HOUSE BILL 7 IS NOT A VERY GOOD THING

Your humble blogger was stunned to see the following statement in an article online... "House Bill 7, a Worker's Compensation Reform Bill passed during the last regular session, is a "very good thing." "
http://www.kilgorenewsherald.com/news/2006/0322/Front_Page/003.html

It more certainly is NOT a good thing...for workers.

Maybe , if you are talking about from the perspective of insurance carriers, it IS a good thing because it screws injured workers (IE, aka injured employees) over.

If you read the rest of the article, you will see that the statement was made by a guy with "risk management", an area that tries to minimize payouts on work comp injuries. Read more selected under Fair Use...

"That's what Ron Walenta, a member of the Texas State Office of Risk Management Board, told local employers yesterday. Walenta was the featured speaker at a breakfast seminar sponsored by the Industrial Relations Committee of the Kilgore Chamber of Commerce and the Kilgore Economic Development Corporation (KEDC).

A number of area employers attended the morning meeting to learn about the recent reforms. Under HB 7, the Worker's Compensation Commission was abolished and functions of that commission moved under the Texas Department of Insurance (TDI). The TDI is now responsible for helping injured workers with claims and disputes. "The dispute resolution process is streamlined by HB 7," Walenta said.

He said the dispute process is streamlined for all parties - workers as well as health care providers. "HB 7 ensures providers are paid in a timely manner for their services," Walenta said. "The TDI is now responsible for monitoring provider networks and reviewing and approving rates charged by insurance carriers." The legislation allows for health care networks, Preferred Provider Organizations (PPO), much like to those in group health insurance plans. "The legislation provides for mandatory PPO networks," Walenta said.

"This system will help lower the cost of worker's compensation to taxpayers while reducing the wait for medical care." Walenta said HB 7 expedites and enhances injured employees' income benefits. He said the PPOs would have control of treating doctors, treatment practices, referrals and billing. "If a doctor is not in the network, then he would not be allowed to treat," Walenta said. "The effect (this legislation has) on workers compensation premiums will be a 50 percent reduction in costs."

Walenta explained that Under HB 7, a worker would select a doctor from within an adequate network panel, similar to the way doctors are chosen in group health plans. Walenta said networks under HB 7 are tailored to meet the specific factors present in workers' compensation care. "One major difference between workers' compensation health care and group health is that workers' compensation is fully paid," he said. Network under HB 7 are restricted to a particular set of providers that are "held to requirements that they make care available and accessible."

Walenta said several other improvements have resulted from the passage of HB 7 in addition to the networking. "More emphasis is placed on care according to evidencebased treatment guidelines and on up-front treatment planning for out-of-network claims where necessary care may be in dispute," Walenta said. The return to work and income benefit enhancements in the bill also apply to both network and non-network claims. The bill also improves the operation of the agencies charged with administering the workers' compensation system. Walenta said all aspects of the bill are not in place yet. "The bill went into effect in September, 2005, and in January, 2006, the first applications for PPOs were filed."

Walenta said 22 applications have been submitted and six have completed the process. He estimates the bill will be fully operational by April. "I'm looking forward to sharing the information with human resource personnel in our banks in Kilgore, Gladewater and Longview," said Carolyn Johnston of City National Bank. "I'm also looking forward to the bank saving money with workers'' compensation." Investment broker Wilbur Yates said he "learned things he was not aware of " concerning worker's compensation. "

---SNIP=============== This is reality distortion at its most blatant. I toil in the fields of Work Comp daily. The spectre of HB7's implementation in full looms like a dark cloud over the fields of injured workers. It is evil and should be vigarously fought by everyone who cares about injured workers. ~John Raymond Baker,DC

