Nov

Change is coming to workers comp

Posted by Joe Paduda on Tuesday, November 17th, 2009 | Comments

And it is coming from all directions. California may be in the process of significant changes due to recent court decisions and the hangover from reform. Texas continues to debate, discuss, and deliberate alterations to their current system. The regulatory and legislative fronts in other states are noticeably quieter, but that silence is more than overcome by the noise from outside the regulatory system.
Brutal competition continues for what little self-insured business is left, while TPAs struggle to differentiate in a market crammed full of me-toos. Complacent carriers have invested little in adjuster education, training, systems, and decision support tools – partly because they have little to invest, but also because they aren’t thinking strategically.
The soft market is going to end – its got nine to fifteen months at the outside. Yet few insurers or TPAs are ready – they’ve been so busy cutting costs, reducing overheard, laying off talented and experienced WC pros that they are in no way shape or form ready to respond to rising medical costs, a renewed emphasis on return to work, loss prevention, and basic claims management. Not to mention the personal angst experienced by the folks left after the reductions – they’re so busy concentrating on keeping their heads down and staying out of the line of fire many aren’t worrying nearly enough about the next turn of the cycle – when costs start to head back up, and payers are woefully unprepared to do anything about it.
Add to the mix health care reform and its attendant impact on workers comp (cost shifting, changes in Medicare’s RBRVS, pharma price increases), a sharp rise in work comp medical expense, and a surge in claims that will come when employment rises once more, and you’ve got the makings of a pretty ugly picture.
The stuff isn’t going to hit the fan until mid 2010 at the earliest, and early 2011 at the latest.
Are you preparing?
What does this mean for you?
If your company isn’t ready, get your resume updated…

Nov

Your drug costs are going up…

Posted by Joe Paduda on Monday, November 16th, 2009 | Comments

The chances of some variety of health insurance reform passing are looking more likely and big pharma is getting ready.
By raising branded drug prices nine percent (so far) this year., and this at a time when the Consumer Price Index fell by 1.3%.
You may recall the big press event when pharma and the White House announced their ‘agreement’ whereby pharma would agree to not fight reform in exchange for reductions of about $8 billion a year in pharma costs. That deal is either off the table, or it wasn’t carefully enough crafted on the front end, because drug companies have been steadily raising prices for brand drugs this year, evidently in anticipation of big changes in the future. In fact, it looks like the increase so far this year more than compensates for the agreed-upon ‘cuts’ announced earlier.
Readers will remember the last time drug prices jumped significantly was just after the Medicare Part D program went into effect, when the largest quarterly increase in years just happened to coincide with the beginning of the program.
There are political as well as practical implications of these price increases. From a political perspective, pharma may be doing to itself exactly what healthplans did with the disastrous release of the PwC ‘report’. Health plans thought they had a deal with the Administration, only to infuriate the White House and Congressional Democrats with the flawed and incomplete ‘analysis’ (even though the concept was right and conclusions accurate, the presentation killed any chance of objective consideration).
With the release of this analysis, Congressional Democrats have yet more evidence of the profit-driven mentality that many believe is directly responsible for our dysfunctional health care system. Do not be surprised if the reaction from Congress is loud, fast and brutal.

What does this mean for you?
This is more of an issue for group and Medicare/caid operations than for workers comp, as comp has a greater percentage of generic fills. But there’s no doubt all payers’ drug costs are going up significantly this year.
If you’re a PBM, get ready to explain higher drug prices.

