Flash from the workerscompzone green eyeshades department, always seeking out future trends for your reading pressure,,,,er, pleasure.

30% of California doctors are over 60 years old. That's well above the national average.

Six out of nine California regions now have a primary care physician shortage. Only the Bay Area, Orange County and Sacramento meet primary care access standards.

Los Angeles, the Central Coast, the Inland Empire and the San Joaquin Valley and San Diego are among the regions underserved by primary care doctors.

As the population ages, this trend is likely to increase. Expanded coverage under the Obama healthcare reforms may exacerbate physician shortages.

Meanwhile, specialists are distributed unevenly among the various California metro areas.

The stats are all in a report of the California Healthcare Foundation in a study by Craig Paxton of Cattaneo and Stroud, a healthcare consulting firm. The study has many nifty graphs and charts, comparing physician access among many metro areas.

The study is found here:
http://www.chcf.org/~/media/Files/PDF/C ... es2010.pdf

Its a study that merits close analysis by workers' comp stakeholders.
Will tomorrow's workers' comp system be struggling to attract treating doctors? Should future regulatory and legislative fixes consider the effect on attracting doctors to comp? Should there be more organized attempts to train doctors for occupational medicine?

Stay tuned.

Julius Young
www.boxerlaw.com

July 20.

That's the deadline for comment on the latest version of the California physician fee schedule. An earlier version of of a revised physician fee schedule has been modified.

The initial proposal was supposedly "budget neutral". With this new version, costs have been added into the system, supposedly funded from cuts in spinal hardware costs and cuts in ambulatory surgical center fees.

The initial proposal followed the release of a study by the The Lewin Group on introduction of RBRVS into the California workers' comp fee schedule.
The Lewin Group study can be found here:
http://www.dir.ca.gov/dwc/RBRVSLewinRep ... rt2010.pdf

Many physicians were highly critical of the first proposed fee revision.

The DWC walks a fine line here. There is enormous pressure to find system cost savings. Medical costs have been increasing significantly (along with loss control costs). Unless medical costs are under control, it's hard to see how indemnity benefits will be brought to adequate levels.

But there needs to also be attention to keeping doctors in the system.
My recent post, "To Treat of Not to Treat", examined this from the perspective of some of the doctors. The question raised was whether it was worth it for doctors to take workers' comp cases:
http://www.workerscompzone.com/index.ph ... 707-091110

The comment forum on the revision to the fee schedule is open til July 20th:
http://www.dir.ca.gov/dwc/DWCWCABForum/ ... hedule.htm

Here is a link to the comments posted so far (note: the DWC often takes down these links after the comment period expires):
http://www.dir.ca.gov/dwc/ForumDocs/Phy ... mments.pdf

Among the comments so far, comments from neurologists and physical medicine doctors are particularly notable. The commenting doctors note that reimbursements for diagnostic procedures such as EMG/NCV testing would be substantially reduced. This would lead to an exodus of neurologists from the comp system, they predict.

As reimbursement schedules are adjusted, someone's ox is likely to get gored. But these changes can substantially affect worker access to treatment.

That's why it's good for doctors to give their input now, up front.

Stay tuned.

Julius Young
www.boxerlaw.com

As a blogger on California workers' comp issues, I sometimes get interesting calls.

Yesterday's call? From doctor's group (to protect confidentiality, I'll mask any particularizing details).

The medical practice is debating whether to join an MPN and whether it wants to treat injured workers under California's workers' comp system.
The caller was seeking input from sources with knowledge about California's workers' comp system.

At first, I envisioned a need to educate the caller about issues that concern providers....utilization review....fee schedule issues....medical treatment guidelines.....lien claims.......

I quickly realized that was unnecessary. The caller already understood what was going on in those areas quite well.

The caller was really looking for something else. What's the benefit in treating workers' comp cases? Why should our doctors do it?

This physician noted that the medical group was already very busy with non-workers' comp patients. The group was a member of various HMO
groups.

Why should they take workers' comp? Was it worth getting involved in the hassles of paperwork documentation and authorization disputes?

I wondered whether their HMO contracts bound them to treat injured workers. The caller didn't think so.

I noted that with changes coming under Obamacare, healthcare reforms could affect treaters in unanticipated ways. Perhaps the doctor group wanted to diversify into workers' comp.

The caller was unmoved.

Did the doctors feel a sense of civic duty to treat some share of the state's working folks? After all, many of the doctors live in the community. The workers they would be treating serve the doctors in various capacities. I appealed to the communitarian, altruistic impulses of the caller.

The caller was unimpressed.

