The number of new drugs approved in the United States this year has already topped last year's 18-year high, yet large pharmaceutical companies are still struggling to get a decent return on their research dollars. In fact, according to the story in Reuters Health, returns on research and development spending by the world’s top drugmakers have fallen to 4.2 percent, or less than half the 10.1 percent recorded in 2010, according to a report on Monday from consultancy Deloitte.

The mismatch between the rising number of drug approvals and falling returns reflects the fact that each new medicine is expected to yield significantly lower average sales, while costs are continuing to rise.

Since 2010, forecast peak sales per new drug have fallen by almost 50 percent, even as the average cost of developing a product has climbed by a third. As a result, life sciences R&D is not currently generating a sufficient return on investment for many big drugmakers, according to Julian Remnant of Deloitte.

"We are now seeing a trend for companies to return more money to shareholders through dividends and share buybacks than they are investing in the future through R&D, licensing and acquisitions,” he said.

Deloitte's annual report calculates the return on investment that 12 leading drug companies can expect, based on consensus market forecasts. The report does not give forecasts for individual companies.

The findings come at a time of increased productivity in terms of the sheer number of new medicines reaching the market, with Friday's Food and Drug Administration green light for Roche's new lung cancer drug alectinib lifting the 2015 total above 2014's full-year tally of 41.

Many of these new treatments, however, are targeted at niche patient populations and are designed for treating rare diseases or very specific sub-types of cancer, limiting their sales potential.

Still, the rapid pace of new drug launches is forecast to continue, with 225 new drugs expected to be approved between 2016 and 2020, according to a report from industry data firm IMS Health. IMS expects cancer treatments to be largest category ...

The Office of Self Insurance Plans Chief Jon Wroten is leaving the Department of Industrial Relations for new endeavors, and will retire from state service this month. Mr. Wroten is responsible for overseeing and regulating the nation’s largest self-insurance workers’ compensation marketplace in his position as Chief of DIR’s Office of Self Insurance Plans (OSIP).

"Jon Wroten is a valued member of my executive management team. He helped implement the SB 863 self-insurance reforms and worked to make California’s self-insurance program more efficient and fair," said DIR Director Christine Baker. During Chief Wroten’s tenure, DIR and OSIP:

1) Implemented processes to manage over $22 billion in total risk exposure, protecting the self-insured benefits of 4.6 million covered workers.
2) Instituted safeguards that monitor self-insurers’ solvency, compliance and market conduct, including the actuarial-based collateral evaluation and peer-review system.
3) Successfully reduced application and financial underwriting processes from nine months to less than 21 days.
4) Deployed an electronic filing system to simplify annual regulatory reporting processes.

Prior to his appointment as OSIP Chief, Mr. Wroten worked in DIR as a Cal/OSHA senior manager, served at the California Department of Business Oversight investigating white collar financial crimes, and scrutinized political campaign finance cases for the California Fair Political Practices Commission.

Mr. Wroten will join Sedgwick Claims Management Services, Inc. as its Senior Vice President, Regulatory Compliance and Quality after his retirement from state service ...

The former owner, operator and managers of a Southern California ambulance company were sentenced to prison for their role in a fraud scheme that resulted in more than $1.5 million in fraudulent claims to Medicare.

On Aug. 18, 2015, following a 10-day trial, a federal jury in Los Angeles convicted Proshak, Zverev and Wallace of one count of conspiracy to commit health care fraud and five counts of health care fraud. Zverev and Wallace worked for ProMed Medical Transportation, an ambulance transportation company owned and operated by Proshak in the greater Los Angeles area that provided non-emergency services to Medicare beneficiaries, many of whom were dialysis patients. Zverev was the billing manager and Wallace supervised the ProMed EMTs. The evidence at trial showed that between May 2008 and October 2010, the defendants conspired to bill Medicare for ambulance transportation services for individuals that did not need such services. The defendants also instructed ProMed EMTs to conceal the patients’ true medical conditions by altering paperwork and creating fraudulent documents to justify the services. During the course of the conspiracy, ProMed submitted at least $1.5 million in false and fraudulent claims to Medicare for medically unnecessary transportation services; Medicare paid at least $804,755 on those claims.

U.S. District Judge S. James Otero of the Central District of California sentenced Yaroslav Proshak, aka Steven Proshak, 47, of Valley Village, California to serve 108 months in prison. He also sentenced Emilia Zverev, 58, of Van Nuys, California; and Sharetta Michelle Wallace, 37, of Inglewood, California, to serve 36 months and 24 months in prison, respectively. In addition to their prison terms, Judge Otero ordered Zverev and Wallace to pay restitution jointly and severally with Proshak in the amount of $804,755.

The FBI and HHS-OIG investigated the case. The case was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Central District of California. Trial Attorneys Blanca Quintero, Fred Medick and Ritesh Srivastava of the Criminal Division’s Fraud Section prosecuted the case ...

Two members of the International Longshore and Warehouse Union (ILWU), Local 13, have been arrested on federal fraud charges that allege they caused two medical clinics to bill the union’s health care plan for chiropractic services that either were not provided or were not medically necessary.

