Author: Joe Paduda

Sep
29

One Call’s credit rating – nerd alert

Posted by Joe Paduda on Thursday, September 29th, 2022 | Comments

Fielded several calls and emails yesterday re the Moody’s credit review of One Call…while always (ok, mostly) happy to talk, rather than answering the same questions multiple times I’ll lay my thoughts out here.

These are in no particular order…

A colleague noted the possibility of a recession might affect One Call’s credit worthiness as a recession would affect employment – thus reducing claims.

Well, not exactly..

I’ve written extensively on how economic ups and downs impact workers’ comp; posts are here. Here’s a quick summary..

At the early stage of a recession, employees who get hurt are less likely to file a workers’ comp claim. While we don’t know why that happens, research suggests it’s because workers are concerned their bosses will eliminate their job while they are out on disability, and they’ll have no job to return to.

graph courtesy NCCI

As the recession deepens, frequency tends to bump up as employees realize their jobs are in real jeopardy.  Claims increase as a result, and it is tougher to find re-employment opportunities for workers ready to resume some level of work. This extends to part-time or other limited duty work that is essential to recovery and return to full duty. So, duration increases too.

In the final stages, as the economy recovers frequency appears to accelerate. Employers put older, less-safe equipment back on line, require workers to put in big overtime hours, hire temps who have minimal training on safety, and the pace of work picks up speed. The result – more injuries.

***If we are in a “recession” it’s a pretty weird one; employment continues to grow, employers are hiring anyone and everyone who applies, and there are more job listings than potential workers to fill them…not exactly what one expects in a recession***

Another suggested the current owners can “just give One Call more money” thereby alleviating cash flow worries.

That’s a possibility – but I’d suggest a pretty unlikely one.

The current owners took over One Call when it was on the brink of bankruptcy; if OC had gone down that route it would have made it less likely OC’s bondholders/lenders would recover all their funds. In my admittedly limited experience, credit investors are much less likely to send more cash to assets that are struggling than private equity investors. And PE firms aren’t exactly enthusiastic about bailouts.

One insightful question focused on whether OC has debt with variable interest rates; those of us with fixed rate mortgages are protected from rate increases while our friends and neighbors with variable rate mortgages are seeing pretty significant increases in their monthly payments.

nerd alert…

OC has several different debt vehicles/types/forms

The First Lien (think of this as your house mortgage) of $700M is Libor+550 Floor <.75 which means that when Libor moves so does their interest payments. Libor moves when the Fed moves so, away you go.

For example in the beginning of the year OC would have been paying the Floor and for September about 2.52%. With the recent Fed increase, that will be going up to over 3%.

Note that One Call may have bought financial instruments that protected it (either in whole or in part) from interest rate changes – these are known as hedges.

[if memory serves One Call also has to pay down principle every quarter to the tune of around $2.1 million; that’s pretty small potatoes for a $1 billion+ enterprise]

Finally word is One Call had recently been awarded new business from a large payer, and this would certainly benefit the company going forward.

This is definitely good news for OC and congratulations are due to the C-suite and sales team (as well as the behind the scene folks involved).

That said, work comp payers are notoriously risk-averse; its too early to tell if Moody’s announcement will give the new customer pause.

What does this mean for you?

This stuff is complicated and one has to be careful making assumptions (I continue to learn to question mine!)

note – if I got anything wrong or you have another view please comment below.

Sep
28

The latest on One Call

Posted by Joe Paduda on Wednesday, September 28th, 2022 | Comments

Since its last-minute recapitalization three years ago, things have been quiet on the financial front for One Call. That changed yesterday; credit rating firm Moody’s released the results of a credit review – which were not good. [you can access the review by registering with Moody’s – there is no cost]

Historical corp rating changes from Moody’s

First, the summary. [I’ve written about One Call extensively; you can find other posts here]

Moody’s downgraded One Call’s Corporate Family rating to Caa1. According to NASDAQ, Caa1 is:

“A rating within speculative grade Moody’s Long-term Corporate Obligation Rating. Obligations rated Caa1 are judged to be of poor standing and are subject to very high credit risk.”

