The long arm of the pharmaceutical industry continues to pervade practically every area of medicine, reaching those who write guidelines that shape doctors' practices, patient advocacy organizations, letter writers to the Centers for Disease Control and Prevention and even oncologists on Twitter, according to a series of papers on money and influence published in JAMA Internal Medicine and an article on NPR.
Researchers Ray Moynihan and Lisa Bero wrote in an accompanying commentary that the "very way we all think about disease - and the best ways to research, define, prevent, and treat it - is being subtly distorted because so many of the ostensibly independent players, including patient advocacy groups, are largely singing tunes acceptable to companies seeking to maximize markets for drugs and devices."
More than two-thirds of patient advocacy organizations that responded to a survey indicated that they had received industry funding in their last fiscal year. For most, the money represented a small share of their budget. But 12 percent said they received more than half of their money from industry.
US Centers for Disease Control and Prevention ( CDC) recently developed guidelines for prescribing opioids for chronic pain. When the draft guidelines were released , there was criticism. Some organizations argued that the development of the guidelines was not transparent and the recommendations were based on weak evidence. Subsequently, the CDC postponed the release of the guidelines and opened them to public comment for a 30-day period.
Researchers Moynihan and Bero analyzed these comments to identify levels of support for the guidelines and whether financial relationships with opioid manufacturers were associated with opposition to the guidelines. The final guidelines were released in March 2016."
158 organizations formally submitted comments after the proposed guidelines were released in February 2016, and 80 percent of them were supportive, though some had recommendations for changes. Organizations that received funding from opioid manufacturers were less supportive of guidelines proposed by the CDC to limit prescribing of the drugs for chronic pain.
Of the 158 organizations, 45 (28.5%) received funding from opioid manufacturers, 25 (15 .8%) had funding ties to other companies in the life sciences, 64 (40.5%) received no funding from the life sciences industry, and funding of the remaining 24 (15.2%) was not known. Of the organizations that received funding from opioid manufacturers, none disclosed these funding sources in their comments; of the organizations that received funding from the life sciences industry, 6 (24%) disclosed their funding.
Fifty-two organizations (32.9%) were supportive of the guidelines without additional recommendations, 75 (47. 5%) were generally supportive with recommendations, 18 (11.4%) were generally not supportive with recommendations, and 13 ( 8.2%) were not supportive.
Opposition to the guidelines was more frequent among organizations with funding from opioid manufacturers than those without funding from the life sciences industry, both overall and for recommendations about limits on opioid dosing and the length of opioid treatment.
Among the 45 groups that received money from opioid makers, though, the level of support was only 62 percent. And none of those groups disclosed their funding sources in their comments. (The CDC did not ask or require them to do so.)
"More people are dying than ever before from these products, and it's important to know how the market is shaped by the spending of drug companies," G. Caleb Alexander, co-director of the Center for Drug Safety and Effectiveness at Johns Hopkins 1University, said in an interview ...
Researchers Ray Moynihan and Lisa Bero wrote in an accompanying commentary that the "very way we all think about disease - and the best ways to research, define, prevent, and treat it - is being subtly distorted because so many of the ostensibly independent players, including patient advocacy groups, are largely singing tunes acceptable to companies seeking to maximize markets for drugs and devices."
More than two-thirds of patient advocacy organizations that responded to a survey indicated that they had received industry funding in their last fiscal year. For most, the money represented a small share of their budget. But 12 percent said they received more than half of their money from industry.
US Centers for Disease Control and Prevention ( CDC) recently developed guidelines for prescribing opioids for chronic pain. When the draft guidelines were released , there was criticism. Some organizations argued that the development of the guidelines was not transparent and the recommendations were based on weak evidence. Subsequently, the CDC postponed the release of the guidelines and opened them to public comment for a 30-day period.
Researchers Moynihan and Bero analyzed these comments to identify levels of support for the guidelines and whether financial relationships with opioid manufacturers were associated with opposition to the guidelines. The final guidelines were released in March 2016."
158 organizations formally submitted comments after the proposed guidelines were released in February 2016, and 80 percent of them were supportive, though some had recommendations for changes. Organizations that received funding from opioid manufacturers were less supportive of guidelines proposed by the CDC to limit prescribing of the drugs for chronic pain.
Of the 158 organizations, 45 (28.5%) received funding from opioid manufacturers, 25 (15 .8%) had funding ties to other companies in the life sciences, 64 (40.5%) received no funding from the life sciences industry, and funding of the remaining 24 (15.2%) was not known. Of the organizations that received funding from opioid manufacturers, none disclosed these funding sources in their comments; of the organizations that received funding from the life sciences industry, 6 (24%) disclosed their funding.
Fifty-two organizations (32.9%) were supportive of the guidelines without additional recommendations, 75 (47. 5%) were generally supportive with recommendations, 18 (11.4%) were generally not supportive with recommendations, and 13 ( 8.2%) were not supportive.
Opposition to the guidelines was more frequent among organizations with funding from opioid manufacturers than those without funding from the life sciences industry, both overall and for recommendations about limits on opioid dosing and the length of opioid treatment.
Among the 45 groups that received money from opioid makers, though, the level of support was only 62 percent. And none of those groups disclosed their funding sources in their comments. (The CDC did not ask or require them to do so.)
"More people are dying than ever before from these products, and it's important to know how the market is shaped by the spending of drug companies," G. Caleb Alexander, co-director of the Center for Drug Safety and Effectiveness at Johns Hopkins 1University, said in an interview ...
The Property Casualty 360 Out Front Ideas with Kimberly George and Mark Walls webinar of 2017 provided thoughts on Workers’ Compensation Issues to Watch in 2017.
Federal Regulations: The U.S. Department of Labor (DOL) under President Obama felt state workers’ compensation systems needed reform, and they were prepared to recommend minimum benefit standards to the states. President Trump’s nominee for Secretary of Labor, Andrew Puzder, has been a vocal opponent of many federal labor regulations. For now, any talk of the federal government getting involved in state workers’ compensation issues seems to be on hold.
Another potential impact of the election results is the direction OSHA may take in 2017 and beyond. In recent years, employers have complained that OSHA was more focused on enforcement than education and training, noting its shift of resources. Recent OSHA policies such as the publicly accessible online database and restrictions on post-injury drug testing were met with significant resistance from the employer community. OSHA falls under DOL and also is likely to have a new direction under the Trump administration.
Leave-of-absence regulations under the federal Family and Medical Leave Act (FMLA) have become increasingly more complex over the past eight years.
Americans with Disabilities Act (ADA) accommodation requests were initially related to ergonomics and transitional work accommodations following an illness or injury. Today, they have become more complex, including everything from bringing service animals into the workplace, allergies and noise accommodations to establishing work-from-home accommodations.
Market Cycles: Workers’ compensation market cycles are generally driven by changes in competition more than changes in exposures. Claims costs over the last 20 years have steadily increased, yet premiums during this same period have gone up and down.
During the January 1 renewal cycle, rates trended flat or slightly down compared to expiring premiums. Some problem states saw higher rates, including California, New York, Illinois and Florida. The declining rates compared to increasing claims costs have caused A.M. Best, Fitch and others to issue a negative outlook on workers’ compensation. This hyper-competitive market cycle is expected to end soon as the new entrants into the marketplace start to see the long-tail losses from their business hitting the books.
Lifetime Awards: Workers’ compensation is a challenge for employers and carriers due to the long-tail claims, that is, premiums collected today must cover losses for years to come. It has an impact on both carriers and employers in the cost of insurance today and future reserves.
The biggest drivers are advances in medical science that increase life expectancies, which in turn increase the exposures for lifetime indemnity and medical benefits. In addition, new drugs and treatments cost more than what they are replacing, especially with the cost difference between brand-name drugs and generic medication. Prosthetics are so much more advanced today than they were 10 years ago, but they also cost significantly more.
Treatment Guidelines: States have implemented a variety of guideline solutions, which include creating unique formularies and treatment guides and also adopting industry-available workers’ compensation guidelines. The lack of guideline consensus across stakeholders including physicians, regulators, payers and suppliers is an ongoing challenge to the system.
Constitutional Challenges: In 2016, elements of the workers’ compensation statutes in five states were found to be unconstitutional by each state’s respective Supreme Court, including the following:
1) Caps on temporary total disability benefits
2) Exclusion of coverage for certain farm workers
3) Caps on attorney fees
4) Time limits for filing cumulative trauma claims
5) Use of the current edition of the American Medical Association guidelines for impairment ratings ...
Federal Regulations: The U.S. Department of Labor (DOL) under President Obama felt state workers’ compensation systems needed reform, and they were prepared to recommend minimum benefit standards to the states. President Trump’s nominee for Secretary of Labor, Andrew Puzder, has been a vocal opponent of many federal labor regulations. For now, any talk of the federal government getting involved in state workers’ compensation issues seems to be on hold.
Another potential impact of the election results is the direction OSHA may take in 2017 and beyond. In recent years, employers have complained that OSHA was more focused on enforcement than education and training, noting its shift of resources. Recent OSHA policies such as the publicly accessible online database and restrictions on post-injury drug testing were met with significant resistance from the employer community. OSHA falls under DOL and also is likely to have a new direction under the Trump administration.
Leave-of-absence regulations under the federal Family and Medical Leave Act (FMLA) have become increasingly more complex over the past eight years.
Americans with Disabilities Act (ADA) accommodation requests were initially related to ergonomics and transitional work accommodations following an illness or injury. Today, they have become more complex, including everything from bringing service animals into the workplace, allergies and noise accommodations to establishing work-from-home accommodations.
Market Cycles: Workers’ compensation market cycles are generally driven by changes in competition more than changes in exposures. Claims costs over the last 20 years have steadily increased, yet premiums during this same period have gone up and down.
During the January 1 renewal cycle, rates trended flat or slightly down compared to expiring premiums. Some problem states saw higher rates, including California, New York, Illinois and Florida. The declining rates compared to increasing claims costs have caused A.M. Best, Fitch and others to issue a negative outlook on workers’ compensation. This hyper-competitive market cycle is expected to end soon as the new entrants into the marketplace start to see the long-tail losses from their business hitting the books.
Lifetime Awards: Workers’ compensation is a challenge for employers and carriers due to the long-tail claims, that is, premiums collected today must cover losses for years to come. It has an impact on both carriers and employers in the cost of insurance today and future reserves.
The biggest drivers are advances in medical science that increase life expectancies, which in turn increase the exposures for lifetime indemnity and medical benefits. In addition, new drugs and treatments cost more than what they are replacing, especially with the cost difference between brand-name drugs and generic medication. Prosthetics are so much more advanced today than they were 10 years ago, but they also cost significantly more.
