Insight, analysis & opinion from Joe Paduda

Jun
7

A reminder – work comp is a tiny part of medical care

Work comp medical expenses total around $30 billion.  Total US medical expenses amount to $3.6 TRILLION.

Clearly work comp is a minuscule part of the healthcare world; less than one percent.

This matters because health care providers – doctors, therapists, facilities, clinics – see very few work comp patients.  While some providers tend to see more work comp patients than others, it’s rare indeed for a provider’s work comp patient population to amount to more than 10 percent overall.

Think about this in terms of regulations, network relationships, systems integration, clinical guidelines and UR requirements.

One patient out of a hundred – that’s how many work comp patients the average physical therapist, prescribing physician, pharmacy or clinic sees. When regulators require prescribers comply with a new formulary or UR prior authorization requirements, they are asking the provider, and the office and clinical staff that work with that provider to:

  • learn something new; and
  • develop, implement, maintain, and potentially modify new workflows and communications protocols and standards.

How would this work out in your world?

In your work, how much of a hassle would it be if one out of every hundred customers – or even one out of 25 – required unique and special handling, different processes, and a failure to comply with those requirements could lead to some type of legal sanction or unhappy customer?

I would suggest that many regulators don’t factor in the obvious challenge inherent in getting clinicians to change their practices for one out of every hundred patients.

Yes, regulators need to ensure regulations meet legislative intent, but often regulators can influence that intent, educate legislators, and if nothing else work diligently to hopefully reduce the potential friction inherent in changed regulations.

Unfortunately, this often isn’t the case. As a result, conflicts arise, conflicts caused by misunderstanding or misinterpretation, or just plain ignorance.  These conflicts may well lead to increased litigation, angry patients, and/or delays in patient care.

It can also lead to providers dropping out of the workers’ comp system, as the hassle just isn’t worth it.

What does this mean for you?

A bit of perspective is always helpful.  It is also essential.

As my late father used to remind me quite often, better to do it right from the start than have to fix it later.

 


Jun
5

The Golden Rule, Part Two

Back to the work comp services business…

A while ago I wrote about how some buyers’ attitudes are a bit overbearing. I know, unusual for me to be rather subtle.

The post itself generated a few comments; many more were sent to me directly with the request they not be made public. I will always honor that request.

But…

Here are a few ways buyers mistreat “vendors”.

  1. The Jerk-Around
    This begins pleasantly enough, with lunches and dinners and meetings building rapport and “relationships.”  The buyer is really, really interested, voicing approval of the vendor’s product/service, requesting more information, discussing needs and priorities. The vendor is convinced the buyer is really interested, it’s just not the right time. Perhaps in a couple months.

    Then, a new management focus appears, and this is on the back burner for a bit. Oops, a change in systems resources is holding things up.  It may be because the buyer is really trying to get a deal done. More likely, the buyer just doesn’t want to say “no”. While understandable, this is the wrong thing to do – for everyone.A fast No is far better than a long maybe.Yes, the sales person is at fault too. They should be asking, probing, talking with others at the buyer’s employer. But if they keep getting the wrong information and are led the wrong way, it’s easy to succumb.

  2. The Disappearing RFP
    This starts with a voluminous request for proposal asking every possible question and attestation in multiple ways. It takes weeks of work by the vendor, pulling scarce resources away from other projects.

    And then…crickets.

    Days become weeks, weeks stretch out into months, and months disappear into the void. Eventually everyone involved forgets what happened, who wrote what why, and where things stand. And the vendor has lost tens of thousands of dollars in labor costs…so has the buyer. Why payers go thru all the work to write an rfp only to abandon it, often without informing – and apologizing to – the respondents, is a mystery.

    (Actually it isn’t…there are way more service providers with way more capacity then there are potential customers, so you’ve got no choice…you HAVE to respond to every RFP even though you know your chances are miniscule…)

    What you’d LIKE to say…

  3. The Change-a-Thon
    The original specs both parties agreed to are set forth in stone. Well, still-liquid mud actually, but mud is just stone that hasn’t solidified quite yet.

    Then, there’s a Note/email/change request… “due to regulatory issues, or a change in management, or because we just forgot something, we now need your data to feed this other system/comply with this standard/include these fields that we never told you we wanted, and/or your staff has to have the following credentials, and/or we need the reports on pink paper on Tuesday.”Oh, and we can’t pay you any more for this.Then there’s another change request, and another, and on it goes.

  4. The “We Need a Better Price”
    You’ve negotiated everything, and it’s pretty much a done deal. Then the buyer – often a procurement person – says they need a better price.  You’ve been hearing for months that the customer wants better service, is leaving their current vendor because of lousy service, and places a premium on service.Except they refuse to pay for it.

