California Medical Association Research Articles

Have Arguments For and Against Medical Aid in Dying Stood the Test of Time?

Have Arguments For and Against Medical Aid in Dying Stood the Test of Time?

Bill Would Include Psychiatrists in Loan Repayment Program in Calif.

Bill Would Include Psychiatrists in Loan Repayment Program in Calif.

In Debating the Right to Die, a Shift in Tone Among Physicians.

In Debating the Right to Die, a Shift in Tone Among Physicians.

Medicare at 50: Hassles Lead to Doctor Opt-Outs

Medicare at 50: Hassles Lead to Doctor Opt-Outs

A step forward: review of the new california provider status law.

On October 1, 2013, California Governor Jerry Brown signed a bill into law that provides provider status to pharmacists.1 This landmark legislation significantly expands the role of pharmacists as health care providers in California. Technically, this law went into effect on January 1, 2014; however, some pieces of the legislation require the California State Board of Pharmacy to adopt new regulations before full implementation.2,3 It is hoped that most of these provisions will be fully approved by the end of 2014.2 The California Provider Status Law states that “pharmacists are healthcare providers who have the authority to provide healthcare services.”1,4 This statement alone could have a major impact on practice and payment models for pharmacists. Beyond this aspect, the bill authorizes all licensed pharmacists to participate in a number of activities including the following2,3: Administration of medications and biologics to patients when ordered by a prescriber. Prior to this legislation, pharmacists were allowed to administer medications via topical and oral routes only. This bill expands approved administration routes to include by injection, among others. Provision of consultation, training, and education about drug therapy, disease management, and disease prevention. Participation in a multidisciplinary review of a patient’s health progress including pharmacist’s access to health information/medical records. Dispensing of self-administered hormonal contraceptives pursuant to an approved statewide protocol. Dispensing of travel medications not requiring a diagnosis, per Centers for Disease Control and Prevention (CDC) recommendations. Dispensing of prescription nicotine replacement products pursuant to an approved statewide protocol. Specific training, certification, recordkeeping, and notification requirements must be met. Independent immunization of patients 3 years of age and older with maintenance of specific training, certification, recordkeeping, and reporting requirements as well. For patients younger than 3 years of age, a physician protocol is still required. Ordering and interpretation of appropriate tests for drug therapy monitoring in conjunction with a primary care provider or prescribing health care provider. The legislation also establishes an Advanced Practice Pharmacist (APP).2,4 Under the law, APPs are authorized to complete patient assessments; order and interpret tests for the appropriate monitoring of medication therapy (in conjunction with the prescriber); refer patients to other health care providers; initiate, modify, and discontinue medications (pursuant to a prescriber’s order and in coordination with an established protocol); and participate in a multidisciplinary approach to the evaluation and management of diseases and health conditions. Pharmacists who wish to receive APP status must complete 2 of the following 3 criteria: a postgraduate residency program, certification in a relevant area of pharmacy practice (ie, pharmacotherapy, ambulatory care, oncology, etc), or provision of clinical services for at least 1 year under a collaborative practice agreement or protocol with a physician, APP pharmacist, collaborative drug therapy management pharmacist, or health system.3 Although a few other states, namely Montana and Washington, already recognize pharmacists as health care providers, the passage of this bill is notable due to the size of California and the number of patients, pharmacists, and other health care providers who are directly affected.5 In California, millions of previously uninsured individuals now have health insurance under the Affordable Care Act. This, along with an aging population and a significant shortage of primary care providers, helped to push this bill through the California legislature.4 Initially, the California Medical Association opposed the legislation due to patient safety concerns; however, once the Association was informed that many pharmacists already perform the clinical activities within the bill, outright opposition diminished.5 Passage of provider status in California goes hand-in-hand with a push for federal legislation currently being undertaken by various national pharmacy organizations including the American College of Clinical Pharmacy (ACCP), American Society of Health-System Pharmacists (ASHP), and the American Pharmacists Association (APhA). These organizations realize the importance of recognizing pharmacists as health care providers for patients and the health care system. The California Provider Status Law is another step forward in the battle for this recognition.