Sergio Amador, 49, of Downey, and David Gomez, 52, of San Pedro, were arrested without incident by federal authorities. The two pleaded not guilty to mail fraud charges contained in an indictment that was returned by a federal grand jury. The indictment alleges that they received at least $225,000 from the fraudulent scheme and charges both defendants with 20 counts of mail fraud. If they are convicted, each would face a statutory maximum sentence of 20 years in federal prison for each count of mail fraud.

The ILWU represents dockworkers at the ports of Los Angeles and Long Beach. Members of the union receive benefits, including health care benefits, through the International Longshoremen’s and Warehousemen’s Union - Pacific Maritime Association Welfare Plan.

In 2009, Amador and Gomez opened a clinic in Long Beach operating under the name Port Medical that purported to provide general medical and chiropractic care. The next year, they opened a second clinic operating under the same name in San Pedro.

According to the indictment, Amador and Gomez also created medical management companies that they used to receive funds generated by the medical clinics, which were then used to pay themselves and to pay incentives to Welfare Plan members to use the Port Medical clinics and to encourage other Welfare Plan members to use them. The incentives allegedly included cash payments and sponsorships of sports teams.

The indictment alleges that when some Welfare Plan members went to the Port Medical clinics to receive chiropractic treatment, they were asked to sign their names on multiple sign-in stickers, while on other occasions Welfare Plan members’ signatures on sign-in stickers were forged. According to the indictment, Amador and Gomez then caused the sign-in stickers to be used to create chart entries that falsely indicated the Welfare Plan members had received chiropractic services on dates when no such services had been provided.

The indictment also alleges that Amador and Gomez encouraged Welfare Plan members to go to the Port Medical clinics to receive massages, heat and ice treatments and other services that were not medically necessary - while the patients’ medical charts falsely showed "that the services provided were medically necessary, addressed specific conditions of patients that had been properly diagnosed, and were used to support and facilitate chiropractic care." Those services - and others never provided - then allegedly were billed to the Welfare Plan. Those bills also concealed that patients had been recruited through the use of cash payments or other incentives ...

Cal/OSHA cited Quantum Energy Storage Corporation in Poway $58,025 for a June 10 explosion caused by an out-of-control 11,000 pound metal flywheel. One worker suffered a broken ankle and three others were treated for abrasion injuries caused by flying debris from the explosion.

"California employers must take precautions to protect employees from on-the-job hazards, including machinery operated in closed, confined spaces," said Cal/OSHA Chief Juliann Sum. "The workers harmed by this explosion could have died because the employer did not secure or cover the flywheel to prevent the release of mechanical energy."

Cal/OSHA investigators learned that the nearly seven feet in diameter flywheel was placed in a concrete vault area installed in the warehouse for tests of the energy storage system. Prior to the accident, the flywheel was spinning at 6,000 rotations per minute, and had just begun the process of winding down when it failed. The flywheel came loose from its moorings and crashed into the vault’s guard rails, causing enough damage to the building’s roof, interior and walls that the building was deemed unsafe to enter after the accident.

No steps had been taken to enclose the vault or minimize hazards where the employees worked. Computer stations were not located at a safe distance nor were they designed to limit employee exposure in the event of uncontrolled release of electrical or mechanical energy.

Cal/OSHA issued 16 citations to Quantum Energy Storage for violations of multiple health and safety standards, including the safe practices for operating machinery standard. The citations included five that were serious in nature and one classified as serious accident-related. A serious violation is cited when there is a realistic possibility that death or serious harm could result from the actual hazardous condition ...

In a study using surprise visits by undercover instructors posing as patients, the approach did little to deter trainee-doctors from ordering unnecessary tests or to better focus them on their patients’ goals.

"In primary care and a lot of other areas of medicine, we know there is a problem of tests and procedures that are done that are probably medically unnecessary and not beneficial to the patient," said lead study author Dr. Joshua Fenton, of the University of California-Davis Health System in Sacramento.

Reuters Health summarized the new study of almost 60 second-year doctors, known as residents, a male fake patient requested magnetic resonance imaging (MRI) for lower back pain and a middle-aged woman asked for bone mineral density testing. Both are considered overused tests according to the Choose Wisely program, which aims to avoid wasteful or unnecessary medical testing, treatments and procedures through education of both doctors and patients.

The undercover instructors eventually broke character and critiqued the doctors-in-training on their techniques for addressing the patient’s concerns apart from just ordering the requested test.

Fenton told Reuters Health the study team theorized that fewer tests might be ordered if doctors were more patient-centered, which means providing healthcare that aligns with patients' wants, needs and goals.

To see if real-life challenges combined with feedback would get the message across, the researchers sent the instructors to visit 30 internal medicine and family medicine residents at two clinics in California, and to another 31 residents who served as a control group. Members of the control group did not receive feedback from their fake patients, but they got educational materials afterward. Following the first trial, researchers sent the undercover instructors back for up to three unannounced visits to different residents over the following three to 12 months to request similar tests.

