Feb
15

Workers’ comp > all other healthcare payers. Period.

and here’s why.

Work comp payers actually care about the patients recovery, return to functionality, ability, and productivity. Work comp HAS to…screwing up recovery = huge financial penalties in the form of claims that last forever, really costly settlements, and migraine-level headaches for all involved.

Whereas in group/individual health, Medicare and Medicaid (mostly), functionality is – at best, and then only rarely – an afterthought.

side note – if you think about it, how dumb is it that 99% of healthcare payers don’t really care whether the $4.2 trillion they spend on healthcare actually improves lives, helps patients stay active, supports functionality, and helps us live the lives we want to live?

answer – dumb as a box of rocks

WCRI’s latest in a never-ending stream of excellent research brought me back to this...researchers examined patient-reported functional outcomes after low-back pain, a far-too-common and sometimes really problematic diagnosis. [report is free to WCRI members and a nominal cost to non-members].

The research compared WC outcomes to those of other payers…and:

  • included patients covered by all types of payers,
  • totaled some 2.4 million patients (!),
  • covered almost 1.3 million PT/OT episodes of care, and
  • used patient-reported functional status specific to the low back pain issue (as captured by FOTO).

The researchers obviously put a LOT of thought into selecting the measure…they describe the process and rationale in detail in the report (ppg. 15 – 19).

credit WCRI

While it is important indeed to consider that workers’ comp patients’ reported functional improvements were not as high as some other payers – and we  need to understand why – that’s secondary to the fact that work comp’s primary focus – return to functionality – is way different from other payers’.

With extremely rare exceptions, no other payers focus on functionality, and almost none do across all patients with all conditions.

Kudos to Sebastian Negrusa, Vennela Thumula, Randall Lea, and Te-Chun Liu for their excellent work.

What does this mean for you?

Work comp gets beat up a lot…this is why – in one extremely important way -workers’ comp is superior to all other payers. 


Feb
13

After 10 days away from the keyboard – family vacation in Mexico and gravel bike race in California – it’s back at it.

shockingly the world kept turning while I was unplugged…

The estimable Charles Gaba has just updated his analysis of US healthcare coverage by payer. Charles’ work is the best I’ve encountered to date…he includes everything from Medicare and Medicaid to Exchange programs to Healthcare Sharing ministries (between 865,000 and 1.5 million, Indian Health Services (2.6 million)…

Here’s the all-in-one view…

Despite all  those gazillions of people with insurance, many hospitals are having real/awful/terrible financial problems. Hospitals’ average margin – according to Kaufman Hall – was -3.4% for the first 11 months of 2022.

That said, things steadily improved during the year…

In the tiny world that is workers’ comp, NCCI released its review of medical inflation…among non-hospital providers (docs, PTs, etc).

Thanks to the good work of Raji Chadarevian and David Colon, we know medical inflation among these providers was…minimal.

As in 1.5% per year over the last decade.

Final note. Facility costs are increasing.

Most payers are doing a really crappy job addressing this; their bill review partners/operations are woefully ill-equipped to ensure your dollars aren’t being Hoovered up by healthcare systems and hospitals.

And yes “most payers”includes you.

To date those increases have been matched by a $2 billion decline in drug spending – which, by the way, has also reduced claim durations (way lower opioid usage = way more claim resolutions).

Physician costs are pretty much flat, drug costs are way down, and facility costs are headed up…net is you need to PLEASE stop catastrophizing about “severity increases” and other nonsense.

If I read one more survey or interview or discussion of workers’ comp execs afraid of “rate inadequacy” or medical inflation or some other incredibly uninformed and wrong-headed and ignorant fear mongering I’m going to call them out publicly.

Just. Stop.

 


Jan
30

LWCC’s got it going on

I was fortunate indeed to attend Louisiana Workers’ Compensation Corporation’s annual provider meeting last week. Well attended, learned a lot, really enjoyed the people and the weather was really nice too.

I was blown away by their office building.

It was gorgeous…open, airy, beautifully appointed, welcoming, spacious, high ceilings and a terrific learning center and gym…it can only be wonderful to work in and it was a delight to experience.

