Category: Health Care Issues

Jul
6

Healthcare Sharing Ministries – the latest

Posted by Joe Paduda on Wednesday, July 6th, 2022 | Comments

Healthcare costs are about to jump again, driven by exploding staffing expenses, continued healthcare provider consolidation, and the brilliant profiteering by some of the largest (mostly for-profit) healthcare systems.

So, what’s a family to do?

A few have turned to Healthcare Sharing Ministries, a thing that looks like health insurance but isn’t. HCSMs purport to “share” health care costs among members in what might best be described as a risk-pooling framework. Almost all claim to be “Christian”, they are largely unregulated (except as charities), don’t comply with insurance regulations or laws in most states, and most have requirements that members:

  • are in good health,
  • make a statement of Christian belief, attend church regularly, don’t use tobacco or have sex outside of marriage and
  • commit to taking care of their own health.

note there are ministries focused on other religious denominations.

So…sounds good right? cheaper healthcare is better…well, HCSMs also:

  • are not legally required to pay your medical bills,
  • require enrollees to do much of the groundwork to get bills paid (negotiate upfront with the provider, get all the paperwork and documentation, pay upfront then seek reimbursement)
  • medically underwrite – meaning they require disclosures of pre-existing conditions and can reject applicants for medical reasons,
  • can refuse coverage to anyone for any reason,
  • have limits on what they’ll pay for healthcare,
  • can’t guarantee healthcare providers will accept sharing ministry coverage, and
  • have appeals processes that aren’t subject to regulatory oversight.

Enrollment is a bit hard to nail down; the Alliance of Health Care Sharing Ministries claims 1.5 million enrollees although it doesn’t specify the year. Other reports indicate AHCSM reported membership was “over 1 million” in February of 2019. Other sources report membership closer to that 1 million figure.

HCSMs tend to be significantly cheaper than health insurance plans, making them increasingly attractive. However, most families that buy health insurance through the exchanges get major subsidies that significantly reduce their premiums.

There have been multiple reports of individuals and families stuck with huge bills after their “Ministry” refused to pay for care. Aliera Healthcare Inc. and Trinity Healthshares, Inc are the most visible example of what can happen without tight regulation. Regulators in multiple states issued cease and desist orders after concluding the companies violated laws; Aliera was found guilty of fraud and filed for bankruptcy late last year.

Tops among concerns is this – HCSMs are NOT required to have enough cash on hand to pay medical bills. Even more concerning, they don’t have to report their finances, cash reserves, expense ratios or other data.

There’s an effort underway to “accredit” HCSMs; the process/requirements don’t appear to address this critical issue and the accreditation board doesn’t include individuals with actuarial or financial credentials.

I’ve asked the lobbying outfit that purports to represent HCSMs for details on the financial portion of that accreditation process. So far they’ve been less than forthcoming.

What does this mean for you?

be very careful.

 

May
27

Things I missed while despairing

Posted by Joe Paduda on Friday, May 27th, 2022 | Comments

We’ll get to what we missed in a second; first this – The slaughter in Buffalo and Uvalde had me focused elsewhere, as it did for many.

That focus must not shift as we celebrate Memorial Day with friends and family; we cannot just move on, as tempting as that is. Rather I’d encourage you to commit to doing something, to be a difference maker.

Please don’t just move on. Please.

  • Get the facts about gun violence here.
  • Support the Sandy Hook parents’ efforts here.
  • Support Moms Demand Action here.

WCRI published two excellent studies this week…thanks to Andrew Kenneally for sharing the news.

The craziness of workers’ comp extends to the prices you pay doctors and therapists for care…how crazy you say?

Bonkers.

Docs in Florida are getting screwed (but FL hospitals are rolling in dough), while their counterparts in Wisconsin are making bank. Like so many things in comp, this makes zero sense.

Download Rebecca (Rui) Yang PhD and Olesya Fomenko PhD’s insightful study – for free – here.

There’s far too little information on the outcomes of chiropractic care. WCRI just published a multi-pronged analysis of chiropractic care’s impact on low back pain, with a comparison of costs and disability duration for patients treated by chiros vs other care givers.

An intro video is here.

The study, authored by Kathryn Mueller, Dongchun Wang, Randall Lea, M.D., and Donald R. Murphy is available for purchase here.

