Insight, analysis & opinion from Joe Paduda

May
21

Hospitals and medical practices are losing billions.

And that has big implications for private insurance and workers’ comp.

An insightful piece by Milbank Fund President Chris Koller details the carnage (Chris and I serve on Commonwealth Care Alliance’s Board of Directors).

Total healthcare spending in March was more than 5% lower than the same month in 2019.

From Altarum’s report:

This decline was led by the two largest spending categories: hospital spending, which showed an 8.7% decline, and spending on physician and clinical services, which declined by a huge 19.3%, year over year.

In late April, outpatient office visits were down more than 60%. Visit counts have rebounded in the last few weeks, but are still quite low – especially for surgical and orthopedic specialties.  (From the Commonwealth Foundation)

The financial impact on healthcare providers is devastating.  To date, big health systems have already lost about $400 million – each.

80% of New York doctors have lost more than half of their income, and providers in other states haven’t fared much better. Not surprisingly the ones hardest hit are those that do procedures – especially surgery. While primary care docs and behavioral specialists have been able to switch some patient visits to tele-services, that isn’t possible for proceduralists.

Implications.

  • Some practices will not survive. New practices, those without strong referral sources, and those with high debt are most at risk.
  • Provider consolidation will ramp up and the number of smaller practices will shrink as the big get bigger – and more powerful. Big practices and healthcare systems are getting more than their share of relief dollars, and are better equipped to make it through months of financial losses. They’ll be snapping up physician practices for pennies on the dollar.
  • Near term, proceduralists are going to favor profitable payers as they open up. Expect provider billing and collection practices to get a lot more aggressive.

Workers’ comp bill review systems, logic, and rules are woefully inadequate and payers using those systems will suffer the consequences.

Private insurers are significantly better off due to much more sophisticated systems…but over the longer term they can expect provider groups will push hard for increased reimbursement.

What does this mean for you?

Workers’ comp payers and private insurers are making a lot of money these days. That will not last.

They would be well-advised to invest now in reimbursement systems, expertise, and tools.

 

 


May
20

Clarification, chronic pain treatment, COVID’s impact, and camel pee

First, a clarification.

Last week’s post re NCCI’s virtual Annual Issues Symposium needs clarification.

Before I published the post I asked NCCI to comment on the lack of any reference to COVID claims counts in the presentation, saying “Any early data would have been quite helpful; any comment?” I received a response and published it in the post. NCCI’s response did not indicate that it did not yet have any Q1 data.
After the post was published, NCCI wrote me to clarify, stating they won’t receive any data on Q1 claims until October, 2020 at the earliest.
NCCI CEO Bill Donnell wrote me as well; here’s the relevant part of that email:
I wanted to respond to what I would label a policy issue. The post includes a sentence…”I can understand why NCCI-and other research organizations don’t want to provide any data that might encourage politicians to look to WC to cover the costs of Covid-19.” I take issue with this because it implies that we would withhold data for political reasons (my interpretation).

Fair point.

If I had known NCCI didn’t have Q1 data, I would not have made that statement. However, Bill’s concern is valid and I should have been more careful with my choice of words – and will be in the future.

Workers’ comp has made remarkable progress preventing overprescribing of opioids to new patients – but there’s much to be done to address chronic pain and long-term opioid use.

One therapy that must be considered is medication-assisted therapy. From HealthAffairs comes new research indicating the long-term use of buprenorphine shows significantly better outcomes than short courses of treatment do.

Research estimates that 28 million surgeries have been postponed or will not be done over a 12 weeks period due to COVID. That’s a major reason US health systems are in dire financial straits…to date, average losses are $400 million. 

Colleague Peter Rousmaniere is having a very productive “retirement”; his latest post at Working Immigrants includes these findings:

  • Nationwide, one quarter of practicing doctors are foreign born [emphasis mine]
  • 23% of all science and engineering workers are foreign born (40% in California)

COVID will alter the US healthcare system – experts opine on 9 potentially significant changes.