But what really impresses me about LWCC is their people and culture – open and constantly learning, humble and very focused on doing the right thing. Unlike many other workers comp carriers, LWCC is about as far from arrogantly self-satisfied as it could be. I’ve seen way too many payers suffer from the “if it wasn’t invented here it didn’t need to be invented” syndrome, secure in the incontrovertible truth that they alone are the BEST.

They of course won’t listen or read this…why waste the time when you’re entirely sure you can’t learn anything from anyone? Especially not a single state carrier in a not-big state solely focused on a single line…

They might learn…if their customers take them down a notch or several, challenge them to compare their processes and outcomes using objective criteria, call them out on their arrogance.

It is clear that senior management really cares about LWCC’s people and are totally committed to doing the right thing. They listen hard and carefully, and respond to what they hear. And it shows; the passion and commitment to doing the right thing by every injured worker and every policyholder was front-and-center, evident in every LWCC person there.

They invest in marketing – which is really, really good. A cogent, really well-designed branding strategy designed to link LWCC to its home state, fresh and engaging graphics, a commitment to telling their stories, a leader who really understands marketing – which is NOT proposal writing, powerpoint editing, or letter writing. It is branding, content, design, strategy, pricing, research, community relations and more.

I don’t know of any other workers’ comp entity that does it as well.

What does this mean for you?

Most of the biggest payers in workers comp can learn a LOT from LWCC. 

 


Jan
26

CMS just reported US healthcare spending topped $4.3 trillion in 2021…almost $13,000 per person.

Meanwhile work comp medical spend for 2021 was likely around $32.5 billion…or 0.74% of US healthcare spend.

Government accounts for about 2/3 of total spend, among private employers Amazon has more health plan participants than any other company…

chart courtesy Mark Farrah and Associates

Old friends and colleagues Adam Fowler and Kevin Tribout’s latest edition of the Policy Guys podcast is up here. Honored to be part of the pod, especially with such distinguished hosts!

Off to Baton Rouge to get together with my friends at LWCC – looking forward to great food and better people.

 

 


Jan
25

Wildly off-topic #13 – Tanks.

Last time we talked about weapons…how many each side had, what’s been lost, and the challenges in replacing those weapons.

Today’s newsfeed arrived with the VERY welcome news that Germany has OK’ed supplying Leopard 2 tanks, and we will be sending Abrams tanks to Ukraine. The UK had committed to send 14 of its Challenger II tanks to Ukraine… Note that countries that use Leopard 2s have to get permission from Germany before sending them to Ukraine; with this latest announcement sources indicate Ukraine will get at least 100 Leopard 2s.

This will supply roughly one brigade – and is about 1/3 of what Ukraines’ leaders say they need.

These are “main battle tanks” [MBTs], a term describing very heavy, very well armored vehicles with very powerful cannons. Unlike the other armored vehicles already sent to or on the way to Ukraine, MBTs are much more likely to survive an IED, land mine, rocket or artillery attack.

Highlights…

  • Leopard 2 tanks are very capable; well armored and with a very powerful cannon, highly mobile, durable and simpler to maintain than the US Abrams tank
  • there are thousands of them in more than 19 armies

  • The US Abrams is equally if not more capable, BUT…
    • guzzles fuel (although it can use jet fuel, gasoline, or diesel)
    • requires a lot more maintenance
    • is really heavy and thus harder to transport

Timing

These will not be there tomorrow…however I’d bet NATO countries will be sending tanks from their current units rather than pulling mothballed older versions and going through what could be a long and difficult process of upgrading them and preparing them for battle.

Then there’s spare parts, fuel, ammunition, training, repair and maintenance  personnel and facilities and transport. These are massive, very complex vehicles that require a lot of care and feeding.

Experts contend that Ukraine’s Army has shown itself quite able to learn complicated weapons systems quickly; it’s use of the HIMARS rocket system, artillery, and anti-ship missiles has been pretty impressive.

What does this mean?

This is a major move, one that will definitely improve Ukraine’s chances of retaking territory. 

That said, like any tool, it comes down to how well it is used. 


Jan
23

Hospital profit margins – a bipolar mess

For profit hospitals have very solid operating margins.

