Category: General Insurance Issues

Apr
29

Air traffic controllers, health care, and Head Start

Posted by Joe Paduda on Monday, April 29th, 2013 | Comments

I fly a lot. You probably do too.  Flying is not much fun – when it’s not downright miserable.  So the news that the furlough of air traffic controllers mandated by sequestration was leading to even more delays was most unwelcome.

Some rejoiced when Congress passed legislation allowing the FAA to stop furloughing workers  – and I’ll admit I was one of the some. Typical American – it’s all about me and my personal convenience.

In the cold light of morning, that’s a very short-sighted perspective.

Sequestration was supposed to be so bad that even the intransigent Congress would come together to pass a budget.  If the FBI couldn’t add any new agents, pork producers couldn’t get their meat inspected, physicians’ payments were reduced, drug approvals delayed, weather reports and warnings more sporadic, Head Start enrollment reduced, the hue and cry would be so unthinkable that even Congress would compromise.

Alas, rather than compromise, some Congresspeole decided protecting their principles was far more important than anything else.

Until the folks who vote complained that – God forbid – they might have to spend another hour in the terminal waiting for a flight.

Congress – Dems and Reps alike – and the President – promptly caved on their principles, ended the certainly annoying but not life-altering inconvenience of travel delays, and thereby showed that flight delays are waaaaaay more important than real solutions to real problems – health care fraud, runaway health care costs, poorly-educated kids, national security.  

If anyone still thinks they’ll solve the big problems, think again.  This was the perfect issue to force compromise.  A principled stand by anyone would have (perhaps) forced compromise – the public was feeling the effects, and that public outrage, channeled effectively, was precisely the intent of the sequestration.

Nope.  When the going got tough a little uncomfortable, the spineless caved. And in so doing screwed the country.

 

 

Apr
23

Workers’ comp drug trends – good news at last – Part 1

Posted by Joe Paduda on Tuesday, April 23rd, 2013 | Comments

There are three workers’ comp drug trend reports out this week; we’ll look at each one (in order I received them).  A cautionary note; it is difficult to compare PBMs’ performance on the basis of their reports; the metrics and basis for those metrics varies, their books of business are different (some have lots of very old claims, others have more state funds than national clients and there are also other differences in payer mix with some payers much more aggressive and willing to work with their PBM on specific issues).

First up is Progressive Solutions’ version. The big PBM saw an average reduction in spend per claim of 0.5 percent, driven by a combination of fewer days’ supply per script and fewer scripts per claim.  Progressive has invested heavily in predictive analytics; the payoff has been a significant drop in opioid usage for targeted claims (15% decrease in morphine equivalents).  The data shared in their report parses out the various factors driving claim cost and risk, with “pharmacy behavior”(number of prescribers, number of pharmacies, medications) becoming increasingly significant as a claim ages.

Progressive’s clients are seeing a reduction in opioids as well, with both long- and short-acting opioid script volume down. This has cut per-claim costs for opioids by 4.2 percent.

The report has an extensive and accessible section on legislative and regulatory trends, with discussions of state regs on repackaging, compounds, and physician dispensing.

The takeaways are this:

  • Analytics and modeling can drive much better results by focusing resources on the big problems. The PBM and WC industries need to continue to up their game, and get smarter about where, when, and how to address cost drivers – generic, one-size-fits-all approaches are costly, inefficient, administratively burdensome, and annoy claimants and physicians.
  • The impact of regulations and legislation on WC pharmacy, and thus workers’ comp costs and outcomes, is increasingly important.  Physician dispensing and compounding are two of the biggest profit-creators for those interested in sucking money out of the comp system.  It behooves all stakeholders to thoroughly understand these issues and get involved.
  • Opioids are being addressed – there’s much to do but a strong focus and assertive programs can and do deliver results.

Finally, Progressive’s report is well-designed and well-written.  Kudos to the folks who actually took all that research and translated it into language the rest of us can understand.

 

 

Apr
18

Screw up and get paid more – only in America’s health care “system”

Posted by Joe Paduda on Thursday, April 18th, 2013 | Comments

Privately insured patients with post-surgical complications – infections, surgical errors, generate 2 – 3 times more margin for hospitals than patients without complications.

To be precise, the average surgery with complications generated $39,017 more “contribution margin” than those without errors or complications.  

According to the authors, “Depending on payer mix, many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications.” [emphasis added]

The authors – quite clearly – noted that there is no evidence, nor do they believe, that hospitals aren’t focused on eliminating these complications despite the obvious negative financial consequences.  And that’s not my point.

The point is this is yet another example of what happens when you pay providers to do things and not on the basis of how well they do them.  If you get a lousy meal in a good restaurant, they’ll usually comp it.  Bad hotel experience?  On the house.  Defective car?  It’s fixed under lemon laws.

But not health care.  If we based payment – at least in part – on the result, we’d likely see much more focus on that result.

What does this mean for you?

Why are you paying providers to fix problems they caused?

