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RAND Report Paints Dismal Financial Picture for SIBTF Benefits

The California Department of Industrial Relations (DIR) contracted with RAND to conduct a comprehensive study of the SIBTF. The goal of the study was to capture as much data as possible to document a wide range of basic facts about the SIBTF program that might provide a foundation for informed deliberation over policy options in response to the SIBTF s recent growth. The study focused on cases that were filed or pending between 2010 and 2022.

RAND built a dataset of SIBTF cases filed and adjudicated between 2010 and 2022. The resulting database offers many important insights into trends in cases filed in SIBTF cases in recent years. The intended audience of this report is primarily DIR officials and other policymakers in the state of California, as well as other interested stakeholders.

According to the 180 page Report which was recently published on the DWC webiste, total annual payments from the SIBTF on the 12 years of cases considered in this report grew from $13.6 million in 2010 to $232 million in 2022. Looking to the future, this analysis estimates $7.9 billion in SIBTF liabilities for cases filed or pending between 2010 and 2022, the midpoint of an estimated range of $6.4 – $10.5 billion.

The recent surge in current and future liabilities can in part be attributed to interpretations of SBITF’s governing statutes, which the Report claims are “vague” on key issues concerning eligibility and compensation, and which are decades old. More recently, the wide parameters of the governing statutes and SIBTF rules have motivated claimants, their representatives, and vendors to make more frequent claims for injuries which in past decades might have yielded smaller benefits or might not have led to any benefits at all.

This report presents data documenting facts and recent trends about the SIBTF program that might provide a foundation for informed deliberation on policy responses to the SIBTF s recent growth. Focusing on cases filed or pending between 2010 and 2022, the authors obtained key findings that support some potential policy responses that might be considered by decisionmakers interested in stabilizing the SIBTF while continuing to promote the broader objectives of the workers compensation system.

The volume of annual applications for SIBTF benefits has nearly tripled since 2015. Roughly steady at about 850 per year from 2010 to 2014, annual volume reached around 2,000 in 2020, and 2,448 in 2022. This trend combines with other factors, including growth in benefit payments, to increase both current and forecasted liabilities for the Fund.

The Report analyzed the effect of Todd v. Subsequent Injuries Benefits Trust Fund (2020) 85 Cal.Comp.Cases 576 (App. Bd. en banc). The Appeals Board issued an en banc decision interpreting Labor Code section 4751, holding as follows: (1) Prior and subsequent permanent disabilities shall be added to the extent they do not overlap in order to determine the “combined permanent disability” specified in section 4751; and (2) SIBTF is liable, under section 4751, for the total amount of the “combined permanent disability,” less the amount due to applicant from the subsequent injury and less credits allowable under section 4753.

According to the Rand Report “This decision made it far more likely that an SIBTF case would reach a combined rating of 100 percent. In the examples above, the combined rating would increase from 75 percent pre-Todd to 100 percent post-Todd.” And that the “sharp changes in case outcomes and PD ratings that immediately followed the Todd decision have implications for benefit payments and SIBTF liabilities.”

And the health characteristics of a portion of claimants who get SIBTF benefits indicate that common, chronic conditions are contributing to the increase in SIBTF liabilities. Permanent partial disabilities that formed the basis for SIBTF benefits frequently included a number of chronic conditions that are rarely seen in the regular workers compensation system and are common attendants to normal aging.

One of the several recommendations was that “the program would benefit from more specific eligibility requirements, and a clear specification of the evidence required to establish that a PPD was actually labor disabling at the time of the SII. Statues could be revised to include only certain types of pre-existing disability, excluding common chronic conditions, and to specify the nature of evidence required to show that a condition was actually labor disabling at the time of the SII.” (Subsequent Industrial Injury)

“Eleven of the 29 states with an active subsequent injury fund (sometimes called second injury fund or multiple injury fund) limit the conditions that may qualify as a PPD to a list specified in the statute, offering precedent for adopting such an approach in California. However, once a list is defined, there will likely be political pressure to expand the list to include additional conditions.”

The Authors warned that in “the absence of policy changes to ensure the SIBTF is implemented in a sustainable and fair way, decisionmakers can reasonably expect that funding demands will exceed the currently available resources and assessments on workers compensation premiums (or on covered payroll for self-insured employers) will have to continue to rise to cover the Fund s growing liabilities.”