CVS to phase out tobacco sales, launch smoking cessation program

Calling the decision "simply the right thing to do for the good of our customers and our company," CVS Caremark will stop selling all tobacco products at its more than 7,600 CVS/pharmacy locations by October 1. The February 5 announcement came a week after the U.S. Surgeon General issued renewed warnings about tobacco use on the 50th anniversary of the Surgeon General's landmark report linking smoking and poor health.

California provider status bill heads to governor

California provider status bill heads to governor

Pharmacy groups speak at House caucus briefing

Provider status for pharmacists, legislation on medication therapy management (MTM), and a care transitions initiative were among the topics of a briefi ng hosted by the Congressional Community Pharmacy Caucus on June 6 in Room 122 of the Cannon House Offi ce Building in Washington, DC. Pharmacists’ patient care services are “a very smart spend in Washington that pays off in a big way,” Jonathan G. Marquess, PharmD, CDE, CPT, a member of the APhA Board of Trustees, said at the briefi ng as part of his example of an elevator speech for provider status. “Patients need to have access to pharmacists’ services both on the federal and the state levels but also within

Medical Malpractice and the Chest Physician

The US malpractice system is based on tort law, which holds physicians responsible for not harming patients intentionally or through negligence. Malpractice claims are brought against physicians from most medical disciplines in proportion to their numbers in practice and to the frequency with which they perform procedures. Claims against chest physicians most commonly allege injuries caused by the following: (1) errors in diagnosis, (2) improper performance of procedures, (3) failure to supervise or monitor care, (4) medication errors, and (5) failure to recognize the complications of treatment. Most of these injuries occur in hospitals, and many of the injured patients die. The social goals of the medical malpractice system include the following: (1) compensating patients injured through negligence, (2) exacting corrective justice, and (3) deterring unsafe practices by creating an economic incentive to take greater precautions. Some patients injured through negligence are compensated, but most are not. Claims are brought against some negligent physicians but also some who are not negligent, and being negligent does not guarantee that a claim will be brought. The deterrent effect of medical malpractice is unproven, and the malpractice system may prompt defensive medicine and increase health-care costs. And by stressing individual accountability, it conflicts with a systems-oriented approach to reducing medical errors.

Influence of genetic discrimination perceptions and knowledge on cancer genetics referral practice among clinicians

PurposeTo describe nongenetics clinicians' perceptions and knowledge of cancer genetics and laws prohibiting genetic discrimination, attitudes toward the use of cancer genetic testing, and referral practices. MethodsInvitations to participate were sent to a random stratified sample of California Medical Association members and to all members of California Association of Nurse Practitioners and California Latino Medical Association. Responders in active practice were eligible and completed a 47-item survey. ResultsThere were 1181 qualified participants (62% physicians). Although 96% viewed genetic testing as beneficial for their patients, 75% believed fear of genetic discrimination would cause patients to decline testing. More than 60% were not aware of federal or California laws prohibiting health insurance discrimination—concern about genetic discrimination was selected as a reason for nonreferral by 11%. A positive attitude toward genetic testing was the strongest predictor of referral (odds ratio: 3.55 [95% confidence interval: 2.24-5.63], P < 0.001) in stepwise logistic regression analyses. The higher the belief in genetic discrimination, the less likely a participant was to refer (odds ratio: 0.72 [95% confidence interval: 0.518-0.991], P < 0.05), whereas more knowledge of genetic discrimination law was associated with comfort recommending (odds ratio: 1.18 [95% confidence interval: 1.11-1.25], P < 0.001) and actual referral (odds ratio: 3.55 [95% confidence interval: 2.24-5.63], P < 0.001). ConclusionConcerns about genetic discrimination and knowledge deficits may be barriers to cancer genetics referrals. Clinician education may help promote access to cancer screening and prevention.

