Department of Industrial Relations

Industrial Medical Council Public Meeting

Holiday Inn – LAX, Los Angeles

Thursday, June 21, 2001

Members present:

Barry Halote, PhD. Patricia Sinnott, PT, MPH

Marvin Lipton, M.D. Maria Mayoral, M.D.

Ira Monosson, M.D. Lawrence Tain, D.C.

Glenn Ocker, DPM, MS Paul E. Wakim, D.O.

Richard Pitts, D.O. Gayle Walsh, D.C.

Michael Roback, M.D. Benjamin Yang, C.A. OMD

Members absent:

Robert Larsen, M.D. Jonathan Ng, M.D., J.D.

Steven Nagelberg, M.D. Richard Sommer, M.Phil., J.D.

    1. The meeting was called to order by Co-Chair Dr. Richard Pitts at 11:00 AM. He mentioned that there would be no meeting in July 2001 and the next meeting would be back in LA in August. We will not alternate with South San Francisco because of the hotel contracts.

    1. Consent Agenda

a. Adoption of the Minutes and Notice of Actions: Dr. Pitts asked for a motion on the Draft Minutes and Notice of Action of the May 17, 2001 IMC meeting.

Action: The Consent Agenda was approved unanimously.

b. Executive Medical Director's Report:

Dr. D. Allan MacKenzie indicated that his EMD report stood as written. He stated the Governor's Office sent a note of recognition and appreciation for the ten members of the workers' comp. community who greatly helped the IMC with its mandates. One of them was Judge Pam Foust who volunteered for the Council some seven full days of consultation between late December and April.

Dr. MacKenzie also gave an update on the Lewin Group study. The important message is the critical path plan is on track. A number of stakeholders made clear to the IMC that the Physician's Office Practice Expense was missing and we need to take action to rectify this. A lot of time could be spent talking about the paper trail and history, however, it's been made clear that for

a significant worker's injury, such as a blown out knee, back trauma, or fracture spine, the fact is that physician's work treating an injured worker may be different from that of a non-industrial patient just as the work his or her office must do to get that injured worker back into the work force is different. The Council's commitment is to move forward with a study of the Physician's Office Practice Expense.

Dr. Ira Monosson agreed with the need to look at the significant differences between private care and workers' comp. care in terms of office costs.

Dr. Monosson: Motion: That the IMC Staff investigate the feasibility of expanding the fee schedule study to include medical practice expenses and that the Staff report back to the Council for action at the August meeting.

It was seconded.

Action: Motion passes.

Dr. MacKenzie also announced that Dr. Linda Rudoph has submitted her resignation to the Administrative Director (AD) effective the first two weeks in July 2001. The IMC made a commitment to continue helping the AD with the medical issues that he is confronted with, as we have done in the past. If anything extra ordinarily comes up in the future, we will offer him all the help that we can give.

c. DWC Report:

Mr. Richard Gannon stated that he is very sorry to see Dr. Linda Rudolph leave the DWC. She has been a very valuable adviser to the AD on variety of medical issues. He acknowledged Dr. Rudolph's role in coordinating IMC with DWC. In his conversation with Mr. Casey Young, Dr. Rudolph has been hired primarily to implement the requirements that a health care organization be established in DWC. She was instrumental in writing the regulations and very valuable to them in a lot of the regulatory processes that made sure the concerns for quality medical care were constantly before DWC. Dr. Rudolph will be working for Department of Health Services.

On the RBRVS transition and the Office Practice Expense component, Mr. Gannon remained convinced of the need to move toward the RBRVS because of the simplicity of the mechanism for updating the fee schedule and especially the issue of improving the fairness of the payment system. Also, it was predicted that RBRVS would give a more rational and predictable payment system. To achieve that fairness, DWC is considering exactly how physicians may be impacted by this change. It would be valuable to find out if there are differences in physician time and office practice expenses between workers' comp. or other systems. This type of study has not been done in the past. He noted that the IMC had included the office practice component in its

initial RFP but it was dropped because no group had bid on it. We are working towards a fair reimbursement system. He encouraged the IMC to see if they can find a method of doing the study that will be helpful to DWC.

Ms. Diane Przepiorski stated that the CA Orthopedic Assn. (COA) appreciated the Council's recognizing the need to move forward with the practice expense component. She said that the more she spoke with Council Members regarding the issue, the more it became apparent that it is going to be very difficult for a study to narrowly look at just the physician's work component versus the overall practice expense as well. If this continued as a separate study, we would have two different offices responding: first on the physician work component and a second study responding to the practice expense side. To get more accurate data, the COA would encourage the IMC to try to do an addendum in the existing Lewin contract so that these studies could, as much as possible be done on a simultaneous path. After the study done in 1997, the COA and CSIMS felt there were significant additional costs in both the physician's work site and the practice expense study. They thought that this would be a key component as they try to move through the transition to a RBRVS system. She asked Mr. Gannon if it is not possible to do an addendum to the contract, how would he envision that the practice expense study results would be incorporated into the final Fee Schedule product.