Travelers Publishes 2024 Injury Impact Report

The Travelers Companies, Inc., the largest workers compensation insurer in the United States, just released its 2024 Injury Impact Report, which examined more than 1.2 million workers compensation claims from 2017 to 2021. The findings revealed that the most common workplace accidents make up the majority of claim costs.

Most frequent causes of injury:

– – Overexertion (29% of claims analyzed).
– – Slips, trips and falls (23%).
– – Being struck by an object (12%).
– – Motor vehicle accidents (5%).
– – Caught-in or caught-between hazards (5%).

Top five drivers of severe claims ($250,000 or more), beginning with the costliest:

– – Slips, trips and falls.
– – Overexertion.
– – Being struck by an object.
– – Motor vehicle accidents.
– – Caught-in or caught-between hazards.

Factors such as inexperience, workforce shortages and maintenance issues are all contributing to these unfortunate and often avoidable accidents,” said Rich Ives, Senior Vice President of Business Insurance Claim at Travelers. “While the number of injuries overall has been trending downward in recent years, our analysis shows that there’s never been a better time for businesses to invest in workplace safety and injury prevention.”

Similar to previous years, the 2024 report found that employees in their first year on the job continue to be the most vulnerable to workplace injuries, accounting for 35% of all workers compensation claims. This year’s analysis also uncovered increases in missed workdays due to injuries:

– – On average, injured employees missed 72 workdays, up one day from last year’s report.
– – The construction industry continued to have the highest average number of lost workdays per injury (103 workdays, up from 99), followed by transportation (83 workdays, up from 77).
– – Injured small-business employees missed an average of 82 workdays, up from 79.

“There are tangible consequences to any injury, and many include long-term, sometimes permanent, effects,” said Chris Hayes, Assistant Vice President of Workers Compensation and Transportation, Risk Control, at Travelers. “By understanding where the risks were in the past, businesses can better identify what to look for and tailor their risk management and employee safety strategies accordingly to help prevent injuries from happening.”

Additional findings from the 2024 Injury Impact Report can be found on the Travelers website. For best practices on creating safer workspaces, visit the Workplace Safety Resources page on the company’s website.

Non Comp Benefits Expanded for Disabled Persons in Need of Voc. Rehab.

Now that injured workers no longer have a formal Workers’ Compensation Rehabilitation Program, the California Department of Rehabilitation may fill some gaps in benefits. The DOR administers a program in cooperation with the Federal Government, aimed at assisting physically and/or mentally handicapped persons in achieving a maximum degree of support. (Welf. & Inst. Code sec. 19000.) This program is funded by 80 percent federal and 20 percent state funds.

The service may be provided only to disabled individuals who are of employable age or who may be expected to be of employable age upon completion of rehabilitation services, and for whom it has been determined vocational rehabilitation may be satisfactorily achieved. (Welf. & Inst. Code sec. 19018.). Although the Department may not be able to provide a living allowance while the person is in training, it may be able to assist the person financially in many other ways. Interested persons should contact the Department of Rehabilitation to determine if they are eligible to receive benefits.

Thus, this appellate case may be of interest to the Workers’ Compensation community, and it concerns the proper interpretation of the term “maintenance” under Title I of the Rehabilitation Act of 1973, as amended (Pub.L. No. 93-112 (Sept. 26, 1973) 87 Stat. 355, 29 U.S.C. § 701 et seq.; the Act), and related California law.

Under the Act, the federal government provides grants to participating states, including California, to help fund vocational rehabilitation services for individuals with disabilities. In California, those services are provided by the Department of Rehabilitation. John Doe is a recipient of such services.

The Department agreed to cover Doe’s law school tuition and other expenses, but it refused to pay his rent while he attended a school that was outside of commuting distance from his home.

Doe argued rent qualified as “maintenance,” a covered expense under the Act and California law. But the Department, while interpreting the same statutes and regulations as Doe, determined the law prohibited it from paying Doe’s rent, which it deemed to be a non-covered “long-term everyday living expense.”

Doe testified that before law school he had been living with his mother and didn’t have to pay rent or utilities. In essence, Doe’s position was that because he had no housing or utility expenses, his rent while in law school was a cost in excess of his normal living expenses. Doe stated he didn’t have the financial ability to pay for rent and would have to drop out of school if the Department didn’t pay it.

An administrative law judge (ALJ) upheld the Department’s decision, and a trial court denied Doe’s petition for writ of mandate. Both the ALJ and the court found that rent was allowable as “maintenance” only for short-term shelter, and not for a term of three years, which was deemed to be long term.