Treatment Guidelines: States have implemented a variety of guideline solutions, which include creating unique formularies and treatment guides and also adopting industry-available workers’ compensation guidelines. The lack of guideline consensus across stakeholders including physicians, regulators, payers and suppliers is an ongoing challenge to the system.
Constitutional Challenges: In 2016, elements of the workers’ compensation statutes in five states were found to be unconstitutional by each state’s respective Supreme Court, including the following:
1) Caps on temporary total disability benefits
2) Exclusion of coverage for certain farm workers
3) Caps on attorney fees
4) Time limits for filing cumulative trauma claims
5) Use of the current edition of the American Medical Association guidelines for impairment ratings ...
TeamHealth Holdings, Inc. is one of the nation's largest providers of outsourced physician staffing solutions for hospitals. The company contracts with hospitals and physician groups in the areas of emergency medicine, hospital medicine, anesthesia and specialty hospitalist services. It also offers combined outsourcing services to single hospitals and hospital systems
TeamHealth has a growing presence in California. In 2014 it announced the acquisition of the operations of Burbank, Calif.-based Primary Critical Care Medical Group (PCCMG). Specializing primarily in hospital and critical care medicine, PCCMG provides clinical services through partnerships with four hospitals and two outpatient primary care clinics in the Southern California market.
IPC Healthcare Inc., was purchased by TeamHealth in November 2015. IPC is headquartered in North Hollywood, on Lankershim Boulevard. IPC manages hospitalist practice groups in the San Francisco Bay Area and the Inland Empire, and nationally. The transaction was valued at approximately $1.6 billion.
TeamHealth's approximately 10,000 affiliated healthcare professionals provide emergency medicine, hospital medicine, anesthesia, urgent care, and pediatric staffing and management services to approximately 900 civilian and military hospitals, clinics, and physician groups in 46 states.
The Department of Justice just announced that TeamHealth Holdings, as successor in interest to IPC has agreed to resolve allegations that IPC violated the False Claims Act by billing Medicare, Medicaid, the Defense Health Agency and the Federal Employees Health Benefits Program for higher and more expensive levels of medical service than were actually performed (a practice known as "up-coding"). Under the settlement agreement, TeamHealth has agreed to pay $60 million, plus interest.
The government contended that IPC knowingly and systematically encouraged false billings by its hospitalists, who are medical professionals whose primary focus is the medical care of hospitalized patients. Specifically, the government alleged that IPC encouraged its hospitalists to bill for a higher level of service than actually provided. IPC’s scheme to improperly maximize billings allegedly included corporate pressure on hospitalists with lower billing levels to "catch up" to their peers.
As part of the settlement, TeamHealth entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) covering the company’s hospital medicine division. This CIA is designed to increase TeamHealth’s accountability and transparency so that the company will avoid or promptly detect future fraud and abuse.
The settlement resolves allegations filed in a lawsuit by Dr. Bijan Oughatiyan, a physician formerly employed by IPC as a hospitalist. The Act also allows the government to intervene and take over the action, as it did in this case. Dr. Oughatiyan will receive approximately $11.4 million from the settlement ...
TeamHealth has a growing presence in California. In 2014 it announced the acquisition of the operations of Burbank, Calif.-based Primary Critical Care Medical Group (PCCMG). Specializing primarily in hospital and critical care medicine, PCCMG provides clinical services through partnerships with four hospitals and two outpatient primary care clinics in the Southern California market.
IPC Healthcare Inc., was purchased by TeamHealth in November 2015. IPC is headquartered in North Hollywood, on Lankershim Boulevard. IPC manages hospitalist practice groups in the San Francisco Bay Area and the Inland Empire, and nationally. The transaction was valued at approximately $1.6 billion.
TeamHealth's approximately 10,000 affiliated healthcare professionals provide emergency medicine, hospital medicine, anesthesia, urgent care, and pediatric staffing and management services to approximately 900 civilian and military hospitals, clinics, and physician groups in 46 states.
The Department of Justice just announced that TeamHealth Holdings, as successor in interest to IPC has agreed to resolve allegations that IPC violated the False Claims Act by billing Medicare, Medicaid, the Defense Health Agency and the Federal Employees Health Benefits Program for higher and more expensive levels of medical service than were actually performed (a practice known as "up-coding"). Under the settlement agreement, TeamHealth has agreed to pay $60 million, plus interest.
The government contended that IPC knowingly and systematically encouraged false billings by its hospitalists, who are medical professionals whose primary focus is the medical care of hospitalized patients. Specifically, the government alleged that IPC encouraged its hospitalists to bill for a higher level of service than actually provided. IPC’s scheme to improperly maximize billings allegedly included corporate pressure on hospitalists with lower billing levels to "catch up" to their peers.
As part of the settlement, TeamHealth entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) covering the company’s hospital medicine division. This CIA is designed to increase TeamHealth’s accountability and transparency so that the company will avoid or promptly detect future fraud and abuse.
The settlement resolves allegations filed in a lawsuit by Dr. Bijan Oughatiyan, a physician formerly employed by IPC as a hospitalist. The Act also allows the government to intervene and take over the action, as it did in this case. Dr. Oughatiyan will receive approximately $11.4 million from the settlement ...
Express Scripts' Prescription Price Index shows continued inflation in the price of medications, with the average list price of the most commonly used brand drugs increasing nearly 11 percent in 2016. From the base price of $100.00 set in January 2008, in December 2016 prices for the most commonly used brand medications increased to $307.86 (in 2008 dollars), a nearly 208 percent increase.
Medications that treat inflammatory conditions and diabetes remain the costliest therapy classes. One of every five dollars spent on prescription drugs was for medication to treat an inflammatory condition or diabetes.
Employers paid, on average, $3587.83 per prescription for a medication to treat an inflammatory condition, such as rheumatoid arthritis. Humira® (adalimumab) and Enbrel® (etanercept) were major trend drivers for the class, with unit cost increases between 10 and 18 percent. Despite having more than 15 available therapies in the class, these two medications accounted for approximately 70 percent of the market share in 2016.
Biosimilar competition in this class could significantly ease spending for employers; however delays in biosimilar availability have limited payers' ability to achieve much relief.
Spending on diabetes medications increased 19.4 percent in 2016, driven by a 14.1 percent increase in unit cost. Total spending on insulins -- which account for 40 percent of all diabetes spending -- increased nearly 10 percent between 2015 and 2016. The average patient out-of-pocket cost for insulin was $36.69 per prescription (adjusted for difference in days' supply), just $1.63 more than 2015.
In 2016, spending on oncology medications increased nearly 22 percent, making it the third-costliest class. Despite savings from generics, including imatinib, the generic for Gleevec®, unit costs for oral oncology medications increased 9.6 percent in 2016. List prices for oral oncology medications, which are not rebated or discounted to any significant extent, have doubled between 2011 and 2016, from $20 per unit to $40 per unit.
One in five people filled a prescription for a pain medication in 2016. Despite a 95 percent generic fill rate for this class of drugs, spending was driven by just two brand-name medications: Lyrica® (pregabalin) and OxyContin® (oxycodone). Pain medications are the fifth costliest class of drugs.
While the Pharmacy Benefit Management companies claim credit for holding down drug, prices, some are critical of the PBM industry.
Three PBMs - Express Scripts, CVS Health and Opitmum RX, a division of UnitedHealth Group - control about 70 percent of the market. The Fortune 500 list gives a sense of their enormous size. UnitedHealth Group and CVS Health are numbers six and seven on the list, while Express Scripts shows up at number 22. J.P. Morgan Chase, Boeing and Microsoft all trail Express Scripts on the Fortune list as do the largest pharmaceutical manufacturers.
Critics of the big PBMs say their pricing practices and a lack of transparency are driving up costs and causing insurers to pay inflated prices without knowing it - eventually passing those costs on to their members. The alleged tactics include keeping an undisclosed amount of the rebates they negotiate while offering their clients a much smaller cut, and charging a "spread" on each prescription that gets processed.
Rebates and spread pricing are agreed upon in the contracts signed by their clients and are very clear about who gets what, the PBMs say. But critics argue the door is open for price gouging without more transparency and if health plan sponsors aren’t savvy in negotiating those contracts ...
Medications that treat inflammatory conditions and diabetes remain the costliest therapy classes. One of every five dollars spent on prescription drugs was for medication to treat an inflammatory condition or diabetes.
Employers paid, on average, $3587.83 per prescription for a medication to treat an inflammatory condition, such as rheumatoid arthritis. Humira® (adalimumab) and Enbrel® (etanercept) were major trend drivers for the class, with unit cost increases between 10 and 18 percent. Despite having more than 15 available therapies in the class, these two medications accounted for approximately 70 percent of the market share in 2016.
Biosimilar competition in this class could significantly ease spending for employers; however delays in biosimilar availability have limited payers' ability to achieve much relief.
Spending on diabetes medications increased 19.4 percent in 2016, driven by a 14.1 percent increase in unit cost. Total spending on insulins -- which account for 40 percent of all diabetes spending -- increased nearly 10 percent between 2015 and 2016. The average patient out-of-pocket cost for insulin was $36.69 per prescription (adjusted for difference in days' supply), just $1.63 more than 2015.
In 2016, spending on oncology medications increased nearly 22 percent, making it the third-costliest class. Despite savings from generics, including imatinib, the generic for Gleevec®, unit costs for oral oncology medications increased 9.6 percent in 2016. List prices for oral oncology medications, which are not rebated or discounted to any significant extent, have doubled between 2011 and 2016, from $20 per unit to $40 per unit.
One in five people filled a prescription for a pain medication in 2016. Despite a 95 percent generic fill rate for this class of drugs, spending was driven by just two brand-name medications: Lyrica® (pregabalin) and OxyContin® (oxycodone). Pain medications are the fifth costliest class of drugs.
While the Pharmacy Benefit Management companies claim credit for holding down drug, prices, some are critical of the PBM industry.
Three PBMs - Express Scripts, CVS Health and Opitmum RX, a division of UnitedHealth Group - control about 70 percent of the market. The Fortune 500 list gives a sense of their enormous size. UnitedHealth Group and CVS Health are numbers six and seven on the list, while Express Scripts shows up at number 22. J.P. Morgan Chase, Boeing and Microsoft all trail Express Scripts on the Fortune list as do the largest pharmaceutical manufacturers.
Critics of the big PBMs say their pricing practices and a lack of transparency are driving up costs and causing insurers to pay inflated prices without knowing it - eventually passing those costs on to their members. The alleged tactics include keeping an undisclosed amount of the rebates they negotiate while offering their clients a much smaller cut, and charging a "spread" on each prescription that gets processed.
Rebates and spread pricing are agreed upon in the contracts signed by their clients and are very clear about who gets what, the PBMs say. But critics argue the door is open for price gouging without more transparency and if health plan sponsors aren’t savvy in negotiating those contracts ...