 

Apr
16

Opioids’ long term impact on workers’ comp – WCRI reports

Posted by Joe Paduda on Tuesday, April 16th, 2013 | Comments

Opioids will be the biggest problem the workers’ comp industry faces over the next few years.  WCRI’s hosting a webinar on the issue later this month, and I’d encourage you to sign up (do it fast, there’s a limit on attendees).

For those unaware of recent research on the issue, here are a few of the issues:

  • there’s huge variation among and between the states; according to WCRI’s latest research,  17% of Louisiana claimants who started using opioids were still using them 3-6 months later, compared to about 3 percent in Arizona.  Clearly the risk of addiction/dependency in LA is much higher than in AZ.
  • Less than a quarter of all long-term opioid users were tested for drugs via urine drug screening.  When you factor in drug testing data that indicates a substantial percentage of claimants prescribed opioids don’t have evidence they’re taking them, it is clear employers and insurers are paying millions for opioids that may not be used for the intended purpose (to be generous).
  • In California, claimants prescribed opioids are off work 3.6 times longer; litigation is 60 percent higher, and their claim costs are twice as high as claimants who don’t receive opioids.

If opioids aren’t on your radar, they soon will be.

If not, you must be in Arizona.

What does this mean for you?

Sign up for the webinar

Apr
4

A worthy research project.

Posted by Joe Paduda on Thursday, April 4th, 2013 | Comments

How many work comp claimants died from opioid overdoses last year in your state?

How many of your claimants died?

As far as I can tell we only know this figure for one state – Washington.  And we only know that because Gary Franklin, the state fund’s medical director did a lot of analysis of a lot of data. That analysis was a major factor in the state’s adoption of strong laws around opioid prescribing, laws that have been directly responsible for a 50 percent reduction in the number of opioid-related deaths of work comp claimants.

So. How many claimants are dying in your state?

Mar
29

The new compounds and who’s making them…

Posted by Joe Paduda on Friday, March 29th, 2013 | Comments

Gensco Labs has been busy filing trademarks for new and wonderful topical medications that are sure to solve myriad problems – to date they’ve filed for 46!  They sure are busy down there in Miramar, Florida!

There are a LOT of Genscos down in Inverness Florida…and the trademarks Gensco holds have been filed by Randy M Goldberg., Esq.  One wonders if this is the same Randy M Goldberg who is listed on his LinkedIn profile as Chief Legal Counsel of…wait for it…

Automated Healthcare Solutions!

If it is, one wonders if ABRY Partners, the private equity firm that has a stake in AHCS, is getting a piece of the pie.  Of course, two of ABRY’s other holdings, York RSG and Gould and Lamb, might not be too excited about that.

As long as we’re wondering, how do Gensco’s scientists get the time to do all that ground-breaking research work as they work tirelessly to bring the wonders of medical genius to injured workers around the country, working side-by-side with selfless people striving to ensure those terrific new medications get in the hands of as many dispensing physicians as possible.

Their medications include such wonders as SpeedGel, TranzGel, InflaGesic, LidoGesic, TranzGesic, and other xxx-Gesics.  Perhaps they’ll make a superduperGesic, or maybe even a TranzLidoSpeedInflaGesicGel…wouldn’t that be GREAT!!

No word if any of these wonder-drugs compounds have made their way to California or if they are some of the medications that have driven the average price per compounded med up some 68 percent.

SpeedGel has a wealth of wonderful ingredients; echinacea purpurea, echinacea angustifolia, aconitum napellus, arnica montana, calendula officinalis flower, hamamelis virginiana root bark/stem bark, atropa belladonna, bellis perennis, chamomile, achillea millefolium, hypericum perforatum and comfrey root gel.

No eye of newt or bat wing extract, but perhaps in a future version…

I’ve heard that the OTC version of SpeedGel is going to or has been pulled from the market – evidently some payers have been confusing it with the prescription version and reducing reimbursement.  Shame on you, payers!  Bad payers!  Fortunately, the REAL SpeedGelRx is going to continue on.  

Alas, some payers don’t see the benefits – this from Summit Holdings in Florida:

“In the first months of 2012, several new creams have entered the market. Again, these are formulated with common over-the-counter ingredients and, interestingly, are marketed exclusively to physicians who see workers’ comp patients. They are assigned National Drug Codes, along with corresponding Average Wholesale Prices.** SpeedGel is priced at $700 for 3 ounces, and TranzGel is listed for $695.

While your patients may not get the bill for these products, these costs have a major impact on the workers’ comp system. Our clients (your patients’ employers) end up paying these costs in increased premiums and, in many cases, actual medical costs.

In most cases, we are denying coverage for these products…” [emphasis added]

What doe this mean for you?

To find out of your claimants are lucky enough to be getting SpeedGelRx, search for NDC 35781-0200-5 and 35356-0647

Mar
27

The Health Care Social Media Review

Posted by Joe Paduda on Wednesday, March 27th, 2013 | Comments

In the “why didn’t this happen sooner” category is Louise Norris’ new review of health care social media blogging – you can find it here.