One potential change will likely NOT include ingesting camel urine to cure COVID…despite a claim that drinking a glass of the elixir three times a day for three days will do just that. (btw, camels are notoriously cranky…one wonders how amenable they are when a urine collector involves himself in a very personal process… and would any injury be compensable?)

There is one bright spot…unlike some other unproven cures, ungulate urine won’t cause heart attacks.

What does this mean for you?

Be careful with assumptions, thank your immigrant healthcare worker, support medication-assisted therapy…and keep your sense of humor.


May
19

COVID update – hope for the best, plan for the worst.

I’ve stayed away from most of the COVID stuff because Tom Lynch at WorkersCompInsider has been… as the kids say…crushing it.

Yesterday’s news that Moderna, a new company in Massachusetts reported very early results from tests of a potential vaccine was welcome indeed. The experimental vaccine appeared to help increase resistance** to COVID19 in a handful of people without undue harm.

It was also extremely preliminary.

The trial actually involved 45 people, but the press reports were based on results from 8. That’s less than a fifth of those involved…as one wag put it, “The drug trial sample size seems to be as big as 2 full of people.”

The double asterisk after “resistance” is because the experiment involved taking a blood sample from those 8 people, putting it in petri dishes with the virus, and measuring the antibodies ability to “kill” the virus. That is waaaaaay different from conveying immunity in the human body.

Perhaps coincidentally, the person charged with leading Operation Warp Speed, the White House initiative to develop a vaccine, has 156,000 shares of stock in Moderna, the vaccine research firm in question. And the company had just been awarded almost a half billion dollars in taxpayer money to help fund research.

I get that we are all looking for any hint of good news, and we all desperately hope Moderna’s vaccine:

  • is effective and preventing COVID;
  • is safe for humans;
  • can be manufactured in huge quantities quickly and cheaply.

But vaccine development is full of fits and starts, blind alleys and dead ends, promising early results leading to disappointing failures.

Fewer than one in ten vaccine candidates reach production. Vaccines typically take 10 – 15 years to develop. “And while biotechnology underlying this drug has existed for nearly 30 years, it has never yielded a working vaccine for any human disease” (quote from NatGeo).

Yet we’ve never seen the might of the entire world’s vaccine expertise focused on a single problem, an unprecedented level of effort that – hopefully – will produce an unprecedented result.

Meanwhile, the virus has killed over 90,000 of our friends, parents, neighbors and grandparents so far, while infecting over 1.5 million of us. Thousands more will die, even if the vaccine is everything we hope it is.

People and organizations who focus on what they can control – reducing the risk of infection – will come out of this far better off than those who ignore the risks that remain real and deadly.

What does this mean for you?

Hope for the best and plan for the worst.

 

 

 

 

A useful discussion of how some companies are handling this crisis is here.


May
15

It’s the facility costs, folks.

Hospitals are drowning in red ink. In many states, workers’ comp is the lifeline.

Privately-insured patients are avoiding hospitals while those facilities have spent huge dollars to buy PPE, make modifications, and ensure they are ready for a COVID19 patient influx.

Kaufman Hall provides the graph; the blue curve shows hospital profits pre-COVID, the yellow line reflects COVID. The “0” vertical line is the breakeven point, so the graph indicates the vast majority of hospitals are losing big bucks.

Staff layoffs are all over the news, while research shows the most profitable facilities are getting disproportionally more taxpayer dollars as part of Congress’ aid packages. Rural hospitals are especially hard hit – and this comes after over 150 closed in the last 15 years.

Where are those facilities going to find the $$ they desperately need?

(your picture here)

Just in time, the fine folk at WCRI published a detailed review of outpatient hospital costs and related services. [free to members, there is a charge for non-members] I read the report (yes, the entire thing, minus the super-wonky discussion of statistical methodology). The lede was spot-on:

While the full impact of COVID-19 is currently unclear, this study will also be a useful baseline to monitor the effects on hospital payments.

The analysis is thorough, comprehensive, and easy to follow. Rui Yang PhD and Olesya Fomenko PhD have analyzed 36 states; here are a few key takeaways.