Some Not for profits are really struggling…others are doing just fine thank you.

credit FierceHealthcare.

That’s the headline – the question is…why? and what does this mean?

First, a little more explanation…

From the Kaiser Family Foundation’s report

So far this year [2022], operating margins among the three largest for-profit health systems in the country have met or exceeded pre-pandemic levels. HCA and Tenet in particular have had high operating margins.

the largest for-profit systems have had operating margins that exceed pre-pandemic levels. [emphasis added]

Also, most hospitals and systems saw declines in investment income; as this falls outside their core business, we are focusing on operating income which excludes investment and other categories.

Why?

It appears that the more profitable hospitals/healthcare systems:

  • saw surgical and other profitable service line volumes return to or exceed pre-pandemic levels
  • better controlled staffing costs; contract staffing costs (traveling nurses and other clinicians) were a major factor for several not-for-profit hospitals
  • benefitted from non-healthcare operations (insurance for UPMC) and financial gains from mergers (e.g. Intermountain Health)
  • increased prices for commercially-insured patients (this is an assumption although there’s this…)

The merger thing continues to be a major influence, with $45 billion in transactions in 2022 across 53 deals… again the results aren’t consistent as some systems really benefited while others did not.

Meanwhile, the American Hospital Association continues to call for higher reimbursement and other federal intervention to help hospitals financials.

For my workers’ comp readers…

Look at the costs of providing care at an HCA hospital vs some of the not-for-profit hospitals in your service areas. You will very likely find HCA’s costs are several times higher than not-for-profits’. 

Oh, and they are waaaay higher in Florida

More on this here.

What does this mean for you?

Don’t use HCA or Tenet facilities. 


Jan
18

Why hospital costs are going up

Because they can.

Healthcare  – and more specifically facility-based healthcare – is a very mature industry and – with one huge exception – exhibits all the hallmarks of such…continued widespread consolidation, shuttering of marginal locations and elimination of unprofitable business lines and centralization of core services.

The “huge exception” is margin compression and price reduction. When any other sector matures, competition becomes fierce and prices come down.

Not so in healthcare, where pricing is opaque at best, and more often opportunistic if not downright predatory.

Over the last 70 years, the percentage of hospitals in health systems has grown by a factor of ten. Unusual indeed is the standalone facility.

That decades-long trend continued in the 2010s, although the pace slackened somewhat as there were fewer hospitals to acquire.

The net is this – most healthcare markets are pretty consolidated, which means one or two systems have pricing power.

Those systems use that power to force ever-higher reimbursement from commercial payers – and workers’ comp.

What does this mean for you?

Facility costs are going up.

 


Jan
10

Workers’ comp 2023 – what does the year hold – part 2

Yesterday the annual crawling-out-on-a-limb began, today it concludes with 5 more predictions for workers’ comp in 2023.

6. The growing impact of global warming will force changes in risk assessment, management and mitigation; technology adoption; and claims.
The predicted (heat injuries, wildfires, hurricane intensity, sea level rise) and unforeseen (atmospheric river-driven flooding, landslides, and destruction and others) changes in climate and weather will lead to more and different injuries and illnesses, higher risks for fire fighters and public safety workers, and unpredictable problems related to polluted storm water runoff, water-borne disease and perhaps invasive species.
Expect revisions to both federal and state OSHA regulations especially around heat and outside workers along with calls for better planning to prepare for severe weather events.

7. Payers and perhaps regulators will make significant efforts to address rising facility costs.
As for-profit healthcare systems look to pad record profits and not-for-profits seek to survive, payers will be looking for better cost control answers than simply doing more of the same stuff they’ve been doing for the last two decades. Network discounts (NOT THE SAME AS SAVINGS) are declining as facilities wise up to most payers’ lackadaisical/ineffective attempts at employee direction and unsophisticated contracting strategies.
Smarter payers will deploy multiple payment integrity layers  – both pre- and post-payment. All should demand more – much more – from their bill review vendors/technology suppliers, all of whom have long refused to entertain the thought that they could do better – much better.

