State of California (California Correctional Health Care Services) (PERB 2823S)

STATE OF CALIFORNIA
DECISION OF THE
PUBLIC EMPLOYMENT RELATIONS BOARD
UNION OF AMERICAN PHYSICIANS &
DENTISTS,
Charging Party,
v.
STATE OF CALIFORNIA (CALIFORNIA
CORRECTIONAL HEALTH CARE
SERVICES),
Respondent.
Case No. SA-CE-2168-S
PERB Decision No. 2823-S
June 29, 2022
Appearances: Weinberg, Roger & Rosenfeld by Anne I. Yen, Attorney, for Union of
American Physicians & Dentists; California Department of Human Resources by
Nicole D. Lobre, Labor Relations Counsel, for State of California (California
Correctional Health Care Services).
Before Banks, Chair; Shiners and Krantz, Members.
DECISION1
KRANTZ, Member: This case is before the Public Employment Relations Board
(PERB or Board) on exceptions by Respondent State of California (California
Correctional Health Care Services) (CCHCS) to the attached proposed decision of an
administrative law judge (ALJ). The complaint in this matter, as amended, alleged that
1 PERB Regulation 32320, subdivision (d) authorizes the Board to designate a
decision, or any part thereof, as non-precedential. (PERB Regulations are codified at
Cal. Code Regs., tit. 8, § 31001 et seq.) Applying the criteria the regulation
enumerates, we designate as non-precedential Parts II-V of the Discussion, the
remedial order, the appendix, and the attached proposed decision. The Introduction,
Factual and Procedural Background, and Part I of the Discussion are precedential.

2
CCHCS violated the Ralph C. Dills Act (Dills Act)2 by: (1) implementing an Integrated
Substance Use Disorder Treatment (ISUDT) program and a Medication Assisted
Treatment (MAT) program without bargaining in good faith with Charging Party Union
of American Physicians & Dentists (UAPD) over the decision and/or the effects
thereof; and (2) failing to bargain in good faith before requiring all UAPD-represented
primary care providers (PCPs) to obtain “X-Waivers” from the federal Drug
Enforcement Administration (DEA) and fully provide ISUDT/MAT services.
After an evidentiary hearing, the parties submitted post-hearing briefs and the
ALJ issued a proposed decision. The ALJ concluded that while CCHCS had no duty to
bargain over its decision to offer the ISUDT and MAT programs, the Dills Act required
CCHCS to bargain over the decision’s negotiable effects on PCPs’ terms and conditions
of employment. The ALJ further concluded that CCHCS failed to comply with this duty.
The ALJ directed CCHCS, among other things, to cease requiring PCPs to obtain
X-Waivers and fully provide MAT, rescind any discipline issued for violating these
mandates, and make PCPs whole.
CCHCS filed five exceptions to the proposed decision. Broadly categorized, the
first four exceptions ask us to reverse the ALJ’s conclusions on liability, as well as
certain factual findings the ALJ reached. The fifth exception argues in the alternative
that, if CCHCS violated the Dills Act, we should modify the ALJ’s proposed remedy.
UAPD filed no exceptions and asks us to affirm the ALJ’s proposed decision.
2 The Dills Act is codified at Government Code section 3512 et seq. All statutory
references are to the Government Code.

