrant with help from the State Medical Board, the Department of Insurance, the Drug Enforcement Agency and the DOJ Office of the Inspector General. At the same time, another alphabet soup of agents searched Salinas’ Chinatown for methamphetamine, heroin, marijuana and cash. Twelve arrests stemmed from that raid.

Between 2005 and 2012, Mangar collected 10 traffic citations for minor incidents, Hazel said. In that time period, he was also sued four times in civil court. This was not the first time Mangar has come under scrutiny from the State Medical Board. On Oct. 5, 2012, Mangar was placed on three years’ probation following an investigation into his treatment between 2003 and 2010 of a 60-year-old man who had chronic neck pain. According to court documents, Mangar kept shoddy records that indicated he examined the patient at times when, in fact, he hadn’t. Mangar prescribed the man Percocet and Oxycontin, both powerful pain killers, according to the records. After the investigation, he was ordered to enroll in prescribing practices and record-keeping courses.

On May 15, 2013, Mangar was cited and fined $350 for failing to submit a quarterly declaration in conjunction with his probation.

On Nov. 6, 2014, Medical Board officials filed a petition to revoke Mangar’s probation. Doing so could result in the loss of Mangar’s physician’s and surgeon’s certificate. The petition revolved around Mangar’s treatment of a 40-year-old man with chronic back pain, according to court records. Although the patient’s quality of life didn’t improve, Mangar continued prescribing him Oxycontin. He later added in Ritalin when the man said he couldn’t stay awake. In doing so, Mangar acted unprofessionally and failed to develop an objective-oriented treatment plan, according to the allegation. A decision is still pending in that petition.

ProPublica analysis shows Mangar was the third-leading hydrocodone prescriber in California in 2012. Hydrocodone, also known as Vicodin, is another powerful pain killer. In 2012, 72 percent and 55 percent of Mangar’s 241 patients filled Schedule II and Schedule III drug prescriptions, respectively, according to ProPublica. Drugs are classified into five categories, per the DEA. Schedule II drugs are potentially highly addictive. Schedule III drugs carry a moderate to low risk of abuse. On average, specialists in Mangar’s area only prescribed Schedule II and Schedule III drugs 4 percent and 13 percent of the time, respectively. Only 23 percent of Mangar’s prescriptions were for brand names, compared with a 29 percent average at other specialists’ offices. But Mangar’s prescriptions also cost $170 on average compared with $99 from other prescribers.

Mangar, who is represented by defense attorney Susan Chapman, is expected to return to court March 5, Hazel said. Mangar and Chapman weren’t immediately available for comment.

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DWC Adjusts OMFS Practitioner Services Section

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The Division of Workers’ Compensation has posted an order adjusting the Physician Services/Non-Physician Practitioner Services section of the Official Medical Fee Schedule (OMFS) to conform to relevant 2015 changes in the Medicare payment system as required by Labor Code section 5307.1.

The Physician and Non-Physician Practitioner Fee Schedule based on the federal Resource Based Relative Value Scale (RBRVS) was adopted pursuant to the requirements of Senate Bill 863 (SB 863) and became effective for services rendered on or after January 1, 2014. As mandated by SB 863, the fee schedule starts with separate conversion factors for surgery, radiology, and “all other services” in 2014 and transitions to a single conversion factor (CF) beginning in 2017, for all services except anesthesia. The 2015 transition conversion factors reflect a blend of 50 percent pre-2014 OMFS CF and 50 percent 120% RBRVS Medicare CF.

The Physician and Non-Physician Practitioner Fee Schedule update order adopts revisions to several sections of Title 8 California Code of Regulations, including the following changes

1) Adopts the CMS Medicare National Physician Fee Schedule Relative Value File(RVU file) RVU15A and related files for services rendered on or after March 1,2015
2) Updates the Conversion Factors, applying the Medicare relative value scaleadjustments and the Medicare Economic Index (MEI) inflation increase to thetransitional conversion factors set forth in the regulation
3) Updates the Statewide Geographic Adjustment Factors
4) Adopts the 2015 National Correct Coding Initiative Edits/2015 NCCI PolicyManual
5) Updates the California specific codes with the MEI inflation increase

The administrative director update order adopting the OMFS adjustments effective for services rendered on or after March 1, 2015, can be found on the DWC website. An explanation of changes is attached to the order, identifying the basis for the changes included in the update.