I tried an economic argument. Perhaps, I noted (not having stats to back up my hypothesis) if the doctors did not take comp cases, would that have a negative effect on the economics of local MRI facilities and surgicenters which may be partially owned by these doctors? Would other treating doctors refer patients to alternative surgicenters and MRI centers instead, negatively affecting the calling doctors' investments?

The caller noted that this argument could resonate with some of his partners, but might not be compelling.

As the call ended, I wondered how often this debate goes on in partnership meetings at doctors groups. Was the call just an "outlier", or was it a mainstream wake-up call showing deep dissatisfaction among doctor groups with practice in the comp system?

Julius Young
www.boxerlaw.com

In these challenging economic times, you'd think that policymakers would want to keep as many jobs here in California as possible.

Good, skilled jobs. Like jobs for physician UR reviewers.

But currently utilization review docs don't have to be California licensed.
In 2008 Governor Schwarzenegger vetoed an attempt to impose a California license requirement on UR reviewers. That bill, carried by now termed-out Assemblywoman Sally Lieber, was AB 2969.

AB 933, carried by Assemblyman Paul Fong of Cupertino, would require UR reviewers to be licensed. Here's a link to the current bill language:
http://www.leginfo.ca.gov/pub/09-10/bil ... en_v98.pdf

One advantage of requiring California licensing for UR docs is that it will cut down on the problem of treating docs having trouble contacting UR because of time zone issues. Currently a California treating doctor who is in surgery in the morning has almost zero chance of speaking to a UR reviewer in Florida who is gone by the time the Cali treating doctor gets back in the office from the surgicenter.

These are the sort of little realities that frustrate doctors. Many end up in the costly and time consuming QME process.

There's a good chance the Governor will veto AB 933 if it reaches his desk. The bill advanced out of Senate committee yesterday, but still faces an uncertain future.

With all the concern about generating California jobs and revenue for California, it's hard to defend allowing out of state doctors to do California utilization review.

It's time to keep the jobs here.

Julius Young
www.boxerlaw.com

In law it's never over til its over.

A bad ruling may cause consternation, but subsequent cases may limit or disapprove of the bad ruling. Courts may change their mind. Subsequent appeals or other court cases give courts a chance to look at concepts in a different way.

Lawyers understand all this, but average people often have trouble accepting the concept.

In 2006 I was very troubled by the Brashear case. It always seemed clear to me that the spinal surgery second opinion procedure under Labor Code 4062(b) required the employer/insurer to instigate the 2nd opinion process.

But that was not the opinion of the WCAB, which issued a "significant panel decision" in Brashear v. Nationwide Studio Fund (2006) 71 CCC 1282. In Brashear the WCAB held that it was the obligation of the worker to instigate the 2nd opinion process. The 2nd opinion process generates a report from an independent spinal surgeon on whether surgery is reasonably required.

But the WCAB saw the error of its ways. In 2009, the WCAB issued an en banc opinion in Cervantes v. El Aguila Food Proiucts, Inc (2009) 74 CCC 1336. Cervantes finds that the burden of requesting a 2nd spinal opinion falls on the employer/insurer, not on the worker.

The Cervantes opinion can be found here:
http://www.dir.ca.gov/wcab/EnBancdecisi ... cedures%20(11-19-09%20final%20draft).pdf

But would the California Court of Appeals agree with the Cervantes logic, or would the Court of Appeals revert to the Brashear holding?

That was the question in Elliott v. WCAB and Newsgroup of Sacramento, a case heard by the California Court of Appeal, First Appellate District, Division Four.

The Elliott opinion was rendered in late February, 2010.The Court adopts the Cervantes line of reasoning in interpreting Labor Code 4062(b).

In a nutshell, an insurer who receives a spinal surgery request must undertake utilization review. If UR approves the surgery the surgery must be authorized. If UR is not done in a timely manner, the surgery must be authorized.

But if UR is done in a timely manner and UR denies the surgery, it is the defendant who must file for a 2nd spinal surgery opinion. The timeframe for filing for a 2nd spinal surgery opinion is 10 days from receipt of the treating physician surgery recommendation. Under 4062(b), an employer must file the request on specified forms (see AD Rule 9788.11).

While it's always possible that another Court of Appeal could reject the logic of Elliot and Cervantes and endorse the Brashear approach, it seems unlikely.

So, six years after the SB 899 reform created the spinal second opinion process, we finally appear to know how it is supposed to work.

The average joe on the street would probably be amazed to hear that it took six years for such a basic statutory procedural issue to be settled.
Six years is a long time.

The law is like that.

Stay tuned.

Julius Young
www.boxerlaw.com

Lawyers know better.