Tag: 2022 News

William Valdez, while employed as a firefighter for the Orange County Fire Authority, sustained a continuous trauma industrial injury in the form of hypertension, coronary artery disease, hands including thumbs, shoulders, feet including toes, and to the upper digestive tract in the form of a hiatal hernia.

In finding permanent disability of 89%, his right and left thumb disabilities were added together rather than combined utilizing the Combined Values Chart in the 2005 Schedule for Rating Permanent Disabilities, as were his right and left foot disabilities. The disabilities were otherwise combined utilizing the Combined Values Chart. (2005 Schedule at pp. 8-1 – 8-4.)

Valdez contended on reconsideration that the WCJ erred in combining applicant’s orthopedic disabilities with his internal medicine disabilities by way of the CVC rather than adding the percentages of permanent disability. Reconsideration was denied in the panel decision of Valdez v Orange County Fire Authority ADJ11323413 (March 2022).

Valdez argues that the orthopedic disabilities should be added to the internal medicine disabilities based on the June 23, 2021 deposition testimony of orthopedist Mitchel Silverman, M.D. Dr. Silverman opined that applicant’s orthopedic impairments did not “overlap” with the internal medicine impairments.He opined that the impairments affected different activities of daily living and work restrictions, although the activities of daily living and work restrictions were not specified.

Explaining why the orthopedic disability should be added to the internal medicine disability, Dr. Silverman testified, “I understand the CVC, but the courts have decided. I haven’t decided, the courts have decided, that there’s a way to look at this in terms of adding them, and I agree in this particular case.”

However the panel concluded that “Dr. Silverman’s report is not substantial medical evidence sufficient to rebut the use of the Combined Values Chart.”

In Athens Administrators v. Workers’ Comp. Appeals Bd. (Kite) (2013) 78 Cal.Comp.Cases 213 (writ den.), the evaluator explained why the disparate impairments were not actually disparate, and the impairments in question were all under the physician’s expertise.

“In contrast, here one specialist is suggesting that we add impairments found by him in his own specialty to impairments in completely different body systems found by a different specialist. As an orthopedist, it was Dr. Silverman’s role to describe and give a whole person impairment with regard to the orthopedic impairment.”

“Dr. Silverman did not give any compelling reason why the orthopedic and internal medicine impairments should be added, and questions beyond applicant’s orthopedic impairment, including applicant’s overall impairment or the operation of the CVC, are beyond Dr. Silverman’s expertise.” (Applied Materials v. Workers’ Comp. Appeals Bd. (D.C.) (2021) 64 Cal.App.5th 1042, 1097 [86 Cal.Comp.Cases 331].)

On April 2020 Rogelio Trigueros filed a claim for workers’ compensation benefits claiming injury to his upper extremities, shoulders, arms, hand and fingers while employed as a farm laborer for respondent Gonzalez Ag., Inc.

On May 4, 2020, employer’s insurance carrier mailed a Notice Regarding Delay of Workers’ Compensation Benefits from Kansas City, Missouri, to petitioner in California.

Sixteen days later, Trigueros requested and obtained a panel of three chiropractic Qualified Medical Evaluators eligible to evaluate his workers’ compensation claim.

The Employer challenged the timing of his request for a QME panel and the matter proceeded to trial, resulting in the workers’ compensation administrative law judge concluding the panel was valid.

Reconsideration was granted, with the WCAB panel agreeing with employer. The WCAB replaced the WCJ’s finding with its own finding that the QME panel was invalid because petitioner prematurely requested it before waiting 20 days from mailing of the Delay Notice. In doing so, the WCAB stated it applied its own rules as set forth under California Code of Regulations, title 8, section 10605 (WCAB rule 10605) rather than the more general CCP § 1013 mail delay provisions.

In its prior en banc decision in Messele v. Pitco Foods, Inc. (2011) 76 Cal.Comp.Cases 956 and as established under section 5316, the WCAB’s own rules govern service of process and any applicable extensions of time to act where they differ from the more generally applicable provisions under CCP § 1013.

However, the Court of Appeal reversed the WCAB and remanded the case of Tigueros v WCAB and Gonzalez Ag., (March, 2022)

In granting the petition for writ of review, the court notified the parties that it appeared the WCAB based its determination on the out-of-state location where the claims administrator mailed the triggering delay notice from instead of the location where it served the notice on petitioner.

WCAB rule 10605 provides that the time added for service is “(1) Five calendar days from the date of service, if the place of address and the place of mailing of the party, attorney or other agent of record being served is within California; (2) Ten calendar days from the date of service, if the place of address and the place of mailing of the party, attorney or other agent of record being served is outside of California but within the United States;

And that, pursuant to WCAB Rule 10605(a)(1), the WCAB instead should have added only five days to the statutory 10-day waiting period, for a total of 15 days, before considering the first day a party may validly request a QME panel.

The WCAB responded that it agreed and requested the Court of Appeal to annul the WCAB’s decision and remand the matter for further proceedings.