The fallout from the Aug. 26 signing of Assembly Bill 2883 eventually became the defining topic of discussion during the fourth quarter among insurance agencies, carriers and most notably business owners who now find it more challenging to exclude themselves from their own workers comp policies. Most industry insiders got their first heads-up in mid-October, just a couple months ahead of the Jan. 1 effective date.
According to the article in the Central Valley Business Journal, the legislation requires all officers, members and partners to be covered under the workers compensation policy unless more restrictive qualifications are met.
To compound the matter, language delaying the application of the bill for in-force policies was omitted from the text. This omission, coupled with the narrower definition of who can be excluded from coverage, caused a massive disruption for the industry as a whole.
If your business is set up as a corporation, you must be an officer or director owning at least 15 percent of issued and outstanding stock on Jan. 1, 2017 to qualify for exclusion.
You must also execute a waiver of your rights to workers comp coverage, certifying under penalty of perjury that you are a qualifying officer or director with the requisite stock ownership.
If your business is organized as a partnership or LLC, you must now be a general partner of a partnership or a managing member of an LLC to qualify for exclusion (no minimum amount of ownership required).
The bill was supported by the American Insurance Association and the Association of California Insurance Companies, who contended the election process for opting out of coverage was not clear and led to abuses of the system.
In a handful of cases, certain employers gamed the system by claiming that employees with no real stake in the entity were officers, then excluding them from coverage.
As is often the case, small to middle-market businesses are experiencing the most devastating impact of the new legislation. Previously excludable individuals are covered as of Jan. 1, and premium for those individuals is accumulating.
In the worst cases, owners who do not perform strictly office work are being assigned to more costly classification codes. Many small businesses are seeing premiums double now that key employees are no longer excludable.
At a minimum, employers who exclude individuals from coverage now have additional paperwork to file with insurance carriers. Some entities have convened roundtable discussions with their insurance agents, accountants and lawyers to restructure corporate shares or reorganize the business to accommodate for continued exclusion of key employees.
...
According to the article in the Central Valley Business Journal, the legislation requires all officers, members and partners to be covered under the workers compensation policy unless more restrictive qualifications are met.
To compound the matter, language delaying the application of the bill for in-force policies was omitted from the text. This omission, coupled with the narrower definition of who can be excluded from coverage, caused a massive disruption for the industry as a whole.
If your business is set up as a corporation, you must be an officer or director owning at least 15 percent of issued and outstanding stock on Jan. 1, 2017 to qualify for exclusion.
You must also execute a waiver of your rights to workers comp coverage, certifying under penalty of perjury that you are a qualifying officer or director with the requisite stock ownership.
If your business is organized as a partnership or LLC, you must now be a general partner of a partnership or a managing member of an LLC to qualify for exclusion (no minimum amount of ownership required).
The bill was supported by the American Insurance Association and the Association of California Insurance Companies, who contended the election process for opting out of coverage was not clear and led to abuses of the system.
In a handful of cases, certain employers gamed the system by claiming that employees with no real stake in the entity were officers, then excluding them from coverage.
As is often the case, small to middle-market businesses are experiencing the most devastating impact of the new legislation. Previously excludable individuals are covered as of Jan. 1, and premium for those individuals is accumulating.
In the worst cases, owners who do not perform strictly office work are being assigned to more costly classification codes. Many small businesses are seeing premiums double now that key employees are no longer excludable.
At a minimum, employers who exclude individuals from coverage now have additional paperwork to file with insurance carriers. Some entities have convened roundtable discussions with their insurance agents, accountants and lawyers to restructure corporate shares or reorganize the business to accommodate for continued exclusion of key employees.
...
Ask Spine Surgeons - is a weekly series of questions posed by Becker's Spine Review to spine surgeons around the country about clinical, business and policy issues affecting spine care. Here are two responses to the question "What are the most exciting spine industry trends you expect to see in 2017?"
Kevin Ju, MD. Spine Surgeon at Texas Back Institute (Plano) says that Spine surgery is an ever-changing landscape. Throughout 2017, he expects that we will continue to see interest in motion-preserving procedures as an alternative to spinal fusion.
As a field, we have seen the development and emphasis of several techniques and technologies over the years that are meant to effect neurological decompression while preserving spinal motion. Examples include laminoplasty over laminectomy and fusion, cervical and lumbar total disc replacement over ACDF or lumbar fusion as well as various interlaminar spacers.
Some of these have been very successful while others have been less so.
In addition to new technical advancements, there will also be more research on when fusion surgery is beneficial. For example, in the last several months two papers were published in the New England Journal of Medicine that investigated the benefits and risks of spinal fusion in addition to decompression for degenerative spondylolisthesis. Throughout 2017, we will likely continue to see an emphasis on trying to avoid spinal fusion surgery when it's appropriate.
On a related note, something that he hopes to see in the upcoming year is more attention on bone health and osteoporosis.
As our population ages, this issue is becoming an increasingly prevalent problem. We need to team up with our medical colleagues and ask our patients about recent bone density tests, history of fragility fractures and prior osteoporosis treatments.
Not only can we help diagnose this problem, but if the patient ultimately requires surgery down the road, optimizing bone health preoperatively is ideal as we all know the perils and complications that plague instrumenting osteoporotic bone.
Early detection and treatment of osteopenia and osteoporosis is key to improving these patients' lives.
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles said he was most keyed in on endoscopic spine.
He had the opportunity to meet a colleague from South Korea where they are doing some amazing things through a scope. He expects it to become pretty hot in the coming year as we focus on outpatient surgery.
Also, we will likely see more instrumentation being done on an outpatient basis, especially with cervical arthroplasty and interspinous stabilization.
Lastly, deformity correction is becoming more and more important in the inpatient setting. I think the focus will be on faster and safer surgeries, possibly with robotic assistance ...
Kevin Ju, MD. Spine Surgeon at Texas Back Institute (Plano) says that Spine surgery is an ever-changing landscape. Throughout 2017, he expects that we will continue to see interest in motion-preserving procedures as an alternative to spinal fusion.
As a field, we have seen the development and emphasis of several techniques and technologies over the years that are meant to effect neurological decompression while preserving spinal motion. Examples include laminoplasty over laminectomy and fusion, cervical and lumbar total disc replacement over ACDF or lumbar fusion as well as various interlaminar spacers.
Some of these have been very successful while others have been less so.
In addition to new technical advancements, there will also be more research on when fusion surgery is beneficial. For example, in the last several months two papers were published in the New England Journal of Medicine that investigated the benefits and risks of spinal fusion in addition to decompression for degenerative spondylolisthesis. Throughout 2017, we will likely continue to see an emphasis on trying to avoid spinal fusion surgery when it's appropriate.
On a related note, something that he hopes to see in the upcoming year is more attention on bone health and osteoporosis.
As our population ages, this issue is becoming an increasingly prevalent problem. We need to team up with our medical colleagues and ask our patients about recent bone density tests, history of fragility fractures and prior osteoporosis treatments.
Not only can we help diagnose this problem, but if the patient ultimately requires surgery down the road, optimizing bone health preoperatively is ideal as we all know the perils and complications that plague instrumenting osteoporotic bone.
Early detection and treatment of osteopenia and osteoporosis is key to improving these patients' lives.
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles said he was most keyed in on endoscopic spine.
He had the opportunity to meet a colleague from South Korea where they are doing some amazing things through a scope. He expects it to become pretty hot in the coming year as we focus on outpatient surgery.
Also, we will likely see more instrumentation being done on an outpatient basis, especially with cervical arthroplasty and interspinous stabilization.
Lastly, deformity correction is becoming more and more important in the inpatient setting. I think the focus will be on faster and safer surgeries, possibly with robotic assistance ...
This was defense attorney Kimberly Allyson Hansen's third discipline proceeding. It arises from her representation of two defendants before the Workers' Compensation Appeals Board. The WCAB imposed sanctions against Hansen and three other attorneys from her law firm after concluding that they had intentionally misled the Board, causing it to take unwarranted action.
According to the 23 page State Bar Opinion (Designated for Publication) "At all times relevant to this matter, she worked as a vice-president at the law firm of Stockwell, Harris, Woolverton & Muehl and was an experienced workers' compensation attorney."
Louis Speight, an employee of Vulcan Materials Company, Western Division, submitted a workers' compensation claim for work-related injuries. During the course of litigation, it took defense attorneys three attempts to obtain a QME panel. The Medical Unit denied the first QME Request "due to the lack of all necessary information." The Medical Unit also informed Hansen that her first QME Request had been filed prematurely. Hansen was directed to "resubmit [her] request as soon as possible..." The Medical Unit notified Hansen it was rejecting her second request because it also lacked "all necessary information. " One week later, on July 28, 2009, Hansen submitted a third QME panel request to the Medical Unit.
Between the second and third QME request, the Speight case was set for conference. The WCALJ overruled defense objections and set the matter for trial. But a defense Petition for Removal was granted on the issue of the QME panel. However defendants "failed to disclose to the WCAB that the Medical Unit had timely advised Hansen that the First and Second QME Requests were deficient."
Three weeks after the Petition for Removal was filed and before the WCAB ruled on it, the Medical Unit issued a QME panel in response to Hansen's third QME Request. "The WCAB granted the Petition for Removal on December 21, 2009, on the grounds that the ALJ should have ordered the matter off calendar to allow the Defendant to obtain a QME panel. Still, Hansen did not notify the Board that a QME panel had already been assigned three months earlier, and she again remained silent when the WCAB issued a second order on March 9, 2010, rescinding the ALJ's trial-setting order and directing the Medical Unit's Medical Director to issue a QME panel."
Three weeks later, the WCAB learned of the true state of affairs when the Medical Director filed a verified Petition for Reconsideration, a Petition to Reopen the Record, and an Offer of Proof, which disclosed that the Medical Unit had in fact timely responded to Hansen, advising her that the First and Second QME Requests had been denied for procedural deficiencies and that the Third QME Request had been granted and a panel had been issued several months earlier.
The WCAB did not take lightly the fact that its orders to the ALJ to vacate the trial setting order and to the Medical Unit to issue a QME panel were based on "a distorted version of the record." The WCAB concluded its hotly contested sanction hearing by saying the "problem was not that the attorneys zealously represented their client; it was that they did so by misleading the WCAB, by concealing material facts, and by supporting their position with half-truths."
As a consequence of the WCAB's actions, the Office of the Chief Trial Counsel of the State Bar (OCTC) initiated disciplinary proceedings against Hansen and her colleague Kevin White, an associate with the Stockwell firm, who attended a mandatory settlement conference. The hearing judge in the disciplinary matter determined against Hanson that "Hansen's participation in the workers' compensation case involved acts of dishonesty constituting moral turpitude. She further found three factors in aggravation (two prior records of discipline, significant harm, and lack of insight) and two factors in mitigation ( cooperation and good character)."