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WCAB Says Applicant Gets One QME Panel at a Time

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The case of Fernando Martinez v Santa Clarita Community College District involves a denied claim of continuous trauma injury to his back, circulatory system, psyche, nervous system, hypertension,diabetes, and upper and lower gastrointestinal system.

The applicant objected to the report from the treating orthopedist Dr. Robert Reisch dated October 3, 2012, based upon “The disability status of the applicant’s medical condition.” The applicant simultaneously filed three separate requests for QME panels in the specialties of orthopedic, psychiatric and internal medicine. All of the requests are dated January 9, 2014. In each of the Form I 06s, the applicant checked off the box indicating that the reason that the QME panel is being requested is “§4062 (nonmedical treatment dispute under 4062).”

An Orthopedic panel issued February 7, 2014. Panels were issued in the specialties of psychiatry and internal medicine on February 10, 2014. The Defendant objected to the internal and psychiatric panels. The parties proceed to trial regarding the limited issue of whether the applicant is entitled to undergo QME panels in orthopedics, psychiatry and internal medicine. The WCJ ordered the defendant to authorize the orthopedic PQME evaluation and found that the applicant was not entitled to undergo PQME evaluations in the specialties of psychiatry and internal medicine, at the time of trial and that issues regarding applicant’s entitlement to psychiatric and internal PQME(s) after completion of the orthopedic PQME evaluation were deferred, with jurisdiction reserved.

The applicant petitioned for removal which was denied in what Lexis is characterizing as a “noteworthy panel decision.” The denial incorporated the reasoning of the WCJ as follows.

The applicant must first complete an initial PQME examination prior to obtaining PQME evaluations in other specialties. The applicant has not met the criteria in rule §31.7 for obtaining different specialties at the time of trial. The applicant also failed to submit the appropriate form to request QME panels regarding other specialties. As per Title 8 California Code of Regulations §31 7 a party “shall” utilize Form 31.7 to request an additional QME panel in a different specialty. It is noted that Fonn 31.7 requires that the prior PQME panel number be identified when requesting other specialties, which could not have been done in this case, as all three QME panels were improperly requested at the same time.

The applicant also failed to comply with the requirements of Labor Code §4062 regarding psychiatric and internal PQMEs. The applicant stated in the three QME requests that the reason for the QME panel is “§4062 (nonmedical treatment dispute under 4062).” However, the letter attached to each PQME request objects solely to the opinions rendered by orthopedist Dr. Reisch in his report dated October 3, 2012. In said report Dr. Reisch stated that the applicant was given refills of Voltaren gel, and was given a Toradol injection. Further, Dr. Reisch stated that the applicant was to continue working modified duties as previously. There is no reference in said report with regard to any alleged internal or psychiatric injuries or complaints. Moreover, the applicant did not object to the findings of a psychiatrist or internal doctor prior to requesting PQME panels in the specialties of psychiatry and internal medicine. Accordingly, the applicant failed to comply with the requirements of Labor Code 4062 with regard to obtaining a PQME panel in specialties other than orthopedics, at the time of trial.

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California Obamacare Botches 100,000 Tax Forms

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The Los Angeles Times reports that California’s Obamacare exchange sent erroneous tax forms to about 100,000 households that received federal premium subsidies last year. At issue is Form 1095-A, which health-law exchanges must send to individuals and families showing how much money they received in 2014 from the federal government to subsidize their health insurance premiums. Covered California said it sent incorrect information on some forms because its customer data didn’t match what health plans had on file. For instance, there may have been a discrepancy for the person’s length of coverage in 2014 and amount of subsidy received.

Amy Palmer, an exchange spokeswoman, said the agency is reconciling that information and sending revised forms to the affected customers later this month. She said customers will also be notified by email when the updated forms are available in their online account. Overall, Covered California sent tax forms to more than 800,000 households statewide.

Obamacare customers who take taxpayer subsidies to cut down the price of health coverage must later fill out Form 1095-A, which documents how much money they received in subsidies in all of 2014. But the total amount of subsidies were incorrect for a large chunk of the exchange’s customers due to the disconnect between the exchange and health insurers. In some cases, the length of time a customer was insured was incorrect, changing the total amount of taxpayer assistance received.