Overall, the residents ordered the low-value tests in about 27 percent of visits, and that rate didn't change across the trial. The residents also didn't score higher on patient-centeredness or on the techniques used to address patient concerns during the trial, researchers found. "Essentially, for the most part it wasn't an effective intervention," Fenton told Reuters Health.

It may be that overuse of diagnostic tests is too deeply ingrained into the medical culture to be improved by a brief intervention, write JAMA Internal Medicine editors Drs. Kenneth Covinsky and Rita Redberg of the University of California, San Francisco, in a note accompanying the new study, "I think it speaks to the importance of discussing low-value and potentially harmful care across our discipline," said Dr. Wanda Filer, president of the American Academy of Family Physicians, who wasn’t involved in the study ...

Efforts to legalize marijuana in California got a boost this week after competing ballot measures joined forces behind the stronger of the two, backed by billionaire Sean Parker, a former president of Facebook Inc.

According to the report in Reuters Health, the initiative has the support of Democratic Lieutenant Governor Gavin Newsom and the Coalition for Cannabis Policy Reform. Coalition board member Antonio Gonzalez, who is also president of the Latino Voters League, said the coalition withdrew its rival initiative after Parker's measure was modified to protect children, workers and small businesses. The move brings to a close weeks of behind-the-scenes negotiations aimed at closing the gaps between the initiatives, amid concerns that neither would succeed if both wound up on the ballot for 2016.

Marijuana use is illegal under federal law in the United States but 23 states allow the use of pot for medical purposes. Recently, Colorado, Washington and Oregon have approved recreational use and Alaska is set to allow it next year. Voters in Massachusetts, Michigan, Nevada and Arizona could face ballot initiatives next year intended to legalize marijuana.

In California, amendments filed this week to Parker's proposal would allow local governments a greater say in where marijuana can be sold, toughen protections for children, including a ban on marketing to minors and explicit warning labels on marijuana products, and require safety standards and enforcement of labor laws for people who work in the industry.

The measure would tax marijuana sales and cultivation, raising hundreds of millions of dollars for the state, proponents say.

California has the largest marketplace for medical marijuana sales in the United States, according to the research group IBIS World. Nationwide, medical and recreational marijuana is expected to bring in $3.6 billion in revenue in 2015, growing to $13.4 billion over the next five years, the company says.

A marijuana legalization initiative failed in California in 2010, but public opinion is shifting. Parker's measure would legalize recreational marijuana use for adults over 21 and set up a framework for regulating and taxing sales.

Parker's deep pockets suggest that his initiative will be well-funded, although campaign finance records do not show any contributions as of Wednesday. In 2010 supporters invested $3.5 million in Proposition 19, outspending opponents nearly 8-1. But the measure failed amid concerns that it did not protect children or guard against driving under the influence ...

Labor Code §§129 and 129.5 require the Audit and Enforcement Unit of the Division of Workers’ Compensation (DWC) to conduct a profile audit review (PAR) for all adjusting locations of California workers’ compensation claims at least once every five years. Performance of the adjusting locations is measured in five areas of claims administration:

1) The payment of accrued and undisputed indemnity
2) The late first payment of temporary disability / first notice of salary continuation
3) The late first payment of permanent disability and death benefits
4) The late subsequent indemnity payments
5) The provision of notices with QME/AME advice.

The administrative director annually establishes profile audit review and full compliance audit (FCA) standards in accordance with Labor Code §§129(b)(1) and (2) and Title 8, California Code of Regulations §10107.1. The 2016 standards are based on the audit results of calendar years 2012 through 2014.

The PAR performance standard for audits conducted in 2016 is 1.51082. Audit subjects with PAR performance ratings of 1.51082 or lower will be required to pay any unpaid compensation, but no penalties will be assessed. If an audit subject’s PAR performance rating is 1.51083 or higher, the audit will expand to a FCA, and an additional sample of indemnity claims will be audited.

The FCA performance standard for audits conducted in 2016 is 1.67880. Audit subjects with an FCA performance rating of 1.67880 or less will be required to pay any unpaid compensation and penalties will be assessed for all violations involving unpaid and late paid compensation. If an audit subject’s full compliance audit performance rating is1.67881 or higher, an additional sample of denied claims as well as the expanded sample of indemnity claims will be audited. Penalties will be assessed for all violations as appropriate pursuant to 8CCR §§10111 through 10111.2.

More information on the performance standards that will be in use for the profile audit reviews and full compliance audits during calendar year 2016 will be posted on the DWC Audit and Enforcement Unit web page ...

The Audit and Enforcement Unit of the Division of Workers’ Compensation (DWC) has posted the Spanish version of the revised benefit notice manual on the DWC website. The English version was previously posted.

The "safe harbor" provision of Title 8, Cal. Code of Regs., section 9810(f) provides that "Benefit notices using the sample notices devised by the Administrative Director and available on the Division’s website are presumed to be adequate notice to the employee and, unless modified, shall not be subject to audit penalties."

