Department of Industrial Relations

Industrial Medical Council Public Meeting

Holiday Inn – LAX, Los Angeles

Thursday, August 16, 2001

Members present:

Barry Halote, PhD. Richard Pitts, D.O.

Robert Larsen, M.D. Michael Roback, M.D

Marvin Lipton, M.D. Patricia Sinnott, PT, MPH

Maria Mayoral, M.D. Richard Sommer, M.Phil., J.D.

Steven Nagelberg, M.D. Lawrence Tain, D.C.

Jonathan Ng, M.D., J.D. Paul E. Wakim, D.O.

Ira Monosson, M.D. Gayle Walsh, D.C.

Glenn Ocker, DPM, MS Benjamin Yang, C.A. OMD

    1. The meeting was called to order by Co-Chair Dr. Richard Pitts at 10:30 AM.

    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 June 21, 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 reported that work on the Physician' Guide 3rd edition is in progress and that the project needs to move forward because its revisions were time sensitive. He said that this would be discussed further in the Education Committee report.

Dr. MacKenzie also discussed the IMC's unfinished treatment guideline project of 1997. He noted that the IMC developed guidelines down to the level of the knee but that we do not have treatment guidelines for common industrial injuries of the foot and ankle. Before completing this task, the IMC elected to wait until the Legislature gave us a podiatrist - Dr. Glenn Ocker. Dr. Ocker has taken the responsibility of doing the ground research to see what treatment guidelines for the foot and ankle exist out there. A work group would then consider the best of the best and could create a working template and then convene a group of subject matter experts who would help us with the final guidelines. The exact process has not been fully determined however, it was

important to go on the record today that this was something that needed to be done. He urged the Council to help us move forward in this area. Once the treatment guideline is done, we should then look at the disability evaluation guideline for the same body parts – foot and ankle.

c. DWC Report:

Ms. Jackie Schauer, Legal Counsel, DWC, represented the Administrative Director, Mr. Richard Gannon, A.D. She gave a brief update on where DWC is with the various fee schedules. With regards to the in-patient hospital fee schedule, they are waiting for Dr. Gardner's final report to CSWH before they can evaluate the next step. DWC is aware of the provision for the supplemental payments for implantable hardware. Cost layout provisions are due to sunset under the regulations at the end of this year and they are monitoring this to make sure that this doesn't happen. They wanted to have no lapse in these regulations pending more global revisions after Dr. Gardner's report. There is a provision under AB 1177 that by statute extends the sunset date, which they are watching. They are prepared to go forward with a regulation to accomplish this, if this doesn't pass or is vetoed.

Regarding the official medical fee schedule, they have a rulemaking period for a technical clean up and clarifications of the regulations [revisions] pending the more global RBRVS change over. The public hearing is on Sept. 13th and written comment period will also close at that time. They encourage comments. The rulemaking materials are available on DWC web site and comments are also accepted by e-mail.

Regarding the RBRVS, they are looking forward to the Lewin study and to see what the Council decides to do with proposed practice expense study. The outcome will determine the timetable for moving to RBRVS. In the meantime, they are looking at what will happen with the ground rules. Mr. Gannon did have a general approach which was sent to the community with a letter last March 2001, to stay as much as possible with the CPT language and CPT codes and to utilize CPT guidelines and to try as much as possible not to have California specific provisions in the fee schedule unless its necessary. They appreciated working with the Dr. Susan McKenzie. They are planning to have public meetings, advisory committee meetings on the ground rules issues for each and every section. The physical medicine section, which was not updated in the last update, may be more extensive and may need more work.

DWC grappled with the timing of this meeting. They have decided to wait until after the preliminary figures from Lewin are in. They are open to suggestions about how to structure the meeting on the ground rules and also how to deal with the HPA payment policies to evaluate which of those they want to integrate in to the system. Some are not related and some are integrally tied into their structure and may be brought in to our system.

Dr. Ira Monosson said he thought there are going to be public meetings before this came to rulemaking, because some of the proposals done years ago were just ignored.

Ms. Schauer said she neglected to mention that the medical- legal fee schedule is part of the rulemaking that they are doing now. She said that this is the time to put comments in on any changes they have not proposed and that the public feels necessary and they could see if it is sufficiently related to rulemaking, so they can include it in the rulemaking and they can have another comment period. If this is not related or too unrelated, they might have to go to the whole rulemaking process to reconsider these issues.

The last issue Ms Schauer brought up was the discerned need to have some modifications to Title 8 California Code of Regulations section 9785 Primary Treating Physician's reporting requirements as well as section 9786, the change of physician's requirements. They had prepared a draft for comments and will appreciate comments from the Council and will also mail copies to interested parties. It tries to grapple with the problem that came up in the Tenet case and deals with recognizing free choice of physicians under 4600 but also recognizing that 4061 and 4062 put some restrictions on how an injured employee can dispute the treating physician's medical determination. DWC are very open to any and all suggestions to make the regulations better and usable.