Psychiatrist Among Powerful Voices in Health Care

Back to table of contents Previous article Next article Members in the NewsFull AccessPsychiatrist Among Powerful Voices in Health CareRich DalyRich DalySearch for more papers by this authorPublished Online:19 Oct 2007https://doi.org/10.1176/pn.42.20.0014Deborah Peel, M.D.: “Even the threat of [patient record] exposure has a really negative impact on our ability to treat mental illness.”What does Texas psychiatrist Deborah Peel, M.D., have in common with Gov. Arnold Schwarzenegger and Sen. Hillary Clinton? For one thing, all three were voted among the most influential voices in the nation's health care system.The readers of Modern Healthcare magazine voted the practicing psychiatrist of 30 years and founder of the foundation Patient Privacy Rights fourth among the 100 “Most Powerful People in Health Care” in August. The sixth annual list was based on 12,600 reader-submitted nominations and final balloting for the 300 most-nominated people. Nearly 265,000 votes were cast.Peel was listed behind Sister Carol Keehan, president of the Catholic Health Association; former Massachusetts Gov. Mitt Romney; and California Gov. Arnold Schwarzenegger. The magazine's readers said they thought she was more powerful than health heavyweights such as Sen. Edward Kennedy, House Speaker Nancy Pelosi, and Bill Gates.Peel became known through her work with the nonprofit foundation she launched in 2003 in Austin, Texas, after realizing the implications of the privacy rule issued as part of the Health Insurance Portability and Accountability Act (HIPAA).The rule “legally authorized more than 4 million entities to use and disclose our personal health information without our consent and over our objections,” she said in an interview with Psychiatric News.Those users of health record information can include financial institutions or employers, who could use what they read in the records to reject loan applicants or job seekers, for example.“Information technology companies' business models are based on selling the patient data entered with their software, because [those data are] so valuable,” Peel said.In a world where more patient health records were becoming easily transferrable to many patients, Peel saw dire consequences for parties. And as a psychiatrist, the immediate and significant harm to her patients from even the fear of disclosure was obvious.“Even the threat of exposure has a really negative impact on our ability to treat mental illness,” Peel said.Her efforts to ensure the privacy of patient records has included educating the media about the daily sale of millions of individual health records, testifying before Congress on the need for federal protections, and working with health information technology businesses to change their practices.“This is a tremendous honor for one of our colleagues,” said Carolyn Robinowitz, M.D., APA president. “Dr. Peel's tireless work as a patient advocate is something to be admired.”Part of that work included her leadership in forming the bipartisan Coalition for Patient Privacy in 2006, which includes more than 40 organizations from across the political spectrum, including the Family Research Council, California Medical Association, and American Civil Liberties Union. The coalition was organized to present a united front to lawmakers to convince them of the need for individuals to control all access to their health records and the consequences of having those records easily accessible to third parties.The coalition has urged Congress to pass legislation that would ensure that the right to health privacy is guaranteed and protected in federal statute beyond the HIPAA law, which allows businesses to sell such data. Peel has also spoken out against legislation, such as the Wired for Health Care Quality Act (S 1814), because she and other privacy advocates maintain that it would undermine patient control of the health records it purports to protect because, in part, it would not recognize a patient's right to health information privacy in routine situations.She has urged health information technology companies to support the use of technology such as consent management systems and health record banking or trusts that allows consumers to have control of their personal health information.Peel also has held a range of leadership positions within APA, including membership in the APA Assembly Allied Organization Liaison Committee and the APA Assembly Committee on Planning. She was president of the Texas Society of Psychiatric Physicians, the state's APA district branch, from 2000 to 2001.More information on the Patient Privacy Rights foundation is posted at<www.patientprivacyrights.org/site/PageServer>.▪ ISSUES NewArchived

Calif. Physicians See Perils in Insurance Reform Plan

Calif. Physicians See Perils in Insurance Reform Plan

Physicians’ Perceived Knowledge of and Responsibility for Managing Patients’ Out-of-Pocket Costs for Prescription Drugs