    So, you’re stuck.  It’s either agree to barely break-even or perhaps even lose money, or agree to the price knowing you’re going to reneg on service once the contract is signed.Which leads to the final problem (although I’m sure you have your own list)

  5. The Procurement Problem
    Oh boy.  The business people have written the specs, delved deeply into your capabilities, certifications, experience, and results.  They fully understand that the service they want – and what you are expert in – is hugely complex, requires deep experience and highly trained staff, and will evolve over time as you work together and learn how to do things smarter/faster.

    The procurement/purchasing folks have been involved, but up till now they’ve been pretty much silent.

    Now they start negotiating price, and the dreaded Service Level Agreement (SLA). They want performance guarantees with financial penalties, but won’t agree to bonuses based on stellar achievements. They may demand you agree to specific time frames and project specs, refusing to factor in possible screwups/delays on their side of the implementation process. They negotiate price like a pitbull; in fact they focus most of their effort ratcheting down the price.Your business contacts plead with you to agree to the terms, saying they’ll work it out. Then, you’re locked in, and once again stuck in the “we can’t afford to deliver this for that price” – so it’s lose money or be accused of failing to deliver.

    (Terrific insights into marketing and procurement here.)

    (Now that I’ve thoroughly angered my friends in purchasing/procurement roles, know that some – a few – are reasonable, thoughtful professionals that seek to understand these issues and recognize the price implications.)

    What does this mean for you?

    You get what you pay for.

    Workers comp services is a shrinking business in a highly mature market. The only way vendors grow is by taking business from a competitor. Buyers have all the negotiating power, and often use every bit of it to wring concessions from suppliers.

    That’s almost always a grave mistake, leading to poor service and poor results.


Jun
4

The next recession – Not if, but when, and how bad will it be?

This month marks the second longest economic expansion in US history; it’s been a decade since things turned around back in June 2009.

Like all expansions, this one is going to end – and there’s mounting evidence it will happen soon.

The latest Fed forecast shows GDP growth slumping to 1.3% this quarter, driven in large part by a drop-off in commercial and industrial construction.

Without Congressional action, we will see another government shutdown this fall; the Treasury will run out of money by early November. There’s hope the Republican-controlled Senate and Democratic-controlled House will reach some sort of deal. Whether an increasingly-volatile President – who has been public about his lack of concern about the possibility of the US defaulting on its debt – will approve it is anyone’s guess.

Absent a deal, $125 billion in Federal spending will be cut immediately, thanks to the 2011 sequestration bill.

Manufacturing growth is slowing. New data shows the U.S. Manufacturing Purchasing Managers’ Index is at its lowest point since the last recession. From Bloomberg:

customers were postponing orders due to growing uncertainty about the outlook. Similarly, new business from abroad contracted by the quickest pace since April 2016 to the first decline since July 2018.

One industry that’s hurting is autos. The president’s latest moves to slap tariffs on Mexico will increase US consumer and business costs alike; the auto industry is particularly vulnerable as Mexico supplies a lot of car parts – and 2.6 million cars – to the US. Analysts project the tariffs would add about $1,300 to the price of an average car. If Trump keeps his promise to continue to raise tariffs, that will jump to $10,000 on Mexican-made autos and trucks by October.

This has caused so much consternation amongst Congressional Republicans that they are actually considering going against Trump…

There’s a lot more data out there on this – the inverted yield curve is perhaps the one most worrying to economists.

So, we can fix this, right. Well, it’s going to be a lot harder to dig out of the next recession than it was to crawl out of the Great Recession. It’s increasingly likely the Fed will slash interest rates this year in an effort to keep the economy growing. Of course, rates are already near historic lows and the Fed has few resources left to buy back debt in “quantitative easing” without risking rising inflation…the tools available to the Fed to reverse a downturn are few and may be overmatched.

What does this mean for you?

It’s going to happen. When it does, worker’s comp payers will see a downtick in claims frequency but likely a rise in claims duration.

From here, my take is the next recession is going to be long and deep; we just don’t have the tools to claw our way out of it.


May
31

Drug price fixing – the impact on workers’ comp

The generic drug manufacturers’ price-fixing scheme raised prices by up to 1,000 percent. There’s good news for workers’ comp payers as the impact has been minimal.

Here’s why.

Workers’ comp is mostly about trauma treatment and pain management; relatively few drugs are involved. Contrast that to Medicaid, Medicare, and health insurance which cover all conditions – and have a much broader “formulary”.

