The California Medical Association (CMA) has launched another assault on SB 899.

First, it attempted unsuccessfully in both the Legislature and before the Division of Workers' Compensation to allow individual providers to opt out of medical provider networks (MPNs) when the network and provider lists are resold to another payer. This effectively would have made it impossible to maintain the networks over the long term.

Now in their sights are utilization review (UR) regulations. Consistent with SB 228 and SB 899, UR regulations require a California-licensed physician to be the medical director, overseeing compliance with utilization review procedures. But the regulations do not require a California-licensed physician to make the initial decisions as to whether to delay, modify or reject a request for authorization. These regulations, lawyers tell us, are consistent with language in SB 228 and SB 899, and coincidentally, language in both the Health and Safety Code and Insurance Code dealing with health insurance utilization review.

CMA claims that by authorizing non-California-licensed physicians to undertake utilization review, DWC Administrative Director Andrea Hoch is allowing unauthorized practice of medicine in California. Well, that's pretty darn serious, isn't it? After all, California doctors claim that out-of-state doctors lack specific expertise in California's workers' compensation laws and treatment protocols. Or is it just a case of good old-fashioned medical franchise protectionism?

"Specific expertise in California's workers' compensation laws" must mean specific expertise in ACOEM treatment guidelines and evidence-based, peer-reviewed, nationally recognized standards of care required to be developed under SB 899. Odd, but these standards probably are not locked up in a vault in Visalia and shown only to CMA members.

In fact, SB 899 developed these standards precisely because California-based "standards" of practice-any treatment an applicant attorney could convince a judge to agree to-not only cost employers billions of dollars but kept injured workers from returning to work.

Maybe CMA's outrage over the AD's rules is, says CMA CEO Jack Lewin, M.D., because it can't talk to [reviewing doctors] when they are far away, because it has no way to evaluate whether those docs are competent, and because it can't complain.

Maybe his version of SB 899 doesn't have the medical-legal process in the Labor Code, and maybe his version of the AD's regulations and SB 899 omitted the provisions stating that only a licensed physician who is competent to evaluate specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician's practice, may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve.

The CMA should read the proposed Labor Code 4610 audit and penalty provisions providing for significant penalties against employers and insurers whose physicians don't meet the criteria of SB 899 and assure that they are competent to make decisions as to whether requests for authorization of treatment are consistent with nationally recognized treatment guidelines required by law.

Now, access for a doctor to talk to someone about denial of authorization, well, that sounds pretty serious, too. Somewhere the Executive must have missed the repeal of the portion of the Labor Code that states that a " workers' compensation insurer, third-party administrator, or other entity that requires, or pursuant to regulation requires, a treating physician to obtain either utilization review or prior authorization in order to diagnose or treat injuries or diseases compensable under this article, shall ensure the availability of those services from 9 a.m. to 5:30 p.m. Pacific coast time of each normal business day." CMA may have missed this, because a review of the analysis of the legislation that enacted this requirement shows that CMA was never a supporter. Of course, it was passed in 1999, so maybe they have conveniently forgotten about it.

When the medical community was taking on the managed care industry during Gray Davis' tenure as governor, it supported a number of bills that set forth guidelines on utilization review. One of those, SB 59 (Perata), required medical directors of health care plans and insurers to have California licenses. The law also stated that "(n)o individual, other than a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider, may deny or modify requests for authorization of health care services for an enrollee for reasons of medical necessity." No mention of a California license, is there?

SB 899 states: "(n)o person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician's practice, requested by the physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve." It, too, explicitly requires medical directors to have California licenses. There is a reason why the language in the Labor Code looks so much like the language in the Health and Safety Code and the Insurance Code-it's called cut and paste, a remarkable device that allows legislative consultants to draft weighty laws in very short order.

Do you still wonder why Director Hoch thought she had the authority to allow competent doctors licensed in other states to review requests for authorization?

This issue can best be summed up by Governor Davis' veto message on AB 58 (Davis), a 1999 bill that expressly required physicians doing UR, not just medical directors, to have a California license: "I have already signed Senate Bill 59 which requires an HMO's Medical Director to be licensed in this state. I am concerned, however, that AB 58 will unduly restrict the ability of health plans and insurers to retain the services of out-of-state professionals (for example, physicians from the Mayo Clinic, Johns Hopkins and Sloan-Kettering) who may be needed to make medical necessity decisions."

Good for you, Gray. As for CMA, unless and until you recognize that there is a problem with the way physicians abuse the prescription drug benefit and make a mint repackaging drugs (yes, we did notice you opposed SB 292), and unless and until you realize that quality medicine is based on national protocols and not those cooked up by judges who are really referees or self-interested industrial medicine "experts" who were a very large part of the problem that SB 228 and SB 899 sought to solve, it is going to be very hard to be sympathetic to your complaints.

In other words, shut up and go away until you wash your hands.