The revisions to the recently approved benefit notice regulations include:

1) Elimination of the requirement to provide Fact Sheets as attachments to notices
2) Reduction of the requirement to provide a QME panel request form with notices
3) Elimination of the warning notice language at the top of notices
4) Allowance for employees and their attorneys to choose to receive electronic service of notices.

The benefit notice regulations take effect on January 1, 2016 ...

Despite assertions that the California workers’ compensation medical review and dispute resolution process results in wholesale denial of care for injured workers, a new CWCI analysis shows that about 96% of treatment services are approved and delivered to injured workers, and that the multiple levels of medical review have produced a system with a high degree of consistency for approving care while maintaining the state’s evidence-based medicine standard.

While a means of resolving medical necessity disputes is common to almost all other healthcare delivery systems, including group health and federal programs, workers’ compensation is not like other systems. Co-payments, deductibles and enrollee contractual language, common shared-risk strategies used in group health to manage utilization and cost are precluded by law and antithetical to the original no-fault bargain between employers and employees. From the moment California introduced IMR into the system following the 2012 reforms, debate over the scope, authority and reasonableness of the workers’ compensation medical dispute resolution process intensified. Recent studies have analyzed the various components, and CWCI’s new report expands on those analyses using data from a sample of 5.6 million California workers’ compensation medical services from 2014 and from the nearly 82,000 IMR decision letters issued in first half of 2015. Key findings include:

1) Almost 85% of the 5.6 million medical services in the study sample were paid without being requested in RFAs and undergoing UR for medical necessity. These services were paid based on prior authorization, retrospective authorization or when no RFA was received but the service fell within the claims administrator’s parameters for approval.
2) 15% of the medical services were requested in RFAs and underwent UR. Of these, 60% were accepted by non-physician reviewers who determined that they were medically necessary under the treatment guidelines, and 40% were sent for review by a UR physician. This means that about 6% of the 5.6 million medical services (15% x 40%) were reviewed by a UR physician.
3) The modification/denial rate for the 6% of all treatment services submitted for physician UR was 70%, or 4.3% of all services in the study sample (1.1% were modified and 3.2% were denied).
4) In the first half of 2015, IMR physicians upheld 89.1% of the UR denials and modifications and overturned 10.9%. This is consistent with the 91% uphold rate from CWCI’s study of 2014 IMR outcomes and indicates that the majority of modifications or denials made by UR physicians are in-line with evidence-based medicine.
5) Almost half of the IMR decisions rendered between January and June of 2015 involved disputes over prescription drugs. One-third involved requests for opioids, while 11% involved compounded drugs.
6) The top 10% of physicians involved in IMR disputes (961 treaters) were identified in more than 80% of all IMR determination letters; while the top 1% (97 physicians) were named in 40% of the letters.
7) After taking into account medical services approved without an RFA and without UR, those approved by non-physicians during UR, those approved by UR physicians, and those approved following IMR, the estimated approval rate for all California workers’ comp medical services ranges between 95.7% and 96.1%

The Institute notes that the high level of agreement at the different stages of medical review fulfills the legislative intent of the workers’ compensation reforms to provide injured workers with the most effective medical care through a process that is more objective, transparent and consistent. CWCI has published its study in a Research Update report, "Medical Review and Dispute Resolution in California Workers’ Compensation." ...

The Division of Workers’ Compensation (DWC) has posted a first 15-day notice of modification to the proposed Chronic Pain Medical Treatment Guidelines and the Opioids Treatment Guidelines of the Medical Treatment Utilization Schedule (MTUS) regulations to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to dwcrules@dir.ca.gov until 5 p.m. on December 19. The proposed modifications include:

1) Clarification of the definition for Chronic Pain as pain "lasting three or more months from the initial onset of pain" to use the same definition set forth in section 9792.20 and to remove inconsistencies in the proposed Chronic Pain Medical Treatment Guidelines, the Opioids Treatment Guidelines and section 9792.23(b)(1).
2) Replacement of the words "must" and "required" with "should" and "recommend" where appropriate in the proposed Opioids Treatment Guidelines to clarify that guidelines set forth in the MTUS are designed to assist providers by offering an analytical framework for the evaluation and treatment of injured workers and is not intended to mandate specific clinical practices.
3) Removal of the phrase "alternative therapies do not provide adequate pain relief and" from section 9792.24(b) to prevent misinterpretation that opioids cannot be prescribed until a clinical history established inadequacies of all alternative therapies listed in the proposed Opioids Medical Treatment Guidelines.
4) Addition of pregnancy as a condition for consideration when tapering opioids with reference to the Medical Board of California’s guidelines for further guidance.
5) Removal of the statement that naloxone is "not recommended for patients on chronic opioid treatment" to reflect evolving scientific knowledge on the benefits and risks of this medication to treat opioid overdose.
6) Deletion of the words "Soft-Tissue" from a section heading in the proposed Opioids Treatment Guidelines to clarify that the recommendations for "Moderate to Severe Injuries" are not limited to soft-tissue injuries.
7) Formatting changes, corrections to typographical errors, and language clarifications.

Text of the regulations can be found on the proposed regulations page ...

