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Court Rejects Constitutional Challenge to Medical Malpractice Recovery Limits

Tracy Dominguez, Ruben Xavier DeLeon claimed that Mercy Hospital of Bakersfield, Arthur Park, M.D., and Hans C. Yu, D.O.provided negligent medical care to Demi Ruben Dominguez and Malakhi Ruben DeLeon resulting in their deaths. They claimed to be the wrongful death heirs to the decedents,

The heirs sought to retain the legal services of the firm of Carpenter, Zuckerman & Rowley (CZR) to represent them in the medical malpractice action against the healthcare defendants. However, CZR claimed it was not economically feasible for it to represent heirs on a contingency basis given the limitations on recovery in malpractice cases for noneconomic losses to $250,000 under Civil Code section 3333.2 and the limitations on contingency fee arrangements under Business and Professions Code section 6146.

CZR said however that it is ready, willing, and able to represent the heirs if it is permitted to charge the contingency fee it ordinarily charges in personal injury matters and if the $250,000 cap on noneconomic damages is lifted.

On May 26, 2020, plaintiffs filed a complaint for declaratory and injunctive relief against the California Attorney General, and the healthcare defendants and challenge the constitutionality of two California statutes – Civil Code section 3333.2, which caps the amount of damages a plaintiff may recoup for noneconomic losses at $250,000 (Civ. Code, § 3333.2, subd. (b)); and Business and Professions Code section 6146, which sets limits on the amount of contingency fees a law firm may charge in representing a plaintiff in a professional negligence action against a health care provider.

Plaintiffs allege Civil Code section 3333.2’s cap on noneconomic damages was “enacted in 1975 and has not been adjusted – for inflation or otherwise – in the intervening nearly 45 years.” Plaintiffs allege “CZR will spend at least $200,000 in costs to prosecute” heirs’ claims against healthcare defendants; and because “the limit on contingent fees applies to [a] client’s net recovery,” CZR would only recover “a mere $20,000 in fees” on a maximum award of $250,000 for noneconomic damages.

The Attorney General demurred to plaintiffs’ complaint and each cause of action therein on the grounds that plaintiffs “do not have standing to assert” any of the alleged causes of action, and each cause of action “fails to state facts sufficient to constitute a cause of action.”

The trial court sustained the demurrer, without leave to amend, finding that plaintiffs are without standing to pursue the claims alleged and have failed to adequately allege facts to support the claims they purport to allege. The Court of Appeal affirmed in the published case of Dominguez v Bonta – F082053 (January 2023).

The challenged statutes were enacted in 1975 as part of The Medical Injury Compensation Reform Act (MICRA). In enacting MICRA, the Legislature found that ‘there was a major health care crisis in the State of California attributable to skyrocketing malpractice premium costs.”

Plaintiffs alleged that one or both of the challenged statutes, separately or in tandem,
(1) impair heirs’ “right to petition the government for redress of grievances” under the First Amendment and Fourteenth Amendment of the United States Constitution and article I, section 3 of the California Constitution;
(2) constitute “a government taking [of] private property without just compensation” in violation of the Fifth Amendment and Fourteenth Amendment of the United States Constitution and article I, section 19 of the California Constitution;
(3) “violate the equal protection provisions” provided by the Fourteenth Amendment to the United States Constitution and article I, section 7 and article IV, section 16 of the California Constitution (as stated in two separate claims by plaintiffs);
(4) “violate the due process provisions” (as stated in two separate claims by plaintiffs) and the “right to petition the government for redress of grievances” under the Fourteenth Amendment to the United States Constitution and article I, section 7, subdivision (a) of the California Constitution; ; and
(5) deprive heirs of their “right to a jury trial as protected by” article I, section 16 of the California Constitution.

The Court reviewed a select number of prior decisions addressing the constitutionality of the challenged statutes, including one of the earliest MICRA-related cases decided by the California Supreme Court, American Bank & Trust Co. v. Community Hospital (1984) 36 Cal.3d 359. However because it concluded “that plaintiffs lack standing to pursue the claims they have alleged, we need not determine whether their allegations are sufficient to state one or more valid causes of action.”

