May
27

The latest on work comp pharmacy

I’m almost halfway thru the 17th (!!) annual survey of Pharmacy Benefit Management in Workers’ Comp.  Here are some VERY preliminary results (which are almost certain to change).

If you are a WC payer and want to participate, drop me a note in the Comments section.  Public versions of past surveys are here, respondents receive a much more detailed version.

Findings

All but one respondent saw a drop in drug spend from 2019 to 2020; the biggest cost reduction driver was fewer claims.

Despite a 7+ year trend of declining drug costs, respondents view prescription drug issues as somewhat more important than other medical issues. This is likely driven by drugs’ impact on recovery and return to work.

Transparency remains a significant concern, with only 2 respondents having full visibility into drug costs. Most want more transparency and no one is really comfortable with AWP.

Opioid spend continues to decline...which is the good news.  Not-so-good is the continued problem of helping long-term users reduce or eliminate opioids. Prescriber intransigence is the major obstacle followed by attorneys blocking access to patients.

Few payers have audited their PBM and those that have are (mostly) just checking AWP pricing compliance.

Several noted out-of-state mail order pharmacies – mostly IWP and entities in Pennsylvania – continue to be a sore spot, adding cost, negatively affecting clinical management, and wasting adjuster time.

What does this mean for you?

Costs are down, but pharmacy is about much more than the price of the pill. 

 


May
26

Have work comp payers given up on physician dispensing?

It sure looks like they/you have.

WCRI’s latest report finds:

  • Physician-dispensed drugs (PDDs) accounted for more than half of drug costs per claim in Q1 2020 in four states – Florida, Georgia, Illinois, and Maryland.
  • In 12 states, doc-dispensed dermatological agents accounted for most payments for this drug class.
  • Louisiana is worst-off, with employers paying $190 per claim for dermo drugs in the 1st quarter of 2020…Illinois is right behind at $181.
  • Kansas and Connecticut saw payments for those dermo drugs triple from Q1 2017 to Q1 2020.

That profit-sucking prescribing by docs in Connecticut is why total drug spend increased 30% in the Nutmeg State – making it one of two states that had drug spend increases. Florida – the home state of PDD – was the other. (Across all subject states, drug costs dropped 41%.)

Having lived in CT for over 20 years, I’m really stumped by the precipitous increase in skin care drugs.

What could POSSIBLY be driving this massive need for occupationally-driven skin care/topicals?

Did sun spots create a pandemic of skin cancer but somehow only affect the second-smallest state?

Did a massive refinery accident expose tens of thousands of workers to burns or skin infections?

Did a hyper-virulent new breed of poison ivy run rampant, affecting thousands of landscaping and municipal workers?

Did the emerging cannabis industry fail to protect its workers from fertilizer burns, exposing thousands of workers to painful blisters?

Did everyone in Connecticut suddenly become unable to swallow a pill?

Of course not.

The real question is this:

why haven’t insurers, TPAs, and self-insured employers used CT’s Medical Care Plan to ban physician dispensing? Payers including the Workers’ Comp Trust of CT have pretty much eliminated physician dispensing.

It’s not just Connecticut.  PDD costs are outrageous, and all credible research indicates PDD is totally unnecessary, increases medical costs, and prolongs disability.

WCRI’s research should be a call to action.  Legislators, regulators, and payers are doing their policyholders and clients a disservice by failing to aggressively attack physician dispensing.

And those clients and policyholders are equally at fault – it is up to you to work with your PBM and payer to stop this rampant profiteering. 

What does this mean for you?

Yeah, I know it’s hard. Most important things are. Get to it.

 

 

 

 

 


May
24

Bipartisanship at last!

An excellent article by Washington Monthly’s Eric Cortellessa described a Senate antitrust hearing focused on hospital and health care system consolidation.

Believe it or not, the problems created by hospital consolidation have brought bipartisanship to the Senate, with arch-conservative Josh Hawley and liberal icon Richard Blumenthal agreeing that consolidation is bad.