3. Urinary Incontinence Work Group/DWC Liaison Work Group Report

Dr. Michael Roback reported on two major activities. They are moving ahead with the guidelines for urinary incontinence. He acknowledged Dr. Wakim for doing an excellent job with the guidelines. Dr. Wakim stated that the guidelines were in progress right now and they had 2nd and 3rd meetings already under the guidance of Dr. Roback. There may be another meeting or two to develop a workable guideline. The next step would be to have a public hearing. Dr. Wakim stated they are awaiting for Mr. Fisher's as well as the AD's determination on what to do and how to proceed with it, in order to make it a working guideline that both the QME as well as the raters can use as a definitive document to determine proper work restrictions for those with urinary incontinence injury.

Dr. Roback also reported that two members of the Disability Evaluation Unit (DEU) attended the IMC Sub-committee meeting, Mr. Blair McGowan, Manager and Mr. Dennis Ehrhardt, Supervisor. The IMC is developing an interaction with them and it is apparent that DEU is in need of an input of medical information that allows them to understand some disability concepts. Dr. Roback was emphasizing two points for the community at large: first it is going to be done in a manner that sets up a policy on how to address this issues, to get some subjects from DEU, develop them in a community manner or scientific and consensus information and try to get

back to them in a manner that they can use. Secondly at various times, there was concern and discussion about the DEU giving us information on how they do things. The way this Committee works is that we are not asking them what they are doing nor how they are handling it. We just give them the medical information and they will decide how they are going to use it to determine disability manner. It is not the IMC's job to give them any concept of levels of disability but it will give them some medical basis. One of the purposes of this Committee is to have a useful interaction with DEU to improve the system for all.

4. Education Committee Report and Recommendations for Action

Dr. Walsh discussed the first topic – the Physician's Guide. The Staff updated and revised the document and gave it to the Council Members at the June meeting. Many of Members, the Staff and the Public gave their feedback. Those changes were incorporated into the present draft. We tried to keep the same format as the original document and just updated, clarified and made grammatical changes, adding some more case laws and boxes that explained difficult topics a little better. Dr. Walsh thanked the people who put this document together, specifically Mr. David Kizer, Dr. Ann Searcy, Lety, the Council and members of the public who have given their input. Right now the IMC is quite pleased to go forward with this document. The intent is to take the next month and see if there are any specific changes, do little technical modification of the document like ensuring page numbers are right, and in case there are any changes legislatively that happen between now and the end of the session which is mid September, to have in place a means of incorporating changes should, the Governor sign it in the middle of October. We should have a final document by mid October or even earlier if nothing passes or vetoed by the governor. Our idea now is to put this into three ring binder print format. Current QMEs will get a copy. We talked about having 'on line' access to the document and trying to encourage people to utilize that instead of having a print format and in the future using that to make periodic changes as things happen, legislation occurs or new case law comes available. She recommended that the Council approve the draft document.

Dr. Walsh: Motion: To approve the Physician's Guide draft, barring any unforeseen changes which may happen legislatively, go with this document as is, with some modification for formatting and if some legislation happens, we need to accommodate and incorporate said changes in the document

It was seconded.

Action: Motion passes.

Dr. Walsh: Motion: To approve the renewals of the following providers for continuing education: (1) California Workers Compensation Enquirer, a distant learning program that puts out a

newsletter where QMEs read the article, take the test and are given QME credit for one half hour credit per article; (2) California Society of Industrial Medicine & Surgery, a program that puts out nine and one quarter hour credits; (3) State Compensation Insurance Fund: two programs, one is a physician's manual, which the QME reads and does a test - a distant learning program for six hours, the second involves two live programs for one and one half hours each; (4) UC Berkeley Center for Occupational & Environmental Health; (5) Academy for Chiropractic Education for a six hour program; (6) American Institute of Acupuncture Orthopedics and Traumatology, just for the continuing education part only.

It was seconded.

Action: Motion passes.

Dr. Walsh: Motion: To deny renewals of the following providers: Innercalm Associates, which mainly dealt with treating physicians and a very basic program not at the level of QME's continuing education, and Resolutions Associates, a basic preparatory program for the QME test.

It was seconded.

Action: Motion passes.

Dr. Walsh: Motion: To approve a new provider: California Coalition on Workers' Compensation for five and one quarter credit hours for QME credit.

It was seconded.

Action: Motion passes.

Dr. Walsh: Motion: To approve a new 12-hour report writing provider: Lerner Education, who has done an extensive 44-hour program in the past, and the renewal of Southern California University of Health Sciences formerly known as LACC, an IDE program for chiropractic doctors who have to take 44 hours in order to meet the qualifications to become a QME.

It was seconded.

Action: Motion passes.