OPPOSE SENATE BILL S.1955

There is a bill out there that could threaten your access to your Chiropractic doctor and to Chiropractic care. The bill is S.1955 Search thomas.loc.gov and you find this... " S.1955 Health Insurance Marketplace Modernization and Affordability Act of 2005 (Introduced in Senate)
BeginningNovember 2, 2005 SECTION 1. SHORT TITLE AND TABLE OF CONTENTS. Sec. 1. Short title and table of contents.TITLE I--SMALL BUSINESS HEALTH PLANS SEC. 101. RULES GOVERNING SMALL BUSINESS HEALTH PLANS. `SEC. 801. SMALL BUSINESS HEALTH PLANS. `SEC. 802. CERTIFICATION OF SMALL BUSINESS HEALTH PLANS. `SEC. 803. REQUIREMENTS RELATING TO SPONSORS AND BOARDS OF TRUSTEES. `SEC. 804. PARTICIPATION AND COVERAGE REQUIREMENTS. `SEC. 805. OTHER REQUIREMENTS RELATING TO PLAN DOCUMENTS, CONTRIBUTION RATES, AND BENEFIT OPTIONS. `SEC. 806. REQUIREMENTS FOR APPLICATION AND RELATED REQUIREMENTS. `SEC. 807. NOTICE REQUIREMENTS FOR VOLUNTARY TERMINATION. `SEC. 808. DEFINITIONS AND RULES OF CONSTRUCTION.`Part 8--Rules Governing Small Business Health Plans SEC. 102. COOPERATION BETWEEN FEDERAL AND STATE AUTHORITIES. SEC. 103. EFFECTIVE DATE AND TRANSITIONAL AND OTHER RULES.TITLE II--NEAR-TERM MARKET RELIEF SEC. 201. NEAR-TERM MARKET RELIEF.`TITLE XXIX--HEALTH CARE INSURANCE MARKETPLACE REFORM `SEC. 2901. GENERAL INSURANCE DEFINITIONS.`Subtitle A--Near-Term Market Relief`PART I--RATING REQUIREMENTS `SEC. 2911. DEFINITIONS. `SEC. 2912. RATING RULES. `SEC. 2913. APPLICATION AND PREEMPTION. `SEC. 2914. CIVIL ACTIONS AND JURISDICTION. `SEC. 2915. SUNSET.`PART II--LOWER COST PLANS `SEC. 2921. DEFINITIONS. `SEC. 2922. OFFERING LOWER COST PLANS. `SEC. 2923. APPLICATION AND PREEMPTION. `SEC. 2924. CIVIL ACTIONS AND JURISDICTION.TITLE III--HARMONIZATION OF HEALTH INSURANCE LAWS SEC. 301. HEALTH INSURANCE REGULATORY HARMONIZATION.`Subtitle B--Regulatory Harmonization `SEC. 2931. DEFINITIONS. `SEC. 2932. HARMONIZED STANDARDS. `SEC. 2933. APPLICATION AND PREEMPTION. `SEC. 2934. CIVIL ACTIONS AND JURISDICTION. `SEC. 2935. AUTHORIZATION OF APPROPRIATIONS." Text is as follows " S.1955 Health Insurance Marketplace Modernization and Affordability Act of 2005 (Introduced in Senate) SEC. 103. EFFECTIVE DATE AND TRANSITIONAL AND OTHER RULES. (a) Effective Date- The amendments made by this title shall take effect 1 year after the date of the enactment of this Act. The Secretary of Labor shall first issue all regulations necessary to carry out the amendments made by this title within 1 year after the date of the enactment of this Act. (b) Treatment of Certain Existing Health Benefits Programs- (1) IN GENERAL- In any case in which, as of the date of the enactment of this Act, an arrangement is maintained in a State for the purpose of providing benefits consisting of medical care for the employees and beneficiaries of its participating employers, at least 200 participating employers make contributions to such arrangement, such arrangement has been in existence for at least 10 years, and such arrangement is licensed under the laws of one or more States to provide such benefits to its participating employers, upon the filing with the applicable authority (as defined in section 808(a)(2) of the Employee Retirement Income Security Act of 1974 (as amended by this subtitle)) by the arrangement of an application for certification of the arrangement under part 8 of subtitle B of title I of such Act-- (A) such arrangement shall be deemed to be a group health plan for purposes of title I of such Act; (B) the requirements of sections 801(a) and 803(a) of the Employee Retirement Income Security Act of 1974 shall be deemed met with respect to such arrangement; (C) the requirements of section 803(b) of such Act shall be deemed met, if the arrangement is operated by a board of trustees which-- (i) is elected by the participating employers, with each employer having one vote; and (ii) has complete fiscal control over the arrangement and which is responsible for all operations of the arrangement; (D) the requirements of section 804(a) of such Act shall be deemed met with respect to such arrangement; and (E) the arrangement may be certified by any applicable authority with respect to its operations in any State only if it operates in such State on the date of certification. The provisions of this subsection shall cease to apply with respect to any such arrangement at such time after the date of the enactment of this Act as the applicable requirements of this subsection are not met with respect to such arrangement or at such time that the arrangement provides coverage to participants and beneficiaries in any State other than the States in which coverage is provided on such date of enactment. (2) DEFINITIONS- For purposes of this subsection, the terms `group health plan', `medical care', and `participating employer' shall have the meanings provided in section 808 of the Employee Retirement Income Security Act of 1974, except that the reference in paragraph (7) of such section to an `small business health plan' shall be deemed a reference to an arrangement referred to in this subsection. TITLE II--NEAR-TERM MARKET RELIEF SEC. 201. NEAR-TERM MARKET RELIEF. The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following: `TITLE XXIX--HEALTH CARE INSURANCE MARKETPLACE REFORM `SEC. 2901. GENERAL INSURANCE DEFINITIONS. `In this title, the terms `health insurance coverage', `health insurance issuer', `group health plan', and `individual health insurance' shall have the meanings given such terms in section 2791. `Subtitle A--Near-Term Market Relief `PART I--RATING REQUIREMENTS `SEC. 2911. DEFINITIONS. `In this part: `(1) ADOPTING STATE- The term `adopting State' means a State that has enacted either the NAIC model rules or the National Interim Model Rating Rules in their entirety and as the exclusive laws of the State that relate to rating in the small group insurance market. `(2) COMMISSION- The term `Commission' means the Harmonized Standards Commission established under section 2921. `(3) ELIGIBLE INSURER- The term `eligible insurer' means a health insurance issuer that is licensed in a nonadopting State and that-- `(A) notifies the Secretary, not later than 30 days prior to the offering of coverage described in this subparagraph, that the issuer intends to offer small group health insurance coverage consistent with the National Interim Model Rating Rules in a nonadopting State; `(B) notifies the insurance department of a nonadopting State (or other State agency), not later than 30 days prior to the offering of coverage described in this subparagraph, that the issuer intends to offer small group health insurance coverage in that State consistent with the National Interim Model Rating Rules, and provides with such notice a copy of any insurance policy that it intends to offer in the State, its most recent annual and quarterly financial reports, and any other information required to be filed with the insurance department of the State (or other State agency) by the Secretary in regulations; and `(C) includes in the terms of the health insurance coverage offered in nonadopting States (including in the terms of any individual certificates that may be offered to individuals in connection with such group health coverage) and filed with the State pursuant to subparagraph (B), a description in the insurer's contract of the National Interim Model Rating Rules and an affirmation that such Rules are included in the terms of such contract. `(4) HEALTH INSURANCE COVERAGE- The term `health insurance coverage' means any coverage issued in small group health insurance market. `(5) NAIC MODEL RULES- The term `NAIC model rules' means the rating rules provided for in the 1992 Adopted Small Employer Health Insurance Availability Model Act of the National Association of Insurance Commissioners. `(6) NATIONAL INTERIM MODEL RATING RULES- The term `National Interim Model Rating Rules' means the rules promulgated under section 2912(a). `(7) NONADOPTING STATE- The term `nonadopting State' means a State that is not an adopting State. `(8) SMALL GROUP INSURANCE MARKET- The term `small group insurance market' shall have the meaning given the term `small group market' in section 2791(e)(5). `(9) STATE LAW- The term `State law' means all laws, decisions, rules, regulations, or other State actions (including actions by a State agency) having the effect of law, of any State. `SEC. 2912. RATING RULES. `(a) National Interim Model Rating Rules- Not later than 6 months after the date of enactment of this title, the Secretary, in consultation with the National Association of Insurance Commissioners, shall, through expedited rulemaking procedures, promulgate National Interim Model Rating Rules that shall be applicable to the small group insurance market in certain States until such time as the provisions of subtitle B become effective. Such Model Rules shall apply in States as provided for in this section beginning with the first plan year after the such Rules are promulgated. `(b) Utilization of NAIC Model Rules- In promulgating the National Interim Model Rating Rules under subsection (a), the Secretary, except as otherwise provided in this subtitle, shall utilize the NAIC model rules regarding premium rating and premium variation. `(c) Transition in Certain States- `(1) IN GENERAL- In promulgating the National Interim Model Rating Rules under subsection (a), the Secretary shall have discretion to modify the NAIC model rules in accordance with this subsection to the extent necessary to provide for a graduated transition, of not to exceed 3 years following the promulgation of such National Interim Rules, with respect to the application of such Rules to States. `(2) INITIAL PREMIUM VARIATION- `(A) IN GENERAL- Under the modified National Interim Model Rating Rules as provided for in paragraph (1), the premium variation provision of subparagraph (C) shall be applicable only with respect to small group policies issued in States which, on the date of enactment of this title, have in place premium rating band requirements that vary by less than 50 percent from the premium variation standards contained in subparagraph (C) with respect to the standards provided for under the NAIC model rules. `(B) OTHER STATES- Health insurance coverage offered in a State that, on the date of enactment of this title, has in place premium rating band requirements that vary by more than 50 percent from the premium variation standards contained in subparagraph (C) shall be subject to such graduated transition schedules as may be provided by the Secretary pursuant to paragraph (1). `(C) AMOUNT OF VARIATION- The amount of a premium rating variation from the base premium rate due to health conditions of covered individuals under this subparagraph shall not exceed a factor of-- `(i) +/- 25 percent upon the issuance of the policy involved; and `(ii) +/- 15 percent upon the renewal of the policy. `(3) OTHER TRANSITIONAL AUTHORITY- In developing the National Interim Model Rating Rules, the Secretary may also provide for the application of transitional standards in certain States with respect to the following: `(A) Independent rating classes for