May
12

Family health insurance costs near $20 grand

Actuarial consulting firm Milliman reported recently that the average American family’s health insurance costs are now over nineteen thousand dollars. Costs have more than doubled in the last ten years.
CORRECTION – Families are paying over $8000 towards the cost of insurance – “$4,728 in employee contributions and $3,280 in employee out-of-pocket cost…”
Think about that.
If medical inflation rates stay the same, we’re looking at the cost of family health insurance hitting $30k a year in six and a half years.
And over $40,000 four years after that.
Of course, trend could accelerate…
If there’s any good news, it is that under health reform, both insurance premiums and out of pocket costs won’t be as much of a killer for those at lower income levels. Out of pocket costs including deductibles will be indexed to income, as will premiums which will be subsidized for those with incomes below 4 times the poverty level (about $88,000 in today’s dollars).
thanks to Jane Saransohn-Kohn for the heads up.


May
11

Examworks – questions I hope someone asked

Update (correction re revenue figures) While flying home from LA yesterday, thru the miracle of airplane wifi I got a note from a colleague stating “MES contributed $13.2 million in revenues in the first quarter of 2011. MES had approx. $129 million in revenues for 2010 (a run-rate of approx. $32 million per quarter).
Am I reading this right??” the net is not exactly, but the earnings report does raise. Few questions.
For those not immersed in this tiny little business, Examworks is a rollup of IME firms, companies that contract with independent doctors to do Independent Medical Exams, primarily for workers comp insurers. Among several other acquisitions last year, Examworks bought MES for some $175 million in cash plus $10 million in assumed debt plus 1.4 million shares of Examworks stock (worth about $25 million) for a total of about $210 million .
If their new acquisition generated about forty million for the first three months of 2010, (deal closed 2/28, so the $13 million was for one month) the obvious question is “was it worth $210 million?”
My colleague was referencing yesterday’s earnings release which was followed by a press conference/call last evening. I didn’t hear the call, so don’t know what was said (will see the transcript by the end of the week). As my investment portfolio demonstrates quite convincingly, I’m no Warren Buffett. But I do know a bit about this business, have helped on a few private equity deals, and can operate a calculator with some facility.
MES’ 2010 EBITDA was about $23.4 million. So, Examworks paid a 11x multiple for MES, a rather princely price. Especially given the Q1 revenue figures.
So, if I was on the call – which I was not – I’d want to ask:

How’s that MES deal?
Have you been able to negotiate more favorable rates with your physicians, and if so, how much lower?
What savings are you seeing from synergies? What kind of synergies have you found?

Here’s hoping someone did.


May
10

RFPs and the mistakes vendors make

I’ve written before about the problems caused by buyers – poor wording of questions, lack of decisiveness, failure to provide feedback, failure to make ANY decision, arrogance and churlish behavior.
But vendors aren’t without blame. I’ve reviewed a lot of proposals from service vendors in my fourteen years as an independent managed care consultant. In that time, I’ve put together a list of the most common, and most frustrating mistakes made by the folks who submit proposals. Here they are.
1. Read the damn thing.
Vendors often write an answer to the question they have in their response library, not the question asked by the buyer. Sure, it may be close, but close isn’t anywhere near close enough. If you’re going to take the time – and it takes a lot of time – to respond, then take the time to do it right. Read the question before you respond, and have someone else, someone knowledgeable with strong analytical and writing skills, review each and every answer before you send it in.
2. Don’t bloviate.
Answer the question quickly, concisely, and accurately. Remember the poor folks who have to read your response have to read several others, and if you get to the point with a minimum of chest thumping and preening, they’ll appreciate it.
3. If the question seems repetitive, or you think you’ve already answered it, answer it again.
Reviewers can be assigned a specific part fo the proposal response, and if they have to go hunting around for your response, it won’t help your cause. And, if you’ve already responded in another section, make darn sure that response was specific to that question and wasn’t salesspeak and puffery.
4. Requirements
If you don’t meet one of the requirements, either a) don’t respond to the RFP; or b) discuss ahead of time with the buyer to make sure you won’t get shot down and then note specifically why you don’t meet that requirement, why it’s not an issue, and what you’ll do to meet that demand (if you can or are willing to) post-award.
5. Write well
Run-on, poorly written sentences with bad grammar, changing tenses, and poor word selection make reading some responses a nightmare. If you don’t KNOW that it is well written, it probably isn’t. Good RFP responses are tight, light on the adjectives, focused and responsive to the question.
If you can’t write a good response, you may kill your chance to win the business.
6. Differentiate
There’s almost always a place where you can clearly and concisely tell the buyer why you’re better and different. This isn’t – ever – a slam on the competition. Instead it is a ‘this is why we do things the way we do, and how it’s the best answer’ statement. If there isn’t a question that offers that opportunity, do it in the cover letter.
7. Confidential information
Many vendors are cautious about providing financials and other information, well aware that it may eventually get out. If there’s information that is quite proprietary and vital, feel free to offer it only when you get to best and finals stage, or make some other offer that keeps it confidential while enabling the buyer to verify you are stable, or have some license or financial stability.
Oh, and write well. Or I’ll ding your response!