Here’s Moody’s summary:

The ratings downgrade reflects the company’s challenges to grow earnings and reduce its very high leverage which stood at over 10x as of June 30, 2022. Despite initiatives to improve operating performance and preserve cash, and Paying-In-Kind interest on the second lien notes, Moody’s expects One Call to generate small positive free cash flow which will not allow for material debt repayment. Without a material improvement in operating performance and meaningful debt reduction, Moody’s expects One Call’s capital structure to become increasingly unsustainable.

There’s a lot to unpack here – here’s my attempt to translate the summary into English (corrections/suggested edits welcomed).
  • One Call has a LOT of debt – as in almost 11 times more debt than it has in EBITDA (earnings) – and it is growing.
  • One Call has to use a lot of its cash flow to pay interest on part of the debt.
  • it does NOT have to pay interest on another chunk of the debt, but if it doesn’t, the missed payments are [usually] added to the principal – which increases the amount of debt (this is known as Payment-in-Kind or PIK debt); this is kind of like credit card debt)
  • as this debt increases it constrains One Call’s financial flexibility, making it hard to invest in technology, people, product development, and other stuff.
  • Moody’s goes on to note that a lot of One Call’s revenue comes from a relatively few customers – this concentration (in Moody’s view) increases pressure on One Call as the loss of one or more of these customers would make it even harder to pay down the debt.
[Moodys also refers to “the loss of a large contract”; no, I do not know details ]
Notably, Moody’s did indicate the rating is “stable” and expects One Call to grow earnings “modestly” over the next 12-18 months.
Okay, nerd alert. One could find fault with one of Moody’s statements regarding a governance issue:
Governance risk is further exacerbated by private equity ownership, which increases the risk of shareholder friendly actions that come at the expense of creditors and has used debt exchanges and recapitalization transaction.
Not mentioned in the Rating action is the fact that the equity owners (affiliates of KKR, Blackstone and Chatham Asset Management) – who control the Board – also own a lot of One Call’s debt. That being the case, it’s hard to see why the Board would screw (sorry, easiest way to convey the point) debt holders.
I spoke with Jay Krueger, One Call’s CEO and a person I consider a friend and he was kind enough to provide responses to several questions.  These are provided verbatim below.

MCM – What impact – if any – will the rating change have on One Call’s customers?

JK – None. We have positive cash flow, strong liquidity, no pending debt maturities, and the backing of some of the world’s largest, most respected investment firms. We talked with many clients yesterday who expressed this was not a concern for them. They continue to be pleased with our strong value proposition, commitment to service, and superior solutions for them and their injured workers.

MCM – After One Call’s recapitalization two years ago, did the current owners (shareholders) continue to hold a significant amount of debt? If so, it strikes me that Moody’s concern about governance risks may be overstated. Thoughts?

JK – Our current owners hold nearly 50 percent of our debt. This is a very real symbol of their commitment to our mission of getting injured workers the care they need when they need it. I believe we are the only company in the industry with an ownership group that also supports the company by participating in the debt structure at such a high level. The shareholders have a high amount of confidence in our team and strategy. So yes, I believe Moody’s concerns are overstated.

MCM – As hiring has continued to increase, and employment as well, it appears likely that claim volumes may also see a slight increase. Any observations or trends relative to claim volumes you can share?

JK – Over the last three months, we have seen month-over-month, low to mid-single digit increases in referral volumes. Some of this increase is seasonal, some of it is related to the macro-economic factors you mentioned, and some of it reflects market share gains we have achieved in 2022. September volumes month-to-date are consistent with this trend, setting us up for a strong fourth quarter.

MCM – Can you elaborate on the large customer “loss” referenced in the Moody’s report?
JK – The Moody’s report referenced some minor adjustments to that customer’s vendor panel. The customer referenced is a large, national TPA that continues to be one of our largest and most important customers.  
Tomorrow, I’ll discuss factors not directly addressed by Moody’s that may impact One Call’s future.
Sep
26

Watch out for gabapentin…

Posted by Joe Paduda on Monday, September 26th, 2022 | Comments

The CDC recently reported gabapentin was involved in one out of every ten fatal overdose deaths in reporting states.