Plaintiffs’ cause of action for declaratory relief is derivative of plaintiffs’ other claims.for medical malpractice in another action. The “actual controversy” language in Code of Civil Procedure section 1060, which is required to establish standing, does not embrace controversies that are ‘conjectural, anticipated to occur in the future, or an attempt to obtain an advisory opinion from the court. Here plaintiffs’ alleged injuries are neither concrete nor actual, and that they are, at the present time, conjectural and hypothetical.

Thus the court concluded that plaintiffs lack standing to challenge Civil Code section 3333.2 and Business and Professions Code section 6146.

WCAB Says Injured County Inmate on Work Program is an Employee

Aaron Brown became an inmate at Los Angeles County jail on approximately February 16, 2018. On March 8, 2018 he transferred to “wayside” facility. One week later, he signed an agreement to participate in the conservation work program, which provided “work time” credits of 1 ½ days for every one day of work in the program.

On March 22, 2018, Brown slipped and fell while walking to the coffee pot at the print shop where he participated in the conservation work program. He reported the injury immediately and was examined at urgent care. He returned to urgent care the next evening due to hip pain. Hours later, he was released on the early release program.

Los Angeles County denied his claim for workers’ compensation benefits claiming there was a lack of and employment relationship.

After conclusion of a trial, the WCJ found that Brown was not an employee for purposes of workers’ compensation benefits. The WCJ relied upon an ordinance passed in 1970 that states that county inmates may be forced to labor and that such county inmates shall not be considered an employee for the purposes of workmen’s compensation insurance. Also submitted into the record is the Inmate Worker Agreement.

Brown’s petition for reconsideration was granted, and the WCAB panel concluded that he was an employee at the time in the case of Brown v County of Los Angeles/Sheriff’s Department – ADJ11278318 (December 2022).

Labor Code section 3351 defines “employee,” and section 3357 provides that “Any person rendering service for another, other than as an independent contractor, or unless expressly excluded herein, is presumed to be an employee.” This is a rebuttable presumption.

Penal Code section 4017 provides that county inmates working in the suppression of fire are considered employees of the county. It does not speak as to the employee status of county inmates who do not work in fire suppression. The employee status of county inmates are thus left to the courts to decide.

In making this determination, courts have looked at whether the work that the inmate performed was “voluntary” or “compulsory” as an incident to incarceration and whether there was consideration for the work performed. If an inmate was performing compulsory work as an incident to penal servitude, he is not an employee and has no rights to workers’ compensation benefits. (Parsons v. Workers’ Comp. Appeals Bd. (1981) 126 Cal.App.3d 629 [46 Cal.Comp.Cases 1304].)

In deciding whether an inmate was performing compulsory or voluntary work, trial courts may ask the following questions (the Rowland factors): (1) Did the county require the worker to work as a condition of incarceration? (2) Did the inmate worker volunteer for the assignment? and (3) What consideration were received, if any; for example, monetary compensation, work-time credits, freedom from incarceration, etc. (Rowland v. County of Sonoma (1990) 220 Cal.App.3d 331, 333-334.).

There is a difference in determining employee status between persons incarcerated in state prison and person incarcerated in county jail. State inmates are statutorily included in the definition of “employee” while county inmates are subjected to a compulsory test to determine their employee status.

In more recent laws, employer control is a major factor in determining employment status (the more employer control, the more likely employment status is found, whereas here, the opposite effect results when applying the compulsory test, in that the more control the county exercises, the more likely the inmate’s work is found to be compulsory without the protections of an employment relationship.

The language in a local ordinance with respect to assigning work to inmates is not determinative, although it may be considered in determining whether the inmate’s work is compulsory or voluntary.

In applying the compulsory test above using the Rowland factors, the WCAB panel concluded that applicant’s work at the time was voluntary. Accordingly, it concluded that applicant is an employee of the county and entitled to workers’ compensation benefits.

NIH Launches Pilot Telehealth Research Program

Prior to the COVID-19 pandemic, telemedicine adoption was far from widespread. Despite obvious benefits of improving access, the technology wasn’t in place, consumers weren’t ready, and providers resisted the shift to virtual care.

