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(c) 2010-2024 Jon L Gelman, All Rights Reserved.

Thursday, December 25, 2014

As Docs Face Big Cuts In Medicaid Pay, Patients May Pay The Price

Today's post was shared by Kaiser Health News and comes from kaiserhealthnews.org

Andy Pasternak, a family doctor in Reno, Nev., has seen more than 100 new Medicaid patients this year after the state expanded the insurance program under the Affordable Care Act.
But he won’t be taking any new ones after Dec. 31.  That’s when the law’s two-year pay raise for primary care doctors like him who see Medicaid patients expires, resulting in fee reductions of 43 percent on average across the country, according to the nonpartisan Urban Institute.


“I don’t want to do this,” Pasternak said about his refusal to see more Medicaid patients next year. But when the temporary pay raise goes away, he and other Nevada doctors will see their fees drop from $75 on average to less than $50 for routine office visits.
“We will lose money when they come to the office,” he said.
Experts fear other doctors will respond the same way as Pasternak, making it harder for millions of poor Americans to find doctors. The pay raise was intended to entice more physicians to treat patients as the program expanded in many states. In the last year, Medicaid enrollment grew by almost 10 million and now covers more than 68 million people nationwide.
The challenge is to convince physicians not just to continue accepting such patients but to take on more without getting paid what they’re used to, said Dr. J. Mario Molina, CEO of Molina Healthcare, one of the nation’s largest Medicaid insurers.
Charles Duarte, CEO of a large community...
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Wednesday, December 24, 2014

CDC worker monitored for possible Ebola exposure in lab error

Health care workers are particularly susceptible to becoming effective with disease. Today's post is shared from cdc.gov/

A laboratory technician for the U.S. Centers for Disease Control and Prevention has been placed under observation for possible exposure to the deadly Ebola virus due to an apparent mix-up in lab specimens, the Atlanta-based agency said on Wednesday.

The technician, who was working on Monday with Ebola specimens that were supposed to have been inactivated but which may instead have contained live virus, will be monitored for signs of infection for 21 days, the disease's incubation period, CDC officials said.

The error follows two high-profile cases of mishandled samples of anthrax and avian influenza at the CDC earlier this year that called into question safety practices at the highly respected research institute and drew criticism from Capitol Hill.

CDC spokeswoman Barbara Reynolds told Reuters the technician's risk of exposure to Ebola, even if the virus were active, was believed to be low and that the worker was not being quarantined while under observation.

She said a small number of other CDC employees who entered the lab where the samples in question were handled also "were assessed and none require monitoring."

"There was no possible exposure outside the secure laboratory at CDC and no exposure or risk to the public," the agency said in a statement. Lab scientists discovered on Tuesday what had transpired, and reported it to superiors within an hour, it said.

The problem occurred when active Ebola virus samples were believed to have been mixed up with specimens that had been rendered inactive for further testing in a lower-security lab down the hall, Reynolds said.

When inactivated specimens turned up the next day in storage, lab personnel realized that they apparently had transferred the wrong samples, ones that had contained active virus material, out of the higher-security lab, Reynolds said.

CDC officials could not be certain because the material in question had by then been destroyed and the lower-security lab decontaminated under routine safety procedures, she said.


Related:

Dec 01, 2014
Today's post is shared from nytimes.com/ A day after a doctor who had returned from Guinea about a week earlier became New York's first Ebola case, the governors of New York and New Jersey announced that they would ...
Nov 01, 2014
The newest legal practice area is Ebola Law. Like the rapidly developing infectious disease the legal ramifications of Ebola are quickly emerging. Issues from medical treatment, lost time payments, medical and product liability ...
Oct 18, 2014
Hazmat workers help each other put on protective clothing before entering The Village Bend East apartment complex where a second health care worker who has tested positive for the Ebola virus resides on October 16, 2014 ...
Oct 25, 2014
The governors of New York and New Jersey on Friday ordered quarantines for all people entering the country through two area airports if they had direct contact with Ebola patients in Guinea, Liberia and Sierra Leone.

