The Trump Administration’s pick to lead OSHA will push the President’s deregulation agenda far and deep as he shifts OSHA to a more “business friendly” focus. According to Administrator-designee A. Prelle Pfuelle,  the watchword will be “compliance assistance” instead of enforcement.

Reports indicate the new Administrator, a former lobbyist for the mining industry, will provide “leadership to curtail funding for enforcement, rescind rules under deregulatory orders, and drop defense of regulations facing legal challenges.” The mining industry has been actively applauding initial moves by President Trump to revoke, rescind, or withdraw several regulations and enforcement actions; Pfuelle may have been instrumental in those early actions.

Pfuelle’s past experience includes stints working as a manager in a diamond mining firm in South Africa, labor relations in Liberia’s oil industry, workplace safety officer in the Pakistani ship-breaking association and most recently lobbyist for the Oklahoma natural gas industry.

The White House’s press release noted Pfuelle’s “extensive international experience in a variety of international industries will help America compete with other countries…getting rid of employment-killing regulations will help our economic recovery…”

In an interview after his appointment was announced, Pfuelle was quoted on a number of topics, including return to work. Responding to a reporter’s question about the employer’s role, Pfuelle said:

“OSHA will work to support President Trump’s efforts to make America Great Again wherever we can. If you think about it, a worker injured on the job opens up a job for another worker…so I’m not sure why we want to push employers so hard to rehire injured workers when there are many great Americans who are looking for work…”

In the White House’ announcement of Pfuelle’s appointment, President Trump said:  “I’ve known Prelle for decades; he helped me find the best diamond for my first wife.  We’ve stayed in close contact, and I was impressed with how he handled the the accident at the Anglo-American Corporation’s Vaal Reefs Mine….while there was some loss of life, he got the mine operating again very quickly…”

According to the reports cited above, first up – after confirmation – is a move to scale back injury reporting requirements.

Speaking about the new electronic reporting requirements Pfuelle opined:

“Employers know when their workers get hurt, and it is their responsibility to make sure they tell us about those situations.  But they have a lot of other things that take up a lot of time, so we can’t and shouldn’t expect reporting to be on the top of their list. As long as they let us know in a reasonable time, that’s fine.”

 

Pfuelle will have to divest his holdings prior to assuming the Administrator position, although, under new rules just released by President Trump’s Office of Ethics, he may choose instead to place them in a “blind trust” directed by his wife Blythe, the daughter of the founder of the Anglo-American Lead Mining company.

It’s among the hottest topics in work comp these days.

Telemedicine will be one of – if not the – most disruptive force in workers’ compensation medical care. Companies such as CHC Telehealth, Go2Care, and AmericanWell are moving rapidly, adopting different business models in an effort to gain first mover advantage.

Looking for a broader perspective, I recently had the chance to interview Jonathan Linkous, CEO of the American Telemedicine Association. Here’s what he had to say…

MCM – What service types/specialties are embracing telemedicine most rapidly?  Why those?

JL – It covers the gamut from primary care to urgent care, but there are some popular specialties – mental health, behavioral health, neurology – stroke care, ICU/CCU. Dermatology is one of the earlier adopters and radiology via remote reading of images has become a standard in the industry

The greatest increase in the number of services has been via consultations with online providers, Intensive Care monitoring either continuously or in evening hours (30% of ICU beds are hooked up to remote monitoring) and remote monitoring of chronic care.

Slower adopters include surgery, although that is changing with some robotics and oversight/proctoring from specialists from a distance

[Telemedicine is now being used for] Initial or follow-up visits with providers. Online consults are growing quite significantly with 1.2 million services delivered to 750,000 members in 2016. Possible stroke victims are being assessed by neurologists remotely today.

In terms of the largest number of people served, the top specialty is radiology where 7 – 10 million pictures are read remotely followed by cardiology with remote monitoring.

MCM – Which payer types are currently involved in telemedicine?

JL – The fastest adoption is by employers and private payers, then Medicaid, then Medicare. [Reimbursement is a driver, as value-based organizations aren’t concerned with billing per service but rather with delivering optimal outcome they see telemedicine as a way to deliver care faster to key patient populations]. The easiest way for providers using telemedicine to get reimbursed is by value-based care and not FFS; it is harder to get it paid for by FFS as need to justify the usage.

MCM – What states or regions appear to be early adopters?  Why those?

JL – Telemedicine started out in rural healthcare [and was] funded by the federal government; today it is urban as that’s where people are. California, AZ, MD have all been early adopters and enablers; in general states are more supportive than Medicare. The VA has been very supportive, as have other governmental payer programs [excluding Medicare].

MCM – What obstacles exist and how are they being addressed?