Most insurers in the US have implemented incentive-based formularies that rely on out-of-pocket costs to influence prescription drug utilization. Medicare Part D plans have broadly adopted such benefit designs. To evaluate physicians' perceptions of their knowledge of formularies and out-of-pocket costs, factors that influence knowledge of costs, physicians' perceived responsibility for helping patients manage their out-of-pocket costs for prescription drugs, and physicians' perceptions of the role of pharmacists in managing these costs. A multiple-choice survey was mailed to a random sample of 1200 physician members of the California Medical Association; a phone survey of nonresponders was then conducted. Of 1027 surveys delivered to correct addresses, 509 (49.6%) responses were received. Thirty-three percent of physicians reported that they were usually or always aware of patients' formularies and 20% were usually or always aware of patients' out-of-pocket costs for medications. Surgeons, emergency department physicians, and physicians that prescribe from more formularies than other physicians are less likely to be aware of patients' out-of-pocket costs, while physicians in large practices and those who use computers to prescribe are more aware. While 91% of physicians agreed that it is important that patients' out-of-pocket costs be managed, 40% somewhat or strongly agreed that it is their responsibility to help. Sixty-five percent of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs. Physicians often lack the knowledge to assist patients in the management of their out-of-pocket costs for prescription drugs and they depend on pharmacists to help patients manage those costs. Computer order entry and resources available in large physician organizations improve physicians' awareness of out-of-pocket costs when prescribing.

May Doctors Refuse Infertility Treatments to Gay Patients?

One of the most sacrosanct principles of medical practice in the United States is that physicians have a right to choose their own patients as long as the patient is not in a medical emergency. During the 1980s, a minority of health care professionals invoked this prerogative in refusing to treat AIDS patients. (1) More recently, doctors incensed over malpractice premiums have refused to care for lawyers and their family members. (2) However, this sort of physician autonomy is not without certain limits--most notably the restrictions found in various federal and state civil rights statutes. No physician or hospital receiving government funding, including Medicare and Medicaid, may discriminate against potential patients on the basis of race, color, religion, or national origin, (3) and many states have expanded these protections to cover gender and sexual orientation. What remains unclear is whether physicians with bona fide religious objections to treating certain patients are exempt from these proscriptions. A California case, currently on appeal before a state court, may soon decide the matter. (4) The plaintiff in the case, Guadalupe T. Benitez, is a thirty-three-year-old medical assistant currently living with a same-sex partner in suburban San Diego. (5) She received infertility treatments at the North Coast Women's Care Medical Group starting in August 1999 and running until July 2000, when her physicians, Christine Brody and Douglas Fenton, refused to continue treating her because of her sexual orientation. According to Benitez, Dr. Brody told her that she had religious-based objections to treating homosexuals to help them conceive children by artificial insemination, while Dr. Fenton refused to authorize a refill of her prescription for the fertility drug Clomid on the same grounds. (6) In response, Benitez filed suit under California's Unruh Civil Rights Act, charging illegal discrimination on the basis of sexual orientation. (7) The case gained widespread attention when the California Medical Association, historically friendly to gay rights, backed the two Christian physicians in their claim that their freedom of religion under the federal and state constitutions trumped the requirements of the state statute. (8) It is the CMA's position that such claims should be addressed on a case-by-case basis, rather than by a blanket rule. The controversy in Benitez v. NCWC stands at the nexus of two competing approaches to the issue of conscience exemptions. On the one hand, most states have statutes that shield medical students and physicians from having to perform procedures, such as abortion and sterilization, to which they object on religious or moral grounds. Several public policy reasons are advanced for these conscience clauses: First, highly qualified physicians, forced to compromise their sincerely held religious beliefs, might leave the field of medicine entirely, and similarly, some prospective physicians might choose to pursue other career paths instead. Second, physicians who object to a particular procedure are not in a position to provide the level of emotional and moral support that their patients have a right to expect. In contrast, our society seems highly unwilling to tolerate physicians who refuse or limit service to an entire class of patients, even when they act out of sincere religious beliefs. It is highly unlikely that any court would permit an Orthodox Jewish physician to provide separate waiting rooms for men and women, or allow a Muslim physician to require all female patients to wear head coverings. (9) The Benitez case, however, presents an instance where both an objection to a specific procedure and to a general class of patients overlap. The physicians at NCWC are unwilling to perform a specific procedure on a general class of patients. Two further concerns in many conscience cases are the impact of an exemption on the overall availability of the procedure and the social stigma and discomfort associated with being refused care. …