Newt Gingrich Is Back: Now Wants To Protect Workers From Unions

Today's post is shared from washingtonpost.com/
On Election Day, voters didn’t just rebel against President Obama. There was another pattern in the candidates they chose: Across the country, they picked pols who explicitly supported individual employee rights.
This wasn’t just a canned part of every Republican’s platform. Govs. Scott Walker of Wisconsin and Rick Snyder of Michigan, for instance, both won reelection after pushing through significant employee-friendly reforms in their first terms. Even in deep-blue Illinois, Republican Bruce Rauner campaigned on a platform to give state employees the right to decide for themselves whether to join a union.

Pro-employee rights candidates now hold majorities in both the U.S. House and Senate, and it’s time for Congress to deliver the pro-employee agenda that has gained so much momentum in the states. Here’s how members can enhance employee rights in the workplace.

The best legislative vehicle for advancing those rights is the Employee Rights Act (ERA). Led by Sen. Orrin Hatch (R-Utah) and Rep. Tom Price (R-Ga.), the ERA has 29 co-sponsors in the Senate and more than 100 in the House. It’s the most significant rewrite of the National Labor Relations Act in decades, with a twist: Instead of the gridlock that comes with trying to rig labor law to benefit either unions or employers, it focuses squarely on the rights of the employees. (All of the law’s provisions can be viewed at EmployeeRightsAct.com.)

Take...
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Related:
Sep 25, 2008
Gingrich is suggesting that employees be “self-insured” for injuries and illnesses and resulting disability freeing the employees of the need to contribute to insurance coverage or Social Security benefits at all. A recent article in ...
May 11, 2011
Common themes of a single payer medical system are emerging. History can repeat itself. The announcement by Newt Gingrich to run for the presidency in 2012, and the anticipated signing of the Vermont Single Payer ...
Dec 07, 2011
The NY Times reports today that presidential hopeful, Newt Gingrich is taking the lead in the Iowa state Caucus poles. Over the past years, during his absence from Washington politics, Gingrich has been involved in lobbying ...
Nov 22, 2011
Newt Gingrich's poll numbers are soaring for the US Presidential nomination. He has announced that he will offer radical proposals including the elimination of child labor laws. For decades child labor laws and penalties have ...

Florida has a Large Percentage of Medicare's top "Controlled-Drug" Prescribers

Today's post is authored by Judge David Langham and shared from flojcc.blogspot.com/

A story was recently published on the WUSF website, Health News Florida. It says that the "prolific prescribers" of some medications are facing "Medicare scrutiny."

A chart in the story reflects the distribution of 192 top prescribing medical providers in 12 states. Of these, 52, or 27% are located here in the Sunshine State. 

The article notes that in 2012, "Medicare covered nearly 27 million prescriptions for powerful narcotic painkillers and stimulants with the highest potential for abuse and dependence." 

Despite efforts at addressing narcotic use, the article notes that this was a "9 percent" increase compared to 2011. 

Thankfully, though Florida has the largest volume of providers represented in this chart, the top prescriber is not in Florida. Dr. Shelinder Aggarwal of Huntsville, Alabama has that distinction. He prescribed "more than 14,000 Schedule 2 prescriptions in 2012." This amounted to "more than 80 percent of his Medicare patients" receiving "at least one prescription for a Schedule 2 drug, in many cases oxycodone."Apparently he is no longer a physician, the article notes he "surrendered his medical license" in 2013. 

The prescription practices are a "real area of concern" for the federal Centers for Medicare and Medicaid Services, according to the director, quoted in the article. 

The article suggests that data in existing resources can...

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Lawyers: A Vanishing Breed


"No one is going to law school. Fewer people enrolled in law school this year than at any point in the last four decades. The number of first-year law students has declined by 28 percent since 2010, hitting a historic low of less than 38,000 in 2014. That might have something to do with their dimming job prospects. "

Click here to read "The 9 Worst Questions Your Parents Will Ask You This Week, and the Data You Need to Answer Them" businessweek.com

Where the Workers' Compensation Medical Dollar Goes in Florida


"Medical cost drivers, particularly in the areas of drugs, hospital inpatient, hospital
outpatient and ambulatory surgical centers (ASC) are noticeably higher in Florida than a
countrywide average. Legislative reform in the reimbursement of these services could
produce substantial savings for Florida employers. "
Florida Office of Insurance Regulation, Workers’ Compensation Annual Report December 2014

Defense Base Act Claims: More Private Military Contractors Head for Iraq

A Shi'ite fighter walks during an intensive security deployment against Islamic State militants in Balad, north of Baghdad December 15, 2014. REUTERS/Mahmoud Raouf Mahmoud
As the US begins to deploy military troops back to Iraq  the number of private military ccontractors will also increase. Logically the number of Defense Base Act claims will also begin to esculate as injuries and illnesses with increase   Today's post is shared from reuters.com/

The U.S. government is preparing to boost the number of private contractors in Iraq as part of President Barack Obama's growing effort to beat back Islamic State militants threatening the Baghdad government, a senior U.S. official said.