JL – Resistance by provider community and HC in general as this is typically a slow adopting industry; that’s dissipating of late. Providers need CMS to move more quickly with this for Medicare. Some state medical boards have been slow in developing practice guidelines. There are licensure issues, and crossing state lines is a complex issue; we need to get that addressed. Regulatory complexity is a burden. The ATA is working on pathways for communities and state medical boards which will get resolved before licensure.

Ancillary professions eg psych, nursing, and physical therapy, are moving faster to resolve licensure issues than medical societies. PT groups are working on interstate compacts now to enable state-to-state reciprocity. [This is likely due in large part to the nature of ancillary practice, as these providers] practice under guidance of a physician. Of course, it is easier to do telemedicine within a state but payment is another issue due to FFS and other requirements. Telemedicine is [as much about] expanding relationships with patients and not just reducing office visits. Telemedicine providers can document findings and notes in a chart and have a record of that as opposed to some of the issues inherent in an office visit such as a “white coat” issue. Parkinsons groups have embraced TM as its hard to get out and see a doc. Specialists are far away and telemedicine can improve access, so patient groups are advocating for TM.

MCM – What is an example of a successful workflow – patient identification, enrollment, delivery, reporting/documentation, billing ?

JL – Key to success is integration. [Originally telemedicine was televideo, now on a desktop or laptop or even phone. He has seen conferences where docs show up and see patients during a meeting.] There has also been an improvement in workflow as electronic records integration is key. This hasn’t been a requirement but can be a huge help if you have robust EMR system that is portable and interoperable – we are a ways from that.

MCM – Does telemedicine support vertically-integrated health systems or is it more an independent practice driver?

JL – Both. Mayo uses e-Consult where for some patients considering a procedure or with a diagnosis, Mayo sends their records go to another Mayo provider perhaps in a different state to do second opinion remotely. Local hospitals can tie into Mayo to differentiate, to take advantage of Mayo providers’ expertise and brand strength. Private practices can use this to expand their practice if they have strong capabilities via patient portal with video consults etc. Some alliances are forming among independent practices in cities to enable providers in different groups to work together.

MCM – What is happening with reimbursement and what does the future hold?

JL – The market sees value. At the federal level it is just a matter of time. [I see a] 5 year timeframe where we are past tipping point to value based care, lots of healthcare systems are looking at these care systems and when the value-based:FFS balance shifts to 50:50 it will flip their business plans which will drive more TM. DoD, Prisons, IHS, others are embracing this – Medicare is last of holdouts.

Anyone interested in diving deep into telehealth can attend the association’s conference…

Some WCRI attendees thought my public criticism of former Republican Sen. Tom Coburn (OK) was inappropriate (many did not).

Here’s why I called him out.

First, in talking about disability, Coburn asserted that SSDI – Social Security Disability Income – participation has exploded due to Democratic policies and politics. He said 25 million Americans are now covered by SSDI.  That is flat-out wrong.

I questioned him publicly about his figure, asking where he got it.  He immediately backtracked, saying it may be 22 or 25 million.  I responded that, according to a quick google search, the actual number was less than 15 million.

Coburn had blamed the opposition party for a huge growth in SSDI that NEVER HAPPENED.  He either made up the number of SSDI beneficiaries, was misled, or lied.

The real number, according to expert Yonatan Benshalom of Mathematica, is 9.8 million. Yonatan’s source is here. [Thanks Yonatan]

Why this matters

If Coburn’s false claim was allowed to stand, many in the audience may have left WCRI believing it.  As policymakers, regulators, and thought leaders in workers comp, they would then have perpetuated the myth.  That would lead to wrong decisions, lousy policy, and “solutions” for problems that don’t exist. For example, lawmakers may have sought legislation requiring an MSA-type allocation to indemnify SSDI for occupational disability from work comp insurers.

A more complex issue involves Coburn’s false assertion that the ACA was rammed thru “without any Republican input.” I noted that:

• The ACA’s core design came from the conservative Heritage Foundation
• The Gang of Six – half Dems, half Reps, met multiple times while ACA was being written – the Republicans were Enzi, Snowe, and Grassley, all of whom dropped out of the Gang under pressure from Republican Minority Leader McConnell.
• As a results of those meetings and other dialogue, multiple components of ACA were added or changed in an effort to garner Republican support including:
  • removal of any public option
  • addition of the Cadillac Tax
  • reduction of the penalty for uninsurance
  • removal of funding requirement for abortion services
  • allowance for “religious” health insurance

Responding to my statements, Coburn said since he “was there”, he knew more about this than I did.  He said was part of the Gang of Six – which he wasn’t.  He WAS involved in a previous version of the “Gang” that dealt with tax reform –– but he was not involved in the Gang’s healthcare discussions. [I was peripherally involved via discussions with Congressional staffers and a meeting with Sen Ron Wyden (D OR) about reform]

There are many sources that refute Coburn’s false statements; here’s one.