Mr. Gannon responded that he has limited ability to predict the regulatory process. One of the advantages to moving to RBRVS is not to have to wait every two years to revise it. He hoped he would not be quoted as saying we are going to revise the fee schedules every year. The possibility for DWC to do this might be simpler than to do it biennial and biennial revisions sometimes take five years. They are likely to phase in on how they move from the existing cost based system to an RBRVS system. Also, we need to see that the CPT codes and RBRVS relationships are revised periodically.

We need to be able to set up the systems so we can take the most common data and translate that in our California fee schedules. He is not saying we would wait for any transition before we have all the data in because it could be conceivably six months from now that we look and see if there is something else we need to study. Hopefully, this could be an ongoing process of getting the most current data and implementing the fee schedules as soon as we can. He did not envision that the 'transition' RBRVS would be a year or a year and a half away. He stated that he hopes it will be closer than that.

Dr. Paul Wakim stated that he shared with CSIMS and the COA's concerns regarding additional time that is spent in other related office activities.

Dr. Marvin Lipton said it is important that both the physician's work study and the office practice component be done in parallel, or be integrated.

Dr. Monosson clarified that it was unstated but implied that the goal was to try to have the practice expense component be included in the Lewin study but this might not be possible for various reasons.

Mr. Bill Hutchins, California Physical Therapy Association thanked the Council for agreeing to look at the practice expense components, something that physicians and non-physician providers such as physical therapist have been discussing for number of years.

Dr. Glenn Ocker stated one of the interesting recent developments has been the mini management team that go into offices to reengineer and increase efficiencies. These consultants have had an increasingly difficult time with the remainder of the activities that take place related to workers' comp, even beyond the physician's component.

Dr. Michael Roback said the more complex the medical issues probably the less complex the medical legal issue and the most explanation. We need to appreciate that complexity is no longer based on the medical model but on the medical legal model because that is where physicians find the greatest time drivers. He noted that we now have to mail reports out of state to different carriers. He said we must determine every aspect of office expenses including the cost of mailing and the cost of duplication of reports. If we can't find somebody to do the whole process, we can surely try to find somebody to do parts of the process.

Ms. Przepiorski added she is not sure how the original contract was written, but believed even in the first round trying to get someone to even do the physician's work component was an issue. When IMC went out for bids and the contract was more open-ended, it might have been a financial limitation and it might have been the wording of the contract, which she is not sure, when the Lewin group stepped forward to do the physician's work sites. She would ask that if it gets into the point where the IMC needs to do a separate contract, that it be a more open ended contract so that bidders are not necessarily restricted by a certain dollar amount. This might encourage more people to bid. She also said that the COA might be able to add to the list of potential bidders, individuals or firms that might be interested in doing the contract and submitting a proposal. They could be helpful in trying to expand the pool of people from whom the IMC solicits bids.

3. IMC/DWC Liaison Work Group Report:

Dr. Michael Roback acknowledged Dr. Wakim for his great effort in putting the incontinence project together. Dr. Roback said hopefully in the next three months they would have a useful product for the DEU. Initially, they asked the DEU to explain where their rating problems

lie. Dr. Roback stated that they are trying to redefine the IMC to focus on problem-solving to meet the communities' needs and not our needs as physicians specifically.

As to the task of liaison with WCAB, they are targeting April as an active DEU/IMC Liason meeting. Hopefully, they will have some communication before that time in terms of issues where they can start to be a problem solver for the community by sharing our medical expertise.

The last issue of concern was the revision of the Physician's Guide. He stated that we have unintentionally misdirected how one describes treatment beyond that which is given. Dr. Roback has distributed corrections for the current Physician's Guide. He said we now have a requirement to distinguish two types of treatment beyond that which is being given: "continuing" and "current. We should encourage the use of one term so that everybody understands the issue. That which is not predictably needed at this time but is probably needed past this time which is "future". Dr. Roback's corrections are the words "continuing or future" treatment as defined. Thus, the injured worker requires "continuing and/or future" rather that further treatment. Dr. Roback apologized and suggested that the Council negate the definitions that he presented in the last meeting. Future treatment basically says not needed at the current time but may be needed in the future. Continuing treatment is more of the former treatment, which is needed at the current time based on the patient's critical status. He added just to say, "discuss future treatment and current treatment" and say, "The doctor should discuss both". This would clarify physicians writing "The patient does not need current treatment, but needs future treatment."

Dr. Roback: Motion: Line 1 which says "providing for future medical treatment", be replaced by "providing for continuing and/or future medical treatment".

It was seconded.

No action taken.

Discussion: Objection by Mr. James Fisher, IMC Legal Counsel. He clarified that it's not an objection but it should be noted for the record that the matter was not noticed in the Agenda.

Dr. Pitts suggested that Dr. Roback submit his corrections or revision to the Physicians Guide in writing upon which the Council will be working this summer.