Both Hansen and the Office of the Chief Trial Counsel of the State Bar (OCTC) appealed. Hansen asserts that this case should be dismissed because she made no misrepresentations to the WCAB, but rather was merely zealously representing her clients. OCTC supports the hearing judge's culpability findings, but requested a finding of more aggravation and less mitigation, and that after appeal there be a recommend disbarment.
Having independently reviewed the record it was found that "Hansen is culpable of acts of moral turpitude, in violation of Business and Professions Code section 6106." However it agreed "with the hearing judge that an 18-month actual suspension is appropriate." ...
According to the 23 page State Bar Opinion (Designated for Publication) "At all times relevant to this matter, she worked as a vice-president at the law firm of Stockwell, Harris, Woolverton & Muehl and was an experienced workers' compensation attorney."
Louis Speight, an employee of Vulcan Materials Company, Western Division, submitted a workers' compensation claim for work-related injuries. During the course of litigation, it took defense attorneys three attempts to obtain a QME panel. The Medical Unit denied the first QME Request "due to the lack of all necessary information." The Medical Unit also informed Hansen that her first QME Request had been filed prematurely. Hansen was directed to "resubmit [her] request as soon as possible..." The Medical Unit notified Hansen it was rejecting her second request because it also lacked "all necessary information. " One week later, on July 28, 2009, Hansen submitted a third QME panel request to the Medical Unit.
Between the second and third QME request, the Speight case was set for conference. The WCALJ overruled defense objections and set the matter for trial. But a defense Petition for Removal was granted on the issue of the QME panel. However defendants "failed to disclose to the WCAB that the Medical Unit had timely advised Hansen that the First and Second QME Requests were deficient."
Three weeks after the Petition for Removal was filed and before the WCAB ruled on it, the Medical Unit issued a QME panel in response to Hansen's third QME Request. "The WCAB granted the Petition for Removal on December 21, 2009, on the grounds that the ALJ should have ordered the matter off calendar to allow the Defendant to obtain a QME panel. Still, Hansen did not notify the Board that a QME panel had already been assigned three months earlier, and she again remained silent when the WCAB issued a second order on March 9, 2010, rescinding the ALJ's trial-setting order and directing the Medical Unit's Medical Director to issue a QME panel."
Three weeks later, the WCAB learned of the true state of affairs when the Medical Director filed a verified Petition for Reconsideration, a Petition to Reopen the Record, and an Offer of Proof, which disclosed that the Medical Unit had in fact timely responded to Hansen, advising her that the First and Second QME Requests had been denied for procedural deficiencies and that the Third QME Request had been granted and a panel had been issued several months earlier.
The WCAB did not take lightly the fact that its orders to the ALJ to vacate the trial setting order and to the Medical Unit to issue a QME panel were based on "a distorted version of the record." The WCAB concluded its hotly contested sanction hearing by saying the "problem was not that the attorneys zealously represented their client; it was that they did so by misleading the WCAB, by concealing material facts, and by supporting their position with half-truths."
As a consequence of the WCAB's actions, the Office of the Chief Trial Counsel of the State Bar (OCTC) initiated disciplinary proceedings against Hansen and her colleague Kevin White, an associate with the Stockwell firm, who attended a mandatory settlement conference. The hearing judge in the disciplinary matter determined against Hanson that "Hansen's participation in the workers' compensation case involved acts of dishonesty constituting moral turpitude. She further found three factors in aggravation (two prior records of discipline, significant harm, and lack of insight) and two factors in mitigation ( cooperation and good character)."
Both Hansen and the Office of the Chief Trial Counsel of the State Bar (OCTC) appealed. Hansen asserts that this case should be dismissed because she made no misrepresentations to the WCAB, but rather was merely zealously representing her clients. OCTC supports the hearing judge's culpability findings, but requested a finding of more aggravation and less mitigation, and that after appeal there be a recommend disbarment.
Having independently reviewed the record it was found that "Hansen is culpable of acts of moral turpitude, in violation of Business and Professions Code section 6106." However it agreed "with the hearing judge that an 18-month actual suspension is appropriate." ...
The Division of Workers’ Compensation has posted an order adjusting the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) section of the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1.
The Centers for Medicare and Medicaid Services (CMS) initially released the DMEPOS Fee Schedule 2017 zip file update in December of 2016. The DMEPOS update was adopted by the DWC Acting Administrative Director’s order of December 15, 2016. Subsequently, CMS issued a revised DMEPOS Fee Schedule zip file for 2017 in order to implement changes required by the 21st Century Cures Act.
The Acting Administrative Director has adopted the revised DMEPOS Fee Schedule zip file for services rendered on or after February 1, 2017.
The update order is effective for services rendered on or after February 1, 2017, and can be found at the DWC website’s OMFS page ...
The Centers for Medicare and Medicaid Services (CMS) initially released the DMEPOS Fee Schedule 2017 zip file update in December of 2016. The DMEPOS update was adopted by the DWC Acting Administrative Director’s order of December 15, 2016. Subsequently, CMS issued a revised DMEPOS Fee Schedule zip file for 2017 in order to implement changes required by the 21st Century Cures Act.
The Acting Administrative Director has adopted the revised DMEPOS Fee Schedule zip file for services rendered on or after February 1, 2017.
The update order is effective for services rendered on or after February 1, 2017, and can be found at the DWC website’s OMFS page ...
The new DOJ guidelines, issued September 9, 2015 and referred to informally as the "Yates Memo" articulated several changes to DOJ policy. In substance the Memo promised that "Americans should never believe, even incorrectly, that one’s criminal activity will go unpunished simply because it was committed on behalf of a corporation." The new policy seeks to hold corporate officers responsible for acts of their corporate employers.
And it seems that the Yates Memo has found a new target. A former senior executive of Tenet Healthcare Corp has been indicted on charges that he participated in a scheme to pay bribes for patient referrals, enabling the U.S. hospital chain to fraudulently bill state Medicaid programs for $400 million.
John Holland, a former senior vice president, was charged in an indictment filed in federal court in Miami with four counts of mail fraud, health care fraud and major fraud against the United States, the U.S. Justice Department said on Wednesday. The charges came after Dallas-based Tenet and two of its Atlanta-area units reached a settlement with the Justice Department and agreed to pay more than $513 million to resolve criminal charges and civil claims in a related settlement.
"These charges underscore our continued commitment to holding both individuals and corporations accountable for their fraudulent conduct," said Acting Assistant Attorney General Kenneth Blanco said in a statement.
Holland, 60, of Dallas, pleaded not guilty during a court hearing in Miami. Richard Deane, his lawyer, said he believed "the company's resolution should have ended the matter." "Mr. Holland is not guilty and we now look forward to presenting this case to a jury," Deane said in a statement.
Prosecutors said Holland beginning in 2000 was chief executive of Tenet-owned North Fulton Medical Center Inc in Roswell, Georgia, and served as senior vice president of operations for Tenet's southern states region from 2006 to 2013.
The indictment said that from 2000 to 2013, Holland and others engaged in a scheme to pay over $12 million in bribes and other illegal inducements to the owners and operators of a firm that operated clinics in Georgia and South Carolina. In exchange, the clinics, which provided prenatal care to mostly undocumented Hispanic women, referred patients to Tenet hospitals and arranged for services to be provided to patients and their newborns at Tenet hospitals. Prosecutors said Holland sought to conceal the scheme by circumventing internal accounting controls and falsifying records.
Prosecutors said the scheme enabled Tenet hospitals to fraudulently bill the Georgia and South Carolina Medicaid Programs for over $400 million, and allowed Tenet to obtain more than $149 million in Medicaid and Medicare funds.
The indictment said Holland also made false statements to the U.S. Department of Health and Human Services' Office of Inspector General about its compliance with the terms of a 2006 agreement reached as part of an earlier settlement.
The case is U.S. v. Holland, U.S. District Court, Southern District of Florida, No. 17-cr-20054 ...
And it seems that the Yates Memo has found a new target. A former senior executive of Tenet Healthcare Corp has been indicted on charges that he participated in a scheme to pay bribes for patient referrals, enabling the U.S. hospital chain to fraudulently bill state Medicaid programs for $400 million.
John Holland, a former senior vice president, was charged in an indictment filed in federal court in Miami with four counts of mail fraud, health care fraud and major fraud against the United States, the U.S. Justice Department said on Wednesday. The charges came after Dallas-based Tenet and two of its Atlanta-area units reached a settlement with the Justice Department and agreed to pay more than $513 million to resolve criminal charges and civil claims in a related settlement.
"These charges underscore our continued commitment to holding both individuals and corporations accountable for their fraudulent conduct," said Acting Assistant Attorney General Kenneth Blanco said in a statement.
Holland, 60, of Dallas, pleaded not guilty during a court hearing in Miami. Richard Deane, his lawyer, said he believed "the company's resolution should have ended the matter." "Mr. Holland is not guilty and we now look forward to presenting this case to a jury," Deane said in a statement.
Prosecutors said Holland beginning in 2000 was chief executive of Tenet-owned North Fulton Medical Center Inc in Roswell, Georgia, and served as senior vice president of operations for Tenet's southern states region from 2006 to 2013.
The indictment said that from 2000 to 2013, Holland and others engaged in a scheme to pay over $12 million in bribes and other illegal inducements to the owners and operators of a firm that operated clinics in Georgia and South Carolina. In exchange, the clinics, which provided prenatal care to mostly undocumented Hispanic women, referred patients to Tenet hospitals and arranged for services to be provided to patients and their newborns at Tenet hospitals. Prosecutors said Holland sought to conceal the scheme by circumventing internal accounting controls and falsifying records.
Prosecutors said the scheme enabled Tenet hospitals to fraudulently bill the Georgia and South Carolina Medicaid Programs for over $400 million, and allowed Tenet to obtain more than $149 million in Medicaid and Medicare funds.
The indictment said Holland also made false statements to the U.S. Department of Health and Human Services' Office of Inspector General about its compliance with the terms of a 2006 agreement reached as part of an earlier settlement.
The case is U.S. v. Holland, U.S. District Court, Southern District of Florida, No. 17-cr-20054 ...
It is not uncommon for histories in medical records to be inconsistent with the history provided by a claimant in a hearing or in a deposition.
Now a small study by researchers explored why symptoms that patients describe to doctors may not always be documented in electronic medical records.
To test out how well the records match reality, researchers compared symptoms that 162 patients checked off on paper-based questionnaires with the information entered in patients’ electronic charts at eye clinics.