Dr. Walsh continued her report regarding the area of auditing the Continuing Education programs. The Committee discussed that we have regulations on how to audit these programs; we need to implement a policy in auditing these programs. Several questions came up as to who should audit, who gets reimbursed for auditing; what kind of procedures to go through; what kind of questionnaires they need to fill out in order to quantify the program and try to keep it consistent with different programs and auditors. In the next couple of months, they are going to plan a policy and they would appreciate input that anyone might have as to what they should be doing and or problems that they might know from past experiences in working with the licensing boards. They would use IMC staff, Council Members and commissioners in this function and would begin to audit some of the providers in the 12-

hour courses. Lastly, the Regulations are now with the Office of Administrative Law and we hope to hear from them soon. Mr. Fisher is keeping in touch with them to make sure there are no problems. One thing that the Committee did not talk about was what's happening with the CPS surveys that are going out to the QMEs.

Dr. MacKenzie responded that the survey is moving on. Initially CPS had proposed that they would get this done quickly. They were thinking of the fall exam but this turned out to be unrealistic. They have to make some very significant changes to the exact wording and the check off boxes on the survey. They have done this with the input of the IMC Staff particularly Dr. Searcy and Mr. Kizer. The plan is to move forward and certainly to have this material ready for the March 2002 exam.

Dr. Pitts again recognized the works done by Mr. Kizer, Dr. Searcy, Lety and Council Members who contributed to the Physician's Guide revision. He said that once the final product is out, that this will be something of which we can be very proud.

5. Fee Schedule Committee Report:

Mr. Richard Sommer reported that they have one item for discussion on the fee schedule committee. He recommended the Council vote for a single source contract to look at office-expenses for physicians as an add-on to the study that they are doing. He mentioned that Ms. Przepiorski spoke two months ago about this issue. He thought this would make sense. He said that Dr. Susan McKenzie, who is not present today, is the only one who would know if this can be approved and that the two can be done together. He would not say if we know for sure that the two can be done together.

Mr. Sommer: Motion: To vote for a single source contract to look at office-expenses for physicians.

Discussion: Dr. MacKenzie stated that Dr. Susan McKenzie did submit language to DGS. It is more appropriate for the Council to approve the sole source type contracting. Dr. McKenzie thought that it was moving forward in the way that we would hope. She also hoped that we would have information by today's Council meeting time however it did not happen.

It was seconded.

Action: Motion passes.

. Dr. Pitts recognized the good work the Council is doing in Committees. He said that it is reflected by the way things happen in the meeting - they run smoother and it's just a different environment. The Committees' work is very critical so he appreciated them and the good work they did in reviewing the Physician's Guide. It is very critical to IMC's success.

Dr. MacKenzie reminded the Council to think about how to complete the treatment guidelines for the foot and ankle. He asked the Co-chairs if this could be put in the agenda for the next meeting and what would be the process in getting this done.

Dr. Nagelberg responded that this could be started in the Executive Committee and then they can decide which way to go because it entails a lot of work to be done.

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

6. Discipline Committee Report:

Dr. Pitts reported that there were two cases, which were previously noticed: on Dr. Allen Salick, M.D., the Council voted to accept the Stipulation. The second case was on Dr. Hermoz Ayvasian, D.P.M., the Council voted to accept the Stipulation and noted that it was our understanding there were no scheduled QME evaluations at this time and the Council instructed Legal Counsel to notify the Respondent that we know he does not have any scheduled exam as of August 16, 2001.

Dr. Pitts said that Ms. Patsi Sinnott's request that the consideration for whether or not a QME who is suspended can complete scheduled QME during the time suspension would be discussed at the next open meeting.

Dr. Pitts agreed with Dr. Roback' s suggestion to have the guidelines on the web.

7. Announcements

Dr. Pitts announced that the next meeting would be on September 20, 2001 in South San Francisco. He also commented that this is a record meeting and thanked everybody for coming.

Meeting adjourned at 12:30 p.m.

Thursday, August 16, 2001

IMC Staff present:

Lety Buenviaje

David Kizer, Esq.

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

Gerry Evans Anne Searcy, M.D

James Fisher, Esq. Larry Williams

DIR Staff:

Jacqueline Schauer, Legal Counsel

Members of the public present:

Diane Przepiorski, COA Jim Sams, Providence Publications

Donald Motzkil, M.D, Phillip M. Lippe. M.D. CANS/AAPM

Rea Crane,CWCI Barbara Stanfield, DC, CA Chiropractic

Linda Coltrin, CA Chiropractic Assoc. Bill Hutchins, eRehab

Doug Hikawa, Priority CompNet Kimberly Wiswell, Kaiser Permanente

Carl Brakensiek, CSIMS Manuel Torres, Pacific Hospital

Jennifer Orosz , HNC Software Jim Snow, APM

Jan Nguyen, CCN Joe Solancho, Care Solutions

Mario Rodriguez, Vision Quest Julie Reynolds, VSC, PT

Vern Goldschmid, CAAA