Have a safe weekend, and remember – Democracy depends on your involvement.

May
25

This is about your children.

Posted by Joe Paduda on Wednesday, May 25th, 2022 | Comments

Once again children have been killed.

Yesterday’s slaughter of little children cut me to the heart, coming the day after I spent hours watching our granddaughter. Hours of delight, wonder, love, joy and promise.  Sitting together in a swing as she munched on goldfish, picking dandelions, working on puzzles and learning more colors, doing nose kisses and picking out her outfit for the day (rain boots, shorts, and a favorite shirt, with a pretty awful ponytail (as it always is when grandpa does it)).

I cannot imagine the heartbreak suffered by families in Uvalde Texas, nor can I imagine how this reverberated among parents of kids killed in Sandy Hook Connecticut a decade ago, ripping open wounds painful beyond measure. That’s awful indeed – what’s worse – if that’s possible – is there have been dozens of mass shootings this year alone.

Look at your kids, your schoolyards, your sports fields, your graduation ceremonies and school plays and imagine the impact of a Uvalde/Sandy Hook/Buffalo/Laguna Woods/Milwaukee/Brooklyn/Sacramento.

If we do not do something about gun violence, some of you, dear readers, may come to understand all too well the heartbreak and utter devastation suffered by families victimized by gun violence.

Make no mistake, this butchery would not happen without grandstanding by vote-seeking pols, lax background checks, wildly inadequate mental health care, incredibly permissive concealed carry laws in some states and easy access to guns, many of which serve no purpose other than killing people.

What does this mean for us?

We are failing to protect children, loved ones, parents and family. This is a national disgrace. 

Note – I am a gun owner and hunter. Family members are first responders, former law enforcement and national security.

 

Apr
4

Facility costs…more bad news

Posted by Joe Paduda on Monday, April 4th, 2022 | Comments

Here’s two things which will likely increase facility costs.

Becker’s reported last week that so far this year hospital and health system margins (with some very notable exceptions) are pretty crappy – down almost 12 percent month over month in February, and a whopping 42% below February 2020 (jsut before COVID).

My bet is significantly higher staffing costs are a major contributor; the giant Henry Ford system said labor costs were up 8% in February over the same month in 2021; Providence’s increase was even higher at 10%.

Couple that with a steep drop-off in health insurance coverage as COVID-related medicaid coverage ends, and you can expect facility costs to jump.

That’s because we’re going to see a lot more uninsureds seeking care at hospitals.

Medicaid is likely the single largest payer today, with about one out of every four of us covered by Medicaid.

The problem will be especially acute in states that have not expanded Medicaid – if your members/insureds/injured workers are in the orange states, you’ve already been paying a hidden tax to help pay for uninsured care delivered by hospitals.

Since states can pretty much determine who gets Medicaid, the problem is even worse in places like Mississippi that have long restricted Medicaid coverage to a very thin slice of the poor.

If you make more than 27% of the federal poverty level, you’re too rich to get Medicaid in Mississippi – which is both the poorest and sickest state in the nation.  (kudos to Louise Norris for her intel on the issue)

What does this mean for you?

Success favors the prepared. If you think you’ve got an answer to this you’re likely wrong. 

Mar
25

WCRI #4 – Provider consolidation’s impact on workers’ comp

Posted by Joe Paduda on Friday, March 25th, 2022 | Comments

Is Not Good.

that’s the primary takeaway from Bogdan Savych PhD’s presentation at WCRI’s annual conference– and a lot of other work I’ve done on the topic.

Consolidation eliminates competition – although I’d posit there’s little true competition in health care services. [I’ve written a LOT about  consolidation and the impact thereof]

There’s solid evidence that consolidation actually leads to increased prices and some research indicating it leads to decreased quality.

So how has healthcare evolved – well, primary care docs shifted from mostly solo practice to employment by health systems or group practices. Note this data is from 2018; consolidation has accelerated since then.

Of course, like everything else in healthcare, it’s local…orthopedic practices in Wisconsin are much more likely to be owned by health systems than those in Delaware.

Dr Savych’s research hit on a critical issue – exactly how many workers’ comp patients do primary care docs see? – the answer is most see almost none – with just one out of every ten physicians seeing more than 10 WC patients per year. Of course orthos see more – but still not many; only about a third see more than 10 claimants per year.

