Transcript Professional Boundaries Presentation

Professional Boundaries
Medical Practice Act, Laws and
Resources
Alan I. Kaplan, Attorney at Law
www.alanikaplan.com
Learning Objectives
• Not to learn all the laws
• Understand Rationale Underlying Laws
• Develop Strategies to:
– Avoid Board Scrutiny
– Invite Board Scrutiny Where Appropriate
– Productively Respond to Board Scrutiny
• Develop Understanding of Political
Realities that Drive Board Actions
What Board Does and Why
• Mission of every health care licensing
board—To protect the public, not the
licensee.
– Burden on licensee to show they acted
properly
– Take pains not to antagonize Board personnel
• Board Members vs. Board Staff
– Differing responsibilities and functions
What Board Does and Why
• Political realities driving board actions
– News Media Reports
• Conrad Murray-Kept Cal License-Board Too Soft
• Texas Board too soft
• Interesting discipline cases reported-sexual
misconduct
– Governor and Legislature
– Board staff responses-actions, website
– Money spent on investigation-”Tipping Point”
Board Structure
• Separation of powers (Legislative,
executive, judicial) within the Board
– Enactment of regulations and policies
– Disciplinary players-Executive staff, Attorney
General, Office of Administrative Hearings
and ALJ
• Powers and rights of Board
• Powers and rights of Licensees
Medical Practice Act
• Structure and Function of Medical Board
• Ban on corporate practice of medicine
(2052)
• Discipline
• Miscellaneous (laser light study, etc.)
Medical Board Regulations
• Passed by Board after public comment
• Same force as statutes
• Board’s interpretation given great weight
by courts
• Posted on Med Board’s website
Medical Board Policies
Written and Unwritten
• Enacted without public comment
• May or may not be on website
• Contrary to Board statements, do not
constitute either law or statement of
standard of care.
Use of Attorneys
• Attitude of Board investigators
• Costs vary based on how early utilized
• Negative perception that presence of
attorney signifies guilt
• Section of attorney-Board experience
• Compensation
• Insurance issues
Adopting proper attitude
•
•
•
•
•
•
Concern with Board’s mission
Candor
Completeness of records produced
Use of expert reports
Behaviors to Avoid
Criminal Violations-First and Second
Offenses
Problem areas
•
•
•
•
•
•
•
Falsifying applications
Crimes-felonies misdemeanors and crimes
Unlicensed practice
Conduct out of the office
CME documentation
Renewal fees
“Unprofessional Conduct”
Resources
•
•
•
•
•
•
•
•
www.Medbd.ca.gov
www.dea.gov
www.abms.org
www.cmanet.org
www.ombc.ca.gov
www.supportprop.org
medbd.ca.gov/pain_guidelines.html
www.alanikaplan.com
Strategies to Avoid Adverse
Scrutiny
•
•
•
•
•
•
•
•
Employees
Patients
Statistical
Transparent record keeping
Internal audits
Criminal violations
Suspicious activity by patients
Business arrangements
Case Examples
•
•
•
•
Med Board Precedential Decisions
Sample Med Board cases
DEA
Medicare/MediCal
Medical Equivalent Dose (MED)
 A measure of the total amount of opioid load
 Opioid Dose Calculator –
www.agencymeddirectors.wa.gov/guidelines.asp
 Ex: oxycontin 10 mgm, 6/d + vicodin 6/d = 120 MED
 MTUS: “Recommend that dosing not exceed 120 mg oral
morphine equivalents per day…In general, the total daily
dose of opioid should not exceed 120 mg MED. Rarely,
and only after pain management consultation, should the
total daily dose of opioid be increased above 120 mg oral
morphine equivalents (Washington, 2007).”
4/4/2017
© Copyright EK Health Services, Inc. ALL RIGHTS RESERVED
Do Not Duplicate or Distribute without written permission
CDC Grand Rounds: Prescription
Drug Overdoses – an epidemic,
January 13, 2012
 2007 – 27,000 unintentional drug overdose deaths , 1
death every 19 minutes.
 2007 – approximately 700 mg of morphine/person, or 1
vicodin q4h for 3 weeks/person
 The highest risk is patients who are prescribed >100
MED and seek care from multiple doctors.
4/4/2017
© Copyright EK Health Services, Inc. ALL RIGHTS RESERVED
Do Not Duplicate or Distribute without written permission
Practitioners’ Dilemma
Minimizing Potential For Abuse and Diversion of
Scheduled Medications Without Compromising
Access For Pain Patients With Legitimate Medical
Needs
Pain Is Subjective. How Do You Measure Pain? How Do
You Measure The Efficacy of the Prescribed
Medication?
4/4/2017
© Copyright EK Health Services, Inc. ALL RIGHTS RESERVED
Do Not Duplicate or Distribute without written permission
17
Practitioners’ Dilemma
Minimizing Potential For Abuse and Diversion of
Scheduled Medications Without Compromising
Access For Pain Patients With Legitimate Medical
Needs
Pain Is Subjective. How Do You Measure Pain? How Do
You Measure The Efficacy of the Prescribed
Medication?
4/4/2017
© Copyright EK Health Services, Inc. ALL RIGHTS RESERVED
Do Not Duplicate or Distribute without written permission
18
Why do doctors overprescribe pain medications?
 They Believe They Are Helping Their Patients.
 They Are Intimidated By Their Patients.
 They Are Naïve And Believe Everything Patients Says About The





Pain… pssst, Patients Have Learned to Exploit the System!
Their Business Model May Depend On Keeping A Large Number
Of Patients On Chronic Medications.
They Believe In The “Medical Model” Of Pain, i.e., The Pain Is
Physiologic.
Inertia
WC Payers Will Not Authorize Detoxification Programs, Cognitive
Behavioral Therapy Or Other Treatment Options.
$$$, Follow The Money!
4/4/2017
© Copyright EK Health Services, Inc. ALL RIGHTS RESERVED
Do Not Duplicate or Distribute without written permission
19
Predictors of Drug Abuse
 Personal and family history of prescription, alcohol, and
illegal drug use
 Age 16 – 45
 Cigarette smoking
 History of preadolescent sexual abuse
 Criminal behavior
 Presence of psychiatric disorder
 Aberrant behavior – appearance
4/4/2017
© Copyright EK Health Services, Inc. ALL RIGHTS RESERVED
Do Not Duplicate or Distribute without written permission
20
CURES
Responsible for assisting in the reduction of
diversion without affecting legitimate practice
and medical care.
4/4/2017
© Copyright EK Health Services, Inc. ALL RIGHTS RESERVED
Do Not Duplicate or Distribute without written permission
21