According to the National Alliance of State Pharmacy Associations, more than a dozen states have expanded what pharmacists can do to include testing and treating people for illnesses such as strep throat, flu, and urinary tract infections and preventing HIV. Some states allow pharmacists to prescribe oral contraceptives or drugs to help people quit smoking. Typically, pharmacists have prescribing authority under agreements with doctors or rules called statewide protocols.

But a report by Kaiser Health News says that a limited number of states have gone further, allowing pharmacists to prescribe medications on their own to treat a broad range of conditions for which there are rapid point-of-care tests, if it’s appropriate based on clinical guidelines.

“We’re seeing more states looking at direct prescribing authority now as opposed to collaborative practice agreements,” said Allie Jo Shipman, director of state policy at the National Alliance of State Pharmacy Associations. The alliance offers point-of-care testing and point-of-care treating training programs for pharmacists and pharmacy students.

The Biden administration, which has leaned on pharmacies to help battle the covid pandemic by administering vaccines and tests, is now calling for a limited number of pharmacies with retail clinics that employ doctors or other health care workers with prescribing authority to directly provide medication rapidly to people who test positive for the virus. The “test-to-treat” program is designed to make sure that people with covid get a course of antiviral medication quickly because it is most effective if used within five days of when someone shows symptoms.

But physicians don’t necessarily welcome this development. Doctor groups have long objected to the taking on of certain types of patient care by pharmacists, nurse practitioners, physician assistants, and other nondoctors unless it is overseen by or approved by physicians.

In November, the American Medical Association, which represents doctors, announced that since 2019, it had successfully opposed more than 100 legislative actions that would have expanded nonphysicians’ scope of practice, called scope creep. The group also issued a statement criticizing the Biden administration’s plan to allow pharmacy-based clinics to prescribe covid antiviral medications, saying that the program poses a danger to patient safety and risks negative health outcomes. And the AMA unsuccessfully opposed a federal decision to let pharmacists give covid vaccines to children younger than 18.

Meanwhile, the American College of Physicians, which represents internists, announced it “opposes independent pharmacist prescriptive privileges and initiation of drug therapy outside of a collective practice agreement, physician standing order or supervision, or similar arrangement.”

The AMA didn’t respond to questions about independent pharmacist prescribing, and the ACP declined to comment on its policy.

But are physicians correct that patient safety is at risk if a doctor isn’t involved in prescribing decisions? Pharmacists say that they want to provide care in line with their training and skills and that they know their limits. And they note that timely prescribing is vital for treating covid and other infectious diseases.

They also note that pharmacists are increasingly part of the multidisciplinary clinical teams that direct patient care at hospitals and in health care systems.

“Pharmacists are the professionals that are the most trained to deal with drug interactions,” said Rita Jew, a pharmacist who is president of the Institute for Safe Medication Practices, a nonprofit that focuses on preventing medication errors. “We monitor patients for both efficacy and side effects. So from that perspective, it’s not a safety concern. Delay in treatment is a concern.”

Many pharmacists are eager to expand their menu of patient services, but payment remains a problem. Pharmacists aren’t generally recognized as service providers under Medicare and don’t typically receive payment when they spend time evaluating, testing, or treating patients. Many private insurers follow Medicare’s lead on payment.

Dr. Jeffrey Singer, a general surgeon and a senior fellow at the libertarian Cato Institute, wrote a recent blog post suggesting that doctors who object to nonphysician prescribing may be more worried about competition than patient safety.

“Rather than work to prevent laws that could meet the needs of patients, the onus is on the profession to persuade people that they need to see a doctor,” Singer said in an interview, adding that he has relied on pharmacists’ expertise in his practice. “I ask them, ‘Is there any particular problem with this drug?’ They have the software. And that’s what they’re trained to do.”

FAIR Health is a national, independent nonprofit organization dedicated to bringing transparency to healthcare costs and health insurance information through data products, consumer resources and health systems research support. FAIR Health possesses the nation’s largest collection of private healthcare claims data, which includes over 36 billion claim records and is growing at a rate of over 2 billion claim records a year.

The new FAIR Health white paper containing the fifth annual edition of FH® Healthcare Indicators and FH® Medical Price Index, shows that telehealth utilization grew nationally 7,060 percent from 2019 to 2020, an increase driven by the COVID-19 pandemic and the limits imposed on certain in-office services, coupled with the greater risk of infection from in-person encounters.

FH Healthcare Indicators reveal trends and patterns in the places where patients receive healthcare. Focusing on alternative places of service – retail clinics, urgent care centers, telehealth and ambulatory surgery centers (ASCs) – as well as emergency rooms (ERs), FH Healthcare Indicators evaluate changes in utilization, geographic and demographic factors, diagnoses, procedures and costs.