How many contractors will deploy to Iraq - beyond the roughly 1,800 now working there for the U.S. State Department - will depend in part, the official said, on how widely dispersed U.S. troops advising Iraqi security forces are, and how far they are from U.S. diplomatic facilities.

Still, the preparations to increase the number of contractors - who can be responsible for everything from security to vehicle repair and food service - underscores Obama's growing commitment in Iraq. When U.S. troops and diplomats venture into war zones, contractors tend to follow, doing jobs once handled by the military itself.

"It is certain that there will have to be some number of contractors brought in for additional support," said the senior U.S. official, speaking on condition of anonymity.
After Islamic State seized large swaths of Iraqi territory and the major city of Mosul in June, Obama ordered U.S. troops back to Iraq. Last month, he authorized roughly...
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Tuesday, December 23, 2014

Union Leaders Attacked at Bangladesh Garment Factories, Investigations Show

Today's post was shared by Steven Greenhouse and comes from mobile.nytimes.com

The garment factory’s closed-circuit camera captured some unusual activity: Out front a female union leader was swarmed by people, pushed to the ground and assaulted while a male union activist was chased away and punched.
Another female union leader entered the factory door and seconds later was pushed outside, then shoved out of camera range.
Two investigations of the episodes depicted in the video, one led by a Washington-based workers’ rights group and another by a prominent American apparel company, determined that the camera footage showed that factory managers directed those attacks at the Global Garments factory in Bangladesh on Nov. 10.
The attacks occurred three months after a female union president was beaten in the head with an iron rod just outside another factory owned by the same company, the Azim Group, requiring her to get more than 20 stitches, workers’ rights groups say. They maintain that company-directed thugs carried out that assault, while the Azim Group said the assault resulted from a feud involving a former husband that, the company’s law firm said, “occurred outside working hours, outside the factory grounds, outside any industrial dispute.”


The Azim Group, which says it has 24 factories and employs 27,000 workers, said it was not involved in either altercation. Mishcon de Reya, a law firm representing Azim, said the November dispute “arose between the workers and union leaders.”
These attacks occurred...
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The New Robber Barons

aldrich2
Today's post is shared from Bill Moyers.com/
The Treason of the Senate
We’ve just watched the Senate and the House — aided and abetted by President Obama — pay off financial interests with provisions in the new spending bill that expand the amount of campaign cash wealthy donors can give, and let banks off the hook for gambling with customer (and taxpayer) money.
What happened in Washington over the past several days sounds strikingly familiar to the First Gilded Age more than a century ago, when senators and representatives were owned by Wall Street and big business. Then, as now, those who footed the bill for political campaigns were richly rewarded with favorable laws.
Bill’s guest this week, historian Steve Fraser, says what was different about the First Gilded Age was that people rose in rebellion against the powers that be. Today we do not see “that enormous resistance,” but he concludes, “people are increasingly fed up… their voices are not being heard. And I think that can only go on for so long without there being more and more outbreaks of what used to be called class struggle, class warfare.”
Steve Fraser is a writer, editor and scholar of American history. Among his books are Every Man a Speculator, Wall Street: America’s Dream Palace and Labor Will Rule. His latest, The Age of Acquiescence: The Life and Death of American Resistance to Organized Wealth and Power, will be published early next...
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AbbVie Deal Heralds Changed Landscape for Hepatitis Drugs