Then came the pandemic – and the need for social distancing. Suddenly, telemedicine was in high demand. As the pandemic surged across the U.S., the use of telemedicine also spiked. In June 2020, approximately 40% of healthcare encounters were conducted virtually. As restrictions lifted, use of telemedicine dropped from the highs of the 2020 lockdowns to a more stable 10-15%.

And telemedine is taking incremental steps toward mainstream adoption with initiatives launched at the federal level this week.

The National Institutes of Health, in collaboration with the Administration for Strategic Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services, has has just launched the Home Test to Treat program, an entirely virtual community health intervention.

Telehealth services provider eMed will implement the Home Test to Treat program. Their services are provided under a contract award by NIBIB contractor, VentureWell. Having administered millions of verified at-home telehealth sessions during the pandemic, eMed will host the user-friendly Home Test to Treat website, where participants can sign up for the program, report symptoms, receive telehealth and antiviral treatment delivery, and coordinate telehealth enabled test kits.

NIBIB also has issued a contract with UMass Chan Medical School, whose researchers, in collaboration with eMed, will analyze data collected from each participating community, including the impacts of a home-based process for testing and treatment, individual attitudes about the Home Test to Treat program, and clinical outcomes from treatments.

Later this month, local and state officials in Berks County, Pennsylvania, will be the first to pilot the Home Test to Treat program. Up to 8,000 eligible residents are anticipated to participate in the program.

Program organizers will gather information from participants to identify best practices and make improvements to the Home Test to Treat model that can be used to implement the program on a larger scale.

Additional communities across the country will be selected to participate based on level of community need, access to healthcare treatment, expected COVID-19 infection rates and socio-economic factors. Through collaborations with local health departments, Home Test to Treat aims to offer services to approximately 100,000 people across the United States in the coming year.

Major pharmacy chains including CVS and Walgreens already offer telehealth services that can help facilitate treatments for COVID-19, and some primary care physicians also provide this option for their patients. Walgreens partnered with companies including DoorDash and Uber to offer free deliveries of COVID-19 antivirals last year.

Hospital Closure Triggers Central California Emergency Declarations

Hospital overcrowding and healthcare access challenges have prompted two counties in Central California to issue emergency declarations in less than a week. Meanwhile, the largest health system in the region has gone out of network with several commercial insurance plans.

According to the story in Becker’s Hospital Review. the emergency declarations over healthcare access largely stem from the recent closure of Madera (Calif.) Community Hospital, the city’s only hospital for about 150,000 residents. It officially shut its doors at midnight on Dec. 30, after Trinity Health’s plan to buy the hospital fell through because the health system didn’t accept the conditions set forth by California Attorney General Rob Bonta, The Fresno Bee reported Jan. 3. The Madera County Sheriff’s Office declared a local state of emergency on Dec. 29, citing the “significant impact” the closure will have on the community.

“The lack of hospital services in Madera County is expected to strain local resources deployed within Madera County, thereby depleting ambulance and response resources such as law enforcement and fire,” the sheriff’s office wrote in a Facebook post. “By proclaiming a local state of emergency we are formally requesting help from state and federal officials.”

The closure means residents in Madera will have to travel at least a half hour to other hospitals, many of which are in neighboring Fresno County and already overcrowded, Madera County officials said during their Dec. 29 meeting.

In response, Fresno County proclaimed its own emergency declaration on Jan. 3, citing the additional strain the Madera hospital’s closure has put on other area hospitals amid a surge in respiratory viruses. The Fresno County Board of Supervisors also said local emergency services were operating under an “assess and refer” policy, which diverts non-emergency patients from hospitals to other sources of care, and that it adopted the emergency resolution to emphasize the need for assistance at the state and federal level, according to the Fresno Bee.

Fresno County’s largest health system, Clovis, Calif.-based Community Health System, operates four hospitals, a cancer institute and other outpatient facilities in the area.

On Dec. 31, in-network contracts expired between Community and several commercial payers, including UnitedHealthcare, Cigna and Anthem Blue Cross. A system spokesperson told Becker’s Jan. 4 the involved parties are still actively negotiating to reach agreements.