Similar to opioids, gabapentin can cause severe breathing difficulties  – which are exacerbated when the drug is combined with other central nervous system depressants (CNS) (e.g. opioids, antidepressants, antianxiety meds).

Illicit use of gabapentin appears to be on the rise…from JAMA:

Gabapentin can produce feelings of euphoria and intoxication and can potentiate opioids’ effects. Individuals who misused the drug reported multiple reasons in a 2019 study, including a desire to enhance the effects of opioids; to achieve a “high” when preferred substances were unavailable, such as when they were living in a treatment facility or were incarcerated; or to self-treat withdrawal or pain. [emphasis added]

Gabapentin is a non-scheduled drug which became much more widely prescribed as opioid scripts declined.  Back in 2018 one out of five chronic pain patients were prescribed gabapentin (or its cousin, pregabalin). There’s some evidence that misuse of gabapentin – which is almost always prescribed off-label – often occurs after the consumer had a prescription for the drug.

And, Parke-Davis, manufacturer of Neurontin – the brand name version of gabapentin – pleaded guilty to promoting off-label use and paid a $430 million fine.

So, what to do?

First – learn more.  Start here – myMatrixx’ Shanea McKinney, PharmD penned an excellent overview way back in 2019.

Then…

  • Dig into your data – what’s been happening with gabapentin?
  • When and where possible, require prior authorization for gabapentin and similar drugs.
  • Educate patients and caregivers about potential risks of the drug.
  • Pay special attention to patients prescribed gabapentin off-label and in combination of other CNS depressants.
  • Consider recommending urine drug testing for gabapentin patients and include it in  the drug test panel.

What does this mean for you?

This looks awfully familiar. 

 

Sep
23

Friday catch-up

Posted by Joe Paduda on Friday, September 23rd, 2022 | Comments

Here’s what happened while we were all in full September mode…

Heat is much more dangerous than other environmental risks.  It’s also insidious, kills more of us than hurricanes, tornadoes, and floods. In July half of Americans lived in places that had excess heat alerts. And it is going to get worse – a lot worse…go here to find out how it will affect your home.

LWCC’s Jill Leonard, CA Joint Powers’ Jeff Rush and I will be discussing the impact of climate change on workers’ comp at National Work Comp Thursday October 20 at 12:30…see you there.

[I’ll also be on a panel focused on claim fraud mitigation with Change Healthcare’s Bill Barbato and Jennifer Gant and the Las Vegas PD’s Task Force Officer Jefferson Grace; that’s Wednesday October 19 at 1:30. ]

Merrill Goozner wrote a great piece dissecting Amazon’s repeated attempts to enter the health care insurance and delivery space.  The giant is looking to acquire One Medical.

From Merrill…

A recent analysis of One Medical’s 182 medical offices showed they are located in the top 10 percent of America’s most fortunate communities. Its clientele, which stood at 736,000 individuals at the end of 2021, is overwhelmingly urban, wealthy, non-Hispanic white, and college-educated.

My take is the bifurcation of our healthcare world is widening; for-profits continue to focus on the most profitable sector, namely fee-for-service employer plans. These plans pay much more than Medicare/Medicaid while avoiding any responsibility for expensive diagnoses.

If you’re curious as to how much your business is worth, here’s a useful piece offering guidance. Key takeaways:

  • most owners and managers of midsize, privately held companies (family-owned and otherwise) operate from day to day with no clear understanding of their value.
  • A close analysis of your firm’s most important value drivers [is key]: those characteristics of your business that make it unique. Even companies in the same industry and with similar metrics may vary widely on everything from the quality of their leadership to pricing power to brand equity.

Finally, WorkCompCentral’s annual Comp Laude celebration is just around the corner – registration is here – see you there.

Sep
22

The hospital shakeout

Posted by Joe Paduda on Thursday, September 22nd, 2022 | Comments

Is well underway.  Likely impacts include:

  • more hospitals shutting down their inpatient operations
  • a decline (!!) in hospital employment
  • even more aggressive land-grab efforts by rival health systems seeking highly profitable commercially insured patients (that’s you, dear reader)
  • doubling down on “revenue maximization” (that’s you, work comp payor)

(Kudos to the estimable Merrill Goozner for his cogent discussion of the issue)

What’s happening…

  • hospital admissions dropped precipitously last year – despite the major impact of COVID admissions. As I noted a while back, COVID patients aren’t very profitable; they rarely get surgeries or other procedures which generate big dollars for hospitals…
  • meanwhile expenses are climbing – driven mostly by labor costs (up $86 billion this year)
  • more than half of all hospitals are going to lose money…before COVID, the money-losing facilities amounted to only a third of the total.

