Department of Industrial Relations

Industrial Medical Council Public Meeting

South San Francisco, Convention Center

Thursday, Sept. 20, 2001

Members present:

Barry Halote, PhD. Michael Roback, M.D

Robert Larsen, M.D., MPH Patricia Sinnott, PT, MPH

Marvin Lipton, M.D. Richard Sommer, M.Phil., J.D.

Maria Mayoral, M.D. Lawrence Tain, D.C.

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

Glenn Ocker, DPM, MS Gayle Walsh, D.C.

Richard Pitts, D.O. Benjamin Yang, C.A. OMD

Members absent:

Ira Monosson, M.D.

Steven Nagelberg, M.D.

1. The meeting was called to order by Co-Chair Dr. Richard Pitts.

Dr. Pitts requested a moment of silence to respect those who died in the horrific events back east and to those who are going in harms way to protect the country.

    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 August 16, 2001 IMC meeting.

Ms. Patsi Sinnott had an editorial change to the minutes: on page two under the DWC Report: "Cost layout" should read "Cost Outliers provisions . . ."

Dr. Gayle Walsh corrected the language on page three, second paragraph: "Dr. Ira Monosson said he thought there are going to be public meetings . . . " should read "Dr. Ira Monosson said he thought the Med-Legal Fee Schedule was going to have public meetings before this came to rulemaking . . ."

Action: The Consent Agenda was approved unanimously.

b. Executive Medical Director's Report:

Dr. D. Allan MacKenzie indicated that his EMD report stands as written. He commented on Council Members' attendance and said this was probably the first time they had more

Council Members than audience. Also, he added that the Council Members felt that there was a need to meet today to show they were doing their job and were serious about it.

At the Executive Committee Meeting, they discussed new budget developments. The Council had completed the first round of budget cuts to meet the reduction in the general fund for the year retroactive to July 2001. They looked at the scenario of a further reduction of 4, 6, and 12% for the year 2002-2003 and submitted a second budget reduction figure for next year. They were advised by DIR that the IMC's share of the Department's reduction cut would be $97,000 and what the IMC did was to utilize the same strategy of giving up monies for positions which had been eliminated but for which we still have the money backing for those positions. The Director and the Governor accepted our submission and in fact our budget reduction maybe less. The IMC was also asked to anticipate projecting what might be the impact if it went to a 10% reduction. We felt that a 10% reduction would impact our mandates by us not being able to fund studies for the AD and DWC.

Dr. MacKenzie said that the IMC needs to consider the possibility of relocating its site. Reasons given were explained on the basis of the structural integrity of the building, the decreasing maintenance that is resulting in health problems and also the impact on hiring. Previously, the Staff presentation to the Executive Committee was one for the renewal of the lease. We've asked the Office of Real Estate Development to do a site search to look for a different venue for the IMC and its staff. This would not directly impact the Council. The IMC meetings would continue to be held in the airport zone hotels in northern and southern California. In a worse case scenario, if a temporary facility is taken, it would be extremely difficult from an organizational point of view that could indirectly impact the Council. We do not expect this to happen. In conclusion, he said, the Council asked for a short term, medium term, and long range plan to protect the health, integrity and function of the IMC. We feel that an important part of the long-term plan was to consider a change of our venue.

Dr. MacKenzie spoke about the QME exam survey. Some of the people at the table and in the audience may have received a hard copy to complete or have been notified and selected to otherwise do the online version of the survey. Also, the Council did elect to rebate those who completed the survey. Dr. MacKenzie heard from the liaison person at CPS that they have reached the five-percent successful completion level. What they are looking for is a 20% return to insure the validity of the exam. There had been some few complaints that the questionnaires were too long; however, generally speaking those were the exceptions and people are doing a good job of completing the form.