Researchers report in an article published in JAMA Ophthalmology that roughly one-third of the time, data on blurry vision from paper questionnaires did not match the electronic records. Symptom information also did not match for glare 48 percent of the time and was discordant in 27 percent of cases for pain and 25 percent for redness.
"Because the electronic health record allows researchers, payers and administrators to extract information from the medical record in a way that has never been previously possible, the implications of capturing patient data in the most accurate way becomes much more imperative," said study co-author Dr. Paula Anne Newman-Casey, an ophthalmologist at the University of Michigan’s Kellogg Eye Center in Ann Arbor.
In theory, the promise of electronic health records is that they can help improve the quality of care and lower costs in part by reducing room for errors. Most U.S. doctors and hospitals now use electronic records, though paper remains common for patient symptom questionnaires.
For the study, researchers examined paper copies of eye symptom questionnaires completed by patients visiting eye clinics between October 2015 and January 2016. Patients rated the severity of common eye issues within the previous week.
Blurry vision was the most common complaint, but when patients reported blurry vision on the questionnaires, the electronic health record correctly noted this in 60 cases but failed to include it in 25 cases.
For patients who didn’t report blurry vision, the electronic records accurately noted this in 26 cases but mistakenly identified this as a problem for 29 patients.
Mismatches were also common for redness, pain, glare, itching, gritty sensation and sensitivity to light. More often than not, the error involved electronic records failing to capture symptoms patients noted on the paper questionnaires.
The study is small and only included patients within a single clinic system, the authors note. Still, the results suggest that electronic health records may not always be reliable tools for clinicians treating patients or for researchers mining data, the authors conclude.
When patient symptoms are missing from electronic records, it can also prompt clinicians to go in the wrong direction looking for a diagnosis and delay patients getting the care they actually need, Dr. Christina Weng of the Cullen Eye Institute and Baylor College of Medicine in Houston writes in an accompanying editorial ...
Now a small study by researchers explored why symptoms that patients describe to doctors may not always be documented in electronic medical records.
To test out how well the records match reality, researchers compared symptoms that 162 patients checked off on paper-based questionnaires with the information entered in patients’ electronic charts at eye clinics.
Researchers report in an article published in JAMA Ophthalmology that roughly one-third of the time, data on blurry vision from paper questionnaires did not match the electronic records. Symptom information also did not match for glare 48 percent of the time and was discordant in 27 percent of cases for pain and 25 percent for redness.
"Because the electronic health record allows researchers, payers and administrators to extract information from the medical record in a way that has never been previously possible, the implications of capturing patient data in the most accurate way becomes much more imperative," said study co-author Dr. Paula Anne Newman-Casey, an ophthalmologist at the University of Michigan’s Kellogg Eye Center in Ann Arbor.
In theory, the promise of electronic health records is that they can help improve the quality of care and lower costs in part by reducing room for errors. Most U.S. doctors and hospitals now use electronic records, though paper remains common for patient symptom questionnaires.
For the study, researchers examined paper copies of eye symptom questionnaires completed by patients visiting eye clinics between October 2015 and January 2016. Patients rated the severity of common eye issues within the previous week.
Blurry vision was the most common complaint, but when patients reported blurry vision on the questionnaires, the electronic health record correctly noted this in 60 cases but failed to include it in 25 cases.
For patients who didn’t report blurry vision, the electronic records accurately noted this in 26 cases but mistakenly identified this as a problem for 29 patients.
Mismatches were also common for redness, pain, glare, itching, gritty sensation and sensitivity to light. More often than not, the error involved electronic records failing to capture symptoms patients noted on the paper questionnaires.
The study is small and only included patients within a single clinic system, the authors note. Still, the results suggest that electronic health records may not always be reliable tools for clinicians treating patients or for researchers mining data, the authors conclude.
When patient symptoms are missing from electronic records, it can also prompt clinicians to go in the wrong direction looking for a diagnosis and delay patients getting the care they actually need, Dr. Christina Weng of the Cullen Eye Institute and Baylor College of Medicine in Houston writes in an accompanying editorial ...
The Division of Workers’ Compensation will administer the next Qualified Medical Evaluator (QME) Competency Examination on Saturday, April 29, 2017.
Physicians who wish to take the exam on that date must submit a completed original Application for Appointment as Qualified Medical Evaluator (QME Form 100). Send all documentation/fees required and complete the Registration for the QME Competency Examination (QME Form 102).
The application and all required documentation must be reviewed and approved by the DWC before a physician can be registered for the exam (Title 8, California Code of Regulations §§10, 11). The application must be postmarked by March 16, 2017 in order to qualify for this exam. Qualified registrants will receive a confirmation letter along with a Candidate Information Booklet by email/mail. The DWC is not responsible for late or lost applications.
All physicians are required to pay a non-refundable/non-rollover $125.00 fee to sit for any upcoming QME examination (Title 8, California Code of Regulations § 11(f)(2)). Before appointment as a QME, the physician shall complete a 12 hour course in disability evaluation report writing approved by the Administrative Director (Labor Code § 139.2). The DWC will assess the annual QME fee after the candidate has successfully passed the QME Competency Exam in order to activate the QME status.
The primary purpose of this examination is to demonstrate the competence of a physician in evaluating medical issues in the workers' compensation system and to evaluate competency with respect to current California Workers' Compensation System terminology, laws, rules, regulations, and medical-legal procedures. The examination is designed to ensure that there is a commonly understood body of knowledge and common language for QMEs which will increase the probability of ratable and impartial medical/legal evaluations of injured workers in California.
The test questions are now organized into four categories:
1) Clinical Assessment/Evaluation and Medical Treatment
2) Disability Issues/QIW/Vouchers/P&S
3) Causation and Apportionment
4) .Basic Laws and Regulations and Report Writing Elements
Candidates will not be asked any questions that assess specific knowledge of medical treatment (e.g., psychology, orthopedics). However, candidates should be familiar with the existence of the DWC evaluation guidelines and AMA Guides.
Please call 1-800-794-6900 or (510) 286-3700 or email QMETest@dir.ca.gov for further assistance. For additional information regarding the qualifications to become a QME, please visit the DWC website ...
Physicians who wish to take the exam on that date must submit a completed original Application for Appointment as Qualified Medical Evaluator (QME Form 100). Send all documentation/fees required and complete the Registration for the QME Competency Examination (QME Form 102).
The application and all required documentation must be reviewed and approved by the DWC before a physician can be registered for the exam (Title 8, California Code of Regulations §§10, 11). The application must be postmarked by March 16, 2017 in order to qualify for this exam. Qualified registrants will receive a confirmation letter along with a Candidate Information Booklet by email/mail. The DWC is not responsible for late or lost applications.
All physicians are required to pay a non-refundable/non-rollover $125.00 fee to sit for any upcoming QME examination (Title 8, California Code of Regulations § 11(f)(2)). Before appointment as a QME, the physician shall complete a 12 hour course in disability evaluation report writing approved by the Administrative Director (Labor Code § 139.2). The DWC will assess the annual QME fee after the candidate has successfully passed the QME Competency Exam in order to activate the QME status.
The primary purpose of this examination is to demonstrate the competence of a physician in evaluating medical issues in the workers' compensation system and to evaluate competency with respect to current California Workers' Compensation System terminology, laws, rules, regulations, and medical-legal procedures. The examination is designed to ensure that there is a commonly understood body of knowledge and common language for QMEs which will increase the probability of ratable and impartial medical/legal evaluations of injured workers in California.
The test questions are now organized into four categories:
1) Clinical Assessment/Evaluation and Medical Treatment
2) Disability Issues/QIW/Vouchers/P&S
3) Causation and Apportionment
4) .Basic Laws and Regulations and Report Writing Elements
Candidates will not be asked any questions that assess specific knowledge of medical treatment (e.g., psychology, orthopedics). However, candidates should be familiar with the existence of the DWC evaluation guidelines and AMA Guides.
Please call 1-800-794-6900 or (510) 286-3700 or email QMETest@dir.ca.gov for further assistance. For additional information regarding the qualifications to become a QME, please visit the DWC website ...
President Trump on Tuesday told a group of drug company executives gathered for a meeting at the White House that they need to "get prices down." Trump has been a critic of high drug prices, and has endorsed measures like allowing Medicare to negotiate prices.
But the president also called for reducing regulations to allow for faster approvals of new drugs and to allow drug companies to bring jobs back to the U.S. "We’re going to be cutting regulation at a level nobody's ever seen before," Trump said in the meeting with executives.
"You can’t get approval for the plant and then you can’t get approval to make the drug, other than that you’re doing fantastic," he said.
Trump called drug prices "astronomical." "U.S. drug companies have produced extraordinary results for our country, but the pricing has been astronomical for our country," he said.
Still, he also offered to make the Food and Drug Administration's approval of new drugs "much faster."
Executives from Merck, Johnson & Johnson, Celgene, Amgen, Eli Lilly, and the PhRMA trade group joined Trump at the meeting. House Energy and Commerce Chairman Greg Walden (R-Ore.) was also on hand.
The Pharmaceutical Research and Manufacturers of America (PhRMA), the main lobbying group for the drug industry, described the White House meeting as positive and productive. "Our industry takes seriously the concerns raised about the affordability and accessibility of prescription medicines, and we have expressed our commitment to working with the administration to advance market-based reforms," said Stephen Ubl, PhRMA's president and CEO, in a statement.
"The current system needs to evolve to enable the private sector to lead the move to a value-driven health care system. To do this, we need to reform existing laws and regulations that are currently preventing private companies from negotiating better deals and paying for medicines based on the value they provide to patients and our health care system."
Trump's calls for government action to address drug prices could face resistance in a Republican-controlled Congress that is far less willing to take action on drug prices than he appears to be.
At the meeting on Tuesday, Trump also spoke out against what he called "price-fixing" in Medicare. "I'll oppose anything that makes it harder for smaller, younger companies to take the risk of bringing their product to a vibrantly competitive market," Trump said. "That includes price-fixing by the biggest dog in the market, Medicare, which is what's happening. But we can increase competition and bidding wars, big time."
Trump slammed drug companies at a press conference earlier this month, declaring they are "getting away with murder."
"Pharma has a lot of lobbies, a lot of lobbyists, a lot of power. And there's very little bidding on drugs," he said.
"We’re the largest buyer of drugs in the world, and yet we don’t bid properly and we’re going to start bidding and save billions of dollars over a period of time." ...
But the president also called for reducing regulations to allow for faster approvals of new drugs and to allow drug companies to bring jobs back to the U.S. "We’re going to be cutting regulation at a level nobody's ever seen before," Trump said in the meeting with executives.
"You can’t get approval for the plant and then you can’t get approval to make the drug, other than that you’re doing fantastic," he said.
Trump called drug prices "astronomical." "U.S. drug companies have produced extraordinary results for our country, but the pricing has been astronomical for our country," he said.