  • costs in states without fixed-amount fee schedules are at least 50% higher than in those with fixed-amount reimbursement
  • in states with fee schedules, percent of charges fee schedules are the worst offenders [my words not the authors’]
  • BUT, there are gaping loopholes in other fee schedule types that allow facilities to maximize reimbursement (looking at you, Florida)
  • many states don’t even have fee schedules, which in some cases is just as bad.

What’s a payer to do?

First, identify low cost, high quality facilities and direct your patients to them.

Second, do NOT allow physicians to schedule surgeries in high-cost facilities. The Golden Rule applies – she who has the gold rules, and you are that “she”.

Third, “cost” is the actual cost, NOT the PPO discount. Don’t be fooled – discounts tend to be higher at high-cost facilities.

More on this issue here, here, and here.


May
14

NCCI – quick hits, a deeper dive, and a critique

Apologies for not getting this out sooner; wanted to wait until I heard back from NCCI on a couple items.

Quick hits

  • Insurers are enjoying record profits.
  • Frequency is down again – continuing a 30+ year downward trend.
  • Medical costs grew  – just barely.
  • Premiums dropped.

A deeper dive

The meeting planners did excellent work, the production was quite good and NCCI’s actuaries and statisticians bravely took on the role of media communicators. CEO and Chair Bill Donnell led things off, noting that the COVID19 pandemic requires agility – a talent not often associated with insurance in general or workers comp in specific (my words not his).

Bill is confident that workers’ comp is in good financial condition to deal with COVID19 – a confidence that is well founded.

For six years the industry has been quite lucrative. Investment gains and underwriting margins have driven record profits – and the profit train kept rolling in 2019.

Steady declines in frequency and relatively stable claim costs over the last five years that continued in 2019 are a big driver of record profits. (I’ve also argued that rates are way too high.)

Chief Actuary Donna Glenn reported private insurers’ reserves grew by $5 billion last year; there’s now a $10 billion reserve redundancy, so the industry has $10 billion more than it projects it needs to cover all current claims liabilities. Coming on top of billions in reserve releases in 2019 it is clear workers’ comp rates are still far too high (my words not Ms Glenn’s).

In 2019 claim frequency dropped again – by 4% – paralleling the long-term trend of 3.8% over the last three decades. According to an NCCI video, key drivers include:

  • better risk management,
  • workplace safety,
  • better training,
  • wellness,
  • automation,
  • a continued shift away from heavy manufacturing and towards a service-based economy.

Intuitively it makes sense that these factors have helped lower claims frequency. However, the video didn’t provide any data or identify any specific research supporting these assertions. I would have expected NCCI  – at its core a research organization – would include references to studies that supported the video’s claims.

I asked NCCI for the research that supported these assertions – as usual Cristine Pike and her colleagues were very responsive; additional research is here and here. However the citations provided didn’t conclusively demonstrate these factors were the cause of frequency declines – and didn’t mention most of the drivers cited in the video.

Donna Glenn, NCCI’s new chief actuary, provided an update on the State of the Line. Lots of good news…

On a per-claim basis, for private carriers, medical severity ticked up 3 points for lost time claims, a very modest change. Combining the 4% decrease in frequency with the 3% increase in severity likely yields no appreciable change in overall workers’ comp medical spend (my assumption, not NCCI’s).

NCCI projects claims incurred in 2019 will ultimately result in a 99% combined ratio reflecting continued underwriting profitability for private carrier business.

Thus it’s not surprising that premiums for state funds and private carriers dropped by $1.6 billion to $47 billion [a 2.6% drop] in 2019 as rates trended down.

Bob Hartwig did provide some context, citing Willis Towers Watson ‘s May 2020 analysis as the basis for projections on changes in workers’ comp premiums motor vehicle accidents and the like

My complaint.