The error affects 100,000 households in the state, out of 800,000 households that received Covered California forms in total. The accurate information is important for people when filing their 2014 taxes. Consumers may have to repay some portion of that government assistance as part of their tax return if their income was higher than what they estimated during enrollment. The blunder puts an extra burden on 100,000 households with Obamacare customers in California just ahead of tax season, who were already facing what experts warn will be the most complicated tax season ever. The 1095-A forms in question are new this year, the government’s answer to the complications Obamacare introduces into filing taxes. Each health-care exchange will issue the forms to customers who received subsidies in the form of tax subsidies. The federal government will issue about 4 million of the new 1095-A forms to Obamacare customers using the federal website this year.

Four in ten low-income Obamacare participants will face sticker shock this April 15 when they discover they owe a great deal of money to the IRS because of a little-known “clawback” provision in the health-care law. A family of four could owe the government as much as $11,200, according to a 2013 prediction by researchers at the University of California, Berkeley. Authors of the UC study, written by supporters of the health-care law, warned the repayment feature could kill future support for Obamacare. “Repayment requirements could lead to public dissatisfaction with the exchanges. And if there is much media attention to the need for repayments, some people could be dissuaded from participating in the exchanges,” they cautioned. The California researchers admitted even a $2,500 repayment could be devastating to a couple. “A repayment requirement of $2,500 could be a financial shock to a family of two earning $50,000 a year,” they stated.

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FDA Identified Research Misconduct Hidden in Plain Sight

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Every year, the FDA inspects several hundred clinical sites performing biomedical research on human participants and occasionally finds evidence of substantial departures from good clinical practice and research misconduct. However according to an investigation published in the JAMA Internal Medicine, the FDA has no systematic method of communicating these findings to the scientific community, leaving open the possibility that research misconduct detected by a government agency goes unremarked in the peer-reviewed literature.

Charles Seife, a New York University journalism professor conducted literature research “to identify published clinical trials in which an FDA inspection found significant evidence of objectionable conditions or practices, to describe violations, and to determine whether the violations are mentioned in the peer-reviewed literature.” He reviewed 78 published papers on clinical trials with which the Food and Drug Administration (FDA) labeled “official action indicated” (OAI), meaning the agency found objectionable conditions or practices significant enough to warrant regulatory action, yet he found that only three of the papers mentioned the OAI status of the trials. The violations included researchers falsifying data and occurrences where clinical trial participants should have been ruled ineligible. His finding was published in the JAMA Internal Medicine “Research Misconduct Identified by the US Food and Drug Administration Out of Sight, Out of Mind, Out of the Peer-Reviewed Literature.”

“This investigation has found numerous studies for which the FDA determined there was significant evidence of fraudulent or otherwise problematic data. Such issues raise questions about the integrity of a clinical trial, and mention of these problems is missing from the relevant peer-reviewed literature. The FDA does not typically notify journals when a site participating in a published clinical trial receives an OAI inspection, nor does it generally make any announcement intended to alert the public about the research misconduct that it finds. The documents the agency discloses tend to be heavily redacted. As a result, it is usually very difficult, or even impossible, to determine which published clinical trials are implicated by the FDA’s allegations of research misconduct.” Seife concluded “When the FDA finds significant departures from good clinical practice, those findings are seldom reflected in the peer-reviewed literature, even when there is evidence of data fabrication or other forms of research misconduct.”

In one of the illustrative cases he reviewed, a case involving a trial of a chemotherapy regimen, the researcher eventually pleaded guilty to fraud and was sentenced to prison after poor results were hidden and a patient died from the treatment (United States of America v. Paul H. Kornak, 03-cr-00436 (Northern District of New York). “Although this episode is described in detail in FDA documents as well as court documents, none of the publications in the peer-reviewed literature associated with the chemotherapy study in which the patient died have any mention of the falsification, fraud, or homicide. The publications associated with two of the three other studies for which the researcher falsified documents also do not report on the violations,” according to the study.