Today's post is shared from NYTimes.com/
In a sign that price competition may take hold for hepatitis C drugs, the nation’s largest manager of prescriptions will require all patients to use AbbVie’s newly approved treatment rather than two widely used medicines from its rival Gilead Sciences.
The pharmacy benefit manager, Express Scripts, said it had negotiated a significant discount from AbbVie in exchange for making the drugmaker’s treatment, Viekira Pak, the exclusive option for 25 million people. Express Scripts also said it would allow all people with hepatitis C to be treated with AbbVie’s drug, not only those with more serious liver damage.
“We really believe we want all patients treated,” Dr. Steve Miller, the chief medical officer of Express Scripts, said in an interview Sunday. He said that AbbVie had made that affordable by offering “a significant discount.”
Gilead’s drugs have set a new standard, curing the vast majority of patients in only 12 weeks with few side effects. But their prices have ignited an outcry. One drug, Sovaldi, has a list price of $84,000 for a typical 12-week course of therapy, or $1,000 per daily pill. The newer Harvoni costs $94,500 for 12 weeks.
Gilead says the prices reflect the value the drugs bring to patients and the health care system. But some health plans, state Medicaid programs and prison systems say the drugs are busting their budgets. Many have been limiting treatment to only the sickest patients. Congress has...
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Medicare tells N.J. hospitals they must do more on patient care, safety

Please post to shared from North jersey.com/
The penalties levied by Medicare against more than one-third of the state’s hospitals over patient-safety issues make clear that New Jersey has a long way to go to make hospital stays safer, experts say.
Twenty-three hospitals statewide, including six in North Jersey, face cuts of 1 percent in their Medicare reimbursement for the year that began Oct. 1. The penalties mean millions of dollars in lost revenue because the government insurance program starting at 65 is the single largest payer for most hospitals.
But “forget about the fact that it’s costing a lot of money,” said David Knowlton, the chief executive of the New Jersey Health Care Quality Institute, a non-profit group that promotes quality, safety, accountability and cost containment in health care. “These hospital-acquired conditions cause a lot of pain.”
Bloodstream and urinary-tract infections that develop because of unsanitary practices in the hospital, as well as collapsed lungs, bedsores, and broken hips from hospital falls contribute to the deaths of an estimated 180,000 Medicare patients nationwide each year. They extend some hospital stays, necessitating additional treatment, and increase the cost of care.
More alarming than New Jersey’s hospitals’ poor performance, compared with that of hospitals in other states, he said, was the fact that the problems cited involved care of the elderly.
The government data upon which...
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….

Jon L. Gelman of Wayne NJ is the author of NJ Workers’ Compensation Law (West-Thompson-Reuters) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson-Reuters). For over 4 decades the Law Offices of Jon L Gelman  1.973.696.7900  jon@gelmans.com  have been representing injured workers and their families who have suffered occupational accidents and illnesses.

Monday, December 22, 2014

McDonald’s charged with abusing workers over wage protests

Today's post is an interview of Steven Greenhouse, retiring Labor reported for the nytimes.com/, condusted on the PBS Newshour.

HARI SREENIVASAN: Yesterday, we told you that the National Labor Relations Board filed formal complaints against McDonald’s and some of its franchisees.
To unpack this story further, we’re joined now by Steven Greenhouse. Until this past week, he was a correspondent for The New York Times who covered labor issues, among other things.
So, what does the NLRB allege that McDonald’s or its franchisees did?
STEVEN GREENHOUSE: So, the Labor Board says that McDonald’s and many of its franchisees around the country improperly retaliated against, spied on workers who participated in this Fight for 15 campaign of fast food workers, demanding a base wage of $15 an hour at fast food restaurants around the country.
HARI SREENIVASAN: OK.
So, there’s usually a distinction between McDonald’s, the owning franchise, or, I guess, the brand, and all of the franchisees. But why are they lumped together in this?
STEVEN GREENHOUSE: What’s really gotten under McDonald’s and the business community’s skin is the general counsel of the National Labor Relations Board is saying McDonald’s is a joint employer with its franchisees.
So, it’s saying that a franchise that might have 30 employees and often acts as if, well, I, the franchise owner, I’m the only employer, the NLRB is saying McDonald’s exercises so much influence over the restaurants, telling them, you know — with all sorts of requirements about how to cook,...
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Workers’ Rights at McDonald’s

Today's post is shared from nytimes.com/, an editorial.

The Fight for $15 is ending the year on a high note. The protest movement, which began in New York City two years ago with fast-food workers demanding at least $15 an hour and the right to unionize without retaliation, has spread to more than 100 cities and many industries, including retail, home care, hospitality and airport services.