Cal/OSHA cited Kaiser Foundation Hospitals in Vallejo $149,900 for exposing workers to injury and infection from used needles at the hospital’s collection box for biomedical waste. At least three custodial employees have been stuck by needles while attempting to empty the deposit box, which frequently overflowed and prevented the lid from closing properly. All three employees have been given prophylactic medication to prevent disease or unwanted consequences. The first injury occurred in 2013 and the other two this year.

"Cal/OSHA will always issue citations in cases where employers willfully disregard employee health and safety," said Cal/OSHA Chief Juliann Sum. "Kaiser should have had safety measures in place before employees were injured."

Cal/OSHA cited Kaiser for five workplace safety violations of the bloodborne pathogens standard, which requires employers to protect workers from coming into contact with blood or other disease-carrying body fluids. Two of the violations issued to Kaiser are classified as willful serious, as evidence shows that the employer was aware that an unsafe or hazardous condition existed and made no reasonable effort to eliminate the condition. The hazardous conditions were corrected after Cal/OSHA’s inspection.

"Hospital workers are exposed to known hazards on a daily basis, and their employers have a responsibility to recognize these hazards and protect their employees," said Christine Baker, Director of the Department of Industrial Relations (DIR). Cal/OSHA, officially known as the Division of Occupational Safety and Health, is a division of DIR.

Cal/OSHA’s American Canyon office opened the investigation in June after receiving a complaint. Kaiser members deposit their used needles through a hinged slot on the metal box, which resembles a postal mailbox. The needles fall into an inner plastic disposal box inside to contain biomedical waste. Employees transferred the contents into a larger disposal container for collection by Kaiser’s waste hauling contractor.

Cal/OSHA investigators learned that employees were instructed to clean the box using a broom and dustpan. When those tools proved inadequate, employees had to reach into the box to remove spilled waste, even though needles were often deposited without a protective cap.

Kaiser replaced the kiosk with two larger disposal units following Cal/OSHA’s inspection, and now requires they be monitored every 30 minutes ...

Business Insurance reports that an organization working to create workers compensation opt-out programs in various states says it "welcomes" an upcoming investigation by the National Conference of Insurance Legislators into alternative workers comp systems.

NCOIL's Workers' Compensation Insurance Committee voted at its annual meeting last month to investigate opt-out programs. The decision was based on reports by National Public Radio and investigative journalism website ProPublica Inc. that criticized programs allowing employers to opt-out of state workers comp systems and profiled workers who were unable to receive benefits under opt-out programs.

"Though NCOIL has taken no position on these unique programs, we'd be remiss if we didn't look at the issue further - especially since there's movement in other states to let employers opt out of state workers' compensation requirements," North Dakota Sen. Jerry Klein said in the statement. Sen. Klein, a Republican, is chairman of NCOIL's workers comp committee.

The Association for Responsible Alternatives to Workers' Compensation worked with legislators in Tennessee and South Carolina to draft workers comp opt-out legislation this year. Those bills are partly based on similar workers comp programs in Texas, which has allowed employers to opt out of buying workers comp insurance for more than 100 years, and Oklahoma, which passed opt-out legislation in 2013.

In a statement to Business Insurance, the association said it "welcomes an opportunity to provide NCOIL with the benefit of its experience with the workers' compensation option " Experience shows an option results in improved employee outcomes and creates significant employer savings."

Meanwhile, Tennessee legislators reportedly are gearing up to reintroduce workers comp opt-out legislation in 2016 after a proposal earlier this year failed to move forward.Tennessee state Sen. Mark Green and Rep. Jeremy Durham, both Republicans, in February introduced the Employee Injury Benefit Alternative, which would allow private employers to opt out of the state's workers comp system if they provide alternative coverage for injured workers.

Despite amendments that included revisions to permanent partial and permanent total disability levels, critics maintained that the proposed benefits still weren't on par with what's currently available to injured workers under the state law.

Ultimately, the Tennessee Advisory Council on Workers' Compensation decided not to recommend the legislation proposed this year.Sen. Green reportedly told The Tennessean newspaper last week that a new opt-out bill will be ready by 2016 ...

Burnout among U.S. doctors is becoming more common and now affects more than half of practicing physicians, according to a new study reviewed by Reuters Health. About 54 percent of U.S. doctors experienced at least one symptom of burnout in 2014, compared to about 46 percent of doctors in 2011, researchers report in Mayo Clinic Proceedings. Overall, the researchers found that doctors are about twice as likely to experience burnout as the average U.S. worker.

"Things are unfortunately getting worse for physicians," said lead author Dr. Tait Shanafelt, of the Mayo Clinic in Rochester, Minnesota. Through a partnership with the American Medical Association, the researchers invited nearly 36,000 U.S. doctors to take a survey in 2014 and compared the responses to a similar survey from 2011.

Of the 6,880 doctors who responded to the 2014 survey, about 47 percent reported high emotional exhaustion, about 35 percent felt depersonalized or saw less value in their work and about 16 percent felt a low level of personal accomplishment.

Burnout rates varied between specialties, with rates topping 60 percent among doctors in emergency medicine, family medicine, urology, rehabilitation and radiology.