3
We have reviewed the proposed decision, the record, and the parties’
arguments. For the reasons we explain, we affirm the ALJ’s overall conclusion that
CCHCS violated the Dills Act, but we partially grant certain exceptions and therefore
adjust the ALJ’s factual findings, legal conclusions, and remedial order. Other than
those instances in which we partially grant an exception, we affirm the ALJ’s
determinations.
FACTUAL AND PROCEDURAL BACKGROUND3
CCHCS provides medical, dental, and mental health services to inmates at
institutions within the California Department of Corrections and Rehabilitation (CDCR).
Since 2005, a court-appointed receiver has overseen health care services for CDCR
inmates pursuant to a federal action currently styled as Plata et al. v. Newsom et al.,
N.D. Cal. No. C01-1351-JST (Plata). In September 2018, the receiver directed CCHCS
to implement a MAT program for inmates with Substance Use Disorder (SUD). CCHCS
developed a plan to do so as part of an overall ISUDT program. The 2019-2020 State
budget allocated $71.3 million to the ISUDT program, and the 2020-2021 budget
allocated $161.9 million to the program.
UAPD exclusively represents State Bargaining Unit 16, which includes
physicians who serve as PCPs for inmate patients within CDCR. The PCPs’
classification specification and job duty statement require PCPs to provide primary
care. This includes diagnosing patients and prescribing them medication and other
treatment. These job descriptions have never specified that PCPs must obtain an
3 The proposed decision includes a more complete statement of facts. This
section sets forth an abbreviated version, providing context for our legal analysis.

4
X-Waiver. They also have never specified SUD or other medical conditions that PCPs
must treat.4
On July 5, 2019, CCHCS notified UAPD of its plan to implement an ISUDT
program and offered to meet with UAPD if requested. ISUDT includes MAT, which, in
turn, includes medication, therapy, and community support. The primary SUD
medication for inmates in the ISUDT and MAT programs is Suboxone, often prescribed
for inmates with opioid use disorder. At this time, PCPs lacking X-Waivers from the
DEA could not prescribe Suboxone beyond three-day “bridge” orders.5
UAPD requested to bargain, and the parties began ISUDT/MAT negotiations on
October 3, 2019. At the parties’ first bargaining session, UAPD proposed, among
other items, that PCPs trained in treating ISUDT/MAT patients should receive a pay
differential. CCHCS responded two months later, stating that the parties should
bargain any economic proposals in negotiations for a successor Memorandum of
Understanding (MOU). However, during the parties’ subsequent MOU negotiations,
CCHCS reversed course and stated that ISUDT/MAT bargaining was the appropriate
forum for discussing proposed compensation adjustments related to those programs.
During the first year of the parties’ ISUDT/MAT negotiations, CCHCS took a
consistent, two-part position in its proposals: (1) Unit 16 employees must attend all
4 PCPs must hold a license to practice medicine in California. In 2006, prior to
the facts relevant to this case, CCHCS also began requiring newly hired PCPs to hold
a certification in internal medicine or family medicine. CCHCS permitted incumbent
PCPs who lacked such certification to remain non-certified, but they would then not
benefit from a pay raise associated with certification.
5 A bridge order allows a physician to provide continuity of care and prevent
withdrawal symptoms before the patient sees a physician who holds an X-Waiver.

5
assigned SUD training and generally must continue MAT prescriptions for patients
already on MAT;6 and (2) at least for the time being, no Unit 16 employee had to
obtain an X-Waiver or initiate MAT for patients with SUD, unless and until the
employee feels competent to do so. CCHCS further proposed that the parties should
reopen negotiations if CCHCS sought to require employees to obtain an X-Waiver
and/or initiate MAT for patients with SUD. As part of its position, CCHCS claimed that
it had no duty to bargain over mandatory trainings, but stated it did have a duty to
bargain over any requirement that PCPs obtain X-Waivers to prescribe SUD
medication.
UAPD did not agree with CCHCS’s overall proposal and filed this unfair practice
charge alleging that CCHCS was violating its duty to bargain. UAPD did, however,
agree to CCHCS’s proposal regarding mandatory SUD training.
PERB’s Office of the General Counsel issued a complaint against CCHCS in
June 2020. On October 20, 2020, three months before the formal hearing on the
complaint commenced, CCHCS wrote UAPD as follows:
“This is to provide a status of the [ISUDT] Program and the
negotiations associated with the program that have been
taking place since October 2019.
“As you are aware, [CDCR] and [CCHCS] launched the
ISUDT Program as part of their legal obligation to provide
constitutionally mandated health care to the inmate/patient
population. The CDCR and CCHCS developed the program
in response to the severity of overdoses and increase[d]
deaths in the institutions tied to opioid abuse. The program
was implemented in January 2020 targeting patients who
6 As the ALJ noted, the record is unclear as to whether continuing existing
prescriptions is the same as ordering three-day bridge prescriptions.