old and new business. `(B) Such additional transition standards as the Secretary may determine necessary for an effective transition. `SEC. 2913. APPLICATION AND PREEMPTION. `(a) Superceding of State Law- `(1) IN GENERAL- This part shall supersede any and all State laws insofar as such State laws (whether enacted prior to or after the date of enactment of this subtitle) relate to rating in the small group insurance market as applied to an eligible insurer, or small group health insurance coverage issued by an eligible insurer, in a nonadopting State. `(2) NONADOPTING STATES- This part shall supersede any and all State laws of a nonadopting State insofar as such State laws (whether enacted prior to or after the date of enactment of this subtitle)-- `(A) prohibit an eligible insurer from offering coverage consistent with the National Interim Model Rating Rules in a nonadopting State; or `(B) discriminate against or among eligible insurers offering health insurance coverage consistent with the National Interim Model Rating Rules in a nonadopting state. `(b) Savings Clause and Construction- `(1) NONAPPLICATION TO ADOPTING STATES- Subsection (a) shall not apply with respect to adopting states. `(2) NONAPPLICATION TO CERTAIN INSURERS- Subsection (a) shall not apply with respect to insurers that do not qualify as eligible insurers that offer small group health insurance coverage in a nonadopting State. `(3) NONAPPLICATION WHERE OBTAINING RELIEF UNDER STATE LAW- Subsection (a)(1) shall not apply to any State law in a nonadopting State to the extent necessary to permit individuals or the insurance department of the State (or other State agency) to obtain relief under State law to require an eligible insurer to comply with the terms of the small group health insurance coverage issued in the nonadopting State. In no case shall this paragraph, or any other provision of this title, be construed to create a cause of action on behalf of an individual or any other person under State law in connection with a group health plan that is subject to the Employee Retirement Income Security Act of 1974 or health insurance coverage issued in connection with such a plan. `(4) NONAPPLICATION TO ENFORCE REQUIREMENTS RELATING TO THE NATIONAL RULE- Subsection (a)(1) shall not apply to any State law in a nonadopting State to the extent necessary to provide the insurance department of the State (or other State agency) with the authority to enforce State law requirements relating to the National Interim Model Rating Rules that are not set forth in the terms of the small group health insurance coverage issued in a nonadopting State, in a manner that is consistent with the National Interim Model Rating Rules and that imposes no greater duties or obligations on health insurance issuers than the National Interim Model Rating Rules. `(5) NONAPPLICATION TO SUBSECTION (A)(2)- Paragraphs (3) and (4) shall not apply with respect to subsection (a)(2). `(6) NO AFFECT ON PREEMPTION- In no case shall this subsection be construed to affect the scope of the preemption provided for under the Employee Retirement Income Security Act of 1974. `(c) Effective Date- This section shall apply beginning in the first plan year following the issuance of the final rules by the Secretary under the National Interim Model Rating Rules. `SEC. 2914. CIVIL ACTIONS AND JURISDICTION. `(a) In General- The district courts of the United States shall have exclusive jurisdiction over civil actions involving the interpretation of this part. `(b) Actions- A health insurance issuer may bring an action in the district courts of the United States for injunctive or other equitable relief against a nonadopting State in connection with the application of a state law that violates this part. `(c) Violations of Section 2913- In the case of a nonadopting State that is in violation of section 2913(a)(2), a health insurance issuer may bring an action in the district courts of the United States for damages against the nonadopting State and, if the health insurance issuer prevails in such action, the district court shall award the health insurance issuer its reasonable attorneys fees and costs. `SEC. 2915. SUNSET. `The National Interim Model Rating Rules shall remain in effect in a non-adopting State until such time as the harmonized national rating rules are promulgated and effective pursuant to part II. Upon such effective date, such harmonized rules shall supersede the National Rules. `PART II--LOWER COST PLANS `SEC. 2921. DEFINITIONS. `In this part: `(1) ADOPTING STATE- The term `adopting State' means a State that has enacted the State Benefit Compendium in its entirety and as the exclusive laws of the State that relate to benefit, service, and provider mandates in the group and individual insurance markets. `(2) ELIGIBLE INSURER- The term `eligible insurer' means a health insurance issuer that is licensed in a nonadopting State and that-- `(A) notifies the Secretary, not later than 30 days prior to the offering of coverage described in this subparagraph, that the issuer intends to offer group health insurance coverage consistent with the State Benefit Compendium in a nonadopting State; `(B) notifies the insurance department of a nonadopting State (or other State agency), not later than 30 days prior to the offering of coverage described in this subparagraph, that the issuer intends to offer group health insurance coverage in that State consistent with the State Benefit Compendium, and provides with such notice a copy of any insurance policy that it intends to offer in the State, its most recent annual and quarterly financial reports, and any other information required to be filed with the insurance department of the State (or other State agency) by the Secretary in regulations; and `(C) includes in the terms of the health insurance coverage offered in nonadopting States (including in the terms of any individual certificates that may be offered to individuals in connection with such group health coverage) and filed with the State pursuant to subparagraph (B), a description in the insurer's contract of the State Benefit Compendium and that adherence to the Compendium is included as a term of such contract. `(3) HEALTH INSURANCE COVERAGE- The term `health insurance coverage' means any coverage issued in the group or individual health insurance markets. `(4) NONADOPTING STATE- The term `nonadopting State' means a State that is not an adopting State. `(5) STATE BENEFIT COMPENDIUM- The term `State Benefit Compendium' means the Compendium issued under section 2922. `(6) STATE LAW- The term `State law' means all laws, decisions, rules, regulations, or other State actions (including actions by a State agency) having the effect of law, of any State. `SEC. 2922. OFFERING LOWER COST PLANS. `(a) List of Required Benefits- Not later than 3 months after the date of enactment of this title, the Secretary shall issue by interim final rule a list (to be known as the `List of Required Benefits') of the benefit, service, and provider mandates that are required to be provided by health insurance issuers in at least 45 States as a result of the application of State benefit, service, and provider mandate laws. `(b) State Benefit Compendium- `(1) VARIANCE- Not later than 12 months after the date of enactment of this title, the Secretary shall issue by interim final rule a compendium (to be known as the `State Benefit Compendium') of harmonized descriptions of the benefit, service, and provider mandates identified under subsection (a). In developing the Compendium, with respect to differences in State mandate laws identified under subsection (a) relating to similar benefits, services, or providers, the Secretary shall review and define the scope and application of such State laws so that a common approach shall be applicable under such Compendium in a uniform manner. In making such determination, the Secretary shall adopt an approach reflective of the approach used by a plurality of the States requiring such benefit, service, or provider mandate. `(2) EFFECT- The State Benefit Compendium shall provide that any State benefit, service, and provider mandate law (enacted prior to or after the date of enactment of this title) other than those described in the Compendium shall not be binding on health insurance issuers in an adopting State. `(3) IMPLEMENTATION- The effective date of the State Benefit Compendium shall be the later of-- `(A) the date that is 12 months from the date of enactment of this title; or `(B) such subsequent date on which the interim final rule for the State Benefit Compendium shall be issued. `(c) Non-Association Coverage- With respect to health insurers selling insurance to small employers (as defined in section 808(a)(10) of the Employee Retirement Income Security Act of 1974), in the event the Secretary fails to issue the State Benefit Compendium within 12 months of the date of enactment of this title, the required scope and application for each benefit or service listed in the List of Required Benefits shall, other than with respect to insurance issued to a Small Business Health Plan, be-- `(1) if the State in which the insurer issues a policy mandates such benefit or service, the scope and application required by such State; or `(2) if the State in which the insurer issues a policy does not mandate such benefit or service, the scope and application required by such other State that does require such benefit or service in which the greatest number of the insurer's small employer policyholders are located. `(d) Updating of State Benefit Compendium- Not later than 2 years after the date on which the Compendium is issued under subsection (b)(1), and every 2 years thereafter, the Secretary, applying the same methodology provided for in subsections (a) and (b)(1), in consultation with the National Association of Insurance Commissioners, shall update the Compendium. " Basically, the upshot of this is that the bill may , according to the Texas Chiropractic Association, "render obsolete all state-enacted “mandates,” including Texas’s “insurance equality” law. Since, the U.S. House of Representatives has already approved similar legislation; all that is left for this bill to become law is action by the full Senate and the signature of the President. This is a major threat to the chiropractic profession If this law passes, all of our laws are gone. Employers will be free to: Eliminate chiropractic benefits Place caps on the number of visits Require a medical doctor to pre-authorize care Place higher deductibles on chiropractic care Discriminate against chiropractic in any manner they choose. Patients will lose all of the protections they now have under Texas law." Those concerned about government running roughshod and taking away your freedom of choice should contact : Senator Kay Bailey Hutchison (202) 224-5922 or (512) 916-5834 Fax (202) 224-0776 or (512)916-5839E-mail: http://hutchison.senate.gov/ Senator John Cornyn (202) 224-2934 or (512) 469-6034Fax: (202) 228-2856 or (512) 469-6020E-mail: http://cornyn.senate.gov/ Here is a sample letter to use http://www.chirotexas.org/documents/S1955letter.pdf