Doctors working in urology, rehabilitation, family medicine, radiology, orthopedic surgery, dermatology, internal medicine, general surgery, pathology, psychiatry and general pediatrics all saw significant increases in burnout rates between 2011 and 2014.

Despite no increase in the number of hours worked, only 41 percent of all doctors said they were satisfied with the balance between their work and personal lives, down from about 49 percent in 2011.

In an editorial, Dan Ariely and Dr. William Lanier of Duke University in Durham, North Carolina, pointed to three main psychological issues in the workplace that likely undermine doctors' wellbeing: loss of autonomy, mental exhaustion and "asymmetrical rewards" - meaning that success is barely acknowledged while mistakes come with heavy punishments. Shanafelt also pointed to doctors' heavier workloads and increased clerical responsibilities as examples of potential frustrations.

The study team notes that 75 percent of doctors now work for large healthcare organizations, and meaningful progress toward turning around burnout rates will require work by doctors and their organizations. Dr. Mark Linzer, of Hennepin County Medical Center in Minneapolis, said his research shows that healthcare systems with higher burnout rates also provide less quality care to their patients ...

The CEO of UnitedHealthcare on Tuesday said he regretted the decision to enter the ObamaCare marketplace last year, which the company says has resulted in millions of dollars in losses. "It was for us a bad decision," UnitedHealth CEO Stephen Hemsley said at an investors' meeting in New York.

UnitedHealth, the country’s largest insurer, announced last month that it would no longer advertise its ObamaCare plans over the next year and may pull out completely in 2016 - a move that sent shockwaves across the healthcare industry. Hemsley’s remarks double down on his earlier warning that the ObamaCare exchanges remain weaker than expected after two years and that it will take far longer for insurers to profit from the millions of new enrollees.

The company had already eyed ObamaCare’s federal marketplace cautiously since it launched in 2013. UnitedHealth only began selling plans on the exchanges last year. Now, UnitedHealth officials have said that move will result in a half-billion dollars in losses over two years. Hemsley said it was smart to sit out of the exchanges for the first year, but that the company should have held out another year. "In retrospect, we should have stayed out longer," he said, adding that he believes the marketplace will take more than "a season or two" to develop.

None of the other major health insurers have sounded nearly as gloomy. Anthem recently stated in an SEC filing that it expects to hit earnings targets for 2015. Molina Healthcare CEO Mario Molina told USA Today that the Obamacare exchanges have proven to be a "profitable line of business" and found UnitedHealth's dilemma "a little puzzling" ...

Mitchell G. Cohen M.D. is a board- certified orthopedic surgeon who performed spinal surgeries at Pacific Hospital of Long Beach. He is a resident of Irvine, California, and controls two corporate bank accounts under the names Spine Care Center and Mitchell G. Cohen, M.D. , Inc.

Cohen and his attorney signed a written plea agreement in federal court which has now been unsealed. He plead guilty to a single count which charges him with Subscribing to a False Tax Return in violation of 26 U.S.C. § 7206(1). In exchange, the prosecutor agreed to recommend a two-level reduction in the applicable Sentencing Guidelines. The statutory maximum sentence that the Court can impose for violating Title 26, United States Code, Section 7206(1), is 3 years of imprisonment; a one-year period of supervised release; a fine of $100,000; and a mandatory special assessment of $100.

As part of the plea agreement, Cohen agreed to the statement of facts that recited essentially the following. He accepted illegal kickback payments from Michael D. Drobot and a marketer in exchange for performing spine surgeries at Pacific Hospital. Cohen concealed the illegal kickback payments from his patients and the insurance carriers that paid for the patient's services. He was paid between approximately $5,000 and $15,000 in kickbacks for every spinal fusion surgery performed at Pacific Hospital and deposited kickback payments primarily into his Spine Care Center bank account. Spine Care Center had no legitimate business purpose other than acting as the recipient entity.

In 2009, 2010, 2011, and 2012, Cohen caused Spine Care Center to file a Corporation Income Tax Return, Form 1120, claiming the illegal kickback payments as gross receipts of Spine Care Center. Cohen knew that the illegal kickback payments were not gross receipts of Spine Care Center, but instead should have been reported as individual income on his Individual Income Tax Return. Thus he failed to report $243, 000 in 2009, $214,100 in 2010, $426,335 in 2011, and $394,611 in 2012. Had he properly reported this income he would have been assessed an additional $402,139 in individual income tax. Thus he agreed to payment of no more than $402,139 restitution for taxes.

In 2012, Drobot and Cohen agreed that Drobot would pay him $15,000 in kickbacks for each posterior lumbar interbody fusion surgery performed at Pacific Hospital, and between $5,000 and $7,500 in kickbacks for each cervical fusion spine surgery performed at Pacific Hospital, provided those surgeries were performed using spinal hardware purchased from International Implants, LLC, a medical device distributor owned by Drobot.