“As Community negotiates in good faith we must ask commercial health plans to acknowledge the unprecedented cost challenges of delivering care to the residents of the Central Valley and join us in reaching a fair and reasonable agreement,” the system wrote on its website.

A spokesperson for UnitedHealthcare told The Fresno Bee Dec. 19 that the system asked for an “egregious and unreasonable” rate increase.

“This is not affordable or sustainable,” the spokesperson said. “We’ve offered [Community Health System] market-competitive rate increases that will ensure its hospitals and facilities continue to be fairly compensated for the care they provide to our members.”

The affected facilities include Community Regional Medical Center, Fresno Heart & Surgical Hospital, Community Behavioral Health Center, Community Subacute & Transitional Care Center, Community Home Health and Community Health Partners, and Clovis Community Medical Center.

On Jan. 2, Centene’s Health Net and Community signed an in-network agreement covering commercial, Medicare and Medi-Cal plans.

CWCI Study Shows WC Hospitalizations Continue to Decline

A new California Workers’ Compensation Institute (CWCI) study finds that after across-the-board declines in California inpatient hospitalizations during the COVID-19 health care crisis of 2020, the number of inpatient stays paid under Medicare, Medi-Cal, and private coverage all began to rebound in 2021, but the number of workers’ compensation hospitalizations fell an additional 5.7%.

The latest results come from a CWCI study that measures and compares the use of inpatient services and procedures in different systems using data compiled by the state on more than 35.3 million hospital stays with 2012 through 2021 discharge dates.

The 2021 decline in workers’ compensation hospitalizations brought the total decline over the past decade to 48.1%, more than triple the 10-year decline of 15.0% noted for hospital stays paid under private coverage, while hospitalizations paid under Medicare were only down 5.2% and those paid by Medi-Cal increased by 11.7%.

Workers’ compensation is by far the smallest program analyzed, representing just 163,249 (<0.5 %) of the California inpatient stays over the 10-year study period, and just 0.3 % in 2021.

Most workers’ compensation hospital stays are for the treatment of musculoskeletal and connective tissue disorders (between 58.1% and 66.0% of the stays since 2012), but COVID’s impact is evident in the recent data, as the percentage of injured worker inpatient stays for the treatment of diseases and disorders of the respiratory system nearly tripled from 2.6% in 2019 to 7.4% in 2020 and remained at an elevated level (7.0%) in 2021.

A review of the hospital stays for diseases and disorders of the respiratory system found that half were for respiratory infections and inflammation, though injured worker hospitalizations in this diagnostic category included a larger share of collapsed lungs or major chest traumas.

Surgical stays are far more prevalent in workers’ compensation than in other systems, with the data showing they accounted for more than 2/3 of injured workers’ inpatient hospitalizations in 2021, versus 24.7% for Medicare, 21.1% for Medi-Cal, and 31.5% for private coverage.

Workers’ compensation inpatient surgeries continue to be led by spinal fusions (17.6% of the 2021 surgeries) and major joint replacements (10.7%).

Despite a sharp decline in workers’ compensation spinal fusions (-59.1% since 2012), they are still far more prevalent among the injured worker inpatient population than among inpatients covered by Medi-Cal (0.6%), Medicare (1.3%); or private coverage (1.8%).

As for workers’ compensation joint replacement surgeries, the Institute found that 87.9% of all injured workers who underwent knee or hip replacements in 2021 were diagnosed with primary osteoarthritis, which tends to develop from mechanical wear and tear, structural degeneration, and joint inflammation, rather than from an acute, direct trauma to the joint associated with a specific injury.

Furthermore, the decline in workers’ compensation inpatient surgeries has been somewhat offset by an increase in the number of injured worker spinal fusions and total joint replacements performed on an outpatient basis..

More detailed findings from the CWCI study have been released in a Research Update Report, “Trends in the Utilization of Inpatient Care in California Workers’ Compensation.”

California Privacy Rights Act (CPRA) Now Applicable to Employers

Employers – and their vendors – need to be aware of the significant changes that are now in effect as the California Privacy Rights Act (CPRA) became operative on January 1, 2023.

The implementation of privacy rights in California began In 1972, when California voters amended the California Constitution to include the right of privacy among the “inalienable” rights of all people.