On Friday, the federal government validated the workers’ concerns when the general counsel’s office of the National Labor Relations Board issued 13 complaints, containing dozens of charges, against the McDonald’s Corporation and many of its franchisees for violating employees’ rights to press for better pay and working conditions. The alleged violations involve coercive conduct against workers who supported the protests, including threats, surveillance, interrogations, firings, discriminatory discipline, reduced hours and excessive restrictions on conversation about unions or work conditions. Managers were also said to have offered promotions in exchange for giving up the fight.

Memo to McDonald’s: Wouldn’t it be easier just to bargain over the terms and conditions of employment?

The N.L.R.B. complaints hold McDonald’s jointly responsible for the labor practices at its franchisees’ restaurants. The “joint employer” designation undercuts the corporation’s longstanding claim that the treatment of McDonald’s workers is not its responsibility, but the sole responsibility of...
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Sunday, December 21, 2014

Senator Boxer calls US chemical facility safety “outrageous” and “unacceptable”

Today's post is shared from scienceblogs.com/

As last week’s Senate Environment and Public Works Committee hearing made abundantly clear, communities throughout the United States are at ongoing risk from potentially disastrous incidents involving hazardous chemicals. A new Congressional Research Service report released concurrently by Senator Edward J. Markey (D-MA), details how thousands of facilities across the country that store and use hazardous chemicals are located in communities, putting millions of Americans at risk. Yet this list of facilities, Senator Markey’s office points out, may not be complete. The report analyzes US Environmental Protection Agency (EPA) data on locations where at least one of 140 different extremely hazardous materials are stored. But this EPA list does not include the highly explosive substance ammonium nitrate – the chemical involved in the April 2013 West, Texas fertilizer plant explosion that killed 15 people and injured approximately 200.

What has happened – or more precisely, not happened – since that incident was the focus of the December 11th Senate hearing. The hearing, convened jointly with the Senate Health, Education, Labor and Pensions Committee, was held to review progress made in implementing President Obama’s Executive Order 13650 issued in August 2013 in the wake of the West, Texas disaster.

“In the 602 days since the West, Texas tragedy there have been 355 chemical...
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Close Down All Second Injury Funds?

Today's post is shared from reduceyourworkerscomp.com/

Employers get little to no relief from state workers compensation second injury funds.  Many state second injury laws are weak, ill defined, are hard to penetrate, and may lack proper funding. Rules and regulations make it hard for a claim to be  acceptance by a second injury fund.

Funding programs for second injury funds vary greatly. Some are funded from insurance carrier premium assessments.  Others are funded from state budgets and legislative action.  Most funding programs may fail to meet the fund exposures or liabilities.  This means that even if a claim is accepted by a fund, the employer may not be able to recover their expended funds. The employer has to handle and pay the claim before seeking reimbursement from the second injury fund.

Second Injury Funds and rules became prevalent after World War II as a program to induce employers to hire handicapped veterans.   By then workers compensation law, legal precedent, and regulation had clearly established that the employer took the employee as is.  This meant any employee with an underlying pathology or disability, who sustained a compensable injury which aggravated or increased the overall heath or disability costs had to be borne by the employer.
The second injury fund program gave the employer relief from the expense of the aggravation or increased disability. The fund would take over the claim handling and cost after certain set periods of time...
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Cancer from asbestos caused by more than one cell mutation

Today's post is shared from sciencedaily.com/

Malignant mesothelioma is a rare form of cancer that affects the mesothelium -- the protective lining that covers the internal organs, such as the lungs, the heart and the abdominal cavity. It is estimated that malignant mesothelioma affects up to 3,200 people in the USA each year, most of whom die within a year of diagnosis. The primary cause of this cancer is exposure to asbestos, which used to be used in building construction. The inhalation of asbestos fibers causes inflammation that can cause mutations in cells even after 30-50 years of dormancy.

Most cancers are thought to be monoclonal, where all the cells in a tumor can be traced back to a mutation in a single cell. Researchers from University of Hawaii Cancer Center set out to investigate whether this was the case with malignant mesothelioma, or if it was polyclonal in which the tumor is the result of the growth of two or more mutant distinct cells.

During early development of the female embryo one of the two X chromosomes becomes inactivated and this inactivation is passed on to all subsequent cells. By tracing this inactivated X using a process called HUMARA assay it is possible to determine whether or not a cancer is monoclonal.