Spine Industry Braces for SPORT Study Results, According to Medtech Insight Newsletter

http://www.genengnews.com/news/bnitem.aspx?name=1180924XSL_NEWSML_TO_NEWSML.xml&css=printOnly.css

The spine industry is bracing for the results of the Spine Patient Outcomes Research Trial (SPORT), according to an article published in the January 2006 issue of "Medtech Insight," a monthly newsletter for the medical technology industry (www.medtechinsight.com).
SPORT, a large-scale, five-year, multimillion dollar study sponsored by the National Institutes of Health (NIH), is comparing the efficacy and cost-effectiveness of spine surgery to nonsurgical management of common conditions associated with low back and leg pain. The study, which was conducted at 11 centers in the U.S., enrolled approximately 1,450 potential surgical candidates in randomized trials and approximately 1,800 into a non-randomized trial comparing surgical to nonsurgical treatments. It focused on the treatment of three major common spinal conditions: herniated disc, spinal stenosis, and degenerative spondylolithesis. Three randomized studies were conducted simultaneously evaluating each condition, with follow-ups at two short-term intervals (six weeks and three months) and five long-term intervals. Primary endpoints include a change in health-related quality of life, as measured by SF-36 scores and Oswestry Disability Index.

"Any effort geared toward increasing the understanding of the cause and treatment of back pain should be commended," reported Sharon O'Reilly, founder of Medtech Insight. "While most professional societies -- including the American Association of Neurosurgeons (AANS), Congress of Neurosurgeons (CNS), AANS/CNS Spine Section, and the North American Spine Society (NASS) -- have applauded this enormous undertaking and believe that such a study is long overdue, many have expressed concern with the study's design, hypothesis, and ultimate goal," stated O'Reilly. Representatives from the AANS and CNS issued a statement in the May 2003 Journal of Neurosurgery acknowledging that while they agreed with the statistical design of the SPORT study, they had concerns about the clinical design of the trial since it seemed to favor nonoperative treatment. They cautioned that "if this incorrectly designed study should become the basis of a national dictum on how to treat these disorders, patients will be deprived of appropriate and effective surgical treatment."

Treatment options aside, neurosurgeons contend that the crux of the matter is the fact that study patients within the surgical group who do not improve will be considered surgical failures, while those within the nonsurgical group who fail treatment and require surgery (in essence, crossover) and then subsequently improve will be considered successes of nonsurgical treatment.

The investigators for the SPORT study estimate that as many as 25 percent of the nonsurgical patients may potentially crossover to surgery. If surgery ultimately relieves their pain, the obvious question is why are these patients not considered surgical successes?
Other criticisms of the study relate to inappropriate or "too lenient" patient selection, since the study includes, for example, patients with bulging discs. According to the experts, patients with bulging discs are poor candidates for surgery and are less likely to respond to surgical treatment. In fact, many surgeons contend that the patients who may benefit most from surgery, such as those with the most acute symptoms and most impressive structural pathology, may be significantly underrepresented in the SPORT study since these patients are less likely to agree to randomization.

Furthermore, it should be noted that patient enrollment in the SPORT study was completed in 2002, before the introduction of many of the newer, standard-of-care spinal technologies now in widespread use. For example, many less-invasive treatment options and newer technologies -- including biologics -- were not yet available in 2002 when the study completed patient enrollment. Many argue that this omission raises concerns about the validity of the SPORT study results.

The SPORT study is also designed to assess the cost-effectiveness of nonsurgical vs. surgical options for treating low back pain. Again, there is a discrepancy in the timeframe and, consequently, cost of nonsurgical and surgical treatments. Resource allocation for the nonsurgical group is being estimated on a 30-day basis, prior to clinic visits, whereas in the surgical group, it is calculated throughout the study. However, with nearly 50 prescription drugs and 40 nonsurgical treatment options available to patients in the nonsurgical cohort, what the study fails to take into account is that in some cases, such methods of treatment will be required for the lifetime of a patient. The goal of surgery, on the other hand, is long-term alleviation of back pain.

With these concerns, it's no wonder that those in the spine community are warning both industry and patients to be wary of the long-range impact of this study on third-party payers. They worry that with such blatant biases, perhaps the ultimate goal of the SPORT study is only to restrict patient access to spine surgery.

Think Twice About Going To The Emergency Room For Back Pain

With low back pain being the number reason why millions of Americans miss work, you would think hospitals around the country would be more compassionate with people who suffer from chronic low back pain. Being a chronic pain sufferer myself who suffers from low back pain with a herniated disc, I know too well how ER doctors treat patients seeking help for some kind of relief. It seems as soon as you walk in and tell them the reason your here to see the doctor is for back pain, your immediately cast in a different light.

The ironic thing in today's modern times, hospitals and ER doctors have available, and can look up information on patients that have on record tests such as, MRI's, CT scans, or any other type of documentation to verify a diagnosis the patient is complaining of. With so many people falsely going to ER rooms complaining of back pain just to get medication, they should actually do a little research before they put you in that category of just seeking medication.

