Author: Joe Paduda

Feb
14

Facility costs and quality – are you operating in the dark?

Posted by Joe Paduda on Wednesday, February 14th, 2024 | Comments

Probably yes.

Facilities account for between a third and half of work comp medical spend – and that share is increasing as health systems and hospitals consolidate.

Reality is there’s major variation between hospitals  – some are stupid expensive, others quite reasonable; some have crappy quality, others excellent quality.

Example…

Here’s a good one for our colleagues in Louisiana…two hospitals less than 15 miles apart, with VERY different costs and similar quality ratings.

Note costs are for MSK conditions…pretty relevant to workers’ comp.

So, you can send your injured workers to a VERY expensive facility  – Tulane – that does a handful of complex surgeries OR…

To a MUCH less expensive facility – Ochsner – that does 14 times more surgeries (practice makes perfect…)

Let’s add a CMS quality metric...for our friends in the Sunshine State, you can send injured workers here…

solid quality, and very reasonable pricing…

or…here (just a few miles away)

to a facility with a bottom-of-the rating by CMS and costs more than double its higher-quality neighbor.

These data are available from a few states and CMS (takes some digging); HSA also has developed a national tool enabling instant facility comparison across multiple quality, patient safety, and cost metrics – drop a comment below if you want info.

What does this mean for you?

Do you want to spend $98,000 at a  facility that does few procedures, or a quarter of that at a facility that does hundreds?

 

 

Feb
8

Drug prices and the power of consensus.

Posted by Joe Paduda on Thursday, February 8th, 2024 | Comments

We Americans pay much more for drugs than anyone else.

Those very high prices are a major contributor to increasing health insurance premiums and Federal and state budgets.

Across the political spectrum, Americans support more government regulation of drug pricing.

Good news is Medicare is now actively negotiating drug prices with manufacturers. That will save patients and taxpayers billions of dollars.

What does this mean for you?

When we agree on what is the right thing to do we get things done.

And will save families and taxpayers lots of money.

Feb
7

Signs of the coming apocalypse

Posted by Joe Paduda on Wednesday, February 7th, 2024 | Comments

Medicare is slashing what it pays physicians, an annual event that – till now – was almost always rejected by Congress.

That will reduce old folks’ access to care, cut workers’ comp fee schedules, and likely lead to more provider consolidation. 

This from Becker’s:

In its 2024 Physician Fee Schedule Final Rule released Nov. 2, CMS reduced overall physician pay by 1.25% and updated the Medicare conversion factor to $32.74, a 3.4% decrease from last year.

Nope, a fix wasn’t in any of the “continuing resolutions” Congress passed last year and earlier in January (“CRs” are a stop-gap, emergency funding step more often seen in desperately poor banana republics than in the “greatest nation in the world.)

As a result, docs’ pay will be cut about 3 1/2%…and they are none too happy about it. (Read this for details on potential implications)

Okay that’s bad, right?

Not as bad as what’s coming.

Reminder – if Congress doesn’t pass a budget – in exactly one month – all Federal agencies – including Medicare, the VA, Defense, the FAA… face budget cuts. Weapons procurement, care for veterans, agriculture inspections, airplane safety inspections (this isn’t a problem, right??) are just a few.

Remember way back (as in two years ago) when Congress’ wait-till-the-last-minute-to-get-stuff-done made us all nuts…if we knew then how dysfunctional the House would be now we’d have been quite happy for what we did have.

Yep, Republicans in the House of Representatives’ refused to even vote on an immigration reform bill – THE hot issue in Washington and around the country – a bill that gave them everything they wanted.

House GOP – Yay, we finally got the soccer ball!  Let’s play! Wait…how do you play? I dunno…you know?  Nope – you? Nuh-uh…you? No clue…you? Uh…I thought it had pointy ends…Someone pick it up…NO way dude! Not me…

What does this mean for you?
To quote HL Mencken, you get the government you deserve, and you deserve to get it good and hard.

PS – Over the lastly 20 years I’ve written a lot about the incredibly screwed-up Medicare reimbursement  process…

Feb
5

Predictions for healthcare in 2024

Posted by Joe Paduda on Monday, February 5th, 2024 | Comments

Some of you know Jay Stith – he’s been working with HSA for half a decade now, heading up data analytics and research. Jay’s brilliant, has a great dry wit, and most of all very insightful.

He sees stuff – others – including me – don’t.

So, I asked Jay to make his predictions for healthcare in 2024…lest the work comp folks stop reading here, remember workers’ comp is the flea on the tail of the healthcare elephant.