Contrary to what others have opined, this didn’t have any significant impact on workers comp, because there were very few “work comp” drugs affected by the price-fixing.

Here’s more from my conversation with Jim Andrews, RPh.

MCM – In your view how did the alleged price fixing affect workers’ comp payers?

Andrews – Since WC utilizes specific drug classes the impact of these 100 drugs could/would be significantly less than that of the commercial and governmental markets (especially Medicare and Medicaid). A quick scan of these drugs (without reviewing the larger WC PBM annual drug trends) reveals that there are blood pressure medications, antibiotics, birth control, dermatological , blood thinners etc. I do not see (might have missed it) – narcotic pain medications.

So the overall cost impact from this companies’ activities do not significantly impact WC by themselves.

MCM – What medications commonly used in workers’ comp may have been involved?

Andrews – Generic Celebrex (celecoxib), generic Neurontin (gabapentin) and generic ketoprofen represent some of the more commonly prescribed drugs utilized today.

[These drugs] didn’t seem to detail the same level of price support that some of the other drugs had e.g. pharmacy and GPO involvement.

[MCM – note data from workers’ comp PBMs indicate the these three drugs account for about 7% of total drug spend].

MCM – There’s a difference between drug reference price (AWP, etc) and the actual price paid. Does the report provide any insight into whether the price fixing actually affected the price paid?

Andrews – It is unclear to me whether the purchase price for these channels actually increased or whether the drug reference price e.g. AWP increased.

MCM – this from Vox shows changes in overall drug costs over time.

What does this mean for you?

Yes, the price-fixing affected workers’ comp, but not much.


May
30

Drug price fixing…the details

A massive price-rigging scheme that drove up drug manufacturer profits by inflating drug prices has been exposed in a lawsuit filed earlier this month by 44 states.

Rather than compete in an open market, manufacturers including Teva, Pfizer, Novartis and Mylan conspired to split up market areas, allowing them to increase prices for more than 100 generic drugs by up to 1000%.

Are you angry yet?

NYTimes:

“A key element of the scheme, the complaint alleges, was an agreement among competitors to cooperate on pricing so each company could maintain a “fair share” of the generic drug markets. At the same time, the companies colluded to raise prices on as many drugs as possible, according to the complaint.”

The Times’ piece added:

“Rather than enter a particular generic drug market by competing on price in order to gain market share,” the complaint states, “competitors in the generic drug industry would systematically and routinely communicate with one another directly, divvy up customers to create an artificial equilibrium in the market, and then maintain anticompetitively high prices.” [emphasis added]

I asked Jim Andrews, RPh, for his thoughts on the suit; here’s the first part of our discussion. [Jim has been working in retail pharmacy and PBM for decades and understands this stuff as well as anyone]

MCM – In your view is the suit filed on solid ground?

Jim – Yes, it is obvious from the volume of materials collected, referenced and cited – that this investigation has been going on for multiple years. I think the sheer volume is indicative of the seriousness of the lawsuit. Many areas of the lawsuit that I found were redacted so I assume they are the most damning.

MCM – What were some of the key claims made by the plaintiffs that caught your attention?

Jim – Hyperinflation of common generic drugs, especially after 2012. Fair share territories maintained between competing generic manufacturers that preserved current drug pricing and prevented price declines. Collusion between competing generic drug companies in the form of sharing confidential information on drugs, pricing, customers and strategies.

MCM – It appears that the alleged behavior has been going on for some time – do you think this type of behavior has occurred before?

Jim – I assume that this had been going on prior to the 2012 time frame referenced in the lawsuit but the 2013/2014 hyperinflation indicates a period of increased strategic cooperation.

What does this mean for you?

The alleged criminal behavior cost consumers – and some payers – millions. 

Tomorrow – what this means for workers’ comp.


May
28

Hey work comp payers – Do Your Job.

Has any workers’ comp insurer, excess carrier, or state fund, any self-insured employer sued opioid manufacturers, distributors, or dispensers?

Have you?

Generic opioid manufacturer Teva just settled a lawsuit with  Oklahoma, paying the state $85 million. Purdue Pharma – in my view the worst company in the world – had already agreed to pay $270 million –  $70 million from the founding Sackler family’s coffers. Next up is Johnson and Johnson subsidiary Cephalon.

Sounds like a lot, right? Well, no.

The annual cost to the rest of us – in taxes, insurance premiums, lost wages, higher drug costs – is in the hundreds of billions of dollars ANNUALLY.

Meanwhile, a massive lawsuit involving 1600 cities, counties, other governmental entities, and Native American groups is headed to trial later this year in Ohio.