For instance, I waited 2 hours in the waiting room, after I got back to see the ER physician, I waited in the room for an additional hour just to hear the nurse tell me I need to go see my primary care physician about substance abuse. I was in shock. I could not believe they thought I was there seeking medications and not truly suffering from pain. When just recently I had two MRI's taken at this same hospital showing indeed I do suffer from herniated discs, and other back problems as well. To add insult to injury, I received a bill the following week charging me for the visit. I wonder what did they do for me. What did they charge me for? The only thing they did in all reality is turn me away. So why do they charge me for turning me away in my time of need.

Unless your in a horrible car wreck, or your wheeled in by ambulance on a stretcher, going to the ER room for pain is a waste of time and money. Not only is it a waste of time and money, your humiliated by the whole ordeal. People who suffer from chronic pain are simply not believed. For whatever the reason may be, ER doctors do not want to treat people in pain. Chronic pain sufferers in America are discriminated again tremendously. Everyone who suffers from pain should write their congressman or senators. Something has to be done.

From Robert Gould at http://www.dailyindia.com/show/4223.php

Group Seeks Federal Ban on Darvocet

http://www.localnewsleader.com/brocktown/stories/index.php?action=fullnews&id=150660



Group Seeks Federal Ban on Darvocet Staff and agencies28 February, 2006
By ANDREW BRIDGES, 53 minutes ago
WASHINGTON - Darvon, Darvocet and related painkillers should be phased out and eventually banned, a watchdog group said Tuesday in a government petition that cited the accidental deaths of at least 2,110 people between 1981 and 1999.
Several hundred more people have died accidentally after taking the prescription narcotics each year since, Public Citizen‘s Health Research Group said in the petition faxed to the Food and Drug Administration . A roughly equal number of people used the drug to commit suicide.
"This a black-and-white example of a drug where its risks far outweigh its benefits," Wolfe said. "There‘s no excuse for this drug to be around."
A phase-out, meant to wean users from the addictive drug, and eventual ban if approved, would follow a similar decision made in January 2005 by the United Kingdom. Health officials there said at the time that the drug was associated with 300 to 400 accidental deaths and suicides each year.
A recent analysis of 26 studies that compared propoxyphene and acetaminophen with just acetaminophen or a dummy pill found the "narcotic combination offered little benefit over acetaminophen alone" in treating pain.
The body transforms propoxyphene into norpropoxyphene, which can build up in the body and is associated with a variety of heart problems, including arrhythmia.

Leading bad faith case from 1978 involves FARMERS

PAGE EDITOR'S NOTE-
In Neal v. Farmers Insurance Exchange, from 1978, we see that, as far back as 1978, one of the group of Farmers Insurance companies, was determined to have been "lowballing" settlements, and not just that, and this is the important point, that
In the leading California bad faith case of Neal v. Farmer's Insurance Exchange, 148 Cal Rptr. 389, 582 P. 2d 980 (1978), the court summarized the evidence against an insurer that had "lowballed" its insured's claim:
"[The] evidence, in brief, indicated that Farmer's refusal to accept (Mrs. Neal's attorney's) offer of settlement, and its subsequent submission of the matter to its attorney for opinion, were all part of a conscious course of conduct, firmly grounded in established company policy, designed to utilize the lamentable circumstances in which Mrs. Neal and her family found themselves, and the exigent financial situation resulting from it, as a lever to force a settlement more favorable to the company than the facts would otherwise have warranted.

In order to prove that the insurer was attempting to exploit the insured's vulnerable position, the Neal court held that the insured may introduce evidence of what the insurer knew about the insured's financial situation:

Thus, in determining whether Farmer's, in breaching its duty to the insured to make a reasonable settlement, did so in a spirit of oppression, the jury was clearly entitled to consider the evidence of the situation of the insured at the time of the proffered settlement insofar as it might be considered to have motivated its actions."
http://library.findlaw.com/2000/Aug/1/128466.html

FARMERS INSURANCE AND WORKERS COMP IN ARKANSAS

http://www.occupationalhazards.com/articles/14689
For the purposes of determining liability, when does a "gradual-onset" injury such as carpal tunnel syndrome legally begin? The Arkansas Court of Appeals ruled Feb. 1 that such an injury begins when the worker becomes aware of the injury.
The question arises out of an appeal filed by Cottage Café Inc. and Farmers Insurance Group after the Arkansas Workers' Compensation Commission ruled that Patricia Collette, a former grill cook at the café, was entitled to workers' compensation benefits for repetitive stress injuries she suffered in 9 years on the job.
On Sept. 29, 2003, Collette dropped a spatula from her hand and was unable to work, according to the appeals court opinion. After seeking medical treatment, Collette was diagnosed with carpal tunnel syndrome and cubital tunnel syndrome.
Just a few weeks before Collette dropped the spatula, Cottage Café had been sold to Leonard Cernak, who switched the café's workers' compensation coverage from Southern Guaranty Insurance to Farmers Group Insurance when he bought the business.
Both insurance companies rejected Collette's workers' compensation claim.
The Workers' Compensation Commission found that Collette was entitled to workers' compensation and that Farmers Insurance was liable for the compensation and benefits awarded.
Farmers Insurance and Cottage Café then appealed the commission's decision, arguing that the commission was wrong in both aspects of its ruling.
Collette's Injuries Were Job-Related
Chief Judge John Pittman, who wrote the appeals court's Feb. 1 opinion, explains that in cases that look at whether someone is entitled to workers' compensation payments, "[w]e will not reverse the commission's decision unless we are convinced that fair-minded persons with the same facts before them could not have reached the same conclusions arrived at by the commission."
For an employee to receive workers' compensation benefits for a gradual-onset injury such as carpal tunnel, Pittman notes, the employee must prove that the injury is job-related, that the injury was severe enough to require medical treatment or cause death or disability and that the injury was a major cause of the disability or need for medical treatment.
Collette testified before the commission that her duties as a grill cook required her to prepare eggs, omelets, hash browns, ham, sausage and bacon and to flip these foods with a spatula as they cooked.
Also, several of Collette's co-workers testified that she was a hard worker, while the mother of the café's prior owner testified that, based on her observations, Collette's injuries undoubtedly are the result of her job duties.
In the opinion of Collette's doctor, her carpal tunnel and cubital tunnel injuries are related to Collette's repetitive motions on the job, and the commission found no evidence suggesting that Collette's injuries resulted from anything else.
In issuing the appeals court's opinion, Pittman weighed this testimony and determined that the Workers' Compensation Commission was correct in ruling that Collette is entitled to workers' compensation for her injuries.
Appeals Court: Commission Ignored Previous Case Law
The second question the appeals court had to answer was whether Southern Guaranty Insurance – which was the insurance carrier of the previous owner of the café – or Farmers Insurance is liable for Collette's workers' compensation payments and benefits.
The Workers' Compensation Commission looked at it this way: Whichever carrier was providing workers' compensation coverage at the time Collette's injury manifested itself – meaning when Collette began to lose time from work and require medical attention and was unable to perform her job – is the one responsible for her workers' compensation payments.
Since the injuries to her right wrist and elbow did not manifest itself until Farmers Insurance had become the carrier, the commission ruled that Farmers Insurance was liable for Collette's workers' comp claim.
Pittman, however, blasted the commission for its interpretation, writing, "[t]he commission cites neither authority nor public policy considerations supporting its adoption of this rule."
"Furthermore," Pittman wrote, "it disregards prior opinions of the Arkansas appellate courts that bear on the question under consideration, i.e., when does a scheduled gradual-onset injury legally commence?"
Interpreting Arkansas case law, Pittman concluded that insurance liability for a gradual-onset injury begins when a worker becomes aware of his or her injury. Based on this reasoning, the appeals court reversed the commission's decision and sent the case back to the commission to determine which insurance carrier is liable for Collette's workers' comp payments based on when she became aware of her injuries.