The Committee also talked about SB 71 and the possibility of new mandates for the Council. He noted the fact that even if SB 71 is not signed, the Council should look at what was proposed for the IMC as a blue print for our long term planning.

c. DWC Report:

Mr. Richard Gannon, Administrative Director, DWC reported that they had a hearing last Sept. 13, 2001 on the technical changes to the Official Medical Fee Schedule. Because of travel concerns and other limitations some people asked to be given an extended deadline for submitting comments. Transcripts of the comments were being prepared and would be available by the first part of next week. The comment period has been extended until October 1st. There were good comments received and a few of them were somewhat controversial. The DWC anticipates that they would be coming forward with an additional 15-day comment. They did get a request for a specific change in the medical-legal fee schedule for a specific provision for reports regarding death cases. They were not considering this a technical cleanup but a new concept that was not currently in the regulations. These would be put in to the changes that would occur at the same time as the over all changes to the fee schedule will be made.

At the last IMC meeting, Ms. Jackie Schauer handed out proposed draft changes to the Regulations sections 9785 and some other ones which dealt with the reactions to the cases that had defined "future, further, and continuing" medical treatment discharge of the patient. They have not received anymore comments. If they do not receive anymore comments in the very near future, they would go ahead with the regulatory process on these sections and anticipate starting the formal rulemaking with the proposed regulatory changes sometime next month.

Mr. Gannon said they scheduled a presentation by IMC staff at their quarterly judge training for April 2002. The IMC presentation would take the better part of the morning. Mr. Gannon was looking forward to working with the liaison committee to formulate what that presentation would be.

Dr. MacKenzie said that Dr. Ira Monosson sent a clear and eloquent letter requesting that DWC consider making the report of a deceased injured worker a ML104 and asked that a copy of this letter to be circulated. Mr. Gannon acknowledged receiving the letter and said this was what he was referring to as a proposal to change the medical-legal fee schedule - not to be considered a technical change but a new concept and they anticipate there would be some discussion on the issue.

d. Legislative Report:

Dr. Pitts recognized Mr. James Fisher's work on the Legislative update that was concise and gave helpful information on what's going on in the Legislature.

3. Psychiatric Committee Report:

Dr. Robert Larsen reported that the Committee met last night for the first time in several months. This was the first meeting since Dr. Maria Mayoral and Dr. Barry Hallote came to the IMC and they were in attendance. Due to the difficult travel circumstances, public committee members from Southern California, Drs. Frank, Tepperman and Repko were not able to attend. All other committee members Drs. Curry, Munday and Kaldore in addition to the IMC members were present. Non-committee members like Mr. Carl Brakensiek, with his wife, participated in the meeting. The Committee discussed access issues of treatment that would probably come forth before the meeting with the working groups that the Lewin Group was putting together. Suggestion was made in the past about changing the fee schedule for psychotherapy services so that certain practitioners depending on training would get adjusted downwards. Other practitioners would get an increase over the current schedule as a means of being able to get people with admitted injuries, evaluated by skilled clinicians. Also there was a concern put forth by Dr. Mayoral about the conduct of physicians doing the examination. There were concerns about this and its impact on injured workers. They discussed what the IMC's role should be beyond what was currently being done in the ethics section of the Physician's Guide and the Ethics committee availability for reviewing these concept complaints.

Dr. Pitts also recognized Dr. Larsen's work with the Psychiatric Committee specifically his keeping the group together and meeting outside the regular venue.

Dr. Michael Roback said that because of Dr. Larsen and his members' efforts, he became more sensitive to issues of privacy. He asked how far are we going in terms of the new Physician's Guideline and other efforts in dealing with the privacy issues.

Dr. Gayle Walsh said the work being done with the Physician's Guide also deals with the issue of confidentiality and that Dr. Larsen had given them some materials.

Dr. Larsen said he talked to Mr. David Kizer about the Physician's Guide which would have some expanded information that would address the education of physicians concerning some of the case laws that have changed since the first Guide came out, with some examples of privacy and confidentiality issues. He said perhaps we could have another Ad Hoc Committee on the concepts of the subject of privacy and confidentiality and to revise the information currently available on the web site or in the pamphlets. The Guideline gave relevant information and some further guidelines in revisions of what we currently have would probably be in order. Dr. Larsen did not think there was an emergency, but perhaps an Ad Hoc Committee would be the way to proceed.