6
enter prison already on [MAT], patients already in prison
categorized as high risk and patients who are anticipating
release from prison and will be transitioning to their
communities.
“Early in the spring, factors began to impact the ISUDT
program. COVID-19 played a large role in the evolution.
Cognitive Behavioral Interventions (CBI) [were] placed on
hold until alternative plans could be identified and
implemented, and the expedited release of inmate/patients
impacted the initial ISUDT focus group. However, during
COVID-19, there was an unforeseen increase in the
number of inmate/patients needing to participate in the
program.
“Specifically, the main factors driving the higher volume of
patients include:
• 	“Not limiting patient access to Addiction Medicine
providers. Rather any patient at higher risk for morbidity
and mortality related to Opioid Use Disorder/Alcohol
Use Disorder is being referred to the ISUDT program
and for MAT evaluations; and
• 	“Majority of patients assessed, are accepting MAT.
Rather than the projected 50% acceptance rate, ISUDT
program acceptance rate is approximately 90%.
“Because of these changes, CCHCS will be expanding the
training to all [PCPs] to allow for PCPs to manage stable
patients on their panels. CCHCS previously informed UAPD
that, as we rolled this program out there would be an
increase, however, there is an urgent need to
operationalize this statewide to ensure proper care is
provided to the program participants. The training will
continue to be Didactic courses and mentoring by the
Addiction Medicine Central Team and the institution
Champions. This will allow all staff to provide services to
ISUDT patients on a statewide basis.
“In addition, CCHCS now needs full PCP participation in the
management of ISUDT patients on their panels including

7
the prescribing of MAT. As discussed several times at the
table, CCHCS could not close the negotiations without the
ability to come back to UAPD should the need arise to
require the PCPs to obtain an X-Waiver. Based on the rapid
growth of the program there will be an expectation for all
[physicians and surgeons] to obtain their X-Waiver by
June 30, 2021, in order to maintain their privileging and
credentialing. As this negotiation table is still open, it is the
intent of CCHCS to address this change in position at our
next scheduled meeting date.”7
The parties held their next bargaining session on October 28, 2020. At that
session, consistent with the October 20 letter, CCHCS proposed that PCPs must
obtain X-Waivers and begin fully providing MAT by June 30, 2021.
UAPD made a counterproposal when the parties held their next bargaining
session on December 2, 2020. Among other items, UAPD proposed that the X-Waiver
and associated new duties would be mandatory only for employees hired on or after
July 1, 2021. In response, CCHCS stated it was a “management decision” that all
PCPs must obtain X-Waivers and participate in MAT, and CCHCS would not negotiate
over that decision. Although the parties met three more times, the record does not
indicate that CCHCS changed its position on bargaining over X-Waivers and
participation in MAT.
7 In the proposed decision, the ALJ labeled this letter the “October 20 directive”
and concluded that it unilaterally directed PCPs to obtain X-Waivers and begin fully
providing MAT. The letter certainly changed CCHCS’s bargaining position. Standing
alone, however, it was not necessarily a “directive.” On the one hand, the letter
notified UAPD of an “expectation” that employees would need to obtain X-Waivers in
the following eight months. But CCHCS apparently did not send the letter to
employees and, overall, the letter largely indicates that CCHCS remained willing to
bargain over this issue. We therefore refer to CCHCS’s letter as simply the
“October 20 letter.”