MCO to Pay Physicians In Lawsuit Settlement

Back to table of contents Previous article Next article Legal NewsFull AccessMCO to Pay Physicians In Lawsuit SettlementMark MoranMark MoranSearch for more papers by this authorPublished Online:5 Aug 2005https://doi.org/10.1176/pn.40.15.00400001aThe California Medical Association (CMA) and more than a dozen other state medical associations agreed to a settlement with Wellpoint/Anthem, the largest remaining health plan defendant in a class-action lawsuit brought against several plans under the Racketeer Influenced and Corrupt Organizations Act (RICO).Among other points in the settlement, Wellpoint agreed to use a patient-friendly definition of medical necessity and agreed to cease using software programs that systematically lowball or deny payment for legitimate patient claims.The settlement also provides $135 million in direct payments to physicians to resolve allegations of unfair reimbursement for more than a decade. The class-action suit, filed five years ago, accuses several for-profit HMOs of using coercive, unfair, and fraudulent means to control physician-patient relationships. In the ensuing years, physician associations in Connecticut, Georgia, Louisiana, Texas, Florida, and other states have joined with CMA.Previous settlements have been reached with Aetna, Cigna, Prudential, and Health Net (Psychiatric News, July 16, 2004; October 15, 2004). Remaining defendants yet to settle include United, Pacificare, Coventry, and Humana.As part of the agreement, Wellpoint agreed to apply the“ patient-friendly” definition of medical necessity outlined in the settlement to mental health care, including substance abuse, according to CMA.Wellpoint will treat participating psychiatrists like other participating physicians with respect to provider directories and referrals, and it will adhere to the “prudent layperson standard” for emergency services. That standard allows for admission to an emergency room and payment for services rendered if the “average layperson” would deem emergency care necessary.“We have a good settlement in terms of psychiatric services being treated the same as other services,” said psychiatrist Catherine Moore, M.D., a member of the CMA Board of Trustees. “This kind of action shows the importance of physicians working together so that we can more effectively fight these huge businesses that are taking us to the cleaners.”Moore told Psychiatric News that Wellpoint's use of“ downcoding”—the practice of changing submitted codes for services to a lower, lesser paid code—was a particularly egregious practice that could have affected psychiatrists, particularly if they used evaluation-and-management codes.Other CMA leaders also lauded the settlement. “CMA began the battle against Wellpoint, California's largest for-profit health plan, five years ago, when it became obvious that insurers promised patients one thing in order to sell a policy and then were doing the opposite when it came time to deliver health care,” said CMA President Michael Sexton, M.D. “This is a tremendous victory for physicians and patients.”CMA President-elect Anmol Mahal, M.D., said the agreement recognizes the principle that “the physicians' input is paramount and not to be second-guessed” by corporate executives.“The Wellpoint/Anthem agreement to implement innovative industry guidelines means that patients will get the quality care they deserve,” Mahal said. “It is a shame that other health plans are still delaying doing what is right for patients.”Under the settlement's provisions that deal with abusive business practices, Wellpoint must do the following:Redefine medical necessity so patients can receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice; cheaper alternatives are permissible only when they are “at least as likely to produce equivalent therapeutic or diagnostic results.”Halt down-coding and other systematic rewriting and devaluing of (CPT) treatment codes by software programs, such as the practice of routinely denying payment for multiple procedures performed on the same day.End unilateral changes to physician contracts made with less than 90 days' written notice and disclose claims adjudication logic.Remove disparaging language about physician fees from explanation-of-benefit forms.Improve its arbitration system to reduce the burden on physicians, including barring provisions that require arbitrations take place more than 50 miles from a physician's office and reimbursing the arbitration fees for physicians who prevail.CMA Chief Executive Officer Jack Lewin, M.D., said he hopes the agreement will usher in a constructive working relationship among physicians and Wellpoint.“While Wellpoint... enjoys a reputation on Wall Street for excellent business management, its relationship with physicians has been on an increasingly sharp downhill slope for more than a decade,” Lewin said.“ This settlement opens the door for a long-overdue and much-improved relationship, including the opportunity to work together to improve patient care and patient safety.”The settlement document is posted online at<www.cmanet.org/upload/wellpoint_settlement_agreement.pdf>. A summary of the settlement is posted at<www.calphys.org/assets/applets/wellpoint_settlement_overview.pdf>.▪ ISSUES NewArchived