The Court of Appeal reversed in the published case of Doe v Department of Rehabilitation -G062519 (August 2024).

The Department agreed to cover tuition less any scholarships or grants, the security deposit for an apartment, initial setup charges for utilities, monthly internet costs, and travel costs for “one way to school at the start of the semester, and at the end of the semester, one roundtrip mileage.” But the Department denied Doe’s request for rent for the anticipated three years of school attendance.  About a week later, Doe signed a 13-month lease for an apartment near the non-commuter school. The monthly rent was $2,865. At that rate, three years of rent would cost $103,140. His request for reimbursement of this expense was denied, because “the Department doesn’t pay for housing.”

In deciding this dispute, the Court of Appeal noted that twenty specific categories of vocational rehabilitation services are enumerated in the Federal Act. (29 U.S.C. § 723(a).). Under the Federal Act, vocational rehabilitation services include “maintenance for additional costs incurred” while receiving such services. (29 U.S.C. § 723(a)(7).)

One example of maintenance is “[t]he cost of short-term shelter that is required in order for an individual to participate in vocational training at a site that is not within commuting distance of an individual’s home.” (34 C.F.R. § 361.5(b)(34) (2022).) As a catchall provision, the federal implementing regulations include a twenty-first category: “Other goods and services determined necessary for the individual with a disability to achieve an employment outcome.” (34 C.F.R. § 361.48(b)(21) (2022).)

As a participating state, California requires that its vocational rehabilitation program “be consistent with the national policy toward people with disabilities articulated in . . . [the Act].” (Welf. & Inst. Code, § 19000, subd. (c).). California’s statute largely tracks the language of the Act and similarly provides for “[m]aintenance, not exceeding the additional costs incurred while participating in rehabilitation.” (Welf. & Inst. Code, § 19150, subd. (a)(8).)

A participating state need not accept all eligible individuals into its vocational rehabilitation program. (29 U.S.C. § 721(a)(5) [order of selection of eligible individuals for services].) But once an individual is accepted as a client, “the scope of [the state agency’s] discretion narrows considerably. The agency is required to provide the client at least with those services enumerated in the Act which are necessary to assist the [eligible] person to achieve his or her vocational goal.” (Schornstein v. New Jersey Division of Vocational Rehabilitation Services (D.N.J. 1981) 519 F. Supp. 773, 779; 29 U.S.C. § 723(a).)

The Court of Appeal concluded that to “determine if a cost can be covered as “maintenance,” the question is whether the cost is in excess of normal expenses and tied to receiving other vocational rehabilitation services – not whether the cost is short- or long-term.”

Accordingly, the matter was remanded so the Department can reconsider Doe’s request under the proper definition of “maintenance.”

Owner of 10 DME Companies Guilty of Defrauding Anthem Blue Cross of $1.7M

The owner of a tattoo removal business in South Gate pleaded guilty to federal criminal charges for recruiting paraplegics in a health care fraud scheme that netted more than $1.7 million and for cheating on his taxes.

Joseph Tusia, 60, of Leominster, Massachusetts, pleaded guilty to a two-count information charging him with health care fraud and tax evasion.

According to his plea agreement, Tusia operated a laser tattoo removal business in South Gate and 10 durable medical equipment supply companies (DMEs) in California, Nevada, and Massachusetts. Tusia controlled the tattoo removal companies and the DMEs but intentionally withheld his name from bank accounts and state registrations to evade tax liability.

On December 30, 2015, Tusia and a co-schemer submitted an application to Anthem Blue Cross for a small group health insurance plan. Anthem’s small group plan permitted benefits and health coverage for permanent employees who worked full-time.

Despite the eligibility requirements, Tusia caused to be submitted to Anthem the names of nine individuals purported to be full-time employees of Tattoo Removal and a person who was a dependent of the Tusia. None of these purported employees were employed by Tattoo Removal or eligible for health insurance coverage under Tattoo Removal’s plan with Anthem.

According to his plea agreement, Tusia identified the Purported Tattoo Removal Employees from his friends and associates who were paraplegic and required medical supplies, knowing and expecting that the Purported Tattoo Removal Employees would purchase their medical supplies from the DMEs that were controlled by Tusia and his associates.