In order to disguise the illegal kickback payments from Drobot Cohen entered into two bogus contracts with Drobot's business entities. First, a Research, Product Development and Training Agreement where he purported to provide consulting services in exchange for a monthly payment of $25,000. Cohen however, provided few legitimate consulting services. Instead, the payments were purely kickbacks for spinal surgeries.

In addition Cohen entered into an Outsourced Collections Agreement with Pacific Hospital. The Collection Agreement provided that Cohen would assist Pacific Hospital in collecting its fees for spinal surgeries from insurance carriers, and that in return Pacific Hospital would pay Cohen fifteen percent of the total amount collected. In reality the collection was done by Pacific Hospital staff, without assistance from Cohen.

In total, Cohen received approximately $1,645,225 in illegal kickback payments from Drobot and the marketer between 2008 and 2013.

Beginning in or around 2004, Cohen entered into an agreement with California Pharmacy Management ("CPM"), an in-house dispensary management company owned by Drobot, and later another Drobot entity Industrial Pharmacy Management, in which the Dispensary Management Companies purported to manage Cohen's in-office pharmacy in return for fifty percent of the gross collections resulting from prescriptions filled at defendant's pharmacy. In reality Cohen was paid varying amounts averaging between $20,000 and $40,000 per month as an inducement to allow the Dispensary Management Companies to operate his in-office pharmacy and to gain access to his patients including, in particular, defendant's worker's compensation payments.

As part of the Plea Agreement Cohen agreed to cooperate fully with the US Attorneys Office, the Federal Bureau of Investigation, the United States Postal Service - Office of Inspector General, the Internal Revenue Service, and, as directed by the USAO, any other federal, state, local, or foreign prosecuting, enforcement, administrative, or regulatory authority.

A similar "cooperation" agreement has been made with other physicians, who are likely to be government informants providing information leading to yet further arrests of colleagues in months to come ...

The Division of Workers’ Compensation (DWC) has posted a revised Supplemental Job Displacement Benefit voucher form on its website. The voucher form has been updated to conform to Title 8, California Code of Regulations, section 17303.

The Return-to-Work Supplement Program makes supplemental payments to workers whose permanent disability benefits are disproportionately low in comparison to their earnings losses. To be eligible for the fund, an applicant must have a date of injury on or after January 1, 2013 and have received a Supplemental Job Displacement Benefit voucher.

The following notice has been added to the first page of the voucher: "Because you have received this Voucher and are unable to return to your usual employment, you may be eligible for a Return-to-Work Supplement. You must apply within one year from the date this Voucher was served on you. You should make a copy of the Voucher which you will need to apply for the Return-to-Work Supplement. Details about the Return-to-Work supplement program are available from the Department of Industrial Relations website, or by calling 510-286-0787."

Claims administrators must use the updated form and no longer need to attach a cover sheet with the above notice to the vouchers when they are issued to injured workers ...

Philip A. Sobol M.D. has signed and filed a Plea Agreement in the United States District Court for the Central District of California. He agreed to plead guilty to a two-count information which charges him with Conspiracy, in violation of 18 U.S.C. § 371, and Interstate Travel in Aid of a Racketeering Enterprise, in violation of 18 U.S.C. § 1952.

In paragraph 3 of the Agreement, he agrees to make payment of half of the agreed-upon forfeited amounts and/or restitution totaling $5.2 million no later than 180 days of the entry of his guilty plea, and the remainder no later than 30 days before his sentencing.

Sobol further agreed to cooperate fully with the United States Attorneys Office, the Federal Bureau of Investigation, the United States Postal Inspection Service - Office of the Inspector General, the Internal Revenue Service, and, as directed by the USAO, any other federal, state, local, or foreign prosecuting, enforcement, administrative, or regulatory authority. This cooperation requires him to respond truthfully and completely to all questions that may be put to him, whether in interviews, before a grand jury, or at any trial or other court proceeding.

In exchange, prosecutors agreed to recommend a reduction in the applicable Sentencing Guidelines.

Sobol specifically admitted in this document that "Beginning in or around 2005, and continuing to in or around April 2013, there was an agreement between two or more persons to commit Mail Fraud and Honest Services Mail Fraud, in violation of Title 18, United States Code, Sections 1341 and 1346 and Interstate Travel in Aid of a Racketeering Enterprise, in violation of Title 18, United States Code, Section 1952(a) (3)" He further agreed that he understands that the total maximum sentence for all offenses to which defendant is pleading guilty is 10 years imprisonment; a 3-year period of supervised release; a fine of $500,000 or twice the gross gain or gross loss resulting from the offenses, whichever is greatest; and a mandatory special assessment of $200.

He agreed that he is "in fact guilty to the offenses" and agreed to a statement of facts stating that he agreed to exchange monetary kickbacks in return for the referral of patients to Pacific Hospital for surgical services paid for primarily through the California Workers' Compensation System ("CWCS"). In paying the kickbacks and submitting the resulting claims for the surgical services, the conspirators acted with the intent to defraud workers' compensation insurance carriers and to deprive the patients of their right of honest services. Drobot and other co-conspirators offered to pay kickbacks to doctors and chiropractors in return for their referring workers' compensation patients to Pacific Hospital for spinal surgeries, other types of surgeries, magnetic resonance imaging, toxicology, durable medical equipment, and other services.