Hawley opined”private equity and their [sic] intervention here is actually helping drive consolidation in a way that is unhealthy in this industry and can be particularly harmful for rural communities…”

Blumenthal: “incentives and self-interest of the private equity funds drive the finances rather than respect and care for the patients who are there or the professional staff who ensure quality care.”

It’s not just private equity – most consolidation is driven by massive health care systems looking to dominate markets and thereby control pricing. And that’s exactly what happens.  According to chair Amy Klobuchar, “hospital prices are 12 percent higher in monopoly markets compared to those with four or more competing hospitals.”

That’s one reason profits are zooming for hospital companies Tenet, UHS, HCA and CHS.

What does this mean for you?

Nothing good.

 


May
21

One is not like the others.

Hospital in patient and outpatient, surgery, DME/home health, PT, pharmacy, imaging, lab…

Which one is NOT like the others??

That’s easy – when it comes to impact on legacy/older claims, it’s all about pharmacy. The older a claim is, the greater the percentage of spend is for drugs.

The older and more costly the claim, the greater the percentage of spend is for drugs (except for those cat claims needing long-term home health/facility care).

And, the higher the reserves, the greater the percentage of those reserves is for drugs (except for those cat claims needing long-term home health/facility care).

Both graphs from NCCI; Medical Services by Size of Claim—2011 Update.

Updated information from NCCI...shows drugs continue to be a major driver of claim costs in older claims…excellent research by NCCI’s Matt Schutz…

especially for those really expensive claims.

But that’s only half the story.  The other half is the impact the type of drugs has on claim outcomes. Most simply, most patients on opioids after 8 years need a lot of help, assistance, patience, and support to recover functionality. Some can do well on opioids – most do not.

What does this mean for you?

So, how are you buying PBM services? 

Do you even ask how the PBM will help reduce long-term drug spend?

Do you ask to see data on their results by age of claim?

Do you dive deep into their abilities, tools, programs and approaches to addressing long-term claims?

Does their reporting support this by identifying, tracking, and quantifying results?

If you aren’t focusing on the PBM’s impact on long-term claims, you’re doing it wrong.

 


May
19

It’s the price – and the network penetration – that drives cost.

That’s the conclusion I reached after reviewing WCRI’s latest treasure trove of research on medical prices paid for professional services in workers’ comp. [report is free to download] Sure utilization is a very important driver, but the biggest difference in medical costs across states is price.

Rebecca Yang PhD and Olesya Fomenko PhD  have outdone themselves with this edition, cementing their reputation as two of the most knowledgeable experts in the nation on medical costs in workers’ comp.

Kudos to WCRI for including data from the first half of 2020 in their report…the fine folk in Boston have done a great job speeding up data collection and analysis to the point where we have data that is less than a year old. This is helpful indeed for anyone trying to understand what’s happening and why and what to do about it.

Takeaways

  • Wisconsin’s professional services (MD, PT, etc) are darned expensive. WI has a very provider-friendly
  • While prices paid in non-FS [fee schedule] states generally increased more than in FS states, NJ is an exception. WCRI noted that NJ saw a pretty significant increase in network penetration during the study period; I’d suggest NJ’s employer direction laws directly contributed to lower price increases.
  • Network participation varies widely, and generally the more the growth in network penetration, the lower the increase in prices paid.  However, in some cases (PA), it doesn’t.
  • Finally, there’s a VERY useful chart on p 39 providing network penetration rates for each of the 36 states studied. 

What does this mean for you?

This is extremely useful information, with many nuggets buried in the 190 page report.  IF you aren’t a WCRI member – join now!


May
17

Good news on the COVID front

Here in the US, life is getting better – a LOT better.

The three main COVID indicators – deaths, hospitalizations, and infections, continue to trend down. That’s due to multiple factors – immunization rates, warmer weather and more outdoor time, and continued physical distancing and mask wearing.  Oh, and about 33 million of us have had confirmed COVID diagnoses…

Deaths are now at their lowest point in almost a year,

Hospitalizations are down by double digits, although ICU admits remain stubbornly high.