8
Meanwhile, the ALJ held six non-consecutive days of hearing beginning on
January 25, 2021. The parties presented their final witnesses and exhibits on the last
hearing day, June 21, 2021, which was shortly before the deadline for PCPs to obtain
X-Waivers and begin fully providing MAT.
CCHCS notified employees that the deadline to obtain X-Waivers was June 30,
2021, and thereafter CCHCS continued to insist on that deadline. This is clear based
on testimony from CCHCS Deputy Director for Medical Services Renee Kanan,
CCHCS negotiator Jan Sale, and Unit 16 PCP Steven Sabo. We also take
administrative notice of the receiver’s June 2021 report to the federal district court in
Plata and related cases, wherein he stated that CDCR “has required all Medical
Services providers” to obtain X-Waivers from the DEA. (https://cchcs.ca.gov/wp-
content/uploads/sites/60/TR/T47_20210601_TriAnnualReport.pdf, p. 5 [as of June 23,
2022].) Thus, while the October 20 letter was not in and of itself a directive to
employees, CCHCS did ultimately require PCPs to obtain X-Waivers and begin fully
providing MAT by on or about July 1, 2021.8
DISCUSSION
Although the Board reviews exceptions to a proposed decision de novo, to the
extent that a proposed decision adequately addresses issues raised by certain
exceptions, the Board need not further analyze those exceptions. (City of San Ramon
(2018) PERB Decision No. 2571-M, p. 5.) The Board also need not address alleged
8 Federal rules regarding X-Waivers changed while the parties litigated the
case. Effective April 2021, PCPs no longer needed X-Waivers to prescribe Suboxone
for up to 30 patients. CCHCS, however, required PCPs “to be X-Waived” to prescribe
Suboxone to at least 100 patients by no later than June 30, 2021.

9
errors that would not impact the outcome. (Ibid.) To the extent an ALJ assesses
credibility based upon observing a witness in the act of testifying, we defer to such
assessments unless the record warrants overturning them. (Los Angeles Unified
School District (2014) PERB Decision No. 2390, p. 12.)
Here, the ALJ found that CCHCS had no duty to bargain over its decision to
institute the ISUDT and MAT programs, but was required to bargain over the potential
effects thereof, including whether PCPs: (1) must complete X-Waiver training and
obtain an X-Waiver; (2) must fully provide MAT; and (3) would receive a salary
increase in exchange for obtaining an X-Waiver and providing MAT. In finding that
management had to bargain over these topics, the ALJ first determined that CCHCS
implemented materially new qualifications and job duties that were not reasonably
comprehended within PCPs’ existing duties. The ALJ then held that CCHCS was not
privileged to implement changes before completing effects negotiations because
CCHCS failed to satisfy the first element of the three-part test set forth in Compton
Community College District (1989) PERB Decision No. 720, pp. 14-15 (Compton). As
a remedy, the ALJ principally ordered CCHCS to rescind its directive requiring PCPs
to obtain an X-Waiver and provide MAT, make employees whole, and resume
bargaining upon request.
Because UAPD filed no exceptions, it has now acceded to the ALJ’s conclusion
that CCHCS had no duty to bargain over its decision to offer ISUDT and MAT
services, and instead had to bargain only over that decision’s effects on employment
terms and conditions. Moreover, CCHCS has declined to argue that its MOU with

10
UAPD permitted it to materially change job duties or qualifications. We express no
opinion on these waived arguments.9
Accepting the conclusions to which neither party excepted, our remaining task
is to determine whether the Dills Act required CCHCS to bargain about the new
programs’ effects on employment terms and conditions, and, if so, whether CCHCS
complied with that duty. In Parts I-V below, we address the issues that CCHCS has
raised in its five sets of exceptions. Where applicable, we note the differences
between our analysis and the proposed decision, as well as between our remedial
order and the ALJ’s proposed order.
I. 	Exception Alleging that CCHCS’s New Requirements Did Not Materially
Change PCPs’ Terms or Conditions of Employment
A charging party can establish that new job duties materially deviated from the
status quo by showing that new duties or assignments are not “reasonably
comprehended” within employees’ prior duties or assignments. (Cerritos Community
College District (2022) PERB Decision No. 2819, pp. 30-31 (Cerritos) [judicial appeal
pending].) “Reasonably comprehended” is an objective standard that refers to what a
reasonable employee would comprehend based on all relevant circumstances,
including, but not limited to, past practice, training, and job descriptions. (County of
Santa Clara (2022) PERB Decision No. 2820-M, p. 6, citing Rio Hondo Community
College District (1982) PERB Decision No. 279, pp. 17-18 [while catchall language in
job description does not overcome evidence of contrary past practice, PERB interprets
9 Pursuant to PERB Regulation 32300, subdivision (e), the Board considers
issues not raised in exceptions only where there is good cause to do so.