Complex Strategy Leads To Success of MH Initiative

Back to table of contents Previous article Next article Government NewsFull AccessComplex Strategy Leads To Success of MH InitiativeKate MulliganKate MulliganSearch for more papers by this authorPublished Online:17 Jun 2005https://doi.org/10.1176/pn.40.12.00400009California voters passed Proposition 63 in November 2004, a ballot initiative that authorizes a 1 percent tax on annual adjusted gross income over $1 million to support county-operated mental health systems.The tax will result in an estimated $1.8 billion in new revenues over the first three years.What lessons does this legislation hold for mental health advocates who are struggling with erosion in financial support for services in other sections of the country?Health policy analysts Richard Scheffler and Neal Adams tackled that question in “Millionaires and Mental Health: Proposition 63 in California” in the May 3 Health Affairs. They noted that California's history of allowing voters to bypass the legislative process and place initiatives on the ballot dates back to 1911. Since then, voters approved 104 of the 303 initiatives that qualified for the ballot.Only 12 initiatives affecting taxes passed. Of those, only three, including Proposition 63, increased taxes.Proposition 63 passed with a majority of 53.8 percent. In the same election, Proposition 72, which would have expanded employer responsibility for health care coverage, failed by a small margin.Passage had “much visible support and little visible opposition,” according to the authors.Randall Hagar, director of government affairs for the California Psychiatric Association (CPA), shares that opinion and worked to develop that support.The CPA was a member of the group that drafted the ballot initiative, he said, and later was represented on the steering committee of the Campaign for Mental Health, which led the effort (Psychiatric News, December 3, 2004).The campaign commissioned polls and focus groups to help with its planning.“We knew we had a winner when the results came back,” said Hagar. “Respondents overwhelmingly replied affirmatively to the question, `Have you or someone you know suffered from a serious mental illness?'”He believes the strong positive response represents a major change in public perception that signals a decrease in stigma in the last 10 years.The phrase “everyone knows someone with mental illness” became a key theme of the campaign.Supporters raised $4.3 million, and opponents raised $17,500. Top contributors to passage included the California Council of Community Mental Health Agencies, California Healthcare Association, California State Council of Service Employees Issues Committee and other unions, and Mental Health Association of Los Angeles County.APA, which gave $25,000 to the campaign, was the only national organization to make a contribution. Hagar said, “Members of the steering committee were duly impressed.”The CPA assisted its five district branches to raise money and secured the support of the California Medical Association. Donations from California physicians reportedly exceeded $100,000, according to Hagar.Scheffler and Adams noted, “The pitch that mental health treatment works was credible and easy to deliver.”Proposition 63 built on the success of legislative initiatives sponsored by Assemblyman Darrell Steinberg (D). The resulting program, which targeted mental health services to people who were homeless, was cited as a model in the 2003 report of the New Freedom Commission on Mental Health.Hagar also credits earlier work by Assemblywoman Helen Thomas (D), who introduced a bill to make mental health services an entitlement. That bill“ served as an inspiration and template for Proposition 63,” he said.Scheffler and Adams listed six primary arguments in favor of passage of Proposition 63 (Original article: see box).To determine the sources of voter support for Proposition 63, the authors examined the independent effect of a number of variables at the county level.Scheffler and Adams found the percentage of registered Democrats to be highly significant and positively correlated to a “yes” vote.The percentage of Hispanic population was highly significant but negatively correlated to a “yes” vote. The authors speculate that the reasons could be differences in the perceived need for mental health services as compared with other voters and the lack of cultural competence in the service delivery system.The rate of homelessness was positively correlated with a “yes” vote but was statistically weak. The authors substituted statewide average data on homelessness for county data when the latter was unavailable.The authors called Proposition 63 “a landmark piece of mental health and fiscal legislation” and noted that the mental health community in California and the nation will be watching carefully to see what happens.Hagar said, “We convened a task force that is working on such issues as the development of state guidelines for the expenditure of funds.”He expects that funds from Proposition 63 could become available to county governments as early as September, although the amounts have yet to be determined.“Millionaires and Mental Health: Proposition 63 in California” is posted at<http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.212v1>.▪ ISSUES NewArchived

Really, most SINCERELY dead: Policy and procedure in the diagnosis of death by neurologic criteria.