The last issue that Dr. Roback dealt with is "The patient is discharged if he is not given a return appointment", which caused him some concern about the concept of abandonment. He requested that Dr. Alan MacKenzie bring back to the August agenda those issues regarding the proposed changes in the Physician's Guide for a vote.

4. Urinary Incontinence Work Group

Dr. Wakim reported that they discussed incontinence and that they are trying to write guidelines to determine some clarifications from the point of view of when it is job related or when it is not; issue of causation; issues with subjective, objective factors and its severity, and the work restrictions based on frequency and need of that; how much of it is apportionable. In two weeks time, Dr. Searcy and Dr. Wakim will put up together a list to present at the next meeting.

5. Education Committee Report and Recommendations for Action

Dr. Walsh reported that Regulations sections 11.5, 50, 55, 118, 119 and 104 went out for another 15-day comment period. The following corrections were made: Under Definitions sections (l) – should read Direct medical treatment "means" instead of "is"; (n) DEU "means" instead of "is"; (r) 2nd sentence should be "There are two categories of providers: educational institutions . . . and governmental agencies. The next change is under Application's Instructions: Section 2 – should read Education Program "or Course"; the first sentence should read: If applying for accreditation, complete this section for a proposed "education" program or "writing course".

Dr. Walsh also reported that Mr. Fisher drafted a regulation change under section 17, adding section c regarding the fee rebates for QMEs who will complete the QME survey.

Dr. Walsh: Motion: To approve the above Regulations sections to be submitted to the Office of Administrative Law for implementation.

It was seconded.

Action: Motion passes.

Dr. Walsh: Motion: To approve the amendment to section 17 of the Regulation to implement the fee rebates on an emergency regulation basis.

It was seconded.

Action: Motion passes.

Dr. Walsh: Motion: To approve the renewals of the following providers for continuing education: (1) California Chiropractic Association for– 3 hours for "Beginning Course Writing" and 3 hours for "Intermediate/Advance Course Writing"; (2) California Society of Physical Medicine and Rehabilitation for a 6 hours program, and a new provider: State Bar of California Workers' Compensation Section for approval of two sections out of four sections with one and half hours each section: one is pain management and the other one is spinal diagnostic for a total of three hours.

It was seconded.

Action: Motion passes.

The last issue in the Education Committee was the Physician's Guide. A draft was distributed to all members. Dr. Walsh said that Mr. David Kizer needs to get the changes back by July 25th in time to make the next draft for August meeting. Members volunteered to review different chapters: Chapter 1-Ms. Sinnott; Chapter 2-Dr. Monosson; Chapter 3-Dr. Roback; Chapters 4 and 8-Dr. Mayoral; Chapter 5-Dr. Halote; Chapter 6-Dr. Ocker; Chapter 7-Dr. Tain. Dr. Pitts reminded the Members to review for the contents, grammar, typos and readability. Dr. Walsh said that they would contact Members who are not present to try and participate. They are going to ask Dr. Robert Larsen to review the confidentiality section and give his input regarding this issue.

Dr. Pitts and the Members recognized the efforts and works done by Dr. Gayle Walsh on behalf of the Council. The Council did not object to the plan of moving the December 20 meeting to the 13th of December. Mr. Larry Williams will work on getting the contract change. On the issue of the hotels in Burbank versus hotels in LAX for future IMC meetings, Dr. MacKenzie announced that we could not get a consistent hotel contract in the Burbank are. The IMC staff would prepare the contract to continue the meeting in LA for the foreseeable future.

The Council meeting closed for a closed session. The meeting resumed at 12 20.

d. Discipline Committee Report:

Dr. Pitts reported on the matter of Dr. Vatche Cabayan, M.D., the Council took under consideration that the Stipulation was accepted with a unanimous vote with one abstention from Ms. Sinnott. On the second matter, Edward Noa, D.C., the Council accepted and adopted the recommendation of William O. Hoover, Administrative Law Judge as noted in the minutes book. No further action was taken in closed section.

4. Announcements

Dr. Pitts announced that the next meeting would be on August 16 in Los Angeles.

Meeting adjourned at 12:30 p.m.

Thursday, June 21, 2001

IMC Staff present:

Lety Buenviaje David Kizer, Esq.

Milagros Diadula Allan MacKenzie, M.D., Exec.Med.Dir.

Jerry Evans Anne Searcy, M.D

James Fisher, Esq. Larry Williams

Elizabeth Ignacio

DIR Staff:

Richard Gannon, Adm. Dir., DWC

Gideon Letz, M.D., Med. Dir., SCIF

Members of the public present:

Diane Przepiorski, COA Julie Reynolds, P.T., USC

Donald Motzkil, Urologist, Bonnie Cardenas, P.T., Cardenas & Assoc.

Rea Crane,CWCI Don Bottomley, D.O., Health Sponsors

Linda Coltrin, CA Chiropractic Assoc. Bill Hutchins, eRehab

Doug Hikawa, Priority CompNet Mike Laubach, BSG Assoc.