Among the key findings:

– – Due to the pandemic and the limits imposed on certain in-office services, coupled with the increased risk of infection from in-person encounters, telehealth grew in 2020 on a scale unseen in previous years. Telehealth utilization increased nationally 41,919 percent from 2015 to 2020, a more than 40-fold increase over the growth of 1,019 percent from 2014 to 2019 reported in last year’s edition. From 2019 to 2020, national growth was 7,060 percent.
– – In all other places of service studied for changes in utilization, utilization decreased from 2019 to 2020, probably because of the impact of COVID-19. Utilization fell 38 percent in ASCs, 30 percent in ERs, 16 percent in urgent care centers and 4 percent in retail clinics.
– – Among the places of service studied, telehealth held the highest percentage of medical claim lines in 2020, with 15.41 percent of all medical claim lines nationally. The comparable percentages for the other places of service were 2.07 percent for ERs, 1.31 percent for urgent care centers, 0.64 percent for ASCs and 0.05 percent for retail clinics.
– – In 2020 as in previous years, more claim lines were submitted for females than males in most age groups in the places of service in which FAIR Health studied gender-related patterns—retail clinics, urgent care centers, telehealth, ASCs and ERs.
– – However, in some places of service, such as retail clinics, urgent care centers, ASCs and ERs, the gap between males and females narrowed. For example, in ERs, in the age group 61-70, the male and female shares were approximately equal (50 percent) in 2020, a change from 2019, when the female share had been 52 percent and the male share 48 percent. This trend bears monitoring in the future.
– – In 2020, the five states in which retail clinic claim lines constituted the greatest percentage of medical claim lines were (from greatest to least) Arkansas, Missouri, Rhode Island, Maine and Minnesota. In 2018, Minnesota had ranked first in this list; in 2019, it ranked third, and in 2020 it fell to fifth.
– – Connecticut, which had been fourth from the bottom in its use of telehealth as a percentage of all medical claim lines by state in 2019, rose to fifth from the top in 2020.
– – In 2020, exposure to communicable diseases joined the list of most common diagnostic categories in retail clinics, urgent care centers and telehealth. This category largely was associated with testing and/or treatment for COVID-19 when a patient was exposed to the condition.
– – Across offices, urgent care centers and retail clinics in 2019, urgent care centers had the highest median charge amount for CPT®2 99203 (30-44-minute new patient office visit), but in 2020 the median charge for an office ($226) was slightly higher than that for an urgent care center ($221).

FH Medical Price Index reports shifts in costs and facilitates useful comparisons among medical prices in six procedure categories from May 2012 to November 2021:

– – Of the six procedure categories, hospital E&Ms had the greatest percent increase in charge amount index, seven percent, and in allowed amount index, five percent.
– – Radiology and medicine each had the smallest percent increase in charge amount index, two percent.
– – Radiology had the smallest percent increase in allowed amount index, one percent.

FAIR Health President Robin Gelburd stated: “This year’s edition of FH Healthcare Indicators and FH Medical Price Index opens a window on the impact of the COVID-19 pandemic on the nation’s healthcare system. We hope that this new edition, like those in previous years, continues to inform decision making throughout the healthcare sector by payors, providers, government officials, policy makers, academic researchers and others.”

As directed by the Joint Legislative Audit Committee, the California State Auditor conducted an audit of the State’s licensure and oversight of hospice agencies and found that the State’s weak controls have created the opportunity for large-scale fraud and abuse.

Hospice is a specialized form of interdisciplinary health care primarily designed to provide palliative care and alleviate the physical, emotional, social, and spiritual discomforts of a person who is experiencing the last phases of life because of a terminal disease.

The fraud indicators that were found particularly in Los Angeles County include the following:

– – A rapid increase in the number of hospice agencies with no clear correlation to increased need.
– – Excessive geographic clustering of hospices with sometimes dozens of separately licensed agencies located in the same building.
– – Unusually long durations of hospice services provided to individual patients.
– – Abnormally high rates of still-living patients discharged from hospice care.
– – Hospice agencies using possibly stolen identities of medical personnel.

According to the report “These indicators strongly suggest that a network or networks of individual perpetrators in Los Angeles County are engaging in a large and organized effort to defraud the Medicare and Medi-Cal hospice programs. Such fraud places at risk the extremely vulnerable population of hospice patients.”

Los Angeles County has experienced a 1,500 percent increase in its number of hospice agencies since 2010. It had more than six-and-a-half times the nationwide average number of hospice agencies relative to its aged population in 2019. Although the majority of hospice services were provided by nonprofit organizations in the past, this recent wave of growth is almost exclusively in for-profit companies.

Investigators identified several areas within Los Angeles County with extremely high concentrations of hospice agencies, including individual buildings supposedly housing dozens of hospice agencies. In fact, the California Department of Public Health reported a single building in the community of Van Nuys as having more than 150 licensed hospice and home health agencies – a number that exceeds the structure’s apparent physical capacity.

Further, numerous indicators suggest that many of these hospice agencies may have been created to fraudulently bill Medicare and Medi-Cal for services rendered to ineligible patients or services not provided at all. This type of fraud can be lucrative. For example, a hospice agency that bills for 20 patients at the most common rate can collect about $122,000 per month.

Despite these widespread problems in the hospice program, Public Health and the two state agencies primarily responsible for identifying and investigating hospice fraud in Medi-Cal – the California Department of Health Care Services and the California Department of Justice – have not sufficiently coordinated their efforts.

In October 2021, California passed a general moratorium on licensing new hospice agencies beginning Jan. 1, 2022, and lasting until one year after the publication of the auditor’s report.