Nov

This week’s oddities and miscellanea from the world of workers’ comp

Posted by Joe Paduda on Friday, November 13th, 2009 | Comments

A few items of note have been accumulating on my desktop, each of them interesting/important but none worthy of a full post. Here they are for your enjoyment and edification:
– In a top candidate for worst idea of the month, WorkCompCentral reported [ sub req] today that the South Carolina Hospital Association wants surgical implants carved out of hospital bills and paid at 100% of the invoice price. You know, the invoice they draw up themselves in the finance office…
– Sources tell me there was a dustup at the Maine Workers Comp conference involving a representative from an IME company and a judge. The disagreement ended up in a fistfight, which resulted in the IME rep getting fired. I’m wondering if cocktails were involved, or if this was the result of a heated discussion over some fine point in Maine’s workers comp regulations. Or both?
– Word comes to MCM from North Dakota that there is a petition circulating demanding the Governor investigate Cynthia Freland, the prosecutor who may well have broken the law in her quest to convict former ND state WC fund CEO Sandy Blunt of something…anything. Fifty signatures are required, and sources in the far north tell me they are well on the way.
– In the ramp-up heading to next week’s annual work comp conference in Chicago, a preliminary and very unscientific poll indicates the new new thing is ebilling, and/or claims systems, and/or the renewed interest of the private equity/venture capital folks in work comp managed care.
– Speaking of which, the level of interest among the people with money to invest in work comp managed care is definitely up, although valuations are not. Typical multiples for deals closed, in process, and under discussion are in the 6 – 7.5x EBITDA range, with the high end rarely seen. There have been two factors limiting activity; low valuations are keeping owners from putting their companies up for sale, and the continued tight credit markets have made it difficult for investors to secure debt financing for deals. That said, the FairPay deal closed earlier this fall, and there are two others in the space that are said to be close to ‘done’.

Nov

Health plans, stock prices, and reform

Posted by Joe Paduda on Thursday, November 12th, 2009 | Comments

There are some things I just don’t get. Bungee jumping, the Ruta de los Conquistadores, body piercing are near the top of the list, just under equity investors’ reactions to health reform.
And it doesn’t look like my health investor puzzlement is going to end any time soon.
Several news items collided in my inbox this week; passage of the House reform bill and multiple analyses thereof; a report that health plans’ medical costs and profitability are worsening, yet many health plan stocks are selling close to their 52-week highs. Huh?
Let’s start with the health plan medical cost report. The good folks at Mark Farrah and Associates published an analysis that, among other things, noted:
– the top eight health plans (covering 59% of the nation’s total insureds) lost 836,000 members in the first half of 2009
– commercial membership was down 1.45 million while MA and Medicare Supplement was up 405,000
– Medical costs are trending higher, and medical loss ratios are as well
The net – profitability has declined, costs are increasing, and membership is dropping. Yikes.
Now, investors don’t seem too worried about these trends. In fact, as of this morning, they seemed to be enamored with the health plan sector as stock prices are up over nine percent over the last month, compared to an S&P that’s just over flat.
Next, health reform and the recent House and Senate bills. What I see that’s scary is the lack of a strong mandate coupled with an end to most underwriting of medical coverage means people can sign up for health insurance when they need it, stop paying premiums when their care is completed, and then re-up if and when they need care again.
Let’s call this the Massachusetts Problem, after what’s been happening to health plans there.
This isn’t conjecture or theory. It’s reality, and it is taking place in a market with a much stronger mandate than the one in the Senate Finance bill.
Finally, a few selected statements from stock analyst types:
– “There were two recent developments of particular concern to WellPoint investors, since the company is a relatively big player in the small-employer and individual markets. First, the Senate Finance Bill included strict insurance market reforms but a weak individual mandate, which could lead to adverse selection, higher premiums, and a smaller market for individual and small-group policies.” (Morningstar) Yet Morningstar rates WellPoint a five-star stock
– They also may not be hurt as badly by a federal health care overhaul as many analysts first worried. Congress is debating ways to cover the uninsured and reduce costs, and health insurance stocks have been sensitive to this debate for months. Shares sank at the start of the year when the reform debate picked up steam, but they have recovered for the most part as the threat of a strong public option that would compete with insurers faded. A possible tax on insurers based on their market share remains a concern. But overall, analysts say the sector remains on sound footing heading into the next few quarters. [notice no discussion of the impact of the end of underwriting coupled with a weak or nonexistent mandate…perhaps it was edited out] istockanalyst
– “I think they’re getting a really bad shake in the current environment,” FTN Equity Capital Markets analyst Peter Costa said. “But the core businesses are there.” istockanalyst
United Healthcare is also a top rated stock, and is trading near its 52-week high.
Analysts may say health plans are somewhat insulated from the individual market, where the underwriting issue is really problematic. True, but as more companies drop their group plans (a multi-year trend that has accelerated this year), the size of the individual market will grow – and health plans will have to get into or expand their offerings in that market if they are going to increase revenues (a mandatory requirement for publicly traded companies).
So here’s where this all leads. Without a strong individual mandate, health plans are going to lose buckets of money insuring people after they get sick. How that translates into a 52-week high is beyond me.
Disclosure – I’ve sold all my health plan stock holdings and don’t have any financial interest whatsoever in the sector. Not because I don’t think there are some good companies out there in the healthplan business (Aetna’s probably at the top of the list), but because provisions in the two health reform bills will kill off the entire industry.