In this study, 16 samples from 14 tumor biopsies from women with mesothelioma had a HUMARA assay performed on them. These were compared to control DNA samples from a healthy male and female, and a known monoclonal cell line. The samples provided insight into the origin of...
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….

Jon L. Gelman of Wayne NJ is the author of NJ Workers’ Compensation Law (West-Thompson-Reuters) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson-Reuters). For over 4 decades the Law Offices of Jon L Gelman  1.973.696.7900  jon@gelmans.com  have been representing injured workers and their families who have suffered occupational accidents and illnesses.

From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages


 
Northwest Financial Services first sued Keith and Katie Herie when they couldn't afford the $14,000 bill for Katie's emergency appendectomy. Since 2006, the Heries have had almost $20,000 taken from their wages to repay medical bills and still owe at least $26,000, with interest mounting. (Steve Hebert for ProPublica)
This story was co-published with NPR and is shared from .propublica.org/

On the eastern edge of St. Joseph, Missouri, lies the small city's only hospital, a landmark of brick and glass. Music from a player piano greets visitors at the main entrance, and inside, the bright hallways seem endless. Long known as Heartland Regional Medical Center, the nonprofit hospital and its system of clinics recently rebranded. Now they're called Mosaic Life Care, because, their promotional materials say: "We offer much more than health care. We offer life care."

Two miles away, at the rear of a low-slung building is a key piece of Mosaic—Heartland's very own for-profit debt collection agency.

When patients receive care at Heartland and don't or can't pay, their bills often end up here at Northwest Financial Services. And if those patients don't meet Northwest's demands, their debts can make another, final stop: the Buchanan County Courthouse.

From 2009 through 2013, Northwest filed more than 11,000 lawsuits. When it secured a judgment, as it typically did, Northwest was entitled to seize a hefty portion of a debtor's paycheck. During those years, the company garnished the pay of about 6,000...
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Saturday, December 20, 2014

Injured North Providence school custodian wins workers’ comp lawsuit against town

Today's post is shared from providencejournal.com/

A North Providence school custodian recently won a workers’ compensation lawsuit against the town.

Joseph J. Adamczyk, who worked at Wayland Elementary School, in North Providence, injured his right shoulder on Aug. 21, 2013 while lifting a chest-high recycling bin filled with old books and being hit by the bin, court documents read. By mid-November of that year, he could no longer work.

Prior to that, he earned an average weekly paycheck of $683.26.

A physician later determined Adamczyk had an anterior/inferior labral tear. He had surgery for the injury in September 2014.

Judge Dianne M. Connor ruled on Dec. 12 that the town pay Adamczyk workers’ compensation benefits — partially disabled for some months and fully for other months –from November 2013 and continuing.

The judge also ordered the town reimburse the Rhode Island Temporary Disability Insurance Fund; pay Adamczyk for his medical treatment, rehabilitation costs, wages he may have earned from another employer while he was injured, and various court costs.
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Ebola Guidelines for the Workers’ Comp Industry

Today's post is shared rom genexservices.com/

The guidelines, “Hemorrhagic Fever Viruses: Ebola and Marburg,” go beyond clinical directives provided by WHO, the CDC or Official Disability Guidelines to provide the much-needed guidance employers and carriers need from a workers’ compensation perspective. “GENEX developed the guidelines at the requests of both internal and external providers and nurse case managers looking for workers’ comp-specific treatment protocols to treat Ebola,” said Dr. Maury Guzick, GENEX branch manager and physician advisor.

“In the workers’ comp field, there are significant risks to health care workers, emergency responders, laboratory and airline staff, among others,” said Guzick. “These workers are more likely to come into contact with an infected person or their bodily fluids. With so many workers at risk, it’s critical that guidelines are developed and made available to help treat infected workers and prevent the spread of diseases such as Ebola and Marburg throughout the U.S. workforce."

Ebola and Marburg are rare RNA filoviruses that cause severe hemorrhagic fever. The viruses are highly contagious, but only through direct contact with an infected person. After the Ebola infection invades the body, it replicates quickly causing vomiting, diarrhea and rash, and can also lead to both external and internal bleeding. As the virus spreads, it can lead to...
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