May
8

Regulatory and legislative trends – NCCI reports

To show just how much I need to get a life, one of the more interesting talks at NCCI las week was a very-well attended general session focused on legislative and regulatory reform. It began with an examination of federal actions beginning with the McCarran Ferguson Act and thru Dodd-Frank, both really important and highly significant legislation that are pretty far outside my area of interest/knowledge/focus.
Things got interesting when we moved into specifics on states. Peter Burton of NCCI noted the fall elections made for a much more Republican slant to most state legislatures and governors’ offices. Jeff Eddinger also spoke, starting off by noting the number of rate increases sought last year about doubled, with NCCI looking for increases in 15 states. Eddinger also reiterated frequency was up nine points last year…
Burton and Eddinger focused on four states – Montana, Illinois,Oklahoma, and North Carolina
The Big Sky State has the highest WC premiums in the nation, a condition that led to an aggressive move by both parties, and by both the legislature and governor, to address costs. The impact of the reforms passed and signed in April is pretty significant – a 22.4% rate decrease. Among the changes from reform, Montana is now an employer direction state, terminated medical benefits after five years (except for permanent claims), and codified usage of the 6th edition of the AMA Guides.
The biggie – Illinois.
IL is known throughout the WC world as a basket case. While Montana’s got troubles, there just isn’t that much business in MT, but there sure is in IL. Caterpillar Tractor has already threatened to leave the state due to work comp, and that, plus the Menard Correctional Center scandal moved comp reform to the top of the list.
As of this week, Gov Quinn has said there looks to be a decent chance that reform will pass despite the partisan battles.
Oklahoma
OK’s WC system is a mess with costs that are the fourth-highest in the nation. The Governor, along with a GOP House and Senate, are likely to get reform completed and signed into law. The bill tightens pharmacy reimbursement, alters the fee schedule, revises IME regulations and makes other changes that together look to reduce premiums significantly.
North Carolina
This is one of the states where government changed dramatically in the GOP landslide of 2009. As a result there is a bill presently under consideration that would, through a variety of specific measures, reduce work comp costs. It is not clear whether this will become law.
There’s a lot more detail available on NCCI’s website on goings-on at other states that wasn’t presented at the conference – you can access it here.


May
6

NCCI on frequency and the impact of older workers

I’m going to skip over two am speeches – while I could indulge my inner pundit and discourse on Charles Krauthammer’s highly selective use of data in his conservative monologue/analysis of President Obama’s psyche and disuss the insights of Arthur Laffer, he of the widely-discredited “Laffer Curve“, the pm sessions were far more interesting.
I do have to provide just one note re Laffer…
Laffer was not only THE supply-side economist; he was also the guy who in August 2006 famously said: “The United States economy has never been in better shape.” Laffer even bet stock broker and UC Berkeley alumnus [and Ron Paul adviser] Peter Schiff a penny that the economy wouldn’t crash.
Barry Lipton led off the research discussion with a drill-down on changes in frequency.