From March 2016 to June 2020, Tusia and his co-schemers submitted fraudulent claims to Anthem on behalf of the DMEs for medical supplies provided to the purported employees, knowing that none of them were eligible for coverage. As a result of these fraudulent claims, Anthem paid the DMEs controlled by Tusia approximately $1,731,215.

Tusia also admitted in his plea agreement to knowingly and willfully failing to report income he received from the DMEs in tax years 2017 through 2020, totaling more than $1,573,644. Tusia admitted that he failed to pay tax to the IRS and that he took affirmatives steps to evade paying taxes, such as by creating the DMEs and opening bank accounts for the DMEs in the names of his associates and co-schemers.

United States District Judge George Wu scheduled a December 5 sentencing hearing, at which time Tusia will face a statutory maximum sentence of 10 years in federal prison on the health care fraud count, and up to five years in federal prison for the tax evasion count.

The United States Department of Labor – Employee Benefits Security Administration, the FBI, and IRS Criminal Investigation are investigating this matter.Assistant United States Attorney Jeff Mitchell of the Major Frauds Section is prosecuting this case.

Cal Supreme Ct. Limits Overlapping PAGA Claims Against Same Employer

Tina Turrieta, Brandon Olson, and Million Seifu each worked as a driver for Lyft, Inc. (Lyft) and each filed a separate action seeking civil penalties under PAGA for Lyft’s alleged failure to pay minimum wages, overtime premiums, and business expense reimbursements.

In September 2019, Turrieta and Lyft attended a mediation. When they failed to reach agreement, the mediator made a settlement proposal based on his valuation of the case, and the parties accepted the proposal.In early December 2019, Turrieta and Lyft signed an agreement settling Turrieta’s action and scheduled a settlement approval hearing for January 2, 2020.

Before that hearing, Olson and Seifu filed separate motions to intervene in Turrieta’s action and submitted objections to the settlement. The trial court denied the motions, approved the settlement, and later denied the motions of Olson and Seifu to vacate the judgment.

Olson and Seifu appealed, challenging both the settlement and the denials of their various motions. The Court of Appeal affirmed, finding that the trial court had properly denied the intervention motions and that Olson and Seifu lacked standing to move in the trial court to vacate the judgment or to challenge the judgment on appeal. Olson petitioned for our review of the appellate court’s decision, asserting that as a deputized agent of the state under PAGA, he has the right, on behalf of the state, to intervene in Turrieta’s action, to move to vacate the judgment in that action, and to have the court consider his objections to the proposed settlement of that action.

The Supreme Court of California affirmed in the case of Turrieta v Lyft Inc., – S271721 (August 2024)

“This case involves what has become a common scenario in PAGA litigation: multiple persons claiming to be an ‘aggrieved employee’ within the meaning of PAGA file separate and independent lawsuits seeking recovery of civil penalties from the same employer for the same alleged Labor Code violations.”

The Labor Code Private Attorneys General Act of 2004 (PAGA) provides that an aggrieved employee, after complying with specified procedural prerequisites, may “commence a civil action” to recover civil penalties that the the California Labor and Workforce Development Agency (LWDA) has statutory authority to collect civil penalties from employers that violate certain provisions of the Labor Code.LWDA may assess and collect. (§ 2699.3, subd. (a)(2)(A).)

The Court of Appeal ruled that Olson and Seifu could not “meet the threshold” requirement under Code of Civil Procedure section 387 for either mandatory or permissive intervention: “[A] direct and immediate interest in the settlement.” (Turrieta v. Lyft, Inc. (2021) 69 Cal.App.5th 955, at pp. 971-972.) For reasons similar to those related to their lack of standing, the court explained, their “position as PAGA plaintiffs in different PAGA actions does not create a direct interest in [Turrieta’s action], in which they are not real parties in interest. [Their] interest in pursuing enforcement of PAGA claims on behalf of the state cannot supersede the same interest held by Turrieta in her own PAGA case. . . . [They] have no personal interest in the PAGA claims and any individual rights they have would not be precluded under the PAGA settlement.” (Id. at p. 977.)

On appeal, the Supreme Court commenced its review of the Court of Appeal decision by saying “In recent years, we have addressed several issues related to PAGA litigation. We begin with a review of the basic principles set forth in our prior PAGA decisions because they provide context for deciding the issues now before us.” Thus this 96 page Opinion is a must read by practitioners in this area of law.