Outside of employment, the biggest single factor affecting workers’ comp is healthcare – hands down.

  1. Hospital/ Health System M&A will ramp up in a big way leading to even more consolidation around the country.
    1. M&A dropped dramatically during COVID so there is an element of catch-up on top of a rapidly changing healthcare industry, financially distressed hospitals/health systems offering themselves as prime takeover candidates, and potentially dropping interest rates all point toward high levels of M&A activity.
  2. And…Facility fees will continue to be the elephant stomping around the room. Remaining high and potentially going higher all while limited efforts are made to curtail them.
    1. A next step to prediction #1 – as consolidation often means high prices. Little activity has occurred to combat facility fees so far and with sexier issues like AI monopolizing meetings I don’t see meaningful action broadly coming.
  3. Staffing shortages will keep already high labor costs high – looking at nurses in particular.
      1. The thousands of physicians and nurses entering the workforce lags the number of physicians who are retiring or simply exiting the industry. This decline coupled with the aging US population is exacerbating the already critical problem. We are, and have been, under-supplied with nurses across the healthcare landscape and between structural issues like not enough nurse education faculty and the median age of nurses >50 this issue is unlikely to change.
  4. Human-caused climate change will disrupt even more businesses with policy progress being slow and insufficient.
    1. We don’t know what we don’t know – climate-related problems are impacting a wide range of business and employee needs. In addition to the obvious employee-injury issues associated with climate change, disruptions to care access, employee-personal-life problems (e.g. damage to home), and climate migration make climate-associated changes more difficult to model and properly account for.
    2. As if we needed more proof, here’s what’s happening in California..
  5. The AI arms race will continue with companies everywhere announcing new AI tools for various business segments BUT true internal buy-in will still be far away as the tools will underwhelm managers dreams for headache-reduction.
    1. Managers are dreaming about the volume of tasks that AI will be able to effectively handle in a fraction of the time while producing higher quality work than their current teams. As companies learn how difficult properly training an AI tool is and how much time/resources are required to make even marginal gains, people will get frustrated about having over-promised and/or having to deal with poorly functioning AI tools – e.g. a bad chatbot or an internal system lacking proper training on a costly outlier situation.
    2. AI and technology improvements will dominate the headlines and capex allocations BUT customer service will remain more correlated to client satisfaction.
    3. Healthcare and insurance have changed a lot over the decades but as technology has gotten fancier and the industry more complex, high quality customer service has remained the top-rated factor when assessing a successful vendor-client relationship… and it will not change this year.

What does this mean for you?

Consolidation = higher facility costs.

Staffing shortages = higher facility costs.

Human-caused climate change = BIG problem.

AI ≠ panacea.

Feb
2

Good news Friday – Crime is down!

Posted by Joe Paduda on Friday, February 2nd, 2024 | Comments

If it bleeds…it leads.

That’s the mantra driving local news reporting, one that really distorts what’s ACTUALLY happening – which is in most cities crime has dropped – a lot. That includes violent crime.

According to the highly-regarded Council on Criminal Justice,

  • The number of homicides in the 30 study cities was 9% lower in the first half of 2023 than in the first half of 2022.
  • Robberies, burglaries and larcenies all decreased in the first half of 2023 compared to the first half of 2022.
  • Levels of nearly all offenses are lower, or barely changed in the first half of 2023 compared with the same period in 2022.

Notably, murder rates peaked 3+ years ago, under the previous administration and have dropped by half since then.

The one area where volumes have increased is in car theft…mostly due to big problems with Kias and Hyundai thefts which are up 1,000% since 2020. …it has gotten so bad police departments in multiple cities are giving away steering wheel locks to Kia and Hyundai owners…

In Milwaukee more than half of car thefts were Kias or Hyundais.

What does this mean for you?

Tell the fear mongers to stuff it.

And put a steering wheel lock on your Kia/Hyundai.

Feb
1

Consequences.

Posted by Joe Paduda on Thursday, February 1st, 2024 | Comments

Since the Supreme Court overturned the right to abortion, almost 60,000 women had rape-caused pregnancies – and live in states where they cannot get an abortion.

From the American Medical Association’s research:

In the 14 states that implemented total abortion bans following the Dobbs decision, we estimated that 519 981 completed rapes were associated with 64 565 pregnancies during the 4 to 18 months that bans were in effect (Table 2). Of these, an estimated 5586 rape-related pregnancies (9%) occurred in states with rape exceptions, and 58 979 (91%) in states with no exception, with 26 313 (45%) in Texas.