8. Premiums will increase – mostly late in the year.
As infrastructure, green energy, re-shoring of chip manufacturing and EV incentives ramp up in the fall so will employment. While there’s disagreement among economists (yeah, who woulda thought??) expect big hiring in categories from archeologists and bridge builders to wireless broadband construction workers.  Manufacturing, heavy construction, trades, logistics will all be hiring…as these tend to be higher frequency (more claims than average) and higher severity (claims are more severe and costly) this means higher premiums and more claims.

Good news indeed for my friends in Cincinnati!

Oh, and mark me down for one who does not see a significant recession in our near future.  I know, I’m no economist (who disagree a lot about this) but hiring is too strong, these major investments are on the horizon, and inflation is coming under control  – all indications that a “soft landing” is more likely than not.

9. SB1127 – aka the CAFE Act (California Attorney Full Employment Act) will cause heartburn and consternation among Golden State employers and tax payers.
SB1127 shortens the time period for employers to determine the compensability of claims, a change which will lead to – among other problems – more initial denials and less time for injured workers to receive medical care while their employer researches the claim. Further, AB1127 appears to allow for penalties of up to $50,000 for claims that are “unreasonably rejected” by the employer – but the bill a) doesn’t define what constitutes an “unreasonable rejection” and b) doesn’t exclude claims that are already closed.

Expect attorneys to look for the Golden Ticket case – one that they think will establish precedence – and pursue it like a starving person at a Vegas buffet (or Cafe’).

There’s good news too…I don’t see much else on the regulatory horizon that is cause for concern.

10. More consolidation among payers and service providers.

Despite a major drop-off in financial investors’ interest in work comp, we’ll see  more consolidation as “strategics” aka TPAs and service providers acquire smaller TPAs and service providers. This is classic mature industry…scale is key, significant growth will mostly be driven by acquiring competitors or companies in complementary or related service and margins are in peril.

The bad news is 2023 prices will likely be a good deal less than in the recent past. Fewer potential buyers, less interest from PE firms, and a growing recognition that workers comp is a declining business (what took these people so long to see this?!) are all contributors.

What does this mean for you?

Prepare for climate change and more employment in higher frequency and severity sectors, and make your bill review company get its act together.


Jan
9

Workers’ comp 2023 – what does the year hold?

Its that time again, when I throw caution (and good sense) to the wind, polish up the crystal ball and guess reveal what big things will happen in worker’s comp this year.

Off the diving board, and hope there’s water in the pool…

  1.  The soft market continues…
    And it won’t harden in 2023. Medical costs remain very much under control (with  an exception), rates continue to drop, employment remains very strong (essential for return-to-work) and there’s lots of payers fighting for market share.
  2. Medical spend is NOT a problem – and will NOT be in 2023.
    With a couple notable exceptions – to be covered in a future post – medical inflation will remain under control. In part this is driven by much lower drug spend and more specifically the continued decline in opioid spend. The latter has a big impact on claim closure and total medical spend.
  3. Behavioral health and its various iterations will gain a lot of traction.
    More State Funds, carriers and TPAs will adopt BH programs, more patients will benefit, and more dollars will be spent. There’s a growing recognition that medical issues aren’t hindering “recovery” near as much as psycho-social ones. This is great/wonderful/long-needed and will really benefit patients and payers alike. Kudos to early adopters, and LETS GO to you laggards!
  4. One Call will be sold. 
    I keep forecasting this…and one day I’ll be right.  It has to be this year. CEO Jay Krueger and colleagues have OCCM on a better track, but structural problems (i.e. declining claim volume) and internalization of One Call-type services by Sedgwick and others make the future…less than promising. Couple that with recent ratings actions by Moody’s and S&P and it’s time to do the deal.
  5. New technology will make its impact felt.
    Wearables, chatbots (I HATE THEM), and Virtual Reality-driven care are three ways tech platforms/systems/things will significantly ramp up in ’23. Expect several large/mid-tier payers to adopt new tech in a major way – aka not just a small pilot.
    Structural issues with health care (try to find a LCSW or Psych-trained counselor), lack of trained adjusters, and frustration with rising rehab expenses are all contributors.  

Later this week – the other 5 predictions.