NCCI has extensive access to workers’ compensation data. Given that the world has dramatically changed from 2019 to today and all of us are desperate for information, a discussion of changes in claim counts and types of claims would have been extremely helpful. I get that data is scant and spotty, but generalities and qualitative statements aren’t nearly as helpful as data. I asked NCCI about this; here’s the response:

NCCI has spoken to a number of carriers about their COVID-19 claim experience.  However, I would be very careful about making assumptions based on these conversations.  Until more time has passed and we can get information from a significant portion of the market, we would not be sharing any observations on COVID-19 claim activity.

Here’s where I’m perplexed. The discussion of frequency drivers attributed declines to a host of factors without citing specific research, data, or studies. That’s an assumption.

NCCI could have – and in my view should have – provided data on Q1 2020 claim counts by claim type (cause). That would not have been an assumption, but rather initial reporting of concrete data.

Given potential moves by governors and legislators to make COVID19 illness a covered condition and the lack of certainty about where this is headed, I can understand why NCCI – and other research organizations – don’t want to provide any data that might encourage politicians to look to workers’ comp to cover the costs of COVID19.

What does this mean for you?

The more we know and the sooner we know it, the better.


May
12

Now, about those drug rebates…

Drug rebate dollars account for a big chunk of brand drug costs – more than 40% in some cases. While list prices for brand drugs have been rising rapidly, net prices – the prices actually paid to the manufacturer – have not.

That’s mostly because manufacturers have been paying rebates to employers, insurers, and others in the drug distribution system.

This from Adam Fein PhD of Drug Channels:

A drug’s net price equals the actual revenues that a manufacturer earns from a drug. The net price equals the list price minus rebates as well as such other reductions as distribution fees, product returns, chargeback discounts to hospitals, price reductions from the 340B Drug Pricing Program, and other purchase discounts.

AARP is one of those making bank off rebates, along with lots of healthplans and insurers.

Workers’ comp

The picture’s a bit different in workers’ comp, for several reasons. Rebate payments tend to be lower because:

  • fewer brand drugs are dispensed to work comp patients
  • far fewer speciality drugs – the really expensive ones – are dispensed to work comp patients
  • the brand drugs dispensed to work comp patients typically don’t have big rebates.

But – there’s always a but – rebates must be considered when evaluating your drug spend. If you are an insurer or self-insured employer, a few things to consider:

  • ask your PBM how rebate payments affect your current pricing, and how.
  • if you’re pricing a new PBM, ask if you’re going to get the rebates paid directly to you, or if rebates are included in a calculation of your drug price
  • find out if you are getting ALL the rebate payments, or other entities in the supply chain are getting a cut. [that’s not necessarily a bad thing, but you do want to know where your dollars are going – because they are your dollars]
    • the big PBMs have more buying power, so you’re more likely to get more of the rebate dollars if you’re working with one of the big players

What does this mean for you?

These are your dollars. You need to ask the hard questions to be sure you’re getting the right answers. 


May
8

COVID19 catch up

Three key takeaways from this week’s COVID19 news.

Do we KNOW how bad things are, who’s dying, and Remdesivir.

  1.  Do we know how many are infected, the death rate, and the number hospitalized/in the ICU/on ventilators?

No.

We are three plus months into the crisis and if anything, the picture is muddier than it was a month ago. From the highly-credible COVID Tracking Project;

it is impossible to assemble anything resembling the real statistics for hospitalizations, ICU admissions, or ventilator usage across the United States.

Also from the Project:

the CDC does offer a national-level account of “specimens tested,” this data is incomplete and lagging, and it uses a different unit (specimens tested) for total tests than for positive results (which are counted in people). This makes it impossible to accurately match testing totals with positive tests to infer a complete picture of COVID-19 testing, even at the national level…a simple count of identified COVID-19 cases doesn’t show the true location or comparative severity of outbreaks. Simple case counts show where people are being tested, not where people are sick. [emphasis added]

Yep, the greatest country on Earth can’t even capture and accurately report infections, hospitalizations, and deaths…you should be pounding your head against the wall.

Or maybe just scream in frustration…

2. Who’s dying.

In the New York City, it’s mostly older folks.

From Statista…

Alas, our nation’s leaders still do NOT KNOW how many of our loved ones in nursing homes have been killed by COVID19. 