Since California voters approved the constitutional right of privacy, the California Legislature has adopted specific mechanisms to safeguard Californians’ privacy, including the Online Privacy Protection Act, the Privacy Rights for California Minors in the Digital World Act, and Shine the Light, but consumers had no right to learn what personal information a business had collected about them and how they used it or to direct businesses not to sell the consumer’s personal information.

San Francisco real estate developer Alastair Mactaggart began advocating for consumer privacy a few years ago, after a Google engineer he met at a dinner party told him Americans would be shocked by how much the company knows about us. Mactaggart successfully pushed the Legislature to pass a landmark data privacy law in 2018, the California Consumer Privacy Act of 2018 (CCPA). into law.

The CCPA gave California consumers the right to learn what information a business has collected about them, to delete their personal information, to stop businesses from selling their personal information, including using it to target them with ads that follow them as they browse the internet from one website to another, and to hold businesses accountable if they do not take reasonable steps to safeguard their personal information.

Mactaggart soon discovered that this law passed by the California legislature needed some changes, so he drove the effort to put Prop. 24 on the 2020 ballot. And voters seemed to have agreed with him.

The California Privacy Rights Act of 2020 (CPRA), also known as Proposition 24, was a California ballot proposition that was approved by a majority of voters after appearing on the ballot for the general election on November 3, 2020. This proposition expands California’s consumer privacy law and builds upon the California Consumer Privacy Act (CCPA) of 2018, which established a foundation for consumer privacy regulations, with an array of consumer privacy rights and business obligations with regard to the collection and sale of personal information.

The new CPRA took effect on Dec. 16, 2020, but most of the provisions revising the CCPA did not become “operative” until Jan. 1, 2023, applying to personal data collected on or after January 1, 2022. The CCPA is codified at Cal. Civ. Code § 1798.100 et seq., and the regulations are found at 11 CCR §§ 999.300 et seq.

CPRA did not replace the CCPA. The CPRA is more accurately described as an amendment of the CCPA. The California Privacy Protection Agency is a new agency, created by the CPRA, which is vested with “full administrative power, authority, and jurisdiction to implement and enforce” the CCPA.

CPRA eliminated the California Consumer Privacy Act’s (CCPA) exemption for employee personal information. Workers now have the same rights as any consumer. This includes requirements that are currently in effect under the CCPA as well as the new requirements added under the CPRA.

CPRA applies only to employees that are California residents, based on the definition of consumer. Businesses with a presence in multiple jurisdictions in the United States can consider applying a uniform approach, but should keep in mind employment laws in those other jurisdictions and any applicable data privacy laws in other jurisdictions. Notably, recent comprehensive data privacy laws passed in Virginia, Colorado, Utah and Connecticut exempt personal data collected in the context of employment.

Employers must provide notice of employees’ rights under the CPRA and give employees a way to tell the employer about their exercise of these rights. The employer has limited time to respond to a request and must properly document all responses.

Business-to-business transactions are now subject to the CPRA. It is not clear how this will apply to worker’s compensation claims administrators who receive information from an employer.

In actions by the California Attorney General, businesses can face penalties of up to $7,500 per intentional violation or $2,500 per unintentional violation (but there is an opportunity to cure any alleged violation within 30 days after receiving notice of the alleged violation). In actions brought by consumers for security breach violations, consumers may recover statutory damages not less than $100 and not greater than $750 per consumer per incident or actual damages, whichever is greater. In actions for statutory damages, consumers must first provide businesses with written notice and an opportunity to cure.

Consumers may also seek injunctive or declaratory relief, as well as any other relief the court deems proper. Businesses may also be subject to an injunction in actions brought by the Attorney General.

Judge Issues Order Stopping the DIR From Implementing Fast Food Act

Last Labor Day, Gavin Newsom signed the Fast Food Standards and Accountability Recovery Act, giving the state’s 550,000 fast food workers a seat at the table and bargaining power.

The Act created a government panel that would set hourly wages for fast-food workers of up to $22 beginning this year and establish workplace standards. The wages can increase annually by the same as the consumer-price index, up to a maximum of 3.5%.