Brilliant and needed.

Mar
20

There is NO OBAMACARE RFID CHIP!

Posted by Joe Paduda on Wednesday, March 20th, 2013 | Comments

Among the top all time posts on MCM was the one a couple weeks ago about the right wing and nut-o-sphere’s claim that the feds are going to require anyone signing up for health insurance will be implanted with an RFID chip containing their medical and financial records.

As of this am, there were 12.386 views of that post.  I kid you not.

To repeat – there is NOTHING in the PPACA legislation or regulations about any RFID chip.

These conspiracy theorists either intentionally or ignorantly mis-read the PPACA’s Medical Device Registry language – which is clearly intended to track medical devices – hip replacements, pacemakers, spinal cages and the like – to “facilitate analysis of postmarket safety and outcomes data.” This language – which is quite simple and quite clear is mis-interpreted to imply that we all are going to get a chip implanted somewhere on our persons.

Of course we need to get these devices tracked – many fail, many are recalled, and there are many complications arising from these devices.  Rather than having no way to figure out who has an implant from the Acme Hip Bone Implant Device Co. by sorting thru paper documents, it only makes sense to have a central source that can identify the Acme patients.

Not only is there nothing in any document about this, but the tin-foil hat crazies propagating this rubbish cite a bill that was never even passed (HR 3200) and is not law as their source for this nefarious plot.  And, it has been refuted by Snopes and about a hundred other investigators.

But the monsters-under-the-bed crowd don’t let facts interfere with their claims – oh, no, not this guy.

There have also been a flood of comments from people claiming this is some part of a master plan of the Illuminati, or the FreeMasons, or some other obscure group bent on world domination.  After posting a couple comments, I’ve trashed the rest.

Mar
6

Obamacare – criticisms considered

Posted by Joe Paduda on Wednesday, March 6th, 2013 | Comments

Over the last week I’ve had several conversations with folks opposed to Obamacare/the Affordable Care Act.  Their criticisms are focused in several general areas:

  • it doesn’t do enough to control costs;
  • it is too expensive and we can’t afford it;
  • it is socialized medicine and violates our country’s foundational free market principles; and/or
  • it is intrusive and injects government into the doctor:patient relationship.

As I’ve said ad nauseum, PPACA (pronounce Pea-Pak-A) is so obviously a product of our vaunted-but-deeply-flawed political system that it should serve as a warning to all future legislators.  It was NEVER supposed to pass and become law as-is; if the Dems hadn’t completely screwed up the Senatorial election in Mass, thereby losing their veto-proof majority in the Senate and therefore had to pass the reform bill already passed by the House in the lame duck session, this conversation never would have happened.

Alas, it did, and here we are.

So, on to the complaints.

We can’t afford it.

C’mon, folks, as if the US health care system was affordable BEFORE Obamacare.  And, the recent announcement by Ala. Sen Jeff Sessions that the ultimate cost will be $6.2 trillion was flat-out wrong; his projections assumed the cost-control provisions of PPACA would be ended.  In fact, the Hill reported:

“the U.S. deficit will decline 1.5 percent as a share of the economy over the next 75 years, according to the GAO. Auditors attributed 1.2 percent of this improvement to the Affordable Care Act.”

Fact is, there are cost control provisions in PPACA, and unless they are repealed, they will reduce the deficit.  Two, the IPAB for one and ACOs, are promising – if only because neither has been proven. But I see another part of PPACA as likely the most effective; the mandate and prohibitions against underwriting.   If we all have to get insurance, and insurers can’t make money by risk selection and actually have to manage care (horrors!!), they’ll actually have to work on improving health, reducing morbidity, and improving the delivery of care – and eventually controlling cost thru their creative approaches.

Dirty truth folks, back in the old days (which includes every day up till 1/1/2014) health insurers spent most of their time/brain power/resources not on managing care, disease management, population health, or any other “health care” thing – but on underwriting. Nope, they worked hardest on figuring out first – who was likely to incur a claim, then second – how can we avoid insuring them.

That game’s over.  Now, insurers are stuck with all of us – healthy, fat, diabetic, blind, fit, gluten-free yoga enthusiasts, old, young, pregnant, single, whatever.  And if they are going to survive, insurers damn well have to figure out how to keep us – all of us – healthy and out of the doctors’ offices/ER.

Their game has changed more than anyone could possibly understand.

Why? Cause the heavy hand of government (that would be a government elected by us, folks) essentially said “enough of this crap.  Figure out how to control costs and improve health, or you’re out of business.”

The PPACA essentially changed – and leveled – the playing field.  The rules are clear.  And so are the penalties.  

Is it perfect? Hell no.  Is any legislation ever perfect?  Same answer.  But it is a LOT better than what we had before. Which, for those with short memories, was a completely out-of-control health system with declining numbers of insureds and rapidly rising costs.