“The FDA has legal as well as ethical responsibilities regarding the scientific misconduct it finds during its inspections. When the agency withholds the identity of a clinical trial affected by scientific misconduct, it does so because it considers the identity to be confidential commercial information, which it feels bound to protect. However, failing to notify the medical or scientific communities about allegations of serious research misconduct in clinical trials is incompatible with the FDA’s mission to protect the public health. Such allegations are relevant to include in the peer-reviewed literature on which physicians and other medical researchers rely to help them choose treatments that they offer to patients and other research participants.”

The article concludes by saying “To better serve the public health, the FDA should make unredacted information about its findings of research misconduct more readily available. The agency should make sure that any substantial evidence of misconduct is available to editors and readers of the scientific literature. One possible mechanism for this would be to use the national clinical trials database: any OAI inspection affecting a trial site should be promptly noted at http://www.clinicaltrials.gov. The FDA should also create a website or a publicly available database that lists all OAI-rated inspections of clinical sites and provides links to copies of the relevant, unredacted, inspection-related documents.”

“The FDA should be more transparent about its findings of research misconduct; however, most of the burden for ensuring the integrity of the research in the peer-reviewed literature falls to the authors of the articles submitted to peer-reviewed journals. Currently, there is no formal requirement for authors seeking to publish clinical trial data to disclose any adverse findings noted during FDA inspections. Journals should require that any such findings be disclosed. Voluntary disclosures are never foolproof, but, as with conflict-of-interest statements, requiring authors and journals to be forthcoming about significant departures from good clinical practice will help raise the standard for the reporting of research toward greater transparency.”

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CWCI Says Medical Report Costs Fell by 30% Last Year

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The average amount paid to a California workers’ compensation treating physician for a medical report fell more than 30 percent in the first quarter of 2014 as the state began to transition to a Resource-Based Relative Value Scale (RBRVS) fee schedule, though a CWCI analysis traces the decline to changes in how various evaluation and management (E/M) services are reimbursed rather than reductions in the fees assigned to the report codes.

California’s transition to an RBRVS fee schedule that began a year ago led to 2 changes affecting physician reporting: 1) consulting physician evaluation services are now billed using an initial visit code, and associated reports are no longer separately reimbursable unless requested by the DWC Administrative Director, the Appeals Board or a Qualified Medical Evaluator in the context of a med-legal evaluation; and 2) the reimbursement to the primary treating physician for medical records review outside the context of a face-to-face E/M service has been bundled into the face-to-face E/M service fee, and there is no longer a separate allowance for a prolonged service fee.

To monitor how physician reporting changed after these changes took effect, CWCI Senior Research Associate Stacy Jones compared data on medical reports for service dates from the first quarter of 2014, when the transition to the new schedule began, to corresponding data from the first quarters of 2011, 2012 and 2013, when the old fee schedule was still in effect. After determining the average amounts paid and the distribution of reports by the nature of the underlying E/M service (i.e., reports associated with initial visits, consultations, follow-up visits, prolonged services), Ms. Jones found that while the average amount paid for all physician reports fell more than 30 percent under the RBRVS fee schedule, the changes in the average reimbursements varied dramatically by type of report.

Comparing the mix of reports associated with the various E/M services revealed that after the rules changed under the new schedule, relatively inexpensive reports on follow-up visits increased from 78 percent to 86 percent of all physician reports, while the biggest declines were in consultation and prolonged service reports, which historically received the highest reimbursements. Consultation reports, which had represented 6 percent of physician reports under the old schedule, and prolonged service reports, which had accounted for 4 percent, both dwindled to less than 1 percent of all reports after the RBRVS schedule took effect. Thus, the initial results on physician reporting following adoption of the new schedule indicate that the change in the mix of reports has been the key factor in reducing the average amount paid for physician reports.

CWCI will continue to monitor the volume, distribution and reimbursement of physician reports in California workers’ comp as more developed data become available. In the meantime, the Institute has published a Research Update report, “Changes in Workers’ Compensation Physician Reporting Under California’s RBRVS Fee Schedule: Initial Results,” which provides additional details and graphics from the latest study. The Research Update report is available to CWCI members and subscribers in the Research section at www.cwci.org.

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H-Wave Suit Against SCIF Claiming Blanket UR Denials Reinstated

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The unpublished Court of Appeal decision in Electronic Waveform Lab v. EK Health Services addresses whether UR is an “official proceeding” within the meaning of Code of Civil Procedure section 425.16, subdivision (e)(2) (the anti-SLAPP statute [SLAPP is the abbreviation for strategic lawsuit against public participation]) and whether the trial court correctly resolved the motion to dismiss under that statute filed by defendant State Compensation Insurance Fund.