And almost half of us have been fully vaccinated.

Parties, events, family get-togethers and social gatherings are becoming more common (we celebrated our daughter’s 30th birthday/engagement at a party with real live people not wearing masks this weekend).

Ok, so that’s all good news.

The not-as-good news is…

Vaccination rates are tapering off, meaning it will likely be tough to get to 75% immunity.  It appears some of the more creative vaccination campaigns are working…NJ’s Shot and a Beer, the Ohio million dollar prize for 5 people picked by lottery, a marijuana joint reward happening in DC and others are showing increases of 8% in the population immunized.

The mask thing.

There’s been a lot of talk about the CDC’s new maskless guidance for those of us who are fully vaccinated (except on airplanes etc) and the “confusion” surrounding the announcement.

While this could definitely been handled better, the back story is we now have a CDC that is completely free from politicization. It looks like the White House and CDC are going above-and- beyond to keep the politicians away from the CDC’s public health guidance. The result is going to be the CDC making announcements and policy recommendations on its own, without guidance from the White House. [Thanks for typo correction Kathy!]

This is a good thing.

What does this mean for you?

Get shotted up so we can get together and do fun stuff!


May
12

And the state of workers comp is…

Pretty terrific.

Put another, more awkward way, COVID’s been very, very good to work comp insurance.

Yesterday kicked off the NCCI Annual Issues Symposium with CEO Bill Donnell’s introduction. Bill set the right tone – we’ve all been humbled, learned not to take anything for granted, and adapted.

The State of the Line address was again led by Chief Actuary Donna Glenn. Donna and her colleagues spoke extensively about the impact of COVID – fewer total claims and a big drop in premiums especially for main-street businesses, hospitality, retail and personal transport (my label, not her’s).

Financial highlights

Net written premiums were down 10% for state funds and private carriers.

Early numbers indicate a calendar year combined ratio of 87% with $14 billion in excess reserves – and only $260 million in COVID losses.

But this financial heyday wasn’t just due to COVID. Last year was the 8th year in a row for rate decreases – many of them in the double-digit range; rates continue to drop, with the vast majority of states seeing significant Year over Year decreases.

Despite plummeting rates, the combined ratio (claims plus all admin costs) has been under 90 for four consecutive years…so rates are STILL too high. While Donna characterized the underwriting gain as a measure of “financial strength”, I’d suggest one could also call it “over-pricing”.

Unpacking the combined ratio we find loss ratios have been under 50% for three years in a row. Investments gained 11% last year. The result – a 2020 pretax operating gain of 24%.

That, esteemed reader, is a very hefty profit margin.

Even heftier when one adds in the $14 billion in excess reserves.

COVID

The average COVID claim cost $6000, and about 75% are lost time claims. COVID claims represented 7% of LT claims.

“Indemnity only” claims are those that had no medical costs – and are pretty much unique to COVID claims. Makes sense when you think about how most of us are affected – a couple weeks of misery at home, followed by a steady recovery, with no external medical care..

Even COVID claims with both indemnity and medical costs ran up $18k in costs – about half the cost of the average WC LT claim.

95% of claims were less than $10,000, 1% of claims accounted for 60% of losses – these tended to be inpatient claims, often with ICU utilization.

My takeaways.

First, work comp is VERY profitable.

Second, insurance rates are still much too high. (Even if claim counts rise, there’s a LOT of excess reserves sitting in insurers’ coffers.)

Third, all the caterwauling about how awful COVID’s impact on work comp was flat out wrong. More to the point, much of it was avoidable if those predicting awfulness had thought about how COVID is treated.

Mark Priven and I – and I’m sure others – figured this out last summer; this isn’t to blow our horn but rather to show all the indicators were there – if one just knew to look for them.

I believe this is because most people in workers’ comp don’t know or understand health care, medical care, health insurance, provider business practices – pretty much anything about the biggest driver of workers’ comp costs.

And that’s why they got COVID predictions so wrong.

 

 


May
11

Will work comp claims increase?

I’m thinking yes.

Here’s why.