This new law established the Fast Food Council within the Department of Industrial Relations until January 1, 2029. It is composed of 10 members to be appointed by the Governor, the Speaker of the Assembly, and the Senate Rules Committee, and would prescribe its powers.

In response to this Act, California small business owners, restaurateurs, franchisees, employees, consumers, and community-based organizations announced the formation of a coalition to refer the FAST Act back to voters and suspend its implementation until they have a say in November 2024. The coalition’s effort is co-chaired jointly by the National Restaurant Association, the U.S. Chamber of Commerce and the International Franchise Association.

The group claimed that the FAST Act would drastically increase food prices by as much as 20% and create a massive new government bureaucracy to regulate locally-owned restaurants.

On December 5, the Save Local Restaurants coalition announced it submitted to county elections officials over one million signatures from Californians in order to prevent AB 257 from taking effect until voters have their say on the November 2024 ballot.

However, Katrina S. Hagen Director, California Department of Industrial Relations, sent the coalition a letter on December 27, 2022 stating that it intends to implement AB 257 – the FAST Act – on January 1, 2023. But “If and when the referendum challenging AB 257 qualifies for the ballot, the law will be put on hold. But in the absence of clear authority providing that AB 257 is suspended merely upon submission of unverified signatures, DIR has an obligation to proceed with implementing the duly enacted statute.”

The Local Restaurants coalition therefore filed a lawsuit on December 29, 2022, claiming that the state’s Constitution dictates that, as part of the referendum process, laws cannot go into effect until voters have an opportunity to exercise their voice and vote on the proposed legislation.

According to a Minute Order in the case dated December 30, 2022 Sacramento County Superior Court Judge Shelleyanne W.L. Chang wrote “The Court is in receipt of the “Memorandum of Points and Authorities in support of Verified Petition for Writ of Mandate and Complaint for Declaratory and Injunctive Relief’ and supporting documentation filed by Petitioners in this matter on December 29, 2022, seeking relief effective December 30, 2022 in connection with a statewide election matter. In light of the incredibly short timeframe provided to the Court to hear this matter, the Court has construed the filing as an ex parte application for a temporary restraining order, which the Court hereby GRANTS. Respondents are temporarily restrained from implementing, enforcing, or taking any other action to effectuate Assembly B,i11257, Stats. 2022, ch. 246.”

The matter is set for an Order to Show Cause re: Preliminary Injunction on January 13, 2023 at 1:30 p.m. in Department 21.

The Superior Court case is Save Local Restaurants vs. Katie Hagen, in her official capacity as Director of the California Department of Industrial Relations – case number 34-2022·80004062-CU-WM-GDS.

Study Shows Robotic Knee Surgeries Reduce Bone and Soft-Tissue injury

The University College Hospital in London researchers were trying to reel in some of the surgical trauma inherent in all surgery. That trauma, better known as local inflammatory response, could be, they hypothesized, a cause of sub-optimal TKA patient outcomes.

A team from University College Hospital in London, United Kingdom designed a study to check that hypothesis and the results, “Inflammatory Response in Robotic-Arm-Assisted Versus Conventional Jig-Based TKA and the Correlation with Early Functional Outcomes.” was published in the November 2, 2022, edition of The Journal of Bone and Joint Surgery. And the study was reviewed in an article just published in Orthopedics This Week (OTW).

Andreas Fontalis, M.D., M.Sc., M.R.C.S. co-author on the research explained to OTW, “There is high incidence of patient dissatisfaction following total knee arthroplasty (TKA), with up to 20% of patients reporting dissatisfaction in an otherwise uncomplicated TKA. The exact etiology is unclear; however, it has been speculated that the local inflammatory response precipitated by surgery may be implicated.”

“Our group recently conducted and disseminated the results of a randomized controlled trial studying the systemic inflammatory response in robotic-arm-assisted versus conventional TKA. We found that robotic-arm-assisted TKA was associated with a transient reduction on the 7th postoperative day and with less iatrogenic soft tissue injury and bone trauma. Conceptually, we hypothesized that it could also be associated with a reduction in local inflammation.”