TEXAS HAS THE WORST RETURN TO WORK RECORD THEY SAY...WONDER WHY?

TEXAS HAS THE WORST RETURN TO WORK RECORD THEY SAY...WONDER WHY?

We often see the statement in the "Let's revamp Texas Work Comp" claptrap that led to the debacle passed as House Bill 7. Texas allegedly has the worst record on returning workers back to work.Wonder Why?

Are they trying to insinuate that Texas workers are lazier than other states, or that we heal more slowly than any other state, or that our doctors are the worst in the nation?All three of the above are patently ridiculous on their face.What is different about Texas? Well, Texas is a "pro insurance" state...probably more so than any other state. It is the ONLY state to allow employers NOT to subscribe at all to the system.What is the natural sequelae of it being a "pro insurance " state?

Well, first off, insurance companies get away with outrageous conduct that would probably be reined in on less "pro insurance" states. The natural outcome of them getting away with outrageous conduct, conduct that even in the pro-insurance laws of Texas, is SUPPOSED to garner sanctions and fines, nothing happens when they do wrong.

This emboldens and enables them to exhibit bad faith in their dealings with doctor and patients and do things like delay or deny treatment and diagnostic imaging on a ridiculous time frame.One of the MAIN reasons that Texas workers take so long to get back to work is that, due to the interference with treatment and diagnosis by the insurance carriers and the adjusters doing their bidding, is patients get stalled in their treatment, and end up getting sent to Designated doctor after Designated Doctor, RMEs, paper reviews, peer to peer, denials, disputes, and on and on.

This is 100 percent the fault of the insurer acting, in my opinion, in bad faith, in direct violation of the covenant of good faith and fair dealing.Of COURSE if the carrier disputes legitimate claims, refuses to pay for diagnostic imaging, refuses to pain for referrals to specialists, refuses to pay for care...the patient literally gets stalled in neutral and cannot make progress on return to work.

For many companies, there is no light duty. Thus, as many of these injured workers are hurt fairly badly in industrial accidents (I've had patients with amputated fingers, bodies caught in conveyor belts, broken bones, had patient in which a "Cherry picker" come down on his head and generate a serious closed head injury..and on and on) and, there is no transition job to get them back onto the job.

They have to be 100 percent or nothing.

And, as Texas is an "at will" employment state, workers can be fired for almost anything, even the most arbitrary and silly of reasons, when they are off work as a result of a doctor's decision, they are less of a target for termination than if they are back at work, even on light duty.And, make no mistake, if you get hurt on the job in Texas, you suddenly find yourself treated like a liability, and even as an enemy.

In the industrial settings, workers, even loyal, hardworking ones that have been there for one or two decades, are treated as cogs in a machine and if that cog breaks or gets worn out, the machine is all too ready to replace that one with a new one ready to take its place.

Of course, large companies will generate a "party line" that they "care" about injured workers, but I dare you to talk to 50 injured workers in this state and find out how they were treated.I deal with these decent , honest, injured workers every day, and without any reservation I can tell you that most are treated shamefully by the carrier, and many, treated shamefully by the employer they have given decades of their lives .So, when you see an "outcomes based study" or see that Texas is going to fund or encourage pilot "RTW" (Return to Work) programs, remember what the source of the problem is.

The real , major source of the crisis in workers returning to work, is mishandling, improper handling, excessive disputes and denials, and other actions of bad faith on the part of insurance carriers, and the adjusters that do their bidding.Want to fix this? Elect state officials who are not in the pocket of the insurance industry.

Plain and simple.

WHAT IS CRUEL AND INHUMANE TREATMENT?

When an insurance company is made aware an insured is suffering, and may be getting worse without care and denies approval, isn't that wrong?

When an insurance company is made aware diagnostic imaging or electrodiagnostic testing is needed to properly diagnose the extent of an injury, and they do not allow it to be done, isn't that cruel?

When an insurance company is made aware that a patient has not been able to return to their previous job because their progress is stalled because the insurance company is not authorizing treatment or diagnostics, wouldn't you say that to allow someone to keep suffering, and perhaps get worse to the point of permanent harm, wouldn't you say that is "cruel and inhumane treatment"?

What kind of person, with their fingers at the drawstrings of the vast bag of money big insurance companies have, can have the unmitigated cruelty to tell a patient "We don't believe you're hurt and are not authorizing treatment to you." What kind of creature plays games with other people's lives like that ?

What kind of being will see that someone has been suffering for months or years, and refuses to allow them to get treatment, refuses to allow them to get advanced imaging that is needed to diagnose whether a disc has herniated or not ?

What kind of being throws roadblock after roadblock up to keep a patient's progress stalled by not letting diagnosis and treatment go forward?

Daily, insurance adjusters sit in their little cubicles, denying payment to doctors, blocking access to care from injured workers.

It happens with such regularlity and frequency, that doctors such as I, almost start to accepting this as business as usual.

When I realized that this morning, it frightened me, because I realized that doctors in another time became used to seeing people treated as numbers, became used to seeing people treated inhumanely, and did nothing.

That was Nazi Germany around 60 years ago. One does not have to be a card carrying member of the National Socialist German Workers Party (Nazi party official name) to be Nazi-Lite. True evil is treating another person or living creature only as means to an end.

It is seeing another person as a functional unit that is only useful to your own purposes. Now, when healthcare becomes only a matter of insurance companies trying to avoid paying out money at all costs, when adjusters treat injured workers like rats in a maze, throwing walls up when they start making progress toward the exit, in MY book, that is not only torturing the patient, but it is cruel and inhumane, and yes, Nazi-Lite (and Nazi like).

What in the hell is wrong with the system that allows this?

And, even more to the point, how can we as doctors, and you as citizens, NOT scream loudly that we are mad as hell and are not going to take it any more.

There is a saying that I originated about an insurance company that is spreading around the internet, and I feel quoting myself is apropos given the quote. The quote is this :

"To see a wrong and not expose it, is to become a silent partner to its continuance."
-Dr. John Raymond Baker,D.C.

I for one am NOT going to be that silent partner in the unconscionable actions I see daily occurring.

Every person must decide for themselves when they are going to speak out against evil. As people, we have heard of the horror of a crowd standing by while a woman is raped, and no one stepping in to stop it.

A study in fact found that the likelihood of any one person initiating an action to stop something like that is inversely proportional to the number of people in attendance.