Still, he also offered to make the Food and Drug Administration's approval of new drugs "much faster."
Executives from Merck, Johnson & Johnson, Celgene, Amgen, Eli Lilly, and the PhRMA trade group joined Trump at the meeting. House Energy and Commerce Chairman Greg Walden (R-Ore.) was also on hand.
The Pharmaceutical Research and Manufacturers of America (PhRMA), the main lobbying group for the drug industry, described the White House meeting as positive and productive. "Our industry takes seriously the concerns raised about the affordability and accessibility of prescription medicines, and we have expressed our commitment to working with the administration to advance market-based reforms," said Stephen Ubl, PhRMA's president and CEO, in a statement.
"The current system needs to evolve to enable the private sector to lead the move to a value-driven health care system. To do this, we need to reform existing laws and regulations that are currently preventing private companies from negotiating better deals and paying for medicines based on the value they provide to patients and our health care system."
Trump's calls for government action to address drug prices could face resistance in a Republican-controlled Congress that is far less willing to take action on drug prices than he appears to be.
At the meeting on Tuesday, Trump also spoke out against what he called "price-fixing" in Medicare. "I'll oppose anything that makes it harder for smaller, younger companies to take the risk of bringing their product to a vibrantly competitive market," Trump said. "That includes price-fixing by the biggest dog in the market, Medicare, which is what's happening. But we can increase competition and bidding wars, big time."
Trump slammed drug companies at a press conference earlier this month, declaring they are "getting away with murder."
"Pharma has a lot of lobbies, a lot of lobbyists, a lot of power. And there's very little bidding on drugs," he said.
"We’re the largest buyer of drugs in the world, and yet we don’t bid properly and we’re going to start bidding and save billions of dollars over a period of time." ...
The Division of Workers’ Compensation has posted the 2016 DWC Audit and Enforcement Unit annual report on its website. The annual report provides information on how claims administrators audited by the DWC performed and includes the Administrative Director’s ranking report for audits conducted in calendar year 2015.
The annual report details the results of audits conducted in 2015 and provides the name and location of each insurer, self-insured employer and third-party administrator audited during that time.
As a result of PAR/FCA audits conducted during calendar year 2015, the Audit and Enforcement Unit found and cited 5,255 violations against claims administrators, with administrative penalties totaling $1,476,147.00. Not all administrative penalties are subject to collection. Under the Labor Code, no penalties are assessed on those “cited” violations unless the audit subject fails the audit at a specific level.
This report to the Legislature summarizes audits conducted in accordance with Labor Code §§129 and 129.5 to assure that injured workers, and their dependents in the event of their death, are provided with all benefits due them in an expeditious manner. The audit findings, by law, must detail the number of files audited, the number and type of violations cited and the amount of an undisputed compensation found due and unpaid to the injured worker.
The DWC Administrative Director’s 2016 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2015. Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director.
The DWC Audit and Enforcement Unit completed a total of 43 profile audit reviews (PAR audits). Compliance officers audited 2729 claim files.Thirty-five audit subjects (81%) met or exceeded the performance standard and therefore had no penalty citations assessed.
Congratulations to all who passed the audit. The following were the top 10 who easily exceeded the PAR Standard set for the year.
1) Schools Insurance Authority \ Sacramento
2) Keenan & Associates \ Pleasanton
3) Warner Bros. Studio Facilities \ Burbank
4) RICA and RICC \ Encino
5) Zenith Insurance Company \ San Diego
6) TriStar Risk Management \ Fresno
7) U.S. Concrete \ San Jose
8) Intercare Holding Insurance Services, Inc. \ Orange
9) Solar Turbines, Inc. \ San Diego
10) Tokio Marine & Nichido Fire Insurance Company \ Pasadena
At the other end of the list, eight audit subjects (19%) failed to meet or exceed the PAR standard, and their audits expanded into a full compliance audit of indemnity claims. Six of the eight audit subjects failed to meet or exceed the FCA 2015 performance standard. These audit subjects were assessed administrative penalties for all penalty citations ...
The annual report details the results of audits conducted in 2015 and provides the name and location of each insurer, self-insured employer and third-party administrator audited during that time.
As a result of PAR/FCA audits conducted during calendar year 2015, the Audit and Enforcement Unit found and cited 5,255 violations against claims administrators, with administrative penalties totaling $1,476,147.00. Not all administrative penalties are subject to collection. Under the Labor Code, no penalties are assessed on those “cited” violations unless the audit subject fails the audit at a specific level.
This report to the Legislature summarizes audits conducted in accordance with Labor Code §§129 and 129.5 to assure that injured workers, and their dependents in the event of their death, are provided with all benefits due them in an expeditious manner. The audit findings, by law, must detail the number of files audited, the number and type of violations cited and the amount of an undisputed compensation found due and unpaid to the injured worker.
The DWC Administrative Director’s 2016 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2015. Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director.
The DWC Audit and Enforcement Unit completed a total of 43 profile audit reviews (PAR audits). Compliance officers audited 2729 claim files.Thirty-five audit subjects (81%) met or exceeded the performance standard and therefore had no penalty citations assessed.
Congratulations to all who passed the audit. The following were the top 10 who easily exceeded the PAR Standard set for the year.
1) Schools Insurance Authority \ Sacramento
2) Keenan & Associates \ Pleasanton
3) Warner Bros. Studio Facilities \ Burbank
4) RICA and RICC \ Encino
5) Zenith Insurance Company \ San Diego
6) TriStar Risk Management \ Fresno
7) U.S. Concrete \ San Jose
8) Intercare Holding Insurance Services, Inc. \ Orange
9) Solar Turbines, Inc. \ San Diego
10) Tokio Marine & Nichido Fire Insurance Company \ Pasadena
At the other end of the list, eight audit subjects (19%) failed to meet or exceed the PAR standard, and their audits expanded into a full compliance audit of indemnity claims. Six of the eight audit subjects failed to meet or exceed the FCA 2015 performance standard. These audit subjects were assessed administrative penalties for all penalty citations ...
The Stanislaus County District Attorney’s Office announced the conviction of a Stanislaus Union School District employee for workers’ compensation insurance fraud.
John Heaton was employed as a campus monitor for the district and reported an on the job injury in November 2015. Heaton filed a workers’ compensation claim and as a result, received medical treatment and workers’ compensation benefits.
During a subsequent investigation, it was alleged Heaton presented false statements and material misrepresentations during a meeting with the school district’s Return to Work Specialist. Heaton misrepresented facts as it related to his physical abilities and limitations associated with his injury.
On January 23, 2017, Heaton pleaded no contest to Insurance Fraud, in violation of Insurance Code section 1871.4(a)(2), as a felony, in that he unlawfully and knowingly made a false and fraudulent material statement in support of obtaining workers’ compensation insurance benefits.
He was sentenced to 30 days jail, three years formal probation and ordered to pay restitution in the amount of $8,341.66 for reimbursement of workers’ compensation benefits and investigation costs.
This case was a joint investigation by Probe Information Services, the California Department of Insurance, Fraud Division and the Amador County District Attorney’s Workers’ Compensation Fraud Unit.
The Fraud Unit investigates insurance fraud cases in Amador, Stanislaus and Calaveras Counties through a grant provided by the California Department of Insurance ...
John Heaton was employed as a campus monitor for the district and reported an on the job injury in November 2015. Heaton filed a workers’ compensation claim and as a result, received medical treatment and workers’ compensation benefits.
During a subsequent investigation, it was alleged Heaton presented false statements and material misrepresentations during a meeting with the school district’s Return to Work Specialist. Heaton misrepresented facts as it related to his physical abilities and limitations associated with his injury.
On January 23, 2017, Heaton pleaded no contest to Insurance Fraud, in violation of Insurance Code section 1871.4(a)(2), as a felony, in that he unlawfully and knowingly made a false and fraudulent material statement in support of obtaining workers’ compensation insurance benefits.
He was sentenced to 30 days jail, three years formal probation and ordered to pay restitution in the amount of $8,341.66 for reimbursement of workers’ compensation benefits and investigation costs.
This case was a joint investigation by Probe Information Services, the California Department of Insurance, Fraud Division and the Amador County District Attorney’s Workers’ Compensation Fraud Unit.
The Fraud Unit investigates insurance fraud cases in Amador, Stanislaus and Calaveras Counties through a grant provided by the California Department of Insurance ...
In one of his last acts of 2016, President Obama signed into law the largest piece of healthcare legislation since the Affordable Care Act. The law - known as the 21st Century Cures Act - has the potential to invigorate medical research, promote innovation and speed the development and FDA approval of new treatments for cancer and other chronic diseases.
It also has the potential for increasing the risk of taking medications - including death. Not long ago, the risks were put into perspective in a controversial article.
The Journal of the American Medical Association published a landmark review by Dr. Barbara Starfield (Johns Hopkins School of Public Health), "Is US health really the best in the world?" In it, Starfield revealed what many people inside the medical establishment already knew: every year, like clockwork, the medical system was killing huge numbers of people.
Each year in the U.S., as Dr. Starfield reported, there are:
1) 12,000 deaths from unnecessary surgeries;
2) 7,000 deaths from medication errors in hospitals;
3) 20,000 deaths from other errors in hospitals;
4) 80,000 deaths from infections acquired in hospitals;
5) 106,000 deaths from FDA-approved correctly prescribed medicines.
The total of medically-caused deaths in the U.S. every year is 225,000. (a conservative estimate)
This makes the medical system the third leading cause of death in America, behind heart disease and cancer.
In the wake of Starfield’s devastating report, other facts came to light: 2.1 million people in America, every year, are hospitalized as a result of reactions to FDA-approved medicines. Annually, 36 million serious adverse reactions to those drugs occur.
Since the FDA approves every medical drug given to the American people, and certifies it as safe and effective, how can that agency remain calm about the fact that these medicines are causing 106,000 deaths per year? Dr. Starfield answered this question in an email interview.
"Even though there will always be adverse events that cannot be anticipated, the fact is that more and more unsafe drugs are being approved for use. Many people attribute that to the fact that the pharmaceutical industry is (for the past ten years or so) required to pay the FDA for reviews [of its new drugs]—which puts the FDA into an untenable position of working for the industry it is regulating. There is a large literature on this."
Can you offer an opinion about how the FDA can be so mortally wrong about so many drugs? "Yes, it cannot divest itself from vested interests. (Again, [there is] a large literature about this, mostly unrecognized by the people because the industry-supported media give it no attention.)"
Perhaps the public and claims administrators should approach the use of newly expedited FDA approved medications with an abundance of caution ...
It also has the potential for increasing the risk of taking medications - including death. Not long ago, the risks were put into perspective in a controversial article.