Waveform manufactures and sells an electrotherapy device, commonly known as an H-Wave device, which physicians may prescribe to assist in treating various muscular injuries. State Fund contracts with EK Health and “independent contractor individual physician reviewers” to provide UR services to workers covered by their employers’ workers’ compensation policies issued by State Fund. Waveform filed suit against EK Health, alleging that EK Health was “situated as a monopolistic ‘gate keeper’ to a significant and substantial market share of patients who are injured on the job.” Waveform further alleged that EK Health and the Reviewers conspired to defame Waveform and consistently denied the H-Wave device for treatment of individual patients, with the result that treating physicians asked Waveform to remove H-Wave equipment from doctors’ offices and physical therapy clinics. Waveform alleged that the conduct of all of the defendants violated the Cartwright Act (Bus. & Prof. Code, §§ 16720 et seq.) and that the acts of EK Health and of a subset of the Reviewers constituted intentional interference with prospective economic advantage and trade libel.

EK Health and the Reviewers filed a special motion to strike the complaint under section 425.16 (anti-SLAPP motion) which was denied. The denial of the EK Health motion was not appealed.

Waveform then filed a first amended complaint adding State Fund as a defendant. Waveform alleged that State Fund had implemented through EK Health a “blanket policy” to deny and reject physicians’ prescriptions for utilization of the H-Wave device in treatment of patients’ injures and that “[w]hile creating the appearance of reviewer independence, EK Health and the reviewers in fact complied with State Fund’s policy that all H-Wave requests be denied.” Waveform alleged, the policy “violates the independent medical decision-making that reviewers are required to engage in. . . .”

State Fund filed its own anti-SLAPP motion seeking to dismiss both causes of action alleged against it. The trial court ruled that State Fund had established that its actions arose from “official proceedings” as its actions constituted “statements made in connection with an issue under consideration in a legally-authorized official proceeding.” The trial court also concluded that plaintiff had not shown a probability of prevailing against State Fund at trial and for these reasons granted the State Funds anti-SLAPP motion and it was dismissed. The Court of Appeal reversed.

The parties contest whether UR is an “official proceeding authorized by law” as that term is used in section 425.16, subdivision (e)(2). State Fund argues that “official proceedings” include administrative agency actions involving review and investigation of grievances, and that the workers’ compensation UR system, which involves resolution of claims for medical treatment, should be similarly viewed. Waveform argues that the UR process is not quasi-judicial or part of a comprehensive statutory licensing scheme which is subject to judicial review by administrative mandate. The Court of Appeal ruled that it was not an official proceeding and distinguished UR from case law on arbitration proceedings by saying “UR review is medical rather than legal and informal rather than formal.” “For this reason alone, the trial court erred in concluding that UR is an “official proceeding” within the meaning of that term in section 425.16, subdivision (e)(2).”

The judgment dismissing State Fund from Waveform’s first amended complaint was reversed.

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Authorities Say Elderly Care Industry “Rampant With Fraud”

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A story published in ChicoER says that an Antioch businesswoman will serve 60 days in jail and pay restitution after pleading guilty to wage theft, tax fraud and a workers’ compensation violation in her operation of elderly care facilities in Antioch and Brentwood, the first conviction in an industry authorities say is “rampant” with fraud.

Florinda Yambao, 62, accepted the plea deal last week, according to the Contra Costa District Attorney’s Office. Yambao’s six Florin White Dove care homes in Antioch and Brentwood remain in operation, however her three-year probation term requires her to install proper payroll systems and undergo state audits, said prosecutor William Murphy. She is required to pay $453,000 in back wages and yet-to-be determined tax charges and state fines as part of her deal.

Nearly $72,000 was recovered from Yambao during a series of September raids on care homes throughout Contra Costa County, all accused of paying workers under the table and for as little as $4 an hour. In some cases, officials have said, caregivers in her employ worked 12 to 16 hours a day for $50 to $80 total.