Almost three weeks after CMS Administrator Seema Verna took to the podium to announce HHS would begin publishing the numbers, we’ve seen nothing.

3. Finally, Remdesivir is NOT a cure – far from it.

The results of a study conducted by NIAID on about 1,000 patients found it does shorten the course of COVID19 – by four (4) days – in some patients. Manufacturer Gilead hasn’t said what remdesivir will cost, but indications are about $4,000 per patient.

NIAID’s study found the anti-viral drug:

  • has been shown to be safe in humans,
  • is given intravenously (it is injected into the blood stream),
  • the course of treatment is 5 – 10 days,
  • has to be administered in a hospital, and
  • the vast majority of patients who recover at home will NOT get the drug.

Perhaps the most important impact will be shortening the course of COVID19 (although that didn’t happen in all patients who got the drug). This will free up more bed-days in facilities and allow them to treat more patients.

Note an earlier study in China did not find remdesivir was effective in treating COVID19. From the study: “Remdesivir use was not associated with a difference in time to clinical improvement”

Lastly, who will actually get the drug depends on luck – some hospitals will get it, others will not, with no rhyme or reason.

For my work comp readers, over at Workers’ Comp Insider Tom Lynch has a quick summary of COVID19 and its impact on workers’ comp.

What does this mean for you?

We should expect way more from our elected officials. 


May
7

Watch those facility costs…

As the coronavirus continues its relentless march, hospitals and health systems are getting crushed. With elective procedures banned in many states, the profitable patients hospitals relied on to generate profits have disappeared. Meanwhile, expenses related to preparing for COVID19 patients have gone thru the roof and so no signs of abating.

Florida is especially hard hit:

A new report by the national consulting firm Crowe shows Florida health systems have suffered nearly a 50% drop in patient volume in March and April.

Hospital owner UHS just withdrew its financial guidance, with management citing concern over the “financial uncertainty caused by the coronavirus disease.” The announcement followed similar moves by  hospital giant HCA, and Maryland’s hospitals are projecting a billion dollar revenue shortfall for the second quarter. Hospitals in Colorado are facing an even larger reduction in revenues and Michigan hospitals are laying off workers, 

“Patient volumes at our acute care hospitals and our behavioral health care facilities were significantly reduced during the second half of March as various COVID-19 policies were implemented by our facilities and federal and state governments. These significant reductions to patient volumes experienced at our facilities have continued into April, 2020.”

The billions sent to hospitals under the CARES Act is no panacea; on average the funds cover less than a week’s revenue.

Implications

More than a dozen rural hospitals  in the South closed last year.  We can expect more in 2020.

Hospitals and healthcare systems are drastically ramping up their “revenue maximization” efforts. Workers’ comp payers, long seen as hugely profitable, now have an even bigger and brighter target on their chests.

What does this mean for you?

Watch those facility costs. 

 


May
4

RIMS, opioids, and awards to drug distributors’ risk managers

Last month RIMS announced its annual awards; one of the recipients is the risk manager for Cardinal Health, another has a similar role at McKesson.

Awarding awards for excellence in risk management to two individuals at companies with huge liabilities for the opioid crisis, and failing to discuss that liability in press releases is pretty shocking.

Both companies are embroiled in ongoing and likely very expensive litigation regarding their responsibility for the opioid crisis. Cardinal just announced a $4.9 billion loss for the first quarter of 2020, attributing the hit entirely to opioid litigation (the company estimated the cost of litigation at $5.6 billion.

West Virginia is one of the states devastated by rampant overuse of opioids; Pulitzer Prize-winning reporter Eric Eyre just published a book detailing his investigation into Cardinal’s role in the opioid crisis.

According to Eyre, Cardinal “saturated the state with hydrocodone and oxycodone — a combined 240 million pills between 2007 and 2012. That amounted to 130 pain pills for every resident.” All told, distributors shipped 780 million pills into West Virginia over that time.