11
job descriptions in the context of employees’ overall role].) For instance, the Board has
found new duties were not reasonably comprehended within an existing assignment
when they required employees to obtain additional credentialing. (County of Santa
Clara, supra, PERB Decision No. 2820-M, p. 6, citing Mt. San Antonio Community
College District (1983) PERB Decision No. 297, p. 11 (Mt. San Antonio).)
An employer also must bargain if it materially alters employees’ workload.
(County of Santa Clara, supra, PERB Decision No. 2820-M, pp. 5-6 & fn. 4; Cerritos,
supra, PERB Decision No. 2819, p. 30; County of Kern (2018) PERB Decision
No. 2615-M, p. 10 & adopting proposed decision at p. 11.) Because this is a separate
inquiry from whether new duties were reasonably comprehended within existing
duties, a charging party need only show that the workload change was material.
(County of Santa Clara, supra, PERB Decision No. 2820-M, p. 6, fn. 4.) Thus, a
change in workload may be found even when the nature of duties assigned does not
materially change—for instance, if an employer assigns fewer employees to perform a
steady amount of work. (See, e.g., Fullerton Union High School District (1978) PERB
Decision No. 53, pp. 7-8.) The converse can also be true: an employer can impose
materially new duties without increasing overall workload, as alleged in County of
Santa Clara, supra, PERB Decision No. 2820-M. However, these two types of material
changes often occur in concert with one another, as UAPD alleges in this case, and
establishing one can aid in proving the other. For instance, if new duties increase
employee workload, that tends to show that the new duties may not have been
reasonably comprehended within existing duties.
This case also requires us to consider a third alternative means of showing a
material change on a bargainable subject: An employer must bargain before materially

12
changing a job qualification unless the change merely complies with an externally
imposed change in law. (County of Sacramento (2020) PERB Decision No. 2745-M,
p. 17.) While a newly-required qualification is subject to bargaining if it is material and
not required by an external change in law, it also may constitute evidence that the
employer has materially changed duties. In other words, if an employer requires a new
qualification while altering duties, the new qualification tends to show that the new
duties were not reasonably comprehended within existing duties. (County of Santa
Clara, supra, PERB Decision No. 2820-M, p. 6; Mt. San Antonio, supra, PERB
Decision No. 297, p. 11.)
To apply these standards, we compare new duties, qualifications, or workload
with the status quo, and we determine if a reasonable employee would find the
changes to be material. (County of Santa Clara, supra, PERB Decision No. 2820-M,
p. 8.) In arguing that it did not make material changes, CCHCS claims the ALJ made
five factual errors and applied incorrect legal reasoning. We consider each argument
in turn. Although we adjust the ALJ’s findings to hew them more precisely to the
record, and we alter the ALJ’s analysis to better match precedent, we ultimately
conclude that CCHCS made material changes to PCPs’ terms and conditions of
employment.
A. 	Factual Findings as to CCHCS’s New Requirements for PCPs
1. 	First factual finding
CCHCS asks us to overturn the ALJ’s finding that new job duties and
qualifications took effect on July 1, 2021. CCHCS first points out that, before this date,
PCPs could participate in the MAT and ISUDT programs on a partial basis. CCHCS
then notes that the evidentiary record closed on June 21, 2021, claiming that the