Why this is happening…

  • states that didn’t expand Medicaid are getting hammered as the other safety net payment programs mostly stopped helping hospitals make up revenue shortfalls.
  • care has largely shifted to outpatient facilities which are way less costly – and generate way less revenue per admit – than inpatient stays
  • it’s really hard to find staff – many are way past burnout, driven by overwork and abusive patients.

What does this mean for you?

Facility costs will go up.

Quality likely won’t.

Sep
13

Wildly off-topic #9 – Russia’s military collapse

Posted by Joe Paduda on Tuesday, September 13th, 2022 | Comments

After seven months of brutal, grinding war, Russia’s military is nearing collapse.

The net – Russia is in deep trouble, so deep that its collapse may well lead to regime change. 

Ukraine has retaken over a thousand square miles of its territory in the past few days.  In the process it has captured hundreds of vehicles, Russian locomotives and rolling stock (freight cars etc), thousands of Russian soldiers, and untold quantities of ammunition and supplies.

First minutes after the liberation of Vovchansk by the Ukrainian defenders; Russian flag comes down, Ukrainian goes up.

you gotta watch this video of a Ukrainian farmer…he’s complaining there are dozens of abandoned Russian tanks but he doesn’t get to keep any…:(

You won’t find much support for that prediction (Russian military collapse) in your usual news feeds, but hear me out. (my past discussion of Russia’s invasion of Ukraine is here)

  1. Russia is running out of troops and there are reports it will NOT/cannot send any more to Ukraine.
    1. very scary thought – Putin may threaten to use tactical nuclear weapons…
  2. Russia’s vaunted military turned out to be a paper tiger due to:
    1. lack of maintenance,
    2. poor training,
    3. very low morale,
    4. awful supply situation,
    5. terrible lack of communication security
  3. Western support (except for Germany, which has been pretty damn unhelpful) and commitment to suffering through energy cutoffs has been critical to Ukrainian successes.
  4. US and other NATO nations are undoubtedly sharing intelligence from intercepted Russian signals, intelligence that ensures the Ukrainians know what Russia will do before their field officers do.
  5. Even if Russia goes to a full-scale mobilization to dramatically increase the size of its military, that won’t work because:
    1. it won’t happen in time to stop the ongoing destruction of its forces in Ukraine
    2. there aren’t enough experienced, veteran, capable officers and soldiers to train up the new recruits
    3. there isn’t equipment, vehicles, ammunition supplies, and a logistical infrastructure and capability to supply new troops and no ability to build/buy/manufacture and transport everything they need to fight.

The net – Russia is in deep trouble, so deep that its collapse may well lead to regime change. Meanwhile, Putin is celebrating the biggest Ferris Wheel in Europe…which promptly broke down a day after Putin’s speech.

Metaphor, anyone?

What does this mean for you?

Hang in there.  Ukraine deserves your support.

Sep
9

If only Florida was like California

Posted by Joe Paduda on Friday, September 9th, 2022 | Comments

If only Florida (‘s commitment to patient safety and responsible prescribing and good workers’ comp medical care) was like California.

But…no.

The Sunshine State’s work comp regulators and legislators don’t seem to care about patient safety or employer/taxpayer costs – at least not when it comes to drugs.

 

If they did, payers wouldn’t have to:

  • pay an upcharge for physician-dispensed drugs,
  • argue that physicians aren’t pharmacists (yes, really),
  • argue that drugs dispensed by physicians should be evaluated for patient safety

Kudos to myMatrixx for weighing in on this and attempting to get insurers and employers involved. Alas if history is any indication, the vast majority of insurers won’t.

Neither will most employers.

I get workers’ comp premiums will continue to decline, leaving fewer and fewer dollars for administrative tasks, like, you know, government affairs.