And, Massachusetts’ Attorney General Maura Healey’s suit against Purdue is pending. The massively detailed complaint is comprehensive and terrifying in its detail; here’s the AG’s record of the billions the Sacklers made from OxyContin.

I’ve asked dozens of work comp execs about this, and with a couple of exceptions, none have reported they are suing anyone in the opioid business.

Why not?

Is it because it’s too much work?

Or insurers don’t really care as they can just increase premiums to pay opioid-related costs?

Neither is remotely acceptable.

Workers’ comp payers – all of you – have a fiduciary responsibility and an ethical and moral duty to recover as much money as possible for their policyholders from the companies and people who’ve addicted, killed, and destroyed work comp patients. Those dollars should go back to the taxpayers and employers harmed by the opioid industry.

What does this mean for you?

Yes it’s going to be hard. Stop making excuses and start doing your job.

 


May
24

Research Roundup

In which I drop a “Nerd Bomb” into your email folder…

Here’s this week’s research-that-impacts-you I found compelling…

From WCRI, a report analyzing the relationship between prices for medical services and patient outcomes. More specifically, authors Olesya Fomenko and Bogdan Savych and ask the question “What happens to worker outcomes when prices increase or decrease?”

The authors used a comparison of workers’ comp medical prices for common office visits to group health, with the latter used as a proxy for adequate or benchmark compensation (my words, not the authors’.)

Key takeaways:

  • Medical prices are “not strongly related to measures of recovery of physical health and functioning, speed and likelihood of return to work, or duration of temporary disability.”
  • But…as all healthcare is local, there are some unexpected (at least to me) findings.
    • in areas where WC pays less than group health, raising WC prices results in more care delivered to WC patients, increased temporary disability (TD), but no significant change in access to care – and no impact on outcomes
    • where WC pays MORE than group, increasing WC prices results in more care delivered to WC patient, less concern about access – but NO meaningful impact on outcomes

Changing bad health behaviors

If you’re using financial incentives to change people’s health behaviors, you may be disappointed. Research published in NEJM indicates support from loved ones and clinical support are  more effective.

Pharmacy costs

Lost in the mostly-incoherent squabbling about drug prices is this: Net prices – that is, what insurers/healthplans/employers/payers paid AFTER rebates – for “traditional” drugs DROPPED last year (specialty med prices increased marginally).

Dr Adam Fein’s analysis of PBM trend rates showed the overall increase across all PBMs was in the low single digits; individual PBM results varied somewhat.

I’d encourage all to read Dr Fein’s post – and to subscribe to Drug Channels.

Speaking of drugs, the American Pain Society – the fine folks partially funded by opioid manufacturers looks to be filing for bankruptcy. 

Finally, how important is clinical care to a person’s overall health?

The answer – not much.

Your family income, environment, whether you take care of yourself – all these are WAAAAAY more important than the quality of care you get.

Which ties in pretty well to the research above about health behaviors.

What does this mean for you?

Get out and take a walk, and lift some weights too!

Note – this is me getting some exercise while on the boy’s annual mountain bike trip in Moab, Utah. Fortunately the “healthy behavior” of riding my bike a lot wasn’t outweighed by my inability to avoid crashing a few times…


May
23

NCCI – final takeaways

NCCI started with a terrific video featuring several people who suffered significant occupational injuries – and how work comp helped them recover. The video was really well done…kudos to NCCI and their partners for publicizing the good work done by many of you.

That’s the people side of things – one that the industry is doing a much better job publicizing. On the business side, the workers’ comp insurance industry has had a seven year run of increasingly positive results – measured by operating gains.

NCCI CEO Bill Donnell noted that technology may be moderating the “insurance cycle”; the hard-and-soft market waves that have bedeviled the industry for decades. The thinking is we’re more on top of indicators and track potential changes in real time, enabling players to anticipate and react quickly.

I’m not so sure.

Look at the stock market, where automated trading algorithms have led to wild swings in stock prices. Different environment to be sure, but a telling example of how tech has led to more volatility – not less.

And, we only know the metrics we are measuring. Things can move very quickly and we likely don’t know all of the factors/indicators/metrics that may – in the future – contribute to changes in WC results.

Frequency has declined by a third over last decade.  But, we’re getting older – more of the workforce is over 55 than ever before. Despite that, frequency keeps declining. While claims counts likely are flat to slightly higher, that is due to employment. As we’re at full employment, we can only expect claim counts to decline in the future.

It’s apparent to me that there are few new issues in workers’ comp that are worth getting excited about. Medical marijuana, the gig economy, fee schedule changes, pending legislation, all generate some excitement – but really, do these things move the needle?