4. Education Committee Report and Recommendations for Action:

Dr. Walsh reported that the Regulations submitted to the Office of Administrative Law were approved, so all of the continuing education and QME report writing courses were official as of either September 23 or October 6. The next round of regulations to be dealt with would be to revise the whole QME status regulations and the Sanction Guidelines and to take a look at everything in light of the new legislation that could be signed by the Governor.

On continuing education, Dr. Walsh said there were two renewals that they recommended for approval: First, the Insurance Education Association (IEA) presented several programs, two programs were approved (1) Selective Topics in Workers' Compensation and (2) From Medicine to Psychology Approaches to Patients with Multiple Problems. The second course was from B Cassidy Seminars: Psychopharmacology 2001, which dealt with psychological traumas.

Dr. Walsh: Motion: To approve the renewals of the above two providers for continuing education.

It was seconded.

Action: Motion passes.

Dr. Walsh also reported that there was another provider Innercalm that they were still considering and that additional materials were just submitted. The Committee felt that were some limited hours that were inappropriate. The Committee would go back to them at the next month's meeting to see if they want to expand their program to meet the criteria where the level of their continuing education needs to be.

In order to get the information out to the providers, Mr. Fisher suggested that we put something in the newsletter regarding new course programs and criteria.

Dr. Walsh stated that they would continue working on: auditing; what the policies would be; and how to bring something to the Council that would deal with auditing of these programs.

5. Fee Schedule Committee Report:

Mr. Richard Sommer reported on the fee schedule. First, he asked Dr. Susan McKenzie to give an update on the Lewin studies.

Dr. McKenzie stated that the Lewin Group would probably present the RBRVS result at the October meeting.

The second study that is underway is the Physicians Work Study and the Lewin Group has put together a panel consisting of treating physicians. The Panel's goal is to give technical advice to the Lewin Group on the Physician Work involved in treating a patient. The Practice Expense Study was approved by the Department of General Services as a contract with the Lewin Group on the sole source basis for that study.

Mr. Sommer said that they had been working with DWC trying to make sure they were working as a team to try and get a good process and good results. In the Sub-committee meeting, there were some concerns raised by several public members that they had nominated people to the second study to work in the E/M study that have not received confirmation if they were accepted. This would be straightened out with the Lewin Group who would get back to these associations. There was a question raised about the process where the preparatory materials were and when these materials would be available to the public. Mr. Sommer said there were none but if there would ever be, it would be made available to the public. They were going to talk to the Lewin Group to make sure the process would go well and straightforward because money and time were being spent for the results to be good and the process dependable. Mr. Brakensiek brought up another issue with the makeup of the Panel for the Physicians Work Study. One of the problems was that the criteria for selection were contradictory. There are a lot of physicians who are not treating anymore but know a lot about payment issues. There was a tough balance to make this group as representative of all groups.

Dr. McKenzie and Mr. Sommers invited everybody to attend a public meeting in the later part of October.

6. Liaison/Urinary Incontinence Work Group Report:

Dr. Paul Wakim reported that they were close to producing something with which they could start working. They presume that they have the product that can be presented to the public and DEU in the next few months. The consensus of the Committee was to work towards educational advisory guidelines. The intent would be to educate the DEU as well as physicians and all concerned regarding the matter of urinary incontinence without making them mandatory. The Committee would have another meeting before the next IMC meeting to review the guidelines.

Dr. Michael Roback stated that he would like to clearly clarify several things. The Committee was in an advisory position, it was not their tasks, neither their interest, nor their participation in what is done by the DEU with the medical information. If the DEU has questions that require medical background and information that would affect the functions of a person at work, the Committee would give these to them. He said they do not want to contaminate the objectivity of the DEU's functions. If they bring issues, they would try their best, in a definitely well established secondary role, to give them some medical information to help them. The DEU may eventually use these for guidelines for urinary incontinence. They would not write guidelines on urinary incontinence because they don't do disability evaluation determination. Mr. Roback would like to make it understood that they are serving DEU's need and not trying to bring forth independent ideas or anything other than to help them if DEU would request them.