Nov

The Rocky Mountain edition of Health Wonk Review

Posted by Joe Paduda on Thursday, November 12th, 2009 | Comments

Friends and colleagues Jay and Louise at Colorado Health Insurance Insider host this week’s edition, featuring the Simpsons explaining all things health policy – as only the Simpsons can.
Great stuff, all in one place for your edification!

Nov

Note to CBO – don’t forget to add that quarter trillion to the cost of health reform

Posted by Joe Paduda on Wednesday, November 11th, 2009 | Comments

Because that’s what it is going to ‘cost’ to replace the current Medicare physician reimbursement scheme with something else. And make no mistake, as Trudy Lieberman of the Columbia Journalism Review points out, most of the nation’s physicians are adamant about ‘fixing’ Medicare reimbursement.
The issue is the Medicare Sustainable Growth Rate (details here). The net is simple – if the SGR formula/process is eliminated, a quarter trillion dollars gets added to the deficit, because that’s the amount the formula/process says has been paid to docs over and above SGR ‘limits’.
Current Congressional protocol requires CBO to ‘score’ any and all health reform proposals; unsurprisingly the SGR ‘fix’ has not been included in any reform measure, because it will push the cost way, way over a trillion dollars.
Thus, thru legislative legerdemain, Congress is avoiding talking about and being held responsible for the real cost of reform.
As long as we have to ‘fix’ the SGR – and I’m not arguing that Part B (physician reimbursement) doesn’t badly need fixing, hows’ about we ‘trade’ SGR elimination for some real reform, like, say, bundled pricing for specific procedures/conditions? Like, maybe, a flat cost for treating an asthmatic patient over a year including facility and physician and lab and other costs?
Or, for those chronic patients with more than one condition, a formula that pays for all their care based on a multiplier indexed to the number, cost, and severity of their conditions?
Or a requirement that all physician bills from practices that don’t have all patients on a share-able electronic medical/health record are paid under a non-fixed SGR, while bills from practices using ‘certified’ EMR are paid under a new schema?
Pretty draconian, you say? Not as draconian as anteing up another quarter trillion bucks, I respond. Sure it will be hard and take some time and isn’t easy and all that other blather. It’s a huge knotty ugly problem, requiring some ugly solutions, and none of them are going to be perfect. But they will be a damn sight more perfect than what we have if we don’t get reform-with-cost-control done this time around – family health care costs above $30,000 within ten years.
It’s time we got more from stakeholders than just their agreement to not block reform. We need a good more arm-twisting and a lot less gentle cajoling.
What’s the net?
Watch to see how Congress and the President handle the SGR redo issue. Do they use SGR as a lever, or do the docs use it as a club?

Nov

Health Wonk Review is up!

Posted by Joe Paduda on Tuesday, November 10th, 2009 | Comments

You gotta see this.
I’m much embarrassed to inform you, dear reader, that Tinker Ready of Boston Health News published the latest – and greatest – of the health wonkosphere last week, while I was asleep at the virtual switch.
Tinker’s HWR is here; you have to see the video of the AHIP singers.
No, really, you have to!