13
record therefore did not include evidence showing what happened on or after July 1,
2021. CCHCS returns to a similar vein of argument in a later exception, claiming that
the ALJ’s findings contain “a factual impossibility” in that the record closed nine days
before the implementation date and therefore cannot show that CCHCS did, in fact,
implement new job qualifications and duties. On the record before us, this argument is
legally and factually untenable.
A change in policy occurs on the date the employer makes a firm decision,
even if the decision does not take effect immediately or never takes effect. (City of
Milpitas (2015) PERB Decision No. 2443-M, p. 15.) Here, there is more than sufficient
evidence that, well before the record closed, CCHCS had firmly decided that PCPs
would take on the new duties and obtain new qualifications by July 1, 2021.
While the October 20 letter did not necessarily constitute a “directive” to
employees, CCHCS’s position crystalized on December 2, 2020, when CCHCS stated
it was a non-negotiable management decision that all PCPs must obtain X-Waivers
and begin fully providing MAT. CCHCS further indicated that its next step was to notify
employees of the new requirements. At the PERB hearing, CCHCS admitted that it in
fact required PCPs to submit their X-Waiver applications before June 2021 given that
the application process generally takes between four and six weeks. Testimony from
Kanan, Sale, and Sabo further proves that CCHCS maintained its announced deadline
for PCPs to become X-Waived and begin providing MAT. Sale, for instance, testified
that while CCHCS/CDCR originally anticipated most PCPs would voluntarily obtain
X-Waivers, not enough PCPs were applying. For that reason, he continued, “we then
had to put out that we were going to require it by a certain date. We just couldn’t wait
any longer for these doctors to get on board.” Finally, the receiver’s June 2021 report

14
similarly leaves no doubt as to what occurred, as he wrote that CDCR “has required all
Medical Services providers to obtain a [DEA] X-Waiver.” Thus, while CCHCS notes
that it allowed partial participation in MAT before July 1, 2021, this does not counter
the overwhelming evidence that well in advance of June 30, 2021, CCHCS
established that date as a firm deadline for its changes.
2. 	Second factual finding
CCHCS next excepts to the ALJ’s finding that “‘the prescribing of MAT’ is the
same thing as requiring PCPs to prescribe Suboxone.” CCHCS notes, for instance,
that requiring a PCP to obtain an X-Waiver does not automatically require the PCP to
prescribe SUD medication to any given patient.
CCHCS fails to acknowledge the context of the ALJ’s finding. The ALJ found
that: (1) CCHCS chose to use Suboxone as the primary medication component of MAT;
and (2) “MAT also includes the use of cognitive behavior therapy (CBT) or cognitive
behavior intervention (CBI).” Based on these findings, the ALJ reasoned that
prescribing Suboxone was not reasonably comprehended within PCPs’ existing job
duties because, unlike other medications, PCPs must provide CBI and teach patients
coping skills when prescribing Suboxone. CCHCS argues the ALJ was incorrect
because PCPs may prescribe Suboxone based on their professional judgment, but
they need not do so. We affirm the ALJ’s inference that a PCP cannot fully participate
in MAT without prescribing Suboxone on at least some occasions. CCHCS provided
no evidence that fully providing MAT would be a de minimis part of PCPs’ duties.
Rather, the record supports the inference that CCHCS materially changed PCPs’
duties.

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3. 	Third factual finding
CCHCS contends the ALJ erred in finding that: (1) prescribing SUD medication
differs from prescribing other medication in that it requires physicians to teach coping
skills and provide CBI, including motivational interviewing; and (2) UAPD-represented
PCPs do not have the time to conduct lengthy motivational interviews with each
patient. The parties largely agree that the standard of care for treating SUD involves
medication, CBI, and other supports, and they also agree that ISUDT and MAT
programs involve far more than medication. However, the parties dispute the extent of
the burden on PCPs.
While CCHCS and CDCR expect counselors to focus on CBI and CBT, the
record nonetheless shows that PCPs were reasonable in understanding that CCHCS
also expected them to provide ISUDT and MAT patients with materially new services
beyond prescribing medication. Indeed, CCHCS’s Care Guide for SUD provides that
behavioral modification is the “cornerstone” for treatment, and PCPs are expected to
“[u]se motivational interviewing to encourage initial and ongoing participation.”
Furthermore, inmate patients were often not receiving CBI or CBT from counselors,
and group therapy sessions were often not available. Most importantly, existing PCP
schedules generally provided 15-minute sessions, but physicians would frequently
need to spend far more time than that to allow for motivational interviewing and other
tasks associated with prescribing SUD medication.10
10 Unit 16 PCP Thomas Bzoskie testified that a physician who prescribes SUD
medication must take the time to understand the psychology behind their patients’
addiction, a task that is unlike the primary care he provided in the past. Unit 16 PCP
Alphonso Swaby similarly explained the difference in prescribing SUD medication,
noting that he had to follow a time-consuming whole person, “360 degree” approach.

