Another Cut at the MPN

Gather around, dear readers, and let your eloquent and intriguing blogger tell you a story.  Once upon a time, in a realm known as California’s workers’ compensation, defendant employers came together to for the mutual benefit of employers and employees alike, creating the medical provider network system to weed out prescription-happy and over-billing medical care providers.

All was well with the world, but at every turn applicant’s attorneys, to the detriment of their clients, and medical providers, to the detriment of their patients, tried to overthrow the MPN system.  The fate of MPNs dangled precariously and uncertainty filled the air when, to the surprise of all, the Workers’ Compensation Appeals Board issued several en banc opinions in the Valdez case, declaring that applicants must limit their treatment to medical provider network physicians, that the reports of non-MPN physicians were inadmissible, and that insurance companies and self-insured employers were not liable for the non-MPN medical bills.  And joyous celebration erupted in the streets!

Then, of course, the world of workers’ compensation came back to its senses and tossed the rule of law out the window.

The case of Michael Thomas v. Safeway Stores, Inc. is making the rounds and creating quiet a bit of chatter on and off the internet.

Michael Thomas sustained an injury to his shoulder and required surgery.  However, applicant’s treating physician wrote a report in which he claimed that the 11 MPN orthopedic surgeons in the San Francisco Bay Area were not qualified to perform the surgery, and that the only man in the world that could possibly save applicant’s shoulder was a surgeon in Washington who had written several articles on the matter and performed the surgeries with some regularity.  One of the treating physician’s more memorable quotes: “If Mr. Thomas was my family member, [the Washington surgeon] is the only one I would even consider treating a case like Mr. Thomas’s.”

I only wonder where the treating physician would send Mr. Thomas if the treating physician himself had to pay for the surgery – it is so easy to be generous with the money of others, after all.

Applicant petitioned for reconsideration of the Workers’ Compensation Judge’s ruling denying the treatment, arguing  that the “reasonable geographic area,” as contemplated by California Code of Regulations section 9780 can be determined on a case-by-case basis, and in this case should include the 812 mile distance to the Washington surgeon’s office.  The WCAB ruled that  the facts in this case compel a finding that a surgeon in Seattle, Washington is in the reasonable geographic area of San Francisco.  Naturally, defendant must pay for flights, accommodations, and whatever fees may come.

Doesn’t this case mean that all you need to beat an MPN is to have a treating physician say none of the locals are qualified?  Hopefully, this will be an isolated lapse in judgment rather than a new policy.

  1. Steve Cattolica
    February 1, 2012 at 9:27 am

    Greg,

    I am not a lawyer, but one might recognize the tactic you take in your blogs as “leading the witness.” I believe the point you are trying to make hinges on your initial statement, ” Once upon a time, in a realm known as California’s workers’ compensation, defendant employers came together to for the mutual benefit of employers and employees alike, creating the medical provider network system to weed out prescription-happy and over-billing medical care providers.” Have you talked with anyone who drafted SB 899 about their intent with respect to MPNs? If so, and if they told you they had “the mutual benefit of…..employees…” in mind, they lied to you. It was simple economics. I ran the states largest HCO until it was sold to Coventry. The business model is clear and has very little to do with quality of care.

    Therefore, the intial premise of your blog is false. What is one to expect from the rest of it?

    • February 2, 2012 at 3:09 pm

      Steve, the MPNs are for the benefit of the employees as much as for the employers. While the employers reap the economic benefit of filtering out unreasonable treating physicians who over-prescribe, over-operate, and over-charge, the employee receives the benefit of having a treating physician who is focused on getting the employee treated and back to work.

      I don’t think you would be hard pressed to find a reasonable person that thinks nothing is better for an injured employee than getting patched up and getting back to work. Everyone wins when that happens except for unscrupulous medical professionals and equipment suppliers. By using an MPN, employers can keep out the doctors that persuade employees that they are never going to get better or that they can not work.

      The MPNs also serve to prevent the less honorable members of the applicant attorneys’ bar from sending their patients to their favorite pill factories and chop shops. The injured employees, and the rest of California, also enjoy the benefit of keeping costs down for employers.

      If, as you suggest, employees do not benefit from MPNs, I ask you to envision a California with an overwhelming unemployed population, consisting of those that have been permanently damaged by corrupt physicians and those that can not find work because of the crippling effect a burdensome workers’ compensation system has on employers.

      If you would like to discuss this further, feel free to e-mail me: gregory.grinberg@htklaw.com

  2. February 2, 2012 at 2:42 pm

    Please tell me this wasn’t for TOS …

    • February 2, 2012 at 3:02 pm

      Irene, I’ll shoot you over a copy of the opinion. Is your comments e-mail acceptable?

  1. February 3, 2012 at 8:04 am
  2. March 30, 2012 at 8:33 am

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