I get workers’ comp is hugely profitable.

I also get that this will change – and when it does those insurers will be looking for nickels in the couch cushions – nickels (and dimes and dollars) they ignored when things were going great.

Right now, payers and employers need to weigh in and tell Florida regulators that Physicians are NOT pharmacies – and therefore patients don’t get to pick a physician to be their pharmacy.

This is a major patient safety issue; physician-dispensed drugs aren’t subject to many of the electronic edits that pharmacy-dispensed drugs are.

So, physicians are almost certainly giving patients drugs that:

  • duplicate patients’ other scripts
  • conflict with patients’ other scripts
  • aren’t appropriate for that patient.

What does this mean for you.

Fight your own battles. I’m not going to do it for you.

From a post way back in 2014…

There is NO reason, no rationale, no logic behind docs dispensing drugs to workers comp claimants.  

Proponents claim it is better care, leading to speedier recovery and lower costs.

We long suspected the opposite is true; that is, claimants getting drugs from docs get more treatment, incur higher medical costs, are out of work longer and run up bigger claim costs than claimants with the exact same injury who don’t get pills from their physicians.

Thanks to CWCI, we know that’s the real impact of doc dispensing.

Now, we know even more – we know that dispensing docs prescribe more opioids for longer times, thereby increasing the risk of addiction and drug diversion and overdoses and death.  Thanks to a research paper authored by Johns Hopkins University Medical School and Accident Fund, there’s clear and convincing proof that doc dispensing is a highly risky, very dangerous, and very expensive proposition.

Here is the money quote:

“we found 39% higher medical costs, 27% higher indemnity costs, and 34% higher frequency of lost-time days associated with physician-dispensed versus pharmacy-dispensed medication. We found even more striking differences related to physician-dispensed opioids versus pharmacy dispensed opioids. The effect was nearly doubled and revealed 78% higher medical costs, 57% higher indemnity costs, and 85% higher frequency of lost-time days associated with physician-dispensed versus pharmacy-dispensed medication. [emphasis added]

Sep
7

Work Comp Pharmacy Week – #2

Posted by Joe Paduda on Wednesday, September 7th, 2022 | Comments

Yesterday we kicked off Workers’ comp pharmacy week with a quick review of WCRI’s latest research.

Today we’ll focus on our annual Survey of Pharmacy Benefit Management in Workers’ Compensation. We’ve been doing this for (gulp!) 19 years, and I’m (belatedly) ready to begin the 2022 Survey. Past public versions of the Survey are available here; there’s no cost and no registration necessary.

Respondents receive a more detailed version to reflect their contribution to the effort.

Top takeaways from last year’s report included:

  • Total work comp drug spend for 2020 was about $3 billion, or about 10% of total medical spend.
    • The percentage decrease from 2019 to 2020 was 12.3%
  • That’s down from $4.8 billion a decade ago.
  • Opioid spend declined 19.3% from 2019 to 2020; Opioids accounted for 17% of total drug spend across all respondents.
  • Pharmacy management remains important despite these decreases, primarily due to respondents’ view that drugs have a disproportionate influence on claim outcomes and disability duration.

Over the next few days we’ll be reaching out to past participants; if you are a payer and would like to participate in the Survey (and get the detailed report) please leave a comment below with your contact information (it won’t be published).

All responses are confidential, are only used in the aggregate or are de-identified to protect confidentiality.

 

Sep
6

Work comp pharmacy week!

Posted by Joe Paduda on Tuesday, September 6th, 2022 | Comments

There’s been a lot of news around work comp pharmacy of late – time to dive into what’s happening, why, and the implications thereof.