There are a whole host of issues with this which we’ll get into in a future post. For now, the net is researchers have to identify the specific physician responsible for the care of and outcomes for specific patients – which is fiendishly difficult especially when that physician moves from a group practice to employment by a health system. Provider identification is the main challenge – but by no means the only one.

Case mix adjusting – the art of comparing patients with similar diagnoses (often primary, secondary, and tertiary) over time – is as or almost as hard to get consistently right.

All that said, Dr Savych noted that cost increases are due more to a shift in the volume and type of procedures than higher prices for individual services.

The initial takeaway (there’s a LOT more research and analysis to do) is vertical integration (physician practices absorbed but health systems) leads to docs providing more expensive services.

What does this mean for you?

Consolidation raises work comp medical costs.

The best way to think about this is on a state-specific basis; understand where there’s more consolidation and watch the type of services delivered to your patients like a hawk.

Mar
11

I told you so.

Posted by Joe Paduda on Friday, March 11th, 2022 | Comments

I cannot stand that statement…yet it is spot on. I’ve been posting on this for some time, often feeling like Cassandra.

Healthcare staffing shortages are fast approaching crisis levels, with major implications for each of us.

From ModernHealthcare:

As of last month, 27% reported critical shortages to the Health and Human Services Department…During crisis levels in the early phases of the pandemic, mortality rates spiked as hospitals rationed care. One-quarter of COVID-19 deaths between March and August 2020 were attributable to overstretched hospitals, according to the National Institutes of Health. Patients with the most serious non-coronavirus illnesses suffered under the same conditions. [emphasis added]

HHS recommended that providers use the Sequential Organ Failure Assessments score, which evaluates organ function to determine patients’ likelihood of mortality if they were to receive treatments or beds. Those most likely to die go untreated and often are diverted to palliative care.

Terminal burnout is the main driver. Nurses and hospital staff have been dealing with entitled, arrogant, mean-spirited patients many of whom are unvaccinated for more than two years.

One of the drivers is the archaic, hidebound, and wildly incompetent way we license nurses. Full disclosure – a future family member and nursing school graduate has been waiting three months for their nursing license paperwork to come through.

This at a time when nursing shortages are forcing hospitals to close entire departments and shutter entire floors.

It doesn’t have to be this way; the licensing compact adopted by 35 states and Guam allows some nurses licensed in one state to practice in others – with limitations.  Revamping the criteria and removing limitations would speed up the licensing process immeasurably.

But the licensing debacle is an effect, not a cause. The real cause is the unvaccinated who get COVID and spread and their enablers.

What does this mean for you?

Some people’s “freedoms” are killing others. 

Mar
1

Stuff you should know

Posted by Joe Paduda on Tuesday, March 1st, 2022 | Comments

When Physician Management Companies took over anesthesia practices, the units (amount of services) and prices went up dramatically (when compared to other practices).

As in 16.5% and 18.7% respectively.

No surprise, prices went up even more – as in 26% – if the PMCs were owned by private equity companies.

The fine folks at WorkCompCentral published the news that OptumRx settled with the Commonwealth of Massachusetts over the Commonwealth’s claim that OptumRx failed to follow workers’ compensation prescription drug pricing procedures. OptumRx agreed to pay the state $5.8 million. The settlement is here.

I’m trying to get more detail on this as the Commonwealth’s press release is a bit confusing.  You’ll know if/when we get more details.

Finally, the conspiracy theory that somehow COVID came from a lab has been put to rest – at least for those of us who believe in science. Somehow I doubt the tin foil hat crowd will accept the news that the virus originated in the Wuhan market.

Where COVID originated 

From Michael Worobey, a co-author on both studies and an evolutionary biologist at the University of Arizona via Medscape “When you look at all the evidence together, it’s an extraordinarily clear picture that the pandemic started at the Wuhan market…”

More details on the two studies:

In one study, researchers used spatial analysis to show that the earliest COVID-19 cases, which were diagnosed in December 2019, were linked to the market. Researchers also found that environmental samples that tested positive for the SARS-CoV-2 virus were associated with animal vendors.