In other words, it's the "Let George Do It" phenomenon, where people always think they will just let someone else act to stop a wrong. That is beyond apathy, it is being complicit in the wrongs that are happening in my view.

I may not be able to do much as one man, but I will not stay silent and watch this torment of patients go by.

The vast discretionary money available in the gigantic bank accounts of insurance companies are SUPPOSED to be there for paying claims of the insured. What it seems the insurance companies see these monies as, are REVENUE GENERATORS through investment and through getting interest from banks.

If they view the financial resources they have as means of generating more money in their corporate greed , then OF COURSE they will fight like wild snakes to prevent any of that money getting spent on anyone for any reason.

This is the source, in my opinion, of these delays, denials, and disputes. They all become virtual stumbling blocks to slow down or deny disbursement of funds to patients and providers.

I am perplexed as to how anyone can get up every morning and look at themselves in the mirror, knowing the kind of hardship, increased pain and suffering, and mental anguish they inflicted yesterday, day before that, the day before that, and they intend to inflict on people that day, and the day after that, and on and on, all in the sake of keeping money and making more and more in obscene amounts.

Will it change? It will not change until enough citizens rise up and demand it gets changed. You as a consumer can boycott the insurance companies that have divisions that are work comp insurance carriers that continue doing this.

You can write your elected representatives, you can write your local paper, you can write your congressman or congress woman in Washington, you can talk to other people and spread the word this is happening, you can start a blog and talk about it.

As long as we allegedly have freedom of speech, you can do a lot.

If after reading this, you do nothing, then yes, you have just become a silent partner in its continuance !
~Dr. John Raymond Baker,DC Longview Texas
This article is Copyright © 2006 by BAKER CHIROPRACTIC, PA / Dr. John Raymond Baker,DC All Rights are reserved. Fair use is authorized as long as there is attribution of its source.

KEYWORDS FOR THIS ARTICLE : Work Comp, workers compensation, doctors, insurance carriers, carrier, texas, longview, tyler,east texas, denial, dispute, care, mri, surgery, herniated disc, bad faith, allowed to get worse, numbness, tingling, pain, back, neck, mid-back, adjuster, adjusters, peer review, peer to peer, paper shuffle, radiculopathy, on the job, injured, injured worker, IW, good faith and fair dealing, covenant, sue, lawsuit, damages, inaction, deny, authorization, preauthorization, certification department

Statement of Commissioner of Work Comp in Texas About Health Networks

"Texas Health Care Networks: A New Approach for Workers' Compensation
By Mike Geeslin

December 2, 2005


House Bill 7 enacted sweeping workers' compensation reforms. One of those reforms was the establishment of health care provider networks. After receiving much thoughtful input from system participants, I am proud to announce that we have now adopted the first set of rules to implement workers' compensation networks in Texas.

Basically, workers' compensation networks will be similar to the managed care networks we see in health insurance, in terms of the regions to be served. The network will serve a particular geographic area. If an employer chooses to utilize a provider network for its workers' compensation claims, then an employee who is injured on the job and lives within the service area will choose a treating doctor from the list of network providers. If the employer does not choose to use a network, or if the employee lives outside the service area, the doctor can be selected from the workers' compensation approved doctor list, just as before.
Workers' compensation is a health delivery system like other health insurance, except that it has the added goal of not just returning to health but also returning to work in some capacity if at all possible. Experienced health care providers dedicated to understanding treatment guidelines, disability durations, and rehabilitation techniques that facilitate timely return to work will be the cornerstone of success.

The network administrators will negotiate with health care providers to build a pool of highly qualified professionals representing all the specialties required to treat workplace injuries. Providers will be able to negotiate their fees and contract requirements, such as procedures requiring preauthorization, while network management handles the administrative functions unique to workers' compensation.

Beginning January 1, 2006, TDI will review applications from networks seeking to be certified. Among the criteria we will be looking at are sound financial resources and an adequate number of health care providers for the service area. We want to make absolutely certain that injured workers have an extensive pool of health care professionals from which to choose.
I want to address a concern that has been raised concerning network care, that it is merely a discount program that will cut corners to save money. If workers' comp health networks are viewed only as a tool to reduce medical costs, without adding any value to the rehabilitation and care of the injured employee, then the networks are headed to failure. Many employers and injured workers with whom I have spoken have emphasized the need for best value, not care on the cheap or, conversely, excessive care. The more effective medical care that a worker receives, the sooner he or she will be back to productive work or to a point where their injury is manageable.

To that end, our network rules incorporate a number of quality assurance tools. Workers' compensation networks are required to be credentialed and must demonstrate that they have a formal complaint and dispute process in place. The networks are also required to track return-to-work statistics to see how well they are getting injured workers back on the job.
In addition, TDI researchers will compile data to assess each network's performance on a yearly basis in the form of a "network report card." The report card will allow comparisons between networks on a variety of measures, including access to care, health-related outcomes, return-to-work outcomes, employee satisfaction with quality of care, and health care costs and utilization of care.

Collectively, we know the problems that occurred during the development of managed care over the past several decades, and this is a new start – a chance in policymaking that does not come very often – to apply what we know works well. As we gain more experience and input from stakeholders, especially the Injured Employee Counsel, we are prepared to revise our network rules as needed, and even implement emergency rules as necessary.
As a guiding principal, no one group can dominate. This is not about one group claiming victory or gaming other stakeholders. It's about balance and building a health care delivery system to which we would entrust our own family and friends. We must all bring our best ideas and attitudes for success to the table and make these networks work for the benefit of the citizens of Texas who are injured on the job.

Mike Geeslin is Texas Insurance Commissioner."

My publc comment on 134.600, preauthorization in Texas Work Comp

March 1, 2006
It is my understanding that public comments are accepted until 3-13-2006 on 134.600.
I have been a doctor involved with treating Work Comp patient since 1990. I am presently a Worm Comp provider on the ADL list for Longview Texas. It is my observation from day to day practice, that more and more doctors are deciding NOT to continue as providers.

The "new" system, as a division of the Texas Department of Insurance, as I understand it, will eliminate the ADL list in 2007. Also, as I understand it, HB 7 was the template on which this "new" Work Comp system would be built, with adoption of rules by Commissioner Betts.

Also, as I understand it, this new system has, as its basic fundamental unit, the development of "health networks". Here it is March 1, 2006, and these networks were , as I understand it, supposed to begin forming in the first part of January, 2006. These networks, comprised of doctors approved of by insurance carriers, would in essence, be "company doctors" and it would be from this list, that an injured worker would be forced to choose.

This in stark contrast to the previous system with a list of "any willing provider" on the ADL list, being able to be a treating doctor.

This in essence, really does rob injured workers of an essential weapon in this Work Comp War, and that is, the ability to choose a doctor who is not beholden to the insurance. I believe this is not fair to workers, and my injured worker patients agree with me, and are uniformly horrified at the proposed rules, which includes but is not limited to taking patients away from established treating doctors and forcing them to choose from the list of company doctors that will be referred to as a "health network".