16
In sum, even if CCHCS did not impose on PCPs an absolute requirement of
providing CBI and teaching coping skills to every patient with SUD, the ALJ made no
error that would alter the outcome of this case. PCPs reasonably understood the new
expectations as materially increasing their duties and workload, including new duties
that were not reasonably comprehended within their previous duties.
4. 	Fourth factual finding
CCHCS excepts to the ALJ’s finding that CCHCS considered modifying PCPs’
job duty statement to include addiction medicine as a desirable qualification for new
hires, and that it is therefore reasonable to infer CCHCS was aware that the existing
job duty statement did not cover such work. While there was evidence regarding a
proposed or actual revised duty statement, the record does not include such a revision
and we therefore decline to speculate about its contents. Furthermore, it is unclear to
which PCP positions the proposed or actual new duty statement might apply. Because
this unclear and unpersuasive evidence does not support the ALJ’s finding, we grant
CCHCS’s exception on this point.
5. 	Fifth factual finding
CCHCS excepts to the following passage in the proposed decision: “The weight
of the evidence demonstrates that addiction medicine is a special area of practice, not
within the expertise of a general practice PCP.” CCHCS contends this finding
“incorrectly infers that CCHCS is requiring PCPs to act as Addiction Specialists.”
Rather, CCHCS argues, the MAT-related duties it requires of PCPs “fall squarely
within the expertise of a general practice PCP” and are “consistent with the community
standard of care.” CCHCS points to evidence that physicians in office-based settings
can prescribe SUD medication, as well as evidence that other primary health care

17
delivery systems are increasing access to MAT.
UAPD, for its part, called six PCPs to testify. Each stated that providing MAT
falls outside the prior scope of their practice. For instance, Christine Kuo testified that
PCPs have no addiction medicine residency training and therefore have a “big gap” to
cross, especially without the help of mental health care providers, to successfully treat
addiction.11
We do not see these competing claims as mutually exclusive. It is entirely
plausible that: (1) addiction medicine is a recognized specialty area; (2) primary care
physicians outside of CCHCS nonetheless may find themselves responsible for
treating SUD (especially when there is a dearth of other options); and (3) PCPs at
CCHCS had largely not done so before the events at issue here. There is no cause for
us to delve further into the extent to which, in modern American medical practice,
addiction medicine may fall partially within primary care and/or partially outside of it.
Further analysis would not substantially aid our inquiry, which involves applying
precedent to determine whether reasonable PCPs at CCHCS would view their
employer’s new requirements as materially changing their qualifications, duties, and/or
workload.
In answering this question, the CCHCS job descriptions for PCPs have limited
utility given that they do not attempt to detail which medical conditions PCPs must
treat on their own versus which conditions PCPs may refer to specialists in whole or in
11 Although it is possible to obtain medical board certification in addiction
medicine, CCHCS does not require PCPs to have any such certification. For this
reason, testimony regarding addiction medicine residency training and medical board
certification bears little weight.