As Coroner, I must aver I thoroughly examined her And she’s not only MERELY dead, She’s really, most SINCERELY dead. —Coroner, after examining the remains of the Wicked Witch of the East. The Coroner reassures the social representative, the mayor, and the legal, ethical, and spiritual representatives in the Land of Oz. From the film The Wizard of Oz , 1939. Few duties of the physician are more difficult than explaining to a family that a loved one has died. This task becomes particularly delicate when death is diagnosed by neurologic criteria. The Council on Ethical Affairs of the California Medical Association (CEA) has developed this topic into a policy and procedure that detail a practical approach to address ethical and social issues encountered at the bedside when physicians diagnose death (see supplementary web material available at www.neurology.org).1 In this article, some of the authors of that policy expand on the section concerning behavior of professional staff toward the family of an individual whose cardiopulmonary support will be withdrawn after a diagnosis of neurologic death. We recommend a more direct conversation with family members than sometimes occurs and offer a model for this sensitive exchange. We organize our discussion around a scene from the 1939 movie The Wizard of Oz because this film contains a memorable and succinct exposition of the elements most reassuring in and essential to a declaration of death. In using this example, we do not mean in any way to diminish the anguish, responsibility, and mystery associated with the passing of loved ones. This scene begins after Dorothy and her house have fallen on the Wicked Witch of the East2: MAYOR (singing): As mayor of the Munchkin City In the county of the Land of Oz, I welcome you most regally. BARRISTER (singing): …

Major Suit Against Insurers Heads to Next Phase

Back to table of contents Previous article Next article Legal NewsFull AccessMajor Suit Against Insurers Heads to Next PhaseChristine LehmannChristine LehmannSearch for more papers by this authorPublished Online:6 Feb 2004https://doi.org/10.1176/pn.39.3.0004A class-action lawsuit brought by 15 medical associations and more than 700,000 physicians against major health insurers will go to trial in September, according to presiding Judge Federico Moreno of the U.S. District Court in the Southern District of Florida, Miami Division.The defendants named in In re: Humana Inc. Managed Care Litigation, which was filed in Miami in 2000, were Aetna, Anthem Blue Cross, Cigna Corporation, Coventry Health Care, Humana Health Plan, Pacifica Health Systems, United Health Group, and Well Point Health Networks. Cigna and Aetna are no longer part of the lawsuit, having settled last year with the plaintiffs for $540 million and $470 million, respectively (Psychiatric News, October 3, 2003; November 7, 2003).The class of physicians consists of those who provided medical services insured by any defendant between August 4, 1990, and September 30, 2002.The lawsuit alleges that the health insurance companies violated the federal Racketeer Influenced and Corrupt Organization (RICO) Act by unfairly denying or delaying payments for medical care. Specific allegations are that the companies “covertly manipulate, maneuver, and exploit long-standing accepted industrywide practices for financial gain, capitation payment schedules are founded on actuarially unsound principles and are manipulated by defendants to increase their profits at the expense of the physicians who provide medical services, [companies] systematically deny and delay payments due physicians and profit from the moneys wrongfully retained” (Psychiatric News, May 3, 2002; October 18, 2002).Similar charges were filed by state medical associations against Blue Cross in a separate lawsuit in September. Last month the North Carolina Medical Society filed a similar lawsuit against the state’s Blue Cross and Blue Shield organization (see story below).Leaders of state medical associations who joined the landmark lawsuit welcomed Moreno’s decision to proceed to trial.Jack Lewin, M.D., CEO of the California Medical Association, remarked in a news release, “Judge Moreno’s order is very encouraging for all of America’s physicians. This case represents the beginning of a new and positive relationship between physicians and the nation’s health plans.”John Allen, M.D., president-elect of the Texas Medical Association, remarked in the release, “This ruling confirms the entire basis on which this landmark case is founded. We look forward to moving ahead on behalf of our patients to correct the abuses of the managed care industry.”Archie Lamb, co-lead counsel for the physicians, said in the release, “This ruling underscores the legitimacy of the physicians’ claims despite the industry’s attempt to stop the case from the beginning. The team of over 200 attorneys who represent the 700,000 physicians have been preparing to take this case to court.”Moreno will now have to rule on an appeal by the defendants to break up the class-action lawsuit and settle a dispute over the trial’s location, according to a January 7 article in Modern Physician.Moreno plans to ask a national panel of judges to decide whether he should remain in charge of the case after three years of pretrial supervision, according to the article.More information about the lawsuit is posted on the Web site of the California Medical Association at www.cmanet.org and on a Web site by Lamb at www.hmocrisis.com. ▪ ISSUES NewArchived