The economy recovery is uneven at best. Auto manufacturing is hamstrung by scarcity of parts and a steel shortage, construction by not enough sawmill and timber workers, and many sectors desperate for parts lamenting the scarcity of shipping containers.

Hotels, restaurants, cruise lines and airlines are still a long way from pre-COVID revenues.

Supply chains will straighten out, demand will drive up wages for workers in key sectors, and that will drive increased employment.

All that may well increase occupational injuries.

from Foresight

As “injury-intensive” industries such as manufacturing, logistics, energy, and construction staff up and accelerate production to meet rising demand, they will:

  • hire inexperienced workers,
  • hire temp workers,
  • increase the speed of work,
  • have less time to train, educate, monitor and protect workers, and
  • increase overtime.

All this will increase the likelihood of injuries.

Add in rising employment, and you get more claims – and likely higher average severity.

That’s bad news for workers, employers, and insurers – but good news for TPAs and service companies.

Expect you’ll hear a lot more from NCCI Chief Actuary Donna Glenn in today’s Annual Issues Symposium.  Will be reporting on the first day of the AIS tomorrow.

What does this mean for you?

Success favors the prepared.


May
7

Research Round-up – the Hospital Edition

Lots of good stuff…

Those darn facility costs…

WCRI’s latest survey of outpatient hospital costs, reimbursement, and all manner of related matters is just off the presses. There’s data about specific states’ costs, network penetration, facility cost trends, surgical costs in WC compared to Medicare, and pretty much anything you need to know.

One surprising data point – network penetration (for outpatient hospital surgeries) has declined in several states over the past 15 years…

HealthAffairs’ latest edition reports on a study showing health system consolidation increases Medicare’s costs.  I’m quite sure your costs increase as well. As health system consolidation continues, so will cost increases.

Another study analyzes the impact of private equity investments in healthcare facilities…

And here’s a state-by-state list of 1-star hospitals – and another for the 5-star ones.

What does this mean for you?

With facilities the fastest growing component of healthcare costs, these resources are valuable indeed.


May
6

The MAJIC Act

The worst provisions of HB1465, aka the “any willing provider whether or not they can spell “workers’ comp” can join an MPN” bill have been removed from the text.

Now, we get to deal with an almost-as-bad bill, which henceforth shall be known as the HB335 – the “Make Adjusters Jump to Inappropriate Conclusions Act”.

Among other things, the MAJIC Act:

  • forces employers to decide if a filed claim is or isn’t compensable in 45 days instead of today’s 90; and
  • forces employers to pay up to $17,000 for medical care while the claim is being investigated.

The MAJIC Act creates problems in an attempt to solve others that don’t exist. 

About one of every eight claims ultimately judged compensable takes 45 – 90 days to investigate.  So, the MAJIC Act would force employers to accept or reject a significant chunk of claims without a full investigation.

I can hear the counterargument now…”well adjusters should just work faster!”  Well, “pushing on a rope” isn’t much of a solution…because adjusters don’t control:

  • whether and when a doctor sends medical records;
  • whether or not a patient responds to calls;
  • whether a qualified medical professional can schedule an appointment;
  • whether or not an investigation has been completed and all relevant information collected;
  • and a lot of other materially-important pieces of the puzzle.

The result will be more provisional denials, leading to more litigation, and higher cost for everyone with no benefit whatsoever for folks injured or sickened on the job.

Then there’s the 70% increase in the employers’ medical liability for claims that have been reported but not accepted. How that number was decided upon is a mystery, because, according to a study just published by CWCI;

  • less than 1 out of every 165 claims incurred costs of more than $10,000.
  • 1 of every 500 denied claims had costs more than $10,000

SB 335 proposes “fixes” to problems that do not exist; there’s no evidence that injured workers are suffering because they are denied care, nor are they harmed because adjusters are doing thorough investigations – as required by state law.

SB 335 will lead to more litigation, which will increase employers’ and taxpayers’ costs while benefiting no one.

What does this mean for you?

Please encourage California legislators to leave the MAJIC to the magicians.