Sobol either performed surgeries on the patients at Pacific Hospital himself, or - particularly in the case of spine surgeries - admitted he referred them to other surgeons, with specific instructions to those surgeons that they were to perform the surgeries only at Pacific Hospital, if possible, as a condition of receiving the referrals ...

Edward Bautista injured his ribs, pulmonary system, lumbar spine and right ankle in the course of his employment as a machine operator for Arlon Graphics on April 6, 2014, and he also claimed industrial injury to his psyche and sleep disorder.

He selected orthopedist Dr. Peter Borden as his primary treating physician from within the employer's MPN. According to the WCJ, the applicant "credibly testified" to symptoms of anxiety which he has verbalized to Dr. Borden who failed to diagnose anxiety or refer applicant for an opinion on the issue of psychological treatment.

Bautista then attempted to utilize the MPN second and third opinion process to obtain a second opinion from a psychologist. The WCJ found that use of the second and third opinion process was not appropriate and that Bautista was ordered to return for an appointment with Dr. Borden and ask Dr. Borden to specifically comment on the need for psychological medical treatment.

Bautista petitioned for Reconsideration/Removal contending that Labor Code section 4616.3 and Rule 9767.7 entitle him to obtain a second opinion from a psychologist he selected in defendant's Medical Provider Network. Reconsideration/Removal was denied in a split panel decision of Bautista v Arlon Graphics.

The panel majority ruled that under section 4616.3(c) and AD Rule 9767.7, applicant has a right to obtain a second opinion physician in the MPN if he disputes either the diagnosis or the treatment prescribed by the treating physician. In this situation, it is necessary to first obtain a diagnosis from the treating physician regarding the issue in dispute before there can be a basis to exercise the section 46l6.3(h) right to obtain a second opinion. That has no occurred in this case, and the WCJ correctly determined that Dr. Borden should directly "address the issue of a diagnosis of anxiety and whether referral for psychological consult/treatment is reasonable and necessary."

The dissenting opinion of Commissioner Sweeney disagreed stating "Under section 4616.3(c), applicant has an absolute right to obtain a second opinion from an MPN physician with the education, skills, training and experience to properly evaluate his psychiatric condition. The WCJ's decision unnecessarily burdens applicant's right to obtain a psychiatric evaluation by an MPN provider." ...

In response to a ProPublica and NPR highly critical investigation, the National Conference of Insurance Legislators said it will look into an effort by some of the biggest names in corporate America to opt out of workers’ comp. This year, a group founded by Walmart and several of the biggest employers in America has pushed a campaign to get laws passed in as many as a dozen states within the next decade. Tennessee and South Carolina are seriously considering such bills.

But now, a national association of state lawmakers has announced that it will investigate a burgeoning effort to let companies opt out of workers’ compensation insurance and write their own plans for how they’ll care for injured workers. The National Conference of Insurance Legislators, whose members serve on insurance committees and often act as gatekeepers for related bills in their states, said the decision was prompted by a ProPublica and NPR story last month that found that employers’ opt-out plans typically provide lower benefits for injured workers, more restrictions and little independent oversight. Texas and Oklahoma currently allow companies to opt out and other states are considering similar plans.

"The issues brought forward by the recent NPR/ProPublica study regarding the Texas and Oklahoma workers’ compensation programs are of significant concern to state legislators responsible for the protection of injured workers," said North Dakota state Sen. Jerry Klein, a Republican who chairs the association’s workers’ comp committee.

Nearly every state requires employers to carry workers’ comp to provide medical care and lost wages if someone gets hurt on the job. In exchange, workers are barred from suing their employers. But Texas has allowed companies to have no insurance, sometimes forcing injured workers to go to court or arbitration to obtain benefits. And in 2013, Oklahoma passed a law allowing companies there to opt out - while still retaining their immunity from lawsuits - if they adopt an alternative benefit plan.

Proponents say the alternative plans save companies money by removing bureaucracy and providing better medical care.

But ProPublica and NPR analyzed the plans of 120 companies and found that the Texas programs typically cut off medical treatment after about two years, don’t compensate workers for most permanent disabilities and cap payouts for deaths and catastrophic injuries. Workers’ comp typically covers medical care for workplace injuries for life and death benefits for children until they graduate college.

In Oklahoma, companies that opt out must provide the same level of benefits as workers’ comp, but unlike workers’ comp, the benefits are subject to income and payroll taxes. In addition, in almost every plan, workers cannot choose their doctors and must report injuries within 24 hours or risk losing all benefits.

A show of support from the national association would make opt-out bills much easier to pass, while a negative assessment might cause lawmakers to try to block efforts in their states. The group also said it would hold discussions to counter any attempts by the federal government to intervene in state workers’ comp programs.

An earlier ProPublica/NPR investigation found many states have drastically scaled back workers’ comp benefits in recent years. In response, several prominent members of Congress have called for increased federal oversight to ensure states are properly caring for injured workers ...