Telfer B. Reynolds, M.D. (1921-2004)

Telfer B. Reynolds, M.D. (1921-2004)

California Law Mandates Employer-Sponsored Coverage

Back to table of contents Previous article Next article Government NewsFull AccessCalifornia Law Mandates Employer-Sponsored CoverageMark MoranMark MoranSearch for more papers by this authorPublished Online:17 Oct 2003https://doi.org/10.1176/pn.38.20.0010California Gov. Gray Davis signed a bill earlier this month requiring some employers in the state to purchase health insurance for workers or pay into a state fund for that coverage.The legislation (SB 2, sponsored by state Sen. John Burton, a Democrat), requires employers to provide health care coverage for employees and dependents that is equivalent to coverage required under California’s public health insurance programs—including dental, vision, and mental health benefits—but that also includes coverage for basic prescription drugs.If an employer chooses not to purchase health insurance for its workers, it must pay into a state fund providing such coverage.The measure, which exempts small employers, is an indicator of increasing anxiety on the part of states about the uninsured. The Center for Health Policy Research at the University of California, Los Angeles, estimates that more than 6.3 million Californians (out of a population of about 35 million) were without insurance for all or part of 2001 and 2002.Under the bill, large employers—those with 200 or more employees—are required to comply with the law by January 1, 2006. “Medium” employers—those with more than 50 employees but fewer than 200—would be required to comply by January 1, 2007. Employers with fewer than 20 workers would be exempt from the law, and those with 20 to 49 workers would be exempt from the law unless the state provides tax credits to help offset the cost of health benefits.At press time, opponents planned to file paperwork to start a referendum that would block the law. A Washington, D.C., think tank released a study concluding that “SB 2 will indirectly cost residents $11.4 billion in lost jobs, lower wages and reduced benefits,” according to the October 6 Los Angeles Times.The California Psychiatric Association (CPA) supported the bill. “We have a real interest in any measure that improves general access to medical care because of its obvious implications for those with mental illness,” Randall Hagar, director of government relations for CPA, told Psychiatric News.“Both because of our public-entitlement programs and because of our mental illness insurance parity statute, we believe that SB 2 will mean that those who don’t qualify currently for public mental health services and are not privately insured will now have access to mental health services for the first time through either employer- or state-provided insurance.”The California Medical Association (CMA) is a cosponsor of the bill.“This unprecedented legislation strikes a fair balance of constructive change and compassion for the plight of the uninsured that is desperately needed in our health care system,” said Ronald Bangasser, M.D., president of the CMA and a family practitioner.Every day “in my wound-care clinic,” he said, “I see firsthand the increasing costs [that being uninsured] passes on, affecting the prices businesses that provide health insurance must pay, leading to overcrowded and underfunded trauma-care systems and emergency rooms.”The text of the bill is posted on the Web at http://info.sen.ca.gov/pub/bill/sen/sb_0001-0050/sb_2_bill_20030913_enrolled.html. ▪ ISSUES NewArchived