Now, on to 134.600. Preauthorization of procedures and services that were not preauthorizable, is creating a real problem for many providers, specifically, Doctors of Chiropractic. Part of the reason is that , at this point, there appears on its face, to be differentially discriminatory denials given to many D.C.s in this state, when many MDs are experiencing fairly good success rates at preauthorization, and though I have not looked at Doctors of Osteopathic Medicine preauthorization success rates, I would guess they would have similar success rates to that of Medical Doctors ( M.D.s).

Also, as I understand it, per the emergency rule adoption, preauthorization is to cover occupational procedural codes and physical therapy codes as defined in the HCPCS.

As I have found out, Chiropractic manipulations / adjustments, with code numbers of 98940 through 98943, are OUTSIDE the range of procedures that must be preauthorized under the emergency rule adoption, and yet, in my office, we are seeing blanket denials of payment based on preauthorization, INCLUDING manipulations, which are , per my understanding, not required to be preauthorized.

Furthermore, as I understand rule, 134.600(f)(3)(A), which states: "(f) The carrier shall...(3) contact the requestor or employee by telephone, facsimile, or electronic transmission with the decision to approve or deny the request: (A) within three working days of receipt of a request for preauthorization...".

We are sending out proper preauthorization requests and NOT getting any answer within the mandated time frame. These carriers are NOT being compliant, and there seems to be no course toward forcing compliance on insurance carriers.

Thus, my complaint is that the preauthorizations are unduly burdensome, unevenly applied, denials are being applied in a discriminatory and arbitrary fashion, and even MORE importantly, the preauthorization rules are being used as a delaying tactic to avoid payment.

The obvious question is "How does this preauthorization system help the patient?" The answer is that it does NOT help the patient. It really hurts the patient and the treating doctor, and frustrates the efforts of treating physicians to provide care and to get proper diagnostic work done.

An outside observer of the system would conclude various basic things about the system as it exists presently.

Field offices, such as the Tyler office on Paluxy, is being bombarded with paperwork, faxes are getting lost, and in general, workers are being overworked and also, confused about what the new rules are.

Injured workers are being kept sick and injured and not allowed to get the care they need, and often, not even essential diagnostic imaging. They are stalled in an administrative and carrier based nightmare of denials, disputes, peer reviews, designated doctors, RMEs, and on and on to the point that many have chronic pain and clinical depression secondary to these problems.

Treating doctors are, without a doubt, quitting the system. It requires more time to do the extra preauthorization requests for staff and doctors, and the ever increasing mountains of denials, distputes, and requests for preauthorization and other authorizations that often never come, make the doctors want to discontinue this headache.

And, with the above situation, again, quo bene (who benefits) ? The patient certainly does not benefit when their treating doctor withdraws from a system which has become so hopelessly mired in paperwork, and so corrupt that nothing can get done within a reasonable time frame, and when they may not even get paid at all on patient care.

As noted earlier, if no health networks form this year, and the ADL base continues to shrink from attrition and frustration, and the ADL list disappears in 2007, it doesn't take an Einstein to see the system is heading for a true crisis point, attributable directly to implementation of the wrongheaded House Bill 7 provisions.

Also, some attorneys are pointing out that if insurance carriers set treatment parameters for doctors in these phantom health networks, and a patient sustains harm and additional injury or loss of function secondary to the enforcement of these diagnostic and treatment parameters, will these insurance carriers be liable for such damages, and at what point does the establish of such parameters and guidelines, constitute the practice of medicine without a license.

To say that House Bill 7 and its implementation is wrongheaded, is to vastly understate the case. I have looked at the Bill, and with few exceptions, it places the real power and advantage in the hands of the employer / insurance carrier, and how is this EVER fair to the injured worker? It manifestly is NOT !

There are several REAL and POSITIVE and CONSTRUCTIVE changes which WOULD have helped the WC system. One would have been to actually require ALL employers to be subscribers, as it is done in EVERY other state that has Work Comp.

From TDI's OWN WEBSITE, a page at:www.tdi.state.tx.us/wc/regulation/roc/nonsub93.html says :"Based on our analysis of TEC, TWCC and survey data, we estimate that 44 percent of Texas employers are nonsubscribers, and 20 percent of Texas employees are employed by non-subscribing employers. Nonsubscription increases as the size of the employer decreases. Forty percent of employers with two to five employees are nonsubscribers compared to 12 percent of employers with more than 1,000 employees."

And, I believe, we can only expect the number to rise, because there is NO punishment for NOT being a subscriber, and in point of fact, injured workers working for non-subscribers, find it all but impossible for an attorney to take their case. I have seen this latter situation in my own patients injured at non-subscriber businesses.

It is quite clear to me, and other doctors I have spoken with, some who have been in the system for 23 years, that the system as it is developing under the Commissioner and implementation of House Bill 7 provisions by way of rule adoption, is more broken than it ever was, and is more UNFAIR to injured workers than it ever was.

Furthermore, I am only a layperson, but I believe that the amount of cases in which the insurance carrier is acting in bad faith and unfair dealing toward the injured worker, is increasing at a phenomenal rate, dare I say, it is expanding exponentially.

Thus, my public comment on 134.600 must be as a subset of my overall comments on the implementation of House Bill 7 in general. It is the complete ruin of the system from a practical and logistical standpoint.

The Work Comp division of TDI is already overloaded, underpaid, and overworked, and as a result, the system is breaking down at a rapid pace.

I would dare to say that at this point, the real driving force behind what is happening at DWC is ENTROPY, the second law of thermodynamics, such that there is the tendency of things to go from a state of order, to a state of chaos, and just as in the physical world, as heat is input into the system (i.e. stress, agitation, frustration), the level of disorder and chaos increases.

I do not believe this is overstating the case.

Besides the mandatory inclusion of all businesses into a subscriber base, the next change that is needed is for a mandatory reassessment of all designated doctors.

As it is, a "bad" or "unfair" designated doctor can stop a patient's care, render them at MMI, and give them a low impairment rating, and can do this on worker after worker for years, without them being removed from the list. In my modification, workers would be able to rate the fairness of Designated Doctor exams, and if a designated doctor gets consistently low ratings, there needs to be an assessment of their practices and procedures, with perhaps spot second opinion exams to see if their results were verifiable.

Next, the newly created :Office of Injured Employee Counsel" needs to be aggressively marketed to injured workers, meaning that ALL injured workers currently in the system should receive an informational paper about the OIEC as a vehicle for consumer advocacy with regard to work comp issues. Most injured workers aren't even aware of this option.

Also, the whole process of Medical Dispute Resolution needs to be expedited and made easier for providers to avail themselves With as many denials and disputes as are being encountered, this process is very necessary, or doctors will not be paid,and if they are not paid, they cannot afford to do Work Comp on a "pro bono" level.

If proactive changes are NOT implemented, I predict rather strongly, this system is in for real problems, both procedurally and legally, and even worse, injured workers will be suffering even more than they are now.

Injured workers as citizens of Texas, deserve better than that.

Please take my comments into consideration as someone who is one of the quickly dwindling list of providers in East Texas.

Respectfully submitted,

John Raymond Baker , B.S.,D.C.
BAKER CHIROPRACTIC, PA