Structurally workers’ comp is a declining industry. Costs continue to moderate, consolidation is the overarching theme, premiums are steadily declining. I challenge anyone to find an employer up in arms about their work comp program.

Contrast that to industry news that many insurers are looking to grow their work comp books.

These two things can’t happen. The drive for growth could push some insurers to cross the stupid line and cut prices below sustainable levels.  Focused intently on their new analytical reports, they won’t see the chasm until they are in it.

 

What does this mean for you?

Those who don’t learn from history are condemned to repeat it.


May
22

Bankruptcy: financial risk and patient impact

What are your risks if one of your vendors goes bankrupt?

Health insurers have gone belly-up in the past, in some cases leaving hundreds of millions in unpaid claims.

Here’s a potential scenario, where a payer – say a TPA or insurer – contracts with a vendor to handle certain types of medical services. The vendor schedules the patient, the patient gets the care, the provider bills the vendor; the vendor bills and is paid by the payer. 30-60 days later the vendor pays the provider.

At least, that’s how it is supposed to work.

Now let’s say the vendor runs into cash flow problems. Provider payment delays increase, and soon there are complaints from providers to the payer, or worse, regulators.

Some savvy payers who stay on top of this stuff immediately require the vendor pay their treating providers immediately after the payer reimburses the vendor. Others figure it’s no big deal and it will work out.

This goes on for a little while longer, until the vendor’s owners – let’s say a big investment firm – decide to walk away and write off their stake in the vendor. The new “owners” are the debt holders, the firms that bought bonds issued by the vendor’s owners. Now, the value of those bonds has dropped , and the bondholders need to quickly re-organize the vendor to cut their losses.

The new owners declare bankruptcy so they can buy some time while they figure out what to do.

No big deal, you say…companies go bankrupt all the time…someone will buy the vendor, and all will be fine.

Uh, no.

The treating providers who are delivering care to your patients now demand that you – the payer – guarantee payment for past bills and for scheduled care. You protest that you’ve already paid those past bills. The treating providers point out that no one’s paid them, and now that the vendor is in bankruptcy, there is no assurance they will ever be paid all they are owed.

The potential consequences include:

  • the patient gets billed, and/or;
  • the Insurance Commission weighs in, and/or;
  • treating providers refuse to continue or deliver treatment until payment is guaranteed by the payer.

So, payers may have to A) pay twice for the care that has been already billed and paid, and B) do so immediately or risk angry patients not getting treated, calling lawyers, and staying out of work even longer.

That’s the immediate problem – and it has to be addressed immediately.

There’s a bigger problem, though, and it’s almost as urgent. 

If the bankrupt vendor is a dominant player in its niche(s), do other vendors have enough capacity to quickly step in and take over? 

If not, how quickly can they ramp up?

If the answer is “not for a while”, how are you going to schedule treatment, collect and review data, manage care – all those functions the vendor was performing?

If you’re a TPA, the problem is even knottier. How do you go back to your employer/insurer clients and tell them they need to pay again for services they already paid for? Oh, and the vendor in question is one you – the TPA – recommended?

What does this mean for you?

Hopefully…nothing.

 

 

 


May
21

NCCI AIS research review – Comparing work comp to group health

Barry Lipton PhD did a quick review of a few ways work comp and group health differ – and how they are sometimes comparable.

The biggest difference is that workers’ comp is very focused on return to work, and more broadly, we care more about functionality.  In group health, not so much.

Differences – other than the obvious e.g. WC=ortho and trauma; group health= everything

  • price differences are 12% higher for work comp than group health,
  • while utilization is 60% higher for workers’ comp
  • so total costs are 77% higher.

This differs by state, with Alabama, Missouri, and Virginia showing the biggest cost difference compared to national averages, and Colorado and South Dakota with the lowest cost compared to that average.

It also differs by type of service – not surprisingly physical medicine is used much more in workers’ comp, driven almost entirely by more utilization.

That’s not surprising, as comp conditions are predominantly musculoskeletal injuries and focused on return to functionality, while group health deals with many more conditions and RTW is irrelevant.

There’s also a big difference in the cost of MRIs…

You can see that Medicare pays way less than work comp (WC is blue, Medicare is green-ish). You can also see the impact of Medicare’s change in reimbursement in 2013; it started to really impact workers comp in the years after 2014 as regulators adopted/factored in/used Medicare’s rate for reimbursement in their state.

What does this mean for you?

Price + Utilization = Cost. But one has to factor in RTW in comp, a focus that is nonexistent in group health.

 


Joe Paduda is the principal of Health Strategy Associates

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