Notably, even in states that allegedly allow exceptions for rape or incest – e.g. Idaho – the AMA found NO abortions have occurred.

So…consequences.

60,000 girls, teens, and women who were raped will have live or dead babies.

The psychological damage will be devastating for them, their loved ones, and their babies.

Make no mistake, the burden will fall on the least fortunate of us...almost everyone subscribed to MCM has healthcare; you and your daughters/wives can travel to states that allow abortion.

The vast majority of victims live in states that have crappy Medicaid coverage, so many/most won’t have coverage for/access to pre-natal care, ob/gyn services, labor and delivery, and infant/pediatric health.

Not to mention mental health.

The shameless hypocrisy of the “protect life” crowd in these states is overwhelming... forcing rape victims to have babies and not providing the women or the babies with healthcare is just…unthinkable.

The cost – in terms of destroyed lives and unfunded/uncovered healthcare expenses – is immeasurable.

What does this mean for you?

WWJD?

 

 

 

Jan
30

NCCI’s executive survey…what medical inflation??

Posted by Joe Paduda on Tuesday, January 30th, 2024 | Comments

A couple weeks back NCCI released information about its annual survey of work comp execs.  About 100 participated in the survey; some of the results were a bit surprising.

Execs were asked about their “concerns” re workers’ comp…frankly I found some of their concerns (financial health? rate adequacy? medical inflation?) puzzling at best.

Here’s a couple questions from my discussion with Damian England, Executive Director, Affiliate Services and Raji Chadarevian, Executive Director-Actuarial Research – and thanks tons to NCCI’s Cristine Pike for making this happen.

Where did the responses rank concerns?

Damian England, Executive Director, Affiliate Services – “While some carriers mentioned multiple concerns, roughly 40% of the responses were related to the financial health of the system and rate adequacy. About a quarter reflected the changing workforce, followed by medical inflation and the economy. Climate change and artificial intelligence were cited as emerging concerns.”

MCM – Rate adequacy concerns?

Damian England, Executive Director, Affiliate Services – Rate adequacy concerns are more of a global fear of the future and the unknown, amid a long-term trend of steady declines in loss costs/rates.  Although the industry in aggregate has seen nearly 10 consecutive years of underwriting profitability, not every carrier has same results or books of business; rather, individual carrier performance varies in many ways from the aggregate.  We also hear about changing underwriting cycles and whether we have the data necessary to recognize a turn in trends, as there is a recognition that recent trends will not last forever.

MCM – Why are they worried about medical costs – which are a non issue?

Raji Chadarevian, Executive Director-Actuarial Research (and all around good guy). – Medical cost drivers are not well understood; some are just looking at the overall medical price index, but medical cost drivers go beyond that. Changing medical practices, new medications, new ways to administer treatments and other transformations need to be considered. It is starting to resonate that some are understanding it is more complex…but there is a misconception in the industry that we look at health insurance rates and think that is representative of medical inflation – those rates [health insurance premiums] are going up but that is not medical inflation.

Also, WC is a long tail business, so a small change in the inflation rate one year can mean a lot in terms of overall cost of claims – that is where some of the concern emanates from – what does it mean for a 20-30 year claim?  Furthermore, for LT claims it isn’t general medical inflation largely driven by physician and facility prices, rather, for claims that are beyond the critical treatment period, medical costs have more to do with the price of Rx, home health care, medical equipment. Prices for HHC and DME have gone up significantly in recent years.

Ok, couple things here.  And please, this is not meant to argue with Raji or Damien, rather to point out that work comp execs need to study up on medical issues and worry about REAL issues, not NON-issues.

  1. Rate adequacy is NOT AN ISSUE. Over the last decade rates have been too high – evidenced by continuing rates drops in almost all states over that period, accompanied by huge profits AND $14 billion in “excess” reserves.
  2. Medical inflation is NOT AN ISSUE. Over the last few years there have been no reports of significant increases in medical trend. None. Zippo, Zilch.
  3. Drug costs have been dropping for years – for lost time claims as well as med onlies.
  4. Claims with ultimate costs >$1 million account for – at most – 15% of total WC costs  – and a huge chunk of that is not medical, but indemnity expense. So, while I get some execs may be concerned about future costs, this feels more like catastrophizing than rational business thinking.
  5. Climate change – hard to believe that this was not one of the top concerns, but completely consistent with the industry’s ignorance of the issue. Talk to insurers, employers, and TPAs in Louisiana and California and they’ll regale you with the horrific and extremely expensive impacts of human-caused climate change.