Furthermore, robotic-arm assistance has features that could translate to a reduced local inflammatory response such as the haptically controlled saw blade and stereotactic boundaries.”

“The surgical workflow during the conventional technique also involves the use of intramedullary femoral referencing and cutting blocks associated with production of substantial metal debris; all of which could be responsible for a more pronounced inflammatory response.”

“We therefore thought it important to objectively study the local inflammation incited by the two procedures and investigate whether any correlation was evident with functional outcomes.

The researchers looked at 30 patients who had TKA for knee osteoarthritis – 15 of whom had traditional TKA and 15 who had robotic-arm-assisted TKA. They obtained data on the inflammatory markers IL-6, IL-8, and tumor necrosis factor (TNF)-alpha.

“In our study,” commented Dr. Fontalis to OTW, “robotic-arm assistance was associated with lower postoperative levels of IL-6 measured in the drain fluid at 6 and 24 hours and lower levels of IL-8 in the drain fluid at 6 hours. We also noticed that pain scores in the robotic-arm-assisted group were significantly lower on days 1,2 and 7 and that both the local and the systemic responses were correlated with pain.”

“We were surprised by how pronounced the differences were with respect to IL-6 levels at the 24-hour post-operative mark, which could reflect the ability of robotic technology to reduce bone and soft-tissue injury by averting multiple cuts and by more precisely executing the preoperative plan.”

Our study furthers evidence of the advantages of robotic arm surgery. Larger studies and clinical correlation may lead to the increased adoption of enhanced technologies such as robotic-arm-assisted surgery in order to improve patient outcomes.”

Researchers Find Good Knee and Hip Surgery Outcomes in Patients Over 90

Undergoing the rigors of hip or knee surgery at 90 years or older (nonagenarians) is, understandably, cause for concern and hesitation.

But a group of researchers in California decided to look at the data and determine, objectively, if these patients indeed have an increased risk of complications and hospital readmission as compared with octogenarians and septuagenarians.

Their work, “Hip and Knee Arthroplasty Outcomes for Nonagenarian Patients,” was published in the November 15, 2022, edition of the Journal of the American Academy of Orthopaedic Surgeons.  This study was reviewed in an article published by Orthopedics This Week (OTW).

Co-author William Bugbee, M.D. chief of the Joint Preservation and Cartilage Restoration Service at Scripps Clinic in La Jolla, told OTW, “As our population ages and more people are living active lives into their nineties and beyond, we are more and more frequently confronted with elderly patients that are suffering with life-defining arthritis of the hip or knee. These patients, like their younger counterparts, are seeking ways to improve the quality of their lives and maintain their independence and mobility and have not had success with nonsurgical care.”

It is now commonplace to perform joint replacement in patients in their seventies and eighties but much less common to do so when people are in their nineties. We felt that there was not enough data to guide us, as surgeons, to provide a clear risk, benefit counseling regarding joint replacement for these very elderly patients.”

Mining the Scripps database, the researchers identified patients aged 90 or older who had primary unilateral total joint arthroplasty (TJA) from 2010 to 2017 by one of five surgeons. A total of 58 nonagenarians were identified, with 31 undergoing total hip arthroplasty (THA) and 27 undergoing total knee arthroplasty (TKA). The researchers matched each nonagenarian with an octogenarian (age 80 to 84 years) and septuagenarian (age 70 to 74 years). The researchers noted complications – either medical or orthopedic – that occurred intraoperatively, during hospital admission, and after hospital discharge.

The team found that nonagenarians had the highest rate of medical complications (33%) compared with octogenarians (14%) and septuagenarians (3%). However, the rates of surgical (orthopedic-related) complications were not statistically different among nonagenarians (12%), octogenarians (9%), and septuagenarians (10%). Hospital readmission rates were highest in nonagenarian patients (11%) but were not statistically different compared with octogenarians (5%) or septuagenarians (2%).

“First, unsurprisingly, complication rates increased with age,” stated Dr. Bugbee to OTW. “Nonagenarians had a higher overall complication rate, but most of these were minor and resolved over time. Importantly, deaths were not more frequent in the oldest group.”