Jan
5

2022 Predictions for workers’ comp – How’d I do part 2

Yesterday we dug into my prescience – or lack thereof – as laid out in my first 5 predictions about workers’ comp in 2022.

Today, it’s the second 5.

6. With one or two exceptions, don’t expect much in the way of private equity investments.

There may be one or two large transactions, and a couple small ones, but outside of that, the bloom on the workers’ comp rose appears to be fading.

Verdict – True.

Enlyte’s sale didn’t happen; sources indicate the price offered didn’t hit the level its owners needed for the big bonuses to kick in. Not good for the employees with options…

Other efforts – MTI America and Medata among them – also didn’t result in sales, while TRISTAR bought Risico and Carisk acquired Advanced Claim Review Specialists – both deals make a lot of sense strategically. There were a few other, smaller transactions, but nothing like what we saw 5+years back.

Oh, and the deals that did happen were NOT PE firm acquisitions, rather strategic investments by other companies in the space.

Adding to that is the reduction in the number of firms interested in workers’ comp services…unlike the halcyon days a few years ago, there are far fewer PE firms focusing on work comp.

7. OneCall will be sold and/or split up. 

The BlackRock and KKR entities that are the current owners are not operators; they are debt owners. CEO Tom Warsop has squeezed out all the squeezable costs – and then some. Growth – defined as new business from new customers – is not happening. Add the overall drag on work comp services from the still-real drop-off in claims and claims services, and the reasons to hold on and hope are few indeed.

Plus, if interest rates increase – which is a distinct possibility – and if private equity interest in workers’ comp continues to diminish from it’s current modest level – also a distinct possibility – OCCM’s owners may well decide to sell soon rather than watch values decline.

Verdict – Nope. OCCM continues to soldier on, although Sedgwick’s move to internalize those services and the continued structural decline in claims frequency make the future uncertain at best.

8. COVID’s impact on costs and rates will prove to be minimal.

COVID claims are cheap, few are anywhere close to catastrophic cost levels, the effect of presumption laws and regulations is not much of an effect at all, and many employers – especially health systems – are forcing employees to use PTO rather than file for WC when they test positive/have symptoms.

Most research organizations and actuaries would do well to reflect how their early predictions were so…bad.

Helpful hint – two places to start; a) the tendency for WC “experts” to catastrophize and b) the almost-complete lack of understanding of healthcare drivers, costs, cost structures, reimbursement, and epidemiology.

Verdict – True.

All the credible research indicates COVID hasn’t been expensive – if anything claims are less costly than non-COVID claims.

9. There will be no big issues in workers’ comp. “Big” defined as important, needle-moving, disruptive, revolutionary.

No, medical marijuana is NOT a big issue – neither is COVID, or presumption, or the mid-term elections (there is ZERO interest in workers’ comp on the federal level) or remote work (does anyone seriously believe office workers tripping over toys will amount to any real dollars?)

Oh, and with rates at all time lows, frequency continuing to drop, and medical costs (with the exception of physical therapy and facilities) flat, coupled with ongoing supply chain and labor market issues, execs at big employers are (justifiably) completely uninterested in workers’ comp.

If the big girls and boys don’t see any issues, there aren’t any.

Verdict – True.

While some pundits/erstwhile “experts” would have you think medical marijuana, COVID, employment, or other issues even more tangential are going to be big issues, reality is there are no big issues in workers comp – save the decades-long drop in claims frequency.

10. Here’s the kicker – the biggest long-term concern for workers’ comp is global warming...yet this is getting zero attention.

There’s going to be an inevitable increase in issues related to heat, flooding, fires, drought, tornados and hurricanes. This is getting more real every day yet remains all-but-ignored by pundits, policy-makers  and rate-makers.  We can expect more heat-related claims. Hurricanes, fires, and tornados will increase in number and severity; affecting logistics, labor, construction, and claims. The research is clear.

Verdict – True.

Yep this is going to be a controversial finding, especially among the human-driven climate change deniers (and other flat-earthers).

Storms are getting more severe, heat-associated “injuries” increasing, and other major weather events (tornadoes, massive blizzards, deep cold snaps) are happening more often and with more intensity.

The verdict.

I got 8 correct, one flat-out wrong, and one is TBD.