The Journal of the American Medical Association published a landmark review by Dr. Barbara Starfield (Johns Hopkins School of Public Health), "Is US health really the best in the world?" In it, Starfield revealed what many people inside the medical establishment already knew: every year, like clockwork, the medical system was killing huge numbers of people.
Each year in the U.S., as Dr. Starfield reported, there are:
1) 12,000 deaths from unnecessary surgeries;
2) 7,000 deaths from medication errors in hospitals;
3) 20,000 deaths from other errors in hospitals;
4) 80,000 deaths from infections acquired in hospitals;
5) 106,000 deaths from FDA-approved correctly prescribed medicines.
The total of medically-caused deaths in the U.S. every year is 225,000. (a conservative estimate)
This makes the medical system the third leading cause of death in America, behind heart disease and cancer.
In the wake of Starfield’s devastating report, other facts came to light: 2.1 million people in America, every year, are hospitalized as a result of reactions to FDA-approved medicines. Annually, 36 million serious adverse reactions to those drugs occur.
Since the FDA approves every medical drug given to the American people, and certifies it as safe and effective, how can that agency remain calm about the fact that these medicines are causing 106,000 deaths per year? Dr. Starfield answered this question in an email interview.
"Even though there will always be adverse events that cannot be anticipated, the fact is that more and more unsafe drugs are being approved for use. Many people attribute that to the fact that the pharmaceutical industry is (for the past ten years or so) required to pay the FDA for reviews [of its new drugs]—which puts the FDA into an untenable position of working for the industry it is regulating. There is a large literature on this."
Can you offer an opinion about how the FDA can be so mortally wrong about so many drugs? "Yes, it cannot divest itself from vested interests. (Again, [there is] a large literature about this, mostly unrecognized by the people because the industry-supported media give it no attention.)"
Perhaps the public and claims administrators should approach the use of newly expedited FDA approved medications with an abundance of caution ...
Fibromyalgia affects roughly 2 to 8 percent of the United States population. Although 80 to 90 percent of people with fibromyalgia are women, men of all ages may have fibromyalgia as well. In fact, up to 1.5 million men in the U.S. may currently have fibromyalgia, and many more will experience it in their lifetime. And some of these cases may end up part of a worker's compensation claim.
Some people are at higher risk of developing fibromyalgia than others. And under current law, apportionment of permanent disability may be based upon causation. According to the article in Medical News Today, as well as gender, other risk factors for developing fibromyalgia include the following:
A personal history of other rheumatic diseases including lupus
A history of mood or depressive disorders
A family history of fibromyalgia
A man's fibromyalgia symptoms may be very different from the symptoms experienced by a woman. Symptoms of fibromyalgia in men may be as widespread as they are in women, but they are often milder and last for less time.
Although they may be milder in men, fibromyalgia symptoms can still range from mild to severe and debilitating. Symptoms will vary from person to person and can include:
Pain and tenderness
Fatigue
Morning stiffness
Irritable bowel syndrome symptoms
Brain fog
Depression
In order to be diagnosed with fibromyalgia, a man must experience widespread pain for more than 3 months. This pain must have no known medical cause. A doctor may do blood tests and imaging to rule out other causes. Fibromyalgia symptoms occur in a number of diseases and disorders that doctors will need to rule out.
But, some doctors may think of fibromyalgia as a woman's condition and not consider fibromyalgia in a man as a viable diagnosis ...
Some people are at higher risk of developing fibromyalgia than others. And under current law, apportionment of permanent disability may be based upon causation. According to the article in Medical News Today, as well as gender, other risk factors for developing fibromyalgia include the following:
A personal history of other rheumatic diseases including lupus
A history of mood or depressive disorders
A family history of fibromyalgia
A man's fibromyalgia symptoms may be very different from the symptoms experienced by a woman. Symptoms of fibromyalgia in men may be as widespread as they are in women, but they are often milder and last for less time.
Although they may be milder in men, fibromyalgia symptoms can still range from mild to severe and debilitating. Symptoms will vary from person to person and can include:
Pain and tenderness
Fatigue
Morning stiffness
Irritable bowel syndrome symptoms
Brain fog
Depression
In order to be diagnosed with fibromyalgia, a man must experience widespread pain for more than 3 months. This pain must have no known medical cause. A doctor may do blood tests and imaging to rule out other causes. Fibromyalgia symptoms occur in a number of diseases and disorders that doctors will need to rule out.
But, some doctors may think of fibromyalgia as a woman's condition and not consider fibromyalgia in a man as a viable diagnosis ...
A top U.S. lawmaker accused the Food and Drug Administration of failing to hand over documents that would show whether its criminal office is fulfilling the critical mission of protecting public health.
House of Representatives Energy and Commerce Committee Chairman Greg Walden told Reuters in a statement, that "The FDA's long-overdue response leaves key questions unanswered about the performance and effectiveness of the FDA's Office of Criminal Investigations."
An FDA spokeswoman did not have an immediate comment.
Walden's comments come about four months after the congressional panel launched an examination into the FDA criminal office and how it was managing cases involving food, drugs and devices.
The review came after Reuters reported that FDA agents were concerned that managers, including former OCI Director George Karavetsos, were forcing them to pursue often toothless cases involving mislabeled foreign-imported injectable drugs, at the expense of cases with more potential to protect the public health.
The agents said they had become the "Botox Police" and were spending hours chasing down doctors who purchased authentic versions of Allergan's popular anti-wrinkle drug that were labeled for use in other countries.
Those concerns came at a time when the office was seeing more than half its opened cases ultimately get closed without action, Reuters found.
Reuters also reported on how the FDA permitted Karavetsos to relocate back to Florida in mid-2016 and run the OCI from its Miami office, even after the FDA had already paid more than $25,000 to move him to Maryland in 2015.
The FDA did not meet the committee's October deadline to provide written answers to questions until Jan. 19. The next day, Karavetsos departed to work for DLA Piper where he will represent drug and device industry clients.
In its letter reviewed by Reuters, the FDA listed its investigative priorities and said that traditional metrics used to gauge success, such as arrests and convictions, cannot capture the impact of its public health mission.
It also provided annual data on arrests, convictions, and the number of opened cases. However, it omitted preliminary-stage investigative numbers from the total number of cases opened each year, which makes the conviction rate appear higher, according to a side-by-side comparison.
Walden said the FDA did not provide a performance plan, among other things.
He also complained of redactions on a separate record, which according to a committee aide contained salary and compensation information for Karavetsos ...
House of Representatives Energy and Commerce Committee Chairman Greg Walden told Reuters in a statement, that "The FDA's long-overdue response leaves key questions unanswered about the performance and effectiveness of the FDA's Office of Criminal Investigations."
An FDA spokeswoman did not have an immediate comment.
Walden's comments come about four months after the congressional panel launched an examination into the FDA criminal office and how it was managing cases involving food, drugs and devices.
The review came after Reuters reported that FDA agents were concerned that managers, including former OCI Director George Karavetsos, were forcing them to pursue often toothless cases involving mislabeled foreign-imported injectable drugs, at the expense of cases with more potential to protect the public health.
The agents said they had become the "Botox Police" and were spending hours chasing down doctors who purchased authentic versions of Allergan's popular anti-wrinkle drug that were labeled for use in other countries.
Those concerns came at a time when the office was seeing more than half its opened cases ultimately get closed without action, Reuters found.
Reuters also reported on how the FDA permitted Karavetsos to relocate back to Florida in mid-2016 and run the OCI from its Miami office, even after the FDA had already paid more than $25,000 to move him to Maryland in 2015.
The FDA did not meet the committee's October deadline to provide written answers to questions until Jan. 19. The next day, Karavetsos departed to work for DLA Piper where he will represent drug and device industry clients.
In its letter reviewed by Reuters, the FDA listed its investigative priorities and said that traditional metrics used to gauge success, such as arrests and convictions, cannot capture the impact of its public health mission.
It also provided annual data on arrests, convictions, and the number of opened cases. However, it omitted preliminary-stage investigative numbers from the total number of cases opened each year, which makes the conviction rate appear higher, according to a side-by-side comparison.
Walden said the FDA did not provide a performance plan, among other things.
He also complained of redactions on a separate record, which according to a committee aide contained salary and compensation information for Karavetsos ...
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 2017 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. The Physician Fee Schedule uses the Medicare 2014 relative value units and 2014 CPT codes.
Relative Value Units (RVUs) for each medical service measure the relative resources associated with the physician’s work (the time and skill required for the procedure), practice expenses (the staff time and costs of maintaining an office), and malpractice expenses. The RVUs compare the resources required for one service to those required for other services. Relative to the pre-2014 OMFS, the RBRVS tends to provide lower relative values for surgical and other technical procedures and higher relative values for E&M services. Most RVUs will be based on Medicare’s RVUs. If Medicare has not established RVUs for a reimbursable procedure code the services will be priced By Report.
A conversion factor (CF) is a dollar amount that is used in a formula to convert the RVUs into a payment amount for a service. The CF determines overall fee schedule payment levels. The fee schedule starts with separate conversion factors for surgery, radiology, and "all other services" in 2014 and transitions to a single CF beginning 2017, for all services except anesthesia. Anesthesia is priced under a different scale (using base units and time units) and will continue to have a separate conversion factor. The Anesthesia conversion factor also transitions during the period 2014 through 2017.
A geographic adjustment factor (GAF) adjusts for geographic differences in the costs of maintaining a physician practice. Medicare uses adjustment factors for nine geographic areas or localities in California, but for California workers’ compensation the regulations adopt statewide average GAFs. For services other than Anesthesia, the RBRVS-based regulation reduces administrative complexity by using statewide average geographic adjustment factors for each RVU component, instead of Medicare’s nine locality adjustments. For Anesthesia, there is one statewide GAF for all anesthesia procedures since anesthesia "base units" are not broken down into work, practice expense and malpractice components.
As mandated by SB 863, the fee schedule started with separate conversion factors for surgery, radiology, and "all other services" in 2014 and transitions to a single conversion factor (CF) in 2017, for all services except anesthesia, which has its own CF. The 2017 CFs were adjusted for the cumulative change in the Medicare Economic Index and the relative value scale adjustment factors.
The acting administrative director update order adopting the OMFS adjustments effective for services rendered on or after March 1, 2017, can be found at the DWC OMFS page. An explanation of changes is attached to the order ...
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. The Physician Fee Schedule uses the Medicare 2014 relative value units and 2014 CPT codes.
Relative Value Units (RVUs) for each medical service measure the relative resources associated with the physician’s work (the time and skill required for the procedure), practice expenses (the staff time and costs of maintaining an office), and malpractice expenses. The RVUs compare the resources required for one service to those required for other services. Relative to the pre-2014 OMFS, the RBRVS tends to provide lower relative values for surgical and other technical procedures and higher relative values for E&M services. Most RVUs will be based on Medicare’s RVUs. If Medicare has not established RVUs for a reimbursable procedure code the services will be priced By Report.