Dr. Larsen suggested than when the task of giving information from the physician's perspective that would help DEU to come up with a disability rating, this Committee should continue with a larger scope, to look at genito-urinary dysfunction from the perspective of treatment. He thought that sexual dysfunction occasionally comes up as a complaint. It was unusual for it to be a ratable disability. It would be helpful to have some guidelines for physicians in this area.

Ms. Patsi Sinnott reassured Dr. Larsen that the Committee has technical experts in assessing, diagnosing problems but also in treating. There are physical therapists who are very involved in both the incontinence and sexual dysfunction component of this disorders who are on the Committee and the Committee provided a good resource to move to the next activity if it is appropriate.

Dr. Ng reminded the Council that a few years ago a good chunk of money was spent to have a document about causation written. This was a well-written document about the general principles of causation and still worth looking at.

Dr. MacKenzie said that he met with Mr. Blair McGowan at their annual meeting and that he saw a new enthusiasm Mr. McGowan had for the Council because he sees how it can help him solve his problems. He talked about the meeting and insisted that Dr. MacKenzie look at the minutes. Dr. MacKenzie felt that the Liaison Committee had made progress in the DEU obtaining medical information that it required and saw a tremendous role for the Council. He did not see or anticipate any problem with the relationship between the DEU and IMC. He and Dr. Roback predicated every public presentation by talking about the altruism about the system. The IMC is not contaminating the DEU and the DEU is not contaminating the IMC. They are both dedicated to explaining the process before any public presentation.

7. Discipline Committee Report:

Dr. Jonathan Ng reported that the Committee would not have a closed session because the case that would be presented to the Council had a last minute negotiation and would be tabled again for next month's meeting.

Dr. Roback requested Dr. MacKenzie to share his presentation to the Defense Attorneys Association's meeting.

Dr. MacKenzie reported that he did a presentation at the annual meeting of the California Defense Attorneys Association. Dr. Roback was also in attendance. In Dr. MacKenzie's tenure with the IMC, this was the only major group that he had not managed to speak to their Board of Directors or their annual meeting. He did an informational presentation and Dr. Roback handled the Q & A period. Dr. Roback did not take a defensive stand instead he went on an offense.

Dr. MacKenzie believes that we have established a new relationship with the defense attorneys and they resolved to take part in the IMC deliberations.

Dr. Roback stated that he attended the meeting because he wanted the defense attorneys to understand that this is a level playing field and that the IMC is proud of the fact that we had been a uniform group not politically motivated, but motivated because we are physicians and health care providers of different nature. We feel privileged and grateful to participate in the workers' comp. system, dedicated to both personal and civic responsibilities and are willing to listen. He encouraged more groups to understand the formal nature of the IMC and how they do things, to participate in order for them to be heard.

8. Announcements

Dr. Pitts announced that the next meeting would be on October 18, 2001 in Holiday Inn, LAX. The date of the December meeting was moved from December 20, 2001 to December 13, 2001 in LAX.

Dr. MacKenzie said that Dr. Anne Searcy succeeded in posting the Sanction Guidelines on the web site. He added that if there are other items that the Council and public wanted to post on the web site, to call Dr. Searcy or any IMC Staff Members.

Meeting adjourned at 12:00 p.m.

Thursday, September 20, 2001

IMC Staff present:

Lety Buenviaje

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

Milagros Diadula Susan McKenzie, M.D.

James Fisher, Esq. Anne Searcy, M.D

David Kizer, Esq Larry Williams

DIR-DWC Staff present:

Richard Gannon, Adm. Director, DWC

Members of the public present:

Philipp M. Lippe, M.D., CANS Arthur Azevedo, Green & Azevedo

David Willat, DC, CA Chiro. Assoc. Diane Przepiorski, CA Ortho. Assoc.

Linda Coltrin, CA Chiropractic Assoc Daniel Donner, CA CSOMA

Peggy Sugarman, CAAA Carl Brakensiek, CSIMS

Sherry Clark, SMA Doug Hikawa, Priority CompNet

Brenda Ramirez, State Comp. Ins. Fund