Nov

Big on health, light on reform

Posted by Joe Paduda on Tuesday, November 10th, 2009 | Comments

Paraphrasing Sen Ron Wyden (D OR) produces the most accurate soundbite description of the House’ health reform bill.
Is this the best we can do?
If the answer is yes, we’re in deeper trouble than even I thought. I’m really disappointed with the Republicans. They are supposed to be the budget hawks, but instead they’ve spent their time railing against abortion funding, illegal immigrants, and death panels, along with scientific research and taxes on device manufacturers. Instead of attempting to govern responsibly, they’ve abandoned all morality in their quest to re-energize the lunatic fringe of their once-dominant party. Now comes news that Maine’s Susan Collins is convening news conferences to rail against the cost of the bill.
With all due respect, Senator, this isn’t exactly new news. Now you’re getting concerned about cost? After nine months of debate, discussion, and appearances on Meet the Press? Not to single out Collins; at least she’s finally saying something rational about cost.
While there’s plenty of blame to pile at the door of the Republicans, it is the Democrats who are to blame for coming up with a huge entitlement program set up to do nothing but grow.
Cost containment as proposed in the bill is in the form of cuts to Medicare totaling about $420 billion, including:
– $155 billion (about) from price cuts to hospitals,
– reductions in Medicare Advantage subsidies,
– increasing drug rebates payable to CMS, and
– requiring CMS to negotiate with pharma for Part D drugs.
Then there’s a potpourri of funding for Accountable Care Organizations, better primary care coordination, research on quality and effectiveness, and other should-have-been-doing-all-along initiatives.
As for real cost containment, methods/techniques/tools that can actually reduce cost over the near term in the public and private sectors? Bupkus. Nada. Zippo.
Sure, at some point in the future this research will result in data we can use to recommend more changes. But by that time we’ll be broke, and China will own everything of substance.
Oh, and when insurance underwriting reform kicks in health plans will have to take all comers, yet at 2.5% of adjusted gross income, the mandate penalty is not tough enough to force compliance. What we’ll get is individuals and families buying coverage when they need it, only to drop it when the condition is fixed/surgery completed/rehab over. And under the terms of the House bill, you could fall off your motorcycle, buy insurance, get treated, and then stop paying premiums when your rehab is over.
I’m no fan of the insurance industry, but that just isn’t fair. And lest you think this isn’t going to happen, talk to Charlie Baker, former CEO of Harvard Pilgrim Health in Mass. It’s happening in Massachusetts today.

Drastic times call for drastic measures. If we aren’t going to seriously consider Wyden-Bennett – and more’s the tragedy if we don’t, then we need cost containment with teeth.
How about starting with normalizing treatment costs for specific conditions? The huge and wildly inappropriate variation in practice patterns and costs associated with conditions such as COPD and back pain and prostate cancer and diabetes and dozens of other conditions have to stop. Medicare should, and could, gradually ratchet down reimbursements across the country till they are match global reimbursement for care delivered by delivery systems that are demonstrably efficient and deliver quality outcomes – Mayo, Lahey, Geisinger, et al.
Or develop an all-payer fee schedule (similar to the one in Japan) allowing all payers access to the Feds negotiating power.
Crazy? Sure. But the current bills will not reduce cost inflation. And therefore, sure as the sun comes up tomorrow, within ten years you will be paying $30,000 for family coverage. And pretty poor coverage at that.

What does this mean for you?
Despair? Disgust?

Nov

Controlling technology, improving health, cutting cost – not as hard as you may think