Although a PAGA plaintiff may use the ordinary tools of civil litigation that are consistent with the statutory authorization to commence an action, such as taking discovery, filing motions, and attending trial, the Supreme Court concluded – for reasons explained in the opinion – that the authority Olson seeks in this case – to intervene in the ongoing PAGA action of another plaintiff asserting overlapping claims, to require a court to consider objections to a proposed settlement in that overlapping action, and to move to vacate the judgment in that action – would be inconsistent with the scheme the Legislature enacted.”

This conclusion best comports with the relevant provisions of PAGA as read in their statutory context, in light of PAGA’s legislative history, and in consideration of the consequences that would follow from adopting Olson’s contrary interpretation.

Injured Worker’s Failure to Cite Evidence in Record Forfeits Claim on Appeal

Daniel Rocha was first hired by the County of Fresno in 2005 to work as a social worker in its Department of Social Services (DSS). While employed at DSS, Rocha developed two injuries for which he required workplace accommodations. Specifically, in 2009, he began experiencing carpal tunnel syndrome and, in 2016, he developed a bulging disc in his back. DSS accommodated Rocha’s medical conditions, in part, by changing his work assignments and reducing his typing and computer time.

According to Rocha, he received positive performance reviews while at DSS. However, given his physical limitations and the extensive work requirements of his position at DSS, Rocha decided to seek transfer to the Fresno County Library, so he transferred to County Library as a senior staff analyst. He was to be trained in his new position by his direct supervisor, Business Manager Jeannie Christiansen. During his employment at County Library, Rocha developed a long list of grievances against Christiansen.

In January 2018, Rocha was given supervisory authority over a new hire, Rachel Acosta, during her probationary period. At Christiansen’s direction, Rocha put Acosta on a performance improvement plan and provided her with “weekly counseling memos to help improve her work.” The relationship between Rocha and Acosta deteriorated, leading to the intervention of Associate County Librarian Raman Bath and Cindy Freeland, a human resources representative.

Bath started a preliminary investigation but then put it on hold because he thought a “cooling off period” might resolve the issues. He would later receive additional information from Acosta that would cause him to resume and complete his investigation.

Soon after May 30, 2018, Rocha took time off for his back injury, and on June 13, 2018, Rocha filed a workers’ compensation claim relating to his carpal tunnel syndrome. After Rocha filed his workers’ compensation claim, County performed an ergonomic evaluation of his workspace. The resulting report indicated Rocha was not previously under any work restrictions. Several adjustments to his workstation were recommended, including, without limitation, an option to have a sit-stand desk and an ambidextrous mouse that could be operated by either hand. In addition, Rocha was advised to “[c]ontinue stretching and moving around throughout the day” and “[t]ake breaks and microbreaks.”

On August 8, 2018, Rocha filed an internal complaint against Christiansen. He alleged Christiansen had been belittling and degrading him for over a year and a half, overloading him with work, and sending him “negative and/or hostile e[-]mails” on a daily basis. In his HR complaint, Rocha recounted many of the issues he had previously made.

On August 29, 2018, County hired an outside investigator, Attorney Amy Oppenheimer, to investigate matters raised by Rocha in his HR complaint. Oppenheimer interviewed nine witnesses, and also reviewed a number of documents. Oppenheimer did not sustain any of Rocha’s accusations against Christiansen.

The situation between Rocha and others subsequently.deteriorated. On February 21, 2019, County issued Rocha a notice of intended order for disciplinary action (notice of intended action) that recommended Rocha’s employment with County be terminated. In lieu of a Skelly conference, Rocha’s attorney of record provided a written response to the notice of intended action. Paul Nerland, who, at the time, was director of HR for County, served as a Skelly officer for County and conducted a Skelly review in connection with the notice of intended action.

Nerland stated he found no “evidence suggesting [Rocha’s] proposed termination was retaliatory or biased” and determined “Rocha had been insubordinate, and then was dishonest about his conduct when questioned”

On May 4, 2020, Rocha filed suit against County, alleging County had violated the California Fair Employment and Housing Act (FEHA) by (1) discriminating against him on the basis of his medical conditions and physical disability, (2) retaliating against him for making protected complaints pertaining to his medical conditions and physical disability, and (3) failing to prevent the alleged acts of discrimination and retaliation. County moved for summary judgment or, alternatively, summary adjudication of the three causes of action in Rocha’s complaint. The trial court granted County’s motion for summary judgment and entered judgment in its favor.

Rocha appealed, and the Court of Appeal affirmed the trial court in the unpublished case of Rocha v. County of Fresno -.F084512 (July 2024).  