After an article by the ChicoER on the searches, Murphy said his office, which has worked with state and federal officials in a yearlong investigation, was flooded with accusations against more homes. “We were inundated with similar problems in other homes in Contra Costa County,” Murphy said. “It appears to be rampant.”

The Contra Costa Employer Fraud Task Force is investigating the owners of nine other care homes that operate 40 facilities in the county. The investigation has uncovered a pattern of underground economy violations where these businesses increased their profits by avoiding taxes, insurance and fair wages, according to the Contra Costa DA’s office. The probe has also found many of the workers are mistreated, working long hours for less than minimum wage, living in substandard conditions, and being forced to care for patients during their time off, the task force said in a statement.

In addition to Yambao, police arrested Sara Abraham and Annette and Julio Sanchez of Abraham Rest Homes Inc. and Sanchez Abraham Corp. after a series of September raids on 19 residential care homes in Walnut Creek, Concord, Brentwood and Antioch. Authorities said about 60 workers were owed $2 million, and $624,000 in state fines against the companies would be split among the workers. Authorities said they were also investigating the owners of Scienn Hall Care homes in Brentwood, but no arrests were made.

While there were no allegations of mistreatment of patients at Yambao’s homes, state records showed that five facilities shown as “Floran Care Home” or “Floran White Dove Care Home” received as many as 19 citations in their inspections. “Ms. Yambao, as the owner and boss of these care facilities, was in a position of power over her employees,” District Attorney Mark Peterson said. “She used that position to exploit the workers and line her own pockets with the cash. It was pure greed.”

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Study Identifies Factors Contributing to Back Pain Risk

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Under SB 899, apportionment can now be based upon causation. Apportionment can be used to divide a specific injury case into two cases, the original specific injury, and then a continuous trauma case if continuous trauma played a causation role in the current medical problem. This strategy can take a life pension specific injury claim and reduce it to two smaller cases neither of which triggers a life pension. For this reason, it becomes significant to follow medical literature as elements of causation are developed in the medical literature. Here is a current example.

New research reveals the physical and psychosocial factors that significantly increase the risk of low back pain onset. In fact, according to the article in Science Daily, results published in Arthritis Care and Research, a journal of the American College of Rheumatology (ACR), show that being engaged in manual tasks involving awkward positions will increase the risk of low back pain by eight times. Those who are distracted during activities or fatigued also significantly increase their risk of acute low back pain.

At some point, nearly 10% of the world’s population experience back pain, which is the leading cause of disability according to the World Health Organization (WHO) Global Burden of Disease report (2010). WHO reports that low back pain has a greater impact on global health than malaria, diabetes, or lung cancer; yet little progress has been made to identify effective prevention strategies.

“Understanding which risk factors contribute to back pain and controlling exposure to these risks is an important first step in prevention,” explains Associate Professor Manuela Ferreira, Ph.D., with The George Institute for Global Health and Sydney Medical School at The University of Sydney in New South Wales, Australia. “Our study is the first to examine brief exposure to a range of modifiable triggers for an acute episode of low back pain.”

For this case-crossover study, researchers recruited 999 participants from 300 primary care clinics in Sydney, Australia, who had an acute low back pain episode between October 2011 and November 2012. Study subjects were asked to report exposure to 12 physical or psychosocial factors in the 96 hours prior to the onset of back pain.

The risk of a new episode of low back pain significantly increased due to a range of triggers, from an odds ratio of 2.7 for moderate to vigorous physical activity to 25.0 for distraction during an activity. Researchers found that age moderated the effect of exposure to heavy loads, with odds ratio for individuals 20, 40, or 60 years of age at 13.6, 6.0, and 2.7, respectively. A new finding not reported previously was that back pain risk was highest between 7:00 a.m. and noon.

“Understanding which modifiable risk factors lead to low back pain is an important step toward controlling a condition that affects so many worldwide,” concludes A/Prof Ferreira. “Our findings enhance knowledge of low back pain triggers and will assist the development of new prevention programs that can reduce suffering from this potentially disabling condition.”

The citation to this study is: Daniel Steffens, Manuela L Ferreira, Jane Latimer, Paulo H Ferreira, Bart W Koes, Fiona Blyth, Qiang Li, Christopher G Maher. What triggers an episode of acute low back pain? A case-crossover study. Arthritis Care Research, 2014; DOI: 10.1002/acr.22533

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