A conversion factor (CF) is a dollar amount that is used in a formula to convert the RVUs into a payment amount for a service. The CF determines overall fee schedule payment levels. The fee schedule starts with separate conversion factors for surgery, radiology, and "all other services" in 2014 and transitions to a single CF beginning 2017, for all services except anesthesia. Anesthesia is priced under a different scale (using base units and time units) and will continue to have a separate conversion factor. The Anesthesia conversion factor also transitions during the period 2014 through 2017.
A geographic adjustment factor (GAF) adjusts for geographic differences in the costs of maintaining a physician practice. Medicare uses adjustment factors for nine geographic areas or localities in California, but for California workers’ compensation the regulations adopt statewide average GAFs. For services other than Anesthesia, the RBRVS-based regulation reduces administrative complexity by using statewide average geographic adjustment factors for each RVU component, instead of Medicare’s nine locality adjustments. For Anesthesia, there is one statewide GAF for all anesthesia procedures since anesthesia "base units" are not broken down into work, practice expense and malpractice components.
As mandated by SB 863, the fee schedule started with separate conversion factors for surgery, radiology, and "all other services" in 2014 and transitions to a single conversion factor (CF) in 2017, for all services except anesthesia, which has its own CF. The 2017 CFs were adjusted for the cumulative change in the Medicare Economic Index and the relative value scale adjustment factors.
The acting administrative director update order adopting the OMFS adjustments effective for services rendered on or after March 1, 2017, can be found at the DWC OMFS page. An explanation of changes is attached to the order ...
The California Supreme Court, in a 7-0 decision, affirmed the authority of the California Insurance Commissioner against a major insurance industry legal challenge to his regulatory authority. The case involves regulations pertaining to homeowner insurance policies, but will have application to his regulatory authority in all areas of insurance, including Workers' Compensation policies.
The back story to this case involves wildfires, which are a fact of life in California. After the 1991 Oakland Hills fire and 2003 Southern California wildfires, legislators discovered an additional aspect of the danger wildfires pose to homeowners - underinsurance. Homeowners discovered that their coverage fell well short of what they needed - sometimes by hundreds of thousands of dollars - to rebuild their homes.
Guaranteed replacement coverage was the norm as recently as the 1990s, but only a limited number of homeowners qualified for such a product - and only a small subset of insurers even offered it. The Legislature took several steps to address the divergence between homeowners’ expectations of insurance coverage and the actual scope of coverage.
Between 1992 and 2005, the Legislature took several steps to address the divergence between homeowners’ expectations of insurance coverage and the actual scope of coverage. The California Insurance Commissioner adopted regulations accordingly, resolving this problem which became effective on June 27, 2011.
The insurance industry, led by the Association of California Insurance Companies and the Personal Insurance Federation of California, filed its lawsuit a few weeks before the regulation took effect, challenging the Insurance commissioner's authority to adopt these regulations. The trial court invalidated the Regulation on the ground that the Commissioner exceeded his authority. And the Court of Appeal affirmed. But the Supreme Court reversed and ruled the insurance commissioner has broad discretion to adopt rules and regulations as necessary to promote the public welfare in the case of the Association of California Insurance Companies vs Dave Jones as Commissioner of the CDI.
The replacement cost regulation reviewed by the Supreme Court is codified at California Code of Regulations, title 10, section 2695.183. The Regulation does not require an insurer to set or recommend a policy limit or to provide an estimate of the cost to rebuild or replace a home. But if the insurer does choose to opine on replacement costs, the Regulation specifies how that estimate is to be calculated and communicated.
It pointed out that in 1959, the Legislature enacted the Unfair Insurance Practices Act (UIPA) (Ins. Code, § 790 et seq.). Its purpose is to regulate trade practices in the business of insurance "by defining, or providing for the determination of, all such practices in this State which constitute unfair methods of competition or unfair or deceptive acts or practices and by prohibiting the trade practices so defined or determined." Empowered by authority granted in the UIPA, the Commissioner may investigate those engaged in the business of insurance.
The UIPA also grants the Commissioner rulemaking power: "The commissioner shall, from time to time as conditions warrant, after notice and public hearing, promulgate reasonable rules and regulations, and amendments and additions thereto, as are necessary to administer this article." With respect to this provision, the Court noted "What authority the Legislature conferred here appears to be quite broad."
"In this instance, the Commissioner undertook an investigation into the widespread problem of underinsurance and, in particular, the disconnect between a homeowner’s expectation and the actual scope of insurance coverage purchased. Based on that investigation, he determined that an incomplete replacement cost estimate - i.e., an estimate that fails to account for all of the costs necessary to rebuild the structure - qualifies as 'a specific kind of misleading statement,' and that regulation of any misleading statement "is authorized by the broad statutory prohibition against false and misleading statements' in section 790.03, subdivision (b)." ...
The back story to this case involves wildfires, which are a fact of life in California. After the 1991 Oakland Hills fire and 2003 Southern California wildfires, legislators discovered an additional aspect of the danger wildfires pose to homeowners - underinsurance. Homeowners discovered that their coverage fell well short of what they needed - sometimes by hundreds of thousands of dollars - to rebuild their homes.
Guaranteed replacement coverage was the norm as recently as the 1990s, but only a limited number of homeowners qualified for such a product - and only a small subset of insurers even offered it. The Legislature took several steps to address the divergence between homeowners’ expectations of insurance coverage and the actual scope of coverage.
Between 1992 and 2005, the Legislature took several steps to address the divergence between homeowners’ expectations of insurance coverage and the actual scope of coverage. The California Insurance Commissioner adopted regulations accordingly, resolving this problem which became effective on June 27, 2011.
The insurance industry, led by the Association of California Insurance Companies and the Personal Insurance Federation of California, filed its lawsuit a few weeks before the regulation took effect, challenging the Insurance commissioner's authority to adopt these regulations. The trial court invalidated the Regulation on the ground that the Commissioner exceeded his authority. And the Court of Appeal affirmed. But the Supreme Court reversed and ruled the insurance commissioner has broad discretion to adopt rules and regulations as necessary to promote the public welfare in the case of the Association of California Insurance Companies vs Dave Jones as Commissioner of the CDI.
The replacement cost regulation reviewed by the Supreme Court is codified at California Code of Regulations, title 10, section 2695.183. The Regulation does not require an insurer to set or recommend a policy limit or to provide an estimate of the cost to rebuild or replace a home. But if the insurer does choose to opine on replacement costs, the Regulation specifies how that estimate is to be calculated and communicated.
It pointed out that in 1959, the Legislature enacted the Unfair Insurance Practices Act (UIPA) (Ins. Code, § 790 et seq.). Its purpose is to regulate trade practices in the business of insurance "by defining, or providing for the determination of, all such practices in this State which constitute unfair methods of competition or unfair or deceptive acts or practices and by prohibiting the trade practices so defined or determined." Empowered by authority granted in the UIPA, the Commissioner may investigate those engaged in the business of insurance.
The UIPA also grants the Commissioner rulemaking power: "The commissioner shall, from time to time as conditions warrant, after notice and public hearing, promulgate reasonable rules and regulations, and amendments and additions thereto, as are necessary to administer this article." With respect to this provision, the Court noted "What authority the Legislature conferred here appears to be quite broad."
"In this instance, the Commissioner undertook an investigation into the widespread problem of underinsurance and, in particular, the disconnect between a homeowner’s expectation and the actual scope of insurance coverage purchased. Based on that investigation, he determined that an incomplete replacement cost estimate - i.e., an estimate that fails to account for all of the costs necessary to rebuild the structure - qualifies as 'a specific kind of misleading statement,' and that regulation of any misleading statement "is authorized by the broad statutory prohibition against false and misleading statements' in section 790.03, subdivision (b)." ...
The Department of Industrial Relations (DIR) and the Commission on Health and Safety and Workers’ Compensation (CHSWC) announced the appointment of Angie Wei to the Commission, where she has served since 2005.
The Senate Rules Committee reappointed Wei as a labor representative.
A total of eight (8) Commissioners are appointed by the Governor and the Legislature. Labor Code 75 establishes that two of the employer members and two of the labor members of the Commission shall be appointed by the Governor for a sub-total of four (4) members. The Senate Committee on Rules and the Speaker of the Assembly shall each appoint one employer and one labor representative for a sub-total of four (4) members.
Angie Wei is the chief of staff of the California Labor Federation, the state AFL-CIO. The state Federation represents 1,200 affiliated unions and over two million workers covered by collective bargaining agreements. Previously, Wei was a program associate for Policyline of Oakland, California, and advocated for the California Immigrant Welfare Collaborative, a coalition of four immigrant rights organizations who came together to respond to cuts in public benefits for immigrants as a result of the 1996 federal welfare reform law.
Ms. Wei holds a Bachelor of Art degree in Political Science and Asian American Studies from the University of California, Berkeley, and a Master of Arts degree in Public Policy from the Kennedy School of Government at Harvard University.
This position does not require Senate confirmation.
Information about CHSWCis available at www.dir.ca.gov/chswc. Information may also be obtained by writing to CHSWC at 1515 Clay Street, 17th floor, Oakland, CA 94612; by calling (510) 622-3959; by faxing a request to 510-286-0499; or by sending an email to chswc@dir.ca.gov ...
The Senate Rules Committee reappointed Wei as a labor representative.
A total of eight (8) Commissioners are appointed by the Governor and the Legislature. Labor Code 75 establishes that two of the employer members and two of the labor members of the Commission shall be appointed by the Governor for a sub-total of four (4) members. The Senate Committee on Rules and the Speaker of the Assembly shall each appoint one employer and one labor representative for a sub-total of four (4) members.
Angie Wei is the chief of staff of the California Labor Federation, the state AFL-CIO. The state Federation represents 1,200 affiliated unions and over two million workers covered by collective bargaining agreements. Previously, Wei was a program associate for Policyline of Oakland, California, and advocated for the California Immigrant Welfare Collaborative, a coalition of four immigrant rights organizations who came together to respond to cuts in public benefits for immigrants as a result of the 1996 federal welfare reform law.
Ms. Wei holds a Bachelor of Art degree in Political Science and Asian American Studies from the University of California, Berkeley, and a Master of Arts degree in Public Policy from the Kennedy School of Government at Harvard University.
This position does not require Senate confirmation.
Information about CHSWCis available at www.dir.ca.gov/chswc. Information may also be obtained by writing to CHSWC at 1515 Clay Street, 17th floor, Oakland, CA 94612; by calling (510) 622-3959; by faxing a request to 510-286-0499; or by sending an email to chswc@dir.ca.gov ...