After reviewing Rocha’s appellate briefs, the Court of Appeal noted that with “only sparse exception, Rocha has failed to cite to any of the actual evidence he submitted in opposition to County’s motion in his appellate briefs.” and thus “deemed “Rocha’s near complete failure to provide citations to evidence and exhibits as a forfeiture of his claims on appeal. Bernard v. Hartford Fire Ins. Co. (1991) 226 Cal.App.3d 1203,1205 [“It is the duty of a party to support the arguments in its briefs by appropriate reference to the record, which includes providing exact page citations.”] “Notwithstanding, we address the merits of Rocha’s forfeited claims below.”

The employee cannot simply show that the employer’s decision was wrong or mistaken, since the factual dispute at issue is whether discriminatory animus motivated the employer, not whether the employer is wise, shrewd, prudent, or competent. [Citations.] Rather, the employee must demonstrate such weaknesses, implausibilities, inconsistencies, incoherencies, or contradictions in the employer’s proffered legitimate reasons for its action that a reasonable factfinder could rationally find them “unworthy of credence,”

The Opinion concluded that “Rocha has not met his burden to provide substantial evidence that County’s reason for terminating his employment was untrue or pretextual as required.”

July 29, 2024 – News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: Court of Appeal Affirms Worker’s Fraud Conviction Based on Sub Rosa. Guidelines Specified for Severability of Unconscionable Arbitration Provisions. Biopharmaceutical Company Resolves Kickback Case for $5.5 Million. Santa Paula Doctor Pleads Guilty to $3 Million Fraud. DaVita Dialysis to Pay $34M to Resolve Allegations of Illegal Kickbacks. Riverside Chiropractor Agrees to Pay $180K to Resolve Fraud Allegations. DOI Calls for WCIRB Study of Workers’ Compensation Silicosis Claims. Ransomware Takes LA Superior Court 36 Office Internal Systems Down.

July 22, 2024 – News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: SIBTF Has Burden of Proof For L.C. 4753 Benefit Reductions. SCOTUS Rules Insurers May Participate in Insured Bankruptcy Proceedings. $500 Million Severance Pay Lawsuit Against Elon Musk Dismissed. S.F. Zen Center Worker Meets ADA Discrimination Ministerial Exception. Privette Doctrine Applies to Injury Working Inside Jet Tank. Guardant Health, Inc. Agrees to Pay $914K to Resolve FCA Charges. Federal Judiciary Has Systemic Sexual Harassment Protection Failures.
Doctors Face Another Medicare Pay Cut – 2.8% in 2025.

2 SoCal Hospitals Among 8 Nationwide Leading In Antimicrobial Stewardship

The Infectious Diseases Society of America (IDSA) is a community of over 13,000 physicians, scientists and public health experts who specialize in infectious diseases. Its purpose is to improve the health of individuals, communities and society by promoting excellence in patient care, education, research, public health and prevention relating to infectious diseases.

The Society just announced the recipients of its Antimicrobial Stewardship Centers of Excellence designation. The eight awarded institutions have created stewardship programs led by infectious diseases-trained physicians and pharmacists that advance science in antimicrobial resistance.

The institutions recently awarded the CoE designation (two of them in California) are:

– – University of Southern California (USC) Norris Cancer Hospital, Los Angeles, CA
– – Keck Hospital of USC (University of Southern California), Los Angeles, CA
– – Baptist Health, Jacksonville, FL
– – Children’s Hospital New Orleans, New Orleans, LA
– – John D. VA Medical Center, Detroit, MI
– – Lake Cumberland Regional Hospital, Somerset, KY
– – Ocean University Medical Center, Brick Township, NJ 08724
– – University of Toledo Medical Center Toledo, OH 43614

The institutions also have achieved standards aligned with evidence-based national guidelines, such as the IDSA-Society for Healthcare Epidemiology of America guidelines and the Centers for Disease Control and Prevention’s Core Elements. A total of 187 programs nationwide have received the designation since the program’s launch in 2017.

“Solving the next public health emergency starts with addressing the threat of antimicrobial resistance at every level,” said Steven K. Schmitt, MD, FIDSA, president of IDSA. “These eight institutions are working to counter the growing problem of resistance, one of the greatest threats facing our future. By honoring them, we are building a community fighting antimicrobial resistance.”