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Recall that frequency has been on an eighteen (or so) year long steady decline or around 3-5% each year. In 2009, overall frequency based on wage adjusted payroll declined by 8.4%, with that decline overcome last year as frequency (number of claims) jumping nine percent. (see NCCI for why it’s probably not really nine percent, but more likely around three percent)
Building off yesterday’s announcement that frequency increased dramatically in 2010, Barry provided background on which types of industry classes (what kinds of jobs in what industries) were seeing what changes in frequency and the relationship of payroll to severity.
Barry was followed by Harry Shuford discussing older workers and their impact on workers comp. This is rather an important topic as older workers – those over 55, are becoming an increasingly large part of the workforce. Shuford put uo a slide that clearly indicated claim frequency variation between age groups essentially disappeared over time. That is, there was wide variation in claim frequency (how often workers are hurt) among age groups in 1994, but very little variation in 2009.
This held true when corrected for job mix. Moreover, severity (cost of the claim) was pretty consistent regardless of age group (for workers over 35, while costs were lower for workers under 35). With that said, there was a rather significant difference in severity when the two groups (above and below 35 years old) were compared, likely caused by the different mix of injuries sustained by the two populations. In fact, about half of the difference in cost was attributed to injury type.
Disability duration was (unsurprisingly) longer for older workers, but a good chunk of the difference was due, again, to the different injury types incurred by the two groups. After considering the various adjustments, medical cost variation was pretty minimal.
The net is most of the impact of baby boomers is “already there”. That is, we likely won’t see much of an uptick in severity due to the aging population in the future.


May
6

Frank Schmid had the honor of conducting the final report at the 2011 NCCI Annual Issues Symposium, and he was well worth the wait. Dr Schmid discussed physician fee schedules, price levels, and ‘price departure’.
Schmid reported not results, but “findings” related to a lot of really intriguing issues. To wit
– how do price and quantity change in response to changes in fee schedule?
– what is the rate of inflation in MD services?
– what is the difference between fee schedule and the actual prices paid, known as ‘price departure’.
– do physicians increase or decrease the quantity of services if a fee schedule declines? are these permanent changes? are they symmetric (reversing the fee schedule reverses the response)
Frank and his colleagues looked at the impact of FS changes on physician service categories and total physician services. I won’t get into the methodology – mostly because it’s way too complex for me to understand, much less describe. NCCi examined four states, FL GA MD and UT.
Florida’s fee schedule increased significantly in January of 2004. Interestingly, prices paid increased when the FS went up, but prices, which before had been about 5% less than FS, were about 10% less after the increase. (note this is consistent with internal data HSA has from payer files). This was even more noticeable with prices for physical medicine, where prices went from 7% below FS to about 25% below after reform. A couple years post-reform, prices actually rose.
The opposite occurred in Maryland, with prices paid actually increasing after the fee schedule was changed midway thru 2004.
Schmid broke this down by actual types of service – evaluation and management codes, etc; the discussion of radiology in Florida was particularly interesting, as Schmid noted that “not only do prices respond to fee schedule changes, but fee schedules respond to price changes”.
There’s a lot of very useful, and interesting information here, and much more to come. I applaud NCCI for digging deep into the pricing and fee schedule issue, as my sense is there’s not near enough understanding of the inter-relationship between price and fee schedule. Future plans are to provide actual results across a score or more of states by the end of the year.
This is great stuff.