No better place to start than WCRI’s just-published study on the latest in drug trends across 28 states. (register here for the no-cost webinar – September 29 at 2 pm eastern). The research looked at trends over the three years from Q1 2018 to Q1 2021 (kudos to WCRI for getting this very recent info out quickly)

Key takeaways from Dongchun Wang, Vennela Thumula, Te-Chun Liu’s research include:

  • Rx payments (all figures are per claim) dropped 15% or more in almost 2/3rds of the 28 states..but went UP in:
    • Connecticut (+22%), Florida (+17%), and Pennsylvania (+14%)(hmmmmm…)
    • notably a major driver of the increase in those states was dermatological agents…driven by physician dispensing and/or mail order pharmacy dispensed drugs in those three states (and others)
  • COVID is a non-factor; COVID claims account for <2% of total Rx costs in most states
  • Other good news – opioids continued to decline in all 28 states – A LOT. As in a decrease of 56% in the median state
  • The biggest drop in spend occurred in New York – a 43% decrease driven by the adoption of a formulary in early 2020.
  • The range in spend is really striking; as of Q1 2021, the lowest state spend for claims with any medical spend was $22 (MA, MN, WI); the highest was almost 10 times higher in – you guessed it – Florida at $201.

So…takeaways

  • States that enable/allow/don’t prevent abusive prescribing and dispensing – looking at you, Connecticut, Georgia, Florida, Louisiana, Pennsylvania, South Carolina – and others – are allowing grifters and thieves to steal money from employers and taxpayers while over-treating patients. 
  • Lotions aka dermatological agents are almost entirely a (pick your term) enabled and perpetrated by physician dispensers and some mail order pharmacies…and the lack of aggressive and useful action by employers and insurers and their lobbyists.

Forecast

Insurers and employers and taxpayers in those states are going to get hammered by these bad actors. Costs for dermatological agents rose more than 50% in PA, CT, SC, FL, GA, VA, NC and MI.

Given the lack of an effective response by payers, their lobbyists and government affairs entities, you can expect more of the same.

What does this mean for you?

  1. Great work on the opioid front – although just slashing opioids is not THE solution to pain – this requires a multi-pronged approach.
  2. re dermatological agents – Do you like getting screwed by profiteers?
Sep
1

Wildly off-topic #8 – Ukraine attacks

Posted by Joe Paduda on Thursday, September 1st, 2022 | Comments

After more than six months of war that some were thinking was going to enter a stalemate, Ukraine flipped the tables on Russia.  Ukrainian forces are driving Russians back in multiple areas, although this is a hard slog.

Ukraine has several distinct advantages in this war.

  1.  Russians don’t really know why they are in Ukraine. Ukrainians know why they are fighting.  The ones on the front lines certainly do and pretty much every other Ukrainian does as well.  Their homes have been attacked, children murdered, and their economy wrecked by a madman. The will to fight is critically important.
  2. The west’s support of Ukraine has enabled it to hold Russia off while building the capacity to defeat the invasion.  We’ve spent billions – thanks to you, American, British, Dutch, Danish, Swedish, Norwegian, French, Polish, Italian, Pakistani, Czech and other tax payers. This has been an investment worth every penny, as the West’s total commitment has shown other would-be territory grabbers (looking at you China) that far from being the “decadent west” we are guarantors of peoples’ right to self determine their government. (sure we get this wrong far too often, but on balance we’re mostly on the right side.)
  3. Russia’s kleptocracy (a state ruled by thieves) has ensured their armed forces have crappy, outdated, and poorly maintained equipment. Sure they have far more cannons and tanks and planes and rockets – but a lot of those don’t work, are worn out or hopelessly obsolete – or their soldiers don’t know how to use them effectively.
  4. Russia’s army has a fundamental flaw – they can’t get the food fuel ammunition and spare parts to where it’s needed. (posted  on this way back in March with lots of details)
    If anything it has gotten worse. The HIMARS rocket systems and other really good artillery we’ve sent Ukraine are destroying ammunition and fuel dumps, blowing up communications centers, and killing dozens of high-ranking colonels and generals, de-capitating Russia’s army just when it is being attacked.

That’s enough of the cheerleading.

The awful truth is Ukraines’ military is losing hundreds of soldiers each week – far less than Russian losses, but devastating nonetheless. I cannot imagine how painful this is to each and every family that’s lost members due to Russian aggression; killed in an apartment building bored by the Russians, blown up by mines near a school, dead in combat or crushed in a shopping mall hit by Russian rockets.

What does this mean for you?

I’m very proud of what we Americans have done and are doing to support Ukraine.

You should be too.

Yes fuel and food prices are higher – make no mistake, that’s due to Putin’s invasion of Ukraine.