18
part. Past practice thus becomes even more relevant. (County of Santa Clara, supra,
PERB Decision No. 2820-M, p. 6 [catchall language in a job description does not
outweigh contrary past practice].)
Turning to the relevant past practice, CCHCS did not require PCPs to obtain
X-Waivers until July 1, 2021. If the new X-Waiver requirement stood alone, there may
have been no bargaining obligation depending on the extent to which the new
qualification materially altered PCPs’ existing qualification requirements. But the
X-Waiver requirement did not stand alone. Rather, it was integrally related to a
significant new set of responsibilities that PCPs had not previously performed. In the
past, mental health professionals had primarily overseen treatment for SUD and
patients’ other mental health needs; CCHCS significantly changed duties and
increased workload by requiring PCPs to take on primary responsibility for SUD, a
complex, immediately life-threatening mental health condition. Accordingly, while we
do not affirm the proposed decision to the extent it arguably found that addiction
medicine falls outside of primary care in American medical practice, this adjustment
leaves intact the well-supported fact that CCHCS implemented material changes to
UAPD-represented PCPs’ terms and conditions of employment.
B. 	Legal Conclusions as to CCHCS’s New Requirements for PCPs
In arguing that it merely assigned PCPs duties that were reasonably
comprehended within their prior duties, CCHCS primarily relies on the last of its
above-discussed factual contentions. Specifically, CCHCS argues that providing MAT
is “within the scope and expertise of a general practice PCP, and not reserved for
addiction specialists,” and that having PCPs do so “is the preferred approach within
the medical community.” (Original underscore.) As discussed above, however,

19
arguments about current American medical practice bear substantially less weight
than arguments about past practice at CCHCS.
Beyond its argument about the allegedly broad nature of primary care, CCHCS
selectively cites past PERB decisions to argue for a broad scope of what constitutes
existing job duties. But even were we to accept those select decisions as the sum of
our precedent, we would still affirm the ALJ. For instance, CCHCS repeatedly cites
Davis Joint Unified School District (1984) PERB Decision No. 393 (Davis), a decision
that does not establish a broad management right to change job duties. (See Cerritos,
supra, PERB Decision No. 2819, p. 31 [Davis cannot be broadly construed].) Davis
does not help CCHCS, as it explicitly notes that management must bargain if it
assigns tasks that are not reasonably understood to be among existing duties, and,
even more importantly for this case, it cautions that increases in “the quantity of work”
must be bargained. (Davis, supra, PERB Decision No. 393, p. 26 & fn. 11, original
underscore.) Here, as discussed above, CCHCS assigned new duties that materially
increased PCPs’ workload.
Other decisions upon which CCHCS relies are similarly unavailing given that
the instant case involves an increase in workload. For instance, in Mt. San Antonio,
supra, PERB Decision No. 297, the Board distinguished between assigning librarians
and counselors to teach classes integrally related to their specialties versus having
them learn to teach new classes that were further afield from what they had previously
taught. (Id. at pp. 10-11.) There was no allegation that such changes materially altered
the total amount of work the school district expected employees to perform. (Ibid.)
Because the record here shows a workload increase, the ALJ ultimately
reached a correct conclusion irrespective of whether assigning PCPs to treat SUD is

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akin to forcing librarians and counselors to learn to teach new classes further afield
from what they had previously taught. However, as an alternate basis for our holding,
we find that CCHCS’s new requirements, in both their premise and design, were, in
fact, sufficiently similar to a school employer assigning courses far enough outside
employees’ prior scope of work that they must obtain new skills and certifications. The
new requirements significantly shifted SUD treatment away from specialists and
toward PCPs. While PCPs outside the prison system may have experience treating
SUDs, UAPD-represented PCPs reasonably viewed these duties as new.
Accordingly, absent a contractual waiver of the right to bargain, CCHCS had
two primary choices for imposing the new requirements. First, it could bargain in good
faith to impasse or agreement, which CCHCS admits it did not do. Second, it could
comply with the requirements of Compton, supra, PERB Decision No. 720, pp. 14-15.
We turn now to CCHCS’s exceptions alleging that it complied with Compton.
II.–V.*
ORDER*
APPENDIX*
ATTACHED PROPOSED DECISION*
* See footnote 1, ante.