Posted by Joe Paduda on Monday, November 9th, 2009 | Comments

The use – and misuse – of technology in medicine is not only a major cost driver, it is also a major cause of unnecessary pain and suffering.
Far too many carotid endarterectomies were performed in a misguided effort to reduce
If we are to have any hope of slowing down the rate of increase in medical costs, we have to stop the abuse of unproven and potentially harmful technology.
WorkCompCentral [sub req] has a great piece on a program run by the State of Washington that does just that. The Health Technology Assessment program “assesses various devices, procedures, medical equipment and diagnostic tests, then issues recommendations that public payers must follow[emphasis added]. Those public payers include the Department of Labor & Industries, which runs the state’s monopoly workers’ compensation program.”
According to an article in the New England Journal of Medicine, HTA determines reimbursement on these technologies for programs including:
“Medicaid, the workers’ compensation program, the state government employee benefit plan, and the corrections department [which] provide $2.9 billion in benefits annually to approximately 773,000 Washington citizens through direct fee-for-service plans”
Before the wingnuts start spouting about death panels, know that the HTA has been widely accepted by politicians from both parties, it passed with a single ‘nay’ vote in 2006, supported by both the state Hospital and Medical Associations, and while individual conclusions may draw opposition, the program itself is viewed very positively.
The process is rigorous. According to the NEJM;
“The program’s assessments are based on a thorough, systematic review of the evidence related to the effectiveness, safety, and cost-effectiveness of a product or service, with each type of evidence examined separately. After considering the “most valid and reliable” evidence on all three of these dimensions, the health technology clinical committee — which must be made up of practicing clinicians — arrives at one of three recommendations: covered without conditions, covered with conditions (such as criteria defining medical necessity), or not covered. The entire process must be transparent.”
HTA is important because it shows what can happen when government intervenes intelligently and carefully. So far, HTA has rendered opinions and set policy on:
* Arthroscopic surgery for osteoarthritis of the knee. (Not covered.)
* Discography for uncomplicated degenerative disk disease. (Not covered.)
* Implantable drug-delivery systems for chronic, non-cancer-related pain. (Not covered.)
* Lumbar fusion for uncomplicated degenerative disk disease. (Covered, with conditions.)
* Upright or positional medical resonance imaging. (Not covered.)
* CT colonography. (Not covered.)
* Pediatric bariatric surgery. (Not covered for patients 18 or younger. Covered with conditions for patients between the ages of 19 to 21.)
These actions have reduced costs by over $20 million since its inception three years ago.
What does this mean for you?
Payers should look closely at following Washington’s lead.

Nov

Who’s going to prosecute the prosecutor?

Posted by Joe Paduda on Thursday, November 5th, 2009 | Comments

The most significant charge leveled against Sandy Blunt, former CEO of the North Dakota State WC fund, never should have been brought. And if it wasn’t, he would never have been convicted of a felony.
Blunt was charged with authorizing sick leave for and failing to collect moving expenses from a Fund exec who was terminated within two years. In theory, if he left within the two years, the moving expenses paid by the Fund should have been reimbursed.
Turns out that the prosecutor who brought the charges, Cynthia Feland, knew that failing to collect the moving expenses was not a crime – yet she brought charges anyway.
She had in writing that the ND Attorney General advised state auditors in October of 2006 that the exec did not voluntarily leave and thus there was no legal authority to collect. This fact was then put in writing to Feland a year before the trial and she
– added it as a crime just weeks before the trial and
– withheld the memo proving it was all legally done, thereby not giving the defense exculpatory evidence she was legally required to provide.
Feland clearly violated her obligation not to bring charges without probable cause, she violated her obligation to turn over witness statements, she violated her state obligation to turn over exculpatory evidence, she violated her federally mandated “Brady” obligation to turn over exculpatory evidence, she violated Blunt’s due process rights by not allowing him a preliminary hearing for probable cause on the issue, and she lied right to the Judge’s face in open court about the whole thing (including that it was in the audit when it was not).
I repeat my query from earlier this week:

What in the hell is going on in North Dakota?
And why is there no coverage of Feland’s potentially criminal activity in the press up there?
Is North Dakota some third world country where the State’s employees can decide which laws they are going to comply with based on what best suits their personal/political needs? Where a person’s personal and professional life can be ruined in what can only be a personal or political vendetta? Shouldn’t someone from the State, the FBI, or another law enforcement entity be investigating Feland?
What does this mean for you?
If Sandy Blunt can get absolutely screwed by the system, so can you.

Author: Joe Paduda