Cardinal, McKesson, and Amerisource Bergen are the largest drug wholesalers in the nation, acting as the middlemen between manufacturers and retail and mail order pharmacies. While all three contend they are just part of the supply chain, they are required to monitor and report shipments of controlled substances – including opioids, a responsibility that is at the center of the litigation.

(This is not to say the three distributors bear all the responsibility for the crisis – far from it. State health officials, the DEA, FDA, prescribing physicians, opioid manufacturers and others all share in that responsibility.)

From the Washington Post:

McKesson, Cardinal Health and AmerisourceBergen, were in and out of court. They paid lots of fines but kept on trucking. In 2018, their chief executives gave sworn testimony before the House of Representatives Committee on Energy and Commerce: All denied contributing to the opioid crisis. Later that year, the committee released the results of an 18-month study. It found that distributors failed to conduct proper oversight of pharmacies by not questioning suspicious activity and not properly monitoring the quantity of painkillers shipped. [emphasis added]

Earlier this year, McKesson agreed to pay investors $175 million to settle claims that “directors failed to maintain adequate internal systems for spotting suspicious opioid shipments…”  According to Bloomberg, U.S. District Judge Claudia Wilken in Oakland, California said the suit raised:

“legitimate questions about whether directors ignored “multiple red flags” about opioid shipments even after agreeing to step up compliance oversight as a result of a deal with the government.

The settlement, produced in part by a series of mediation sessions, calls for McKesson to add two new independent directors to its board, to beef up compliance training for directors and improvements in internal systems designed to red-flag suspicious orders, according to court filings.”

McKesson is the also the subject of a criminal probe launched by Federal prosecutors in Brooklyn, NY. 

So, the world’s leading risk management organization conferred prestigious awards on risk management professionals at two companies that have massive financial liability – and I would argue ethical responsibility – for what can only be described as a massive risk management failure. And one is the subject of a Federal criminal probe.

I contacted RIMS to inquire about the decision criteria used by the individuals to select the award recipients, stating:

I’m curious as to the decision criteria employed by the award committee that resulted in awards to these two executives. While their accomplishments are impressive and their achievements notable, I’d like to understand how the opioid settlement issue factored into the award decision.

RIMS Communications Director Josh Salter was kind enough to provide an initial response:

RIMS awards are reviewed and selected by volunteers. This group of risk professionals is charged with vetting all submissions and then, using their experience in the profession, making a decision based on the applicant’s accomplishments. While the volunteer group changes from year to year, I will share this information with them.

I asked Mr Salter if he would facilitate a discussion with any members of the committee and offered to keep the names of those members confidential; to date and after multiple requests I have not received a response. [I’m certainly willing to hear from Mr Salter and committee members]

Eyre’s editor, Ned Chilton, coined the term “sustained outrage” to define what he saw as an essential responsibility of news organizations, a demand that media keep the focus on injustices instead of reporting on a calamity and moving on. I’ve been reporting on the opioid crisis since 2005; over the last two years my passion and drive has burned out.

That’s my fault.

I struggle to understand how RIMS could confer prestigious awards for “risk management” on individuals at two huge companies that bear significant responsibility for the opioid crisis – and not even mention the opioid issue in publicity around the awards. This is not to impugn the professionalism, ethics, or abilities of the individuals recognized by RIMS, rather to ask a very uncomfortable question, one RIMS needs to address.

What does this mean for you?

We cannot let crisis fatigue take our focus off opioids.

[PS – kudos to Tristar’s Mary Ann Lubeskie for her ongoing and tireless efforts to keep opioids front and center… you can follow her at @maryannlubeskie on Twitter]

 

 

 


May
1

Friday Funday

Another week in physical isolation – no business trips, lots of zooming, plenty of dog walks.

Suzie’s not stressing…

She’s doing the Vulcan mind-meld with brother Louie…

And the pups let Deb borrow the dog grooming tools to clean me up a bit (yes I still have two ears)

Some folks are seeing the bright side…

And others are making the best of it.

Have a sports-free weekend!


Joe Paduda is the principal of Health Strategy Associates

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