A recently published CDC fact sheet analyzes the threat of Antimicrobial Resistance (AMR) in the U.S. and the impact COVID-19 had on health care facilities. CDC says the number of reported clinical cases of C. auris increased nearly five-fold from 2019 to 2022. Additionally, CDC shows that six bacterial antimicrobial-resistant hospital-onset infections increased by a combined 20% during the COVID-19 pandemic compared to the pre-pandemic period, peaking in 2021 and remaining above pre-pandemic levels in 2022.

“Fighting antimicrobial resistance remains a priority for IDSA as we continue to support legislative efforts to strengthen the U.S. response to antimicrobial resistance by advocating for passage of the Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Act,” Dr. Schmitt said.

The core criteria for the CoE program place emphasis on an institution’s ability to implement stewardship protocols by integrating best practices to slow the emergence of resistance, optimize the treatment of infections, reduce adverse events associated with antibiotic use and to address other challenging areas related to antimicrobial stewardship. A panel of IDSA member experts in antimicrobial stewardship, including ID-trained physicians and ID-trained pharmacists, evaluate CoE applications against high-level criteria established by IDSA leadership for determining merit.

Proposed Law to Fine Insurers for “Ghost” Provider Networks

Assemblymember Chris Holden’s Assembly Bill 236 would give state regulators authority to fine insurers if their lists of in-network doctors, hospitals, mental health workers, labs and imaging centers aren’t up-to-date and accurate.

According to the author, “despite California having one of the nation’s strongest laws on health plan provider directories, compliance is at an unbelievable low. Recent studies have found that some health plans have inaccuracy rates as high as 80%, and major plans like Anthem and Kaiser have inaccurate information for 20%-38% of providers.”

“These inaccuracies in provider referral lists are often referred to as ‘ghost networks’ because the referrals simply do not exist. As a result, consumers bear the responsibility of sorting through these grossly inaccurate lists, sifting through directories in an effort to find care, calling provider after provider, only to be told the provider is no longer in-network, no longer accepting new patients, or even no longer in practice.”

“This is especially harmful to those already suffering from health care inequity, such as those with limited English proficiency and persons with disabilities. Ghost networks contribute to inequity in health care by leaving Californians to fend for themselves in their most vulnerable time”.

The bill tackling what are disparagingly called “ghost networks” has so far passed the Assembly and the Senate Health Committees with only Republicans in opposition, and despite the lobbying powerhouses representing California doctors and insurers fighting the bill every step of the way.

Doctors and insurers blame each other for problems in the directories, but they argue the bill is unnecessary, burdensome on them and that laws on the books already address the problem.

Combined, the groups have given at least $4.7 million to California legislators since 2015, according to the Digital Democracy database.

CalMatters reports that along with opposition from influential lobbyists for doctors and insurers, the measure also received a lukewarm response from the state agency that would enforce the bill if it becomes law.

As the Legislature and Gov. Gavin Newsom sought to address a $30 billion budget deficit this year, the Department of Managed Health Care estimated that the bill would cost $12 million to bring on “additional staff.” According to the bill’s analysis, the new employees are needed to develop regulations, forms and to monitor “provider directory accuracy.”

The estimate of $12 million is the equivalent of 80 employees each making $150,000 a year – figures that could alarm Newsom’s budget team and the lawmakers who dole out cash to state agencies on the Senate Appropriations Committee, where the bill will be considered in the coming weeks.

Holden’s bill would require an insurer’s provider directory to be at least 60% accurate by this time next year and 95% accurate by July 1, 2028. The insurers would face fines up to $10,000 for every 1,000 enrolled customers each year if they didn’t hit the benchmarks. Kaiser, for instance, says it provides care to 9.4 million Californians.

The bill also says patients who mistakenly use an out-of-network doctor due to inaccurate information from provider lists cannot be charged out-of-network rates.

Under the federal Consolidated Appropriations Act (CAA) of 2021, “No Surprises Act,” providers and health care facilities must generally refund enrollees amounts paid in excess of in-network cost-sharing amounts with interest, if the enrollee has inadvertently received out-of-network care due to inaccurate provider directory information, and if the provider or facility billed the enrollee for an amount in excess of in-network cost-sharing amounts, and the enrollee paid the bill.

In addition, providers and health care facilities must maintain business processes to submit provider directory information at specified times to support plan and issuers in maintaining accurate, up to date provider directories. Contract provisions can require a provider to be removed at the time of the contract termination, and the plan to bear financial responsibility for providing inaccurate network status information to an enrollee.