May
5

After this morning’s sobering announcement of a 115 combined ratio for work comp, things didn’t get much more rosy in Bob Hartwig’s presentation on the “post-crisis world”.
Since 2005, work comp net written premiums have dropped from about $50 billion to $35, a drop of about 30%. That’s a massive loss, and that’s why everyone, and every business even remotely connected to the work comp insurance has been hammered over the last few years.
It’s got to get better, right?
right?
For that we turn to Bob Hartwig,who covered everything from Bid Laden to jobs to
Hartwig is always entertaining, enthusiastic, and engaging – hard to do when you’re talking insurance. He started out discussing the Terrorism Risk Insurance Program, and specifically the question “now that Bin Laden is dead, do we still need it?”
Absolutely, says Hartwig, who cited the $40 billion cost of 9/11 and noted that any future disaster would almost by definition result in high claims – and high costs – for workers injured or killed in an attack.
Moving on to the Japanese disaster, total costs are estimated to fall somewhere in the $12 to $45 billion level, with most coming in around $25-30 billion.
With the insured costs of the Japanese catastrophe and domestic, primarily weather-related disasters well up above $40 billion, what’s the implication for work comp insurers? Most of the impact will be on the reinsurance markets, which, while they won’t directly impact comp, certainly will as comp insurers get renewals from their reinsurers. Hartwig noted that the impact – over the near term, will be minimal to nonexistent.
The job front is looking up – as there have been two million new jobs created since January 2011, with significantly stronger growth over the last two months adding almost a half-million jobs in February and March alone. This – of course – is great news for work comp as it adds billions in payroll to what – as we noted earlier today – has been a work comp premium base suffering from lower revenues.
The impact of small business and construction were discussed in detail – listening to Hartwig is somewhat analogous to drinking from the proverbial firehose – but the net is there aren’t enough small businesses starting (as of March 2011), too many went bankrupt over the last two years, and all forms of construction haven’t grown enough – or quickly enough – to add a lot of premium dollars over the near term. When construction and small business start-ups get going, that will be good news indeed for insurers.
Reserve releases have been helping to keep the overall P&C insurance industry combined ratio at a decent level (a bit above 100), but when (not IF) these releases stop, the combined ratio will bump up.
So, what does this all mean?
Hartwig appears to believe the work comp market will remain level, with the positive impact of increasing employment balanced by lots of available capital.
My sense is the impact of rising health care costs will be more significant than most think, and will overcome some of the positive factors noted by Hartwig.
We’ll see.


May
5

2010 work comp – results “deteriorated”

This morning NCCI released the 2010 results for private work comp insurers – and they aren’t good. The combined ratio climbed to 115%, an increase of a full five points over 2009. The combined ratio is a key measure of industry performance and the deterioration marks continued decline in the health of work comp.
While the number itself is discouraging, one carrier’s decision to add $800 million to reserves was a major contributor.
The economy and employment also added to the poor results, as premium declined by 1.3 points. Premium is based in part on the number of people working thus the recession’s impact on hiring helped drag results down.
As I’ve been predicting for some time, frequency popped up significantly last year. The ‘real’ bump was about three percent, although NCCI is reporting nine with the difference accounted for by “distortions in collected data.”
More to come later today.


May
5

Coventry’s 2011 Q1 work comp results

Last week Coventry released their Q1 2011 earnings report, and things are looking good.
First, the workers comp results. Revenues were up slightly, to $191.6 million, a 4% increase over the prior year’s quarter. For the last few months, Coventry’s new CFO Randy Giles has been immersed in the business prior to assuming his new role. Given the inordinate profitability of the comp sector, it’s not surprising Giles was focused on WC; the company is relying on the cash from WC to fund it’s investment in other areas as it prepares for the brave new world of post-reform healthcare in 2014.
Overall, the Louisiana suit is still dragging on Coventry, as it placed “$150.5 million into escrow to fund a preliminary settlement of the Louisiana provider class action charge as disclosed in the Q4 2010.” Note that this is a preliminary settlement reserve; there may – or may not – be an additional allocation when the final settlement is determined. And there’s also the possibility the suit will be overturned at some point.
While Coventry doesn’t report earnings for work comp, word is it remains extraordinarily profitable, driven in part by price increases pushed thru for network business over the last eighteen months or so.
Next week – after NCCI – we’ll look at Coventry’s other results.