What does this mean for you?

Execs are working about non-issues and willfully ignoring those that will have real and sustained impact on the industry.

 

Jan
25

Dumbest law of the month…#2

Posted by Joe Paduda on Thursday, January 25th, 2024 | Comments

Okay, this isn’t a law, rather a school board ruling.

But it is so amazingly, blindingly, completely stupid that it beggars belief.

Last June the duly-elected Escambia County School Board  banned 8 dictionaries and encyclopedias because they…wait for it…contain depictions or descriptions of sexual conduct.

Who knows if these vile, disgusting, immoral books contained anything problematic…but under Florida’s “Don’t Say Gay” law, one parent – yup, just one – can force a school to pull a book from its shelves and conduct a lengthy review to ascertain if it is – according to some made-up criteria – inappropriate for that school.

So, let’s see…what could qualify?

  • A parent kissing their spouse?
  • Reproduction by an earthworm?
  • A trout laying eggs?
  • A medical textbook describing intercourse?

Those are all “sexual conduct…

That’s not the worst of it. Under Florida’s law, ANY parent could force a school too pull ANY book – which could include…the Bible…which does reference various activities that could be construed as “sexual conduct”.

What does this mean for you?

Don’t let your kids go to Escambia County schools.

 

 

Jan
22

What should happen in workers’ comp – but probably won’t

Posted by Joe Paduda on Monday, January 22nd, 2024 | Comments

I’ve finally figured out that what I think should happen often doesn’t.

So, here’s my take on the 5 things that SHOULD happen in worker’s comp this year but likely won’t.

  1. We won’t hear more caterwauling about “rising medical costs”.
    Ha. The latest NCCI research indicates execs still don’t understand what’s really happening with medical costs – despite NCCI’s diligent efforts to educate same.
  2. Work comp execs will embrace innovation.
    I wrote about this three years ago here. Basically,

    1. execs got to be execs by avoiding anything remotely risky.
    2. The industry is making billions in profits so why try anything new.
    3. Frequency and premium rates are declining, so why try something for a declining business?
    4. And worker’s comp is mandatory in 48 states, so they’ll have to buy it from someone.
  3. Buyers will stop asking about/measuring/caring about medical “savings”.
    I’ve written about this a gazillion times…here’s one example. The net – it’s really easy to show a reduction below list price – we Americans have been trained to do just that.
    Even when it makes zero sense…follow the link to get why there’s a horrendously ugly sport jacket here…

    Oh, And, this industry is pretty lazy.
  4. The industry will wake up to human-caused global warming. 
    Ha. Nice to see that some pundits have finally raised this as an issue – but jeez people it’s 2024, and we’ve KNOWN we are boiling the planet for decades. Nope, there will be minor moves, with little public discussion among or by work comp execs.
    Why?
    Great question.
  5. The industry will seriously embrace behavioral health, take major steps to understand this as a disability driver, and seek out meaningful solutions.
    Sure, some have – and kudos to them for doing so – And kudos to good friend, colleague, and mentor Bill Zachry, David Vittoria of Carisk, Dr Les Kertay, and others who have been leading the charge.
    But let’s get real folks…disability is as much- if not more – mental/emotional/
    psychological as physical, yet far too many payers don’t want to accept that blindingly obvious truth, scared of “owning the psych”.”
    You already own it.

    (Carisk is an HSA client)

 

Jan
19

Good news Friday…

Posted by Joe Paduda on Friday, January 19th, 2024 | Comments

The best possible news hit the wires yesterday – there won’t be a government shutdown next week.

The House – in a bipartisan vote – passed a continuing resolution (aka CR) to keep current funding levels in place till early March, giving the House and Senate time to negotiate on 12 individual spending bills.

The really good news is this passage:

  • was bipartisan, with 207 Democrats and 107 Republicans joining together to pass the CR
  • did not result in a move to oust current House Speaker Mike Johnson (R LA) (a similar bill cost then-speaker Kevin McCarthy R CA the Speakership)

While it is way too early to celebrate a new era of bipartisanship and congratulate the radicals on both ends of the spectrum for their maturity, and

…it is mind-blowing that we now celebrate a near-government shutdown as “good” news, 

Given recent history this does count as good news.

What does this mean for you?

That said, we cannot continue governing like this.  Thoughtful, principled compromise must return to Washington.