“Elderly patients are generally most worried about being either ‘more crippled’ or dying when undergoing elective orthopaedic surgery. We found here was no statistically significant difference in orthopaedic complications or mortality in the older cohort of patients in their nineties compared to patients in their seventies or eighties. Furthermore, these patients are just as happy with their outcome as any other group.”

I believe that this study demonstrates that age alone should not be an absolute contraindication to joint replacement surgery and that nonagenarians with severe hip or knee arthritis should be afforded the opportunity to choose surgical care as an alternative to the status quo of their lives. Surgical care involves risk at any age, but we can now better define that risk for this group of nonagenarian patients.”

NLRB Says USC Student Athletes are USC, Pac-12 and NCAA Employees

In 2020, activism among players at academic Institutions sky-rocketed. In addition to social rights issues, player groups sought open communication between players and university and NCAA leadership, and, ultimately, a “college football players’ association” to represent them.

And these players at Academic Institutions have been gaining more power as they better understand their value in generating billions of dollars in revenue for their colleges and universities, athletic conferences, and the NCAA. And their litigation is being closely followed by employment law communities.

In February 2021, General Counsel for the National Labor Relations Board, Jennifer Abruzzo, issued a memorandum (GC 21-08) on the status of college athletes as “employees” under the National Labor Relations Act. Statutory Rights of Players at Academic Institutions (Student-Athletes) Under the National Labor Relations Act,.

The student athletes also found support from the United States Supreme Court when it decided Alston v NCAA 141 S. Ct. 2141 (2021) in June of last year. SCOTUS recognized that amateurism in college sports has changed significantly in recent decades, and ruled that the NCAA can’t use the‘amateurism’ label to break antitrust laws.

Justice Kavanaugh, in his concurring opinion in Alston, went further. He strongly suggested that the NCAA’s remaining compensation rules also violate antitrust laws and questioned “whether the NCAA and its member colleges can continue to justify not paying student athletes a fair share” of the billions of dollars in revenue that they generate. Moreover, he suggested that one mechanism by which colleges and students could resolve the difficult questions regarding compensation is by “engag[ing] in collective bargaining.”

This SCOTUS decision is likely a precursor to more changes to come in college athletics. Specifically, commentators argue that, as courts “continue to chip away at NCAA restrictions on benefits to student-athletes, more compensation that is untethered to academics brings student-athletes more fully within ‘employee status’ under the law.”

After these successful legal developments, a group that advocates for college athletes in California filed unfair labor practice charges in February 2022, with the National Labor Relations Board on behalf of football players and men’s and women’s basketball players at UCLA and the University of Southern California. The charges, made by the National College Players Association, also name the NCAA and the Pac-12 Conference, essentially claiming that the association and the conference jointly employ the athletes along with the schools.

The filings follow a similar effort started by another athlete-advocacy group, the College Basketball Players Association, which filed a charge against the NCAA. Both bids come in the wake of the National Labor Relations Board’s general counsel memorandum in September.

Following this filing, on December 15, 2022, the Regional Director of the Los Angeles Region of the National Labor Relations Board the NLRB’s Division of Advice has directed the NLRB Region to pursue the NCPA’s unfair labor practice (ULP) charges against USC, the Pac-12 Conference, and the NCAA as joint, statutory employers of USC football players, men’s basketball players, and women’s basketball players.

At the request of NLRB’s Division of Advice, the NCPA agreed to withdraw its ULP charge against UCLA, a state funded school, but will continue against USC a private institution, and the NLRB’s Los Angeles Region will now take action to force a settlement with the employers to end the ULPs or prosecute the employers and go to trial.

If upheld, USC football and basketball players’ employee status under joint employers (college,conference, and NCAA) will ultimately apply to all FBS football players and Division I basketball players at private schools.

If the Pac-12 and NCAA are found to be employers, it could open the doors for athletes at other Football Bowl Subdivision schools to argue that they are employees, even if they attend public schools such as UCLA.

The NCPA’s case with the NLRB is the latest in a string of unionization efforts among college athletes and their advocates. Another recent effort came in 2014 and 2015, when Northwestern football players attempted to unionize. The NLRB declined to accept jurisdiction in the case, however, saying at the time that it did not have jurisdiction over public schools.