For those interested in the real story, an excerpt:

[Senate Finance Committee] Chairman Max Baucus (D MT), in the spring of 2009, signaled his desire to find a bipartisan compromise, working especially closely with Grassley, his dear friend and Republican counterpart, who had been deeply involved in crafting the Republican alternative to Clintoncare. Baucus and Grassley convened an informal group of three Democrats and three Republicans on the committee, which became known as the “Gang of Six.” They covered the parties’ ideological bases; the other GOPers were conservative Mike Enzi of Wyoming and moderate Olympia Snowe of Maine, and the Democrats were liberal Jeff Bingaman of New Mexico and moderate Kent Conrad of North Dakota.

Baucus very deliberately started the talks with a template that was the core of the 1993-4 Republican [health reform] plan, built around an individual mandate and exchanges with private insurers—much to the chagrin of many Democrats and liberals who wanted, if not a single-payer system, at least one with a public insurance option. Through the summer, the Gang of Six engaged in detailed discussions and negotiations to turn a template into a plan. But as the summer wore along, it became clear that something had changed; both Grassley and Enzi began to signal that participation in the talks—and their demands for changes in the evolving plan—would not translate into a bipartisan agreement.What became clear before September, when the talks fell apart, is that Senate Republican Leader Mitch McConnell had warned both Grassley and Enzi that their futures in the Senate would be much dimmer if they moved toward a deal with the Democrats that would produce legislation to be signed by Barack Obama. They both listened to their leader. An early embrace by both of the framework turned to shrill anti-reform rhetoric by Grassley—talking, for example, about death panels that would kill grandma—and statements by Enzi that he was not going to sign on to a deal.

The false narrative that Democrats rammed thru ACA without any Republican involvement has become accepted fact by many who haven’t read anything but headlines. Coburn’s false statements perpetuated that nonsense, and he deserved to be called out publicly for them.

There’s a bigger problem here – ideological blinders worn by some make it seemingly impossible for those individuals to accept facts. Fact-free discussions, or, even worse, decisions based on beliefs that are the opposite of reality lead to bad public policy.

What does this mean for you?

The people who attend WCRI are enormously influential in our little industry.   They will determine the future of workers’ comp, how employees are treated and who will pay for that treatment.

They deserve to hear the truth.

PS – to the several anonymous commenters – as I’ve stated here numerous times, I don’t publish anonymous comments from cowards afraid to identify themselves.

Call centers often use average call time (ACT, also known as Average Handling Time or AHT)) as a metric to measure customer service “efficiency”.

That is a really dumb idea. 

Especially in workers’ comp.  In fact, one could make a compelling argument that the lower the ACT, the worse the outcome – defined as customer loyalty and likelihood the customer will “buy” again.

In the real world outside of work comp, there are lots of ways customers can get answers to questions about products and services; YouTube, reddit, websites, and even Yelp are just a couple. In that “real world”, customers who call service centers have a specific question, which MAY lend itself to a pretty quick answer.  But it’s just as likely the customer has a complex question which does NOT lend itself to a quick answer…This from the article linked above:

AHT might have been a fine way to gauge performance on simple issues like address changes, balance inquiries, or delivery tracking, when throughput was the name of the game, it’s a terrible way to assess performance on complex issues that by definition take more time to handle. [emphasis added]

While YouTube et al do provide customers with helpful info, those “alternative customer service resources” don’t really exist in work comp.  The business just doesn’t lend itself to automation, because:

• issues are often jurisdictionally-related and those regulations often change with minimal notice.  Moreover, many states are pretty small in terms of work comp claim totals, so it’s hard to justify allocating big business analyst/programming resources to automating answers about new state claim reporting requirements in Montana (no offense to my many esteemed colleagues in Big Sky Country)
• answers may have significant downstream legal implications so nuance and opinions can matter a lot
• patients rarely know much at all about workers’ comp and want to talk with someone who does.  The interaction is really more about listening and empathy than just providing correct answers.
• Calming down an angry, confused, or upset customer takes time

More importantly, treating call center workers as machines who must produce X widgets (defined as handled calls) per hour isn’t likely to make those workers love their jobs, care about their customers, or want to stay at your company.

In fact, they’ll “perform” to expectations, working hard to get off the line as quickly as possible, regardless of whether the customer’s happy or not.

So, you’ll get what you want – “efficiency”.  And your customers will go elsewhere.

What does this mean for you?

Do you like it when a “customer service” rep hurries you off the line, can’t seem to understand or care about your problem, or even if they do, turfs you off to someone else or, heaven forbid, the company’s website?