In another study, researchers found that two major viral lineages of the coronavirus resulted from at least two events when the virus spread from animals into humans. The first transmission most likely happened in late November or early December 2019, they wrote, and the other likely happened a few weeks later.

There’s an excellent synopsis of the research and methodologies here. If you want to weigh in, please review the article at the link first.

What does this mean for you?

For-profit healthcare can be very problematic, and science always wins.

We are all shocked and heartsick over Putin’s War on Ukraine – if you want to help Ukraine and Ukrainians, please consider a contribution to Care. Care is a very reputable and highly effective NGO with a rich history of successfully mitigating disasters and helping people.

Feb
17

COVID update

Posted by Joe Paduda on Thursday, February 17th, 2022 | Comments

yes, things are getting better – but that’s not universal, as some states/regions are still dealing with the Omicron tsunami.

First, idiot alert…

An Oklahoma hospital was forced to lock down its ICU due to what can only be described as rampant idiocy.  From Medpage Today:

In a recent press release, [a] church group [that has been protesting outside the facility and making threats against its staff online], known as Ekklesia Oklahoma, called Mercy Hospital an “evil Marxist controlled death camp.” [emphasis added]

Court documents stated that the founder of the group called one of the hospital’s doctors a “murderer,” noting that members even posted the doctor’s home address online, according to KFOR.

It’s not just Oklahoma…in Boston, a neo-Nazi group protesting outside the hospital called Brigham and Women’s Hospital “anti-white.” The stupidity of the protestors is stunning, as is their twisting of facts.

As I’v noted multiple times, we have family members in emergency medicine/critical care.  These types of attacks happen every day, everywhere. Patients yell, scream, hit, spit on staff. Some patients’ family members call and make demands, cursing at staff who refuse to dispense ivermectin. They abuse them mercilessly.

And nurses and staff are supposed to stand there and take it.

Would you tolerate that in your job?

What does this mean for you?

These idiots and their enablers are destroying our healthcare system. Call them out. 

Facts

COVID infections are associated with much higher use of medications to address behavioral health conditions. That’s from a study published in the British Medical Journal. The study was conducted by the Veteran’s Administration and analyzed data on over 150,000 patients with a previous acute COVID diagnosis.

From the BMJ:

people with covid-19 show an increased risk of incident mental health disorders, including anxiety disorders, depressive disorders, stress and adjustment disorders, opioid use disorder, other (non-opioid) substance use disorders, neurocognitive decline, and sleep disorders. The risks were evident even among those who were not admitted to hospital during the acute phase of covid-19—this group represents most people with covid-19 [emphasis added]

Vaccinations are good

A UK meta-analysis focused on long-COVID found that individuals previously infected with COVID benefited from vaccinations, and those with COVID that got a vaccination did better than those without a vaccination.

  • Six of the 8 studies assessing the effectiveness of vaccination before COVID-19 infection suggested that vaccinated cases (1 or 2 doses) were less likely to develop symptoms of long COVID following infection, in the short term (4 weeks after infection), medium term (12 to 20 weeks after infection) and long term (6 months after infection).
      • Six of the 8 studies assessing the effectiveness of vaccination before COVID-19 infection suggested that vaccinated cases (1 or 2 doses) were less likely to develop symptoms of long COVID following infection, in the short term (4 weeks after infection), medium term (12 to 20 weeks after infection) and long term (6 months after infection).

      Finally, more support for the benefit of vaccinations for those previously infected with COVID.  

      A study published in the new England Journal of Medicine found that:

      Among patients who had recovered from Covid-19, the receipt of at least one dose of the BNT162b2 vaccine was associated with a significantly lower risk of recurrent infection.

      So, yeah, just because you had COVID doesn’t mean you don’t need the jab.

      What does this mean for you?

      Get vaccinated. 

Feb
16

Quick hits…

Posted by Joe Paduda on Wednesday, February 16th, 2022 | Comments

I’ve done a few podcasts recently, and find them to be a lot of fun. Yvonne and Rafael hosted me in a kick off the second season of their Deconstructing Comp pod…we dove into opioids, humility, making things real, testifying before Congress, physician dispensing, blogging and grandkids.

CWCI’s annual meeting is DIFFERENT this year.

The fine folks at CWCI recognize that many members and other usual attendees are still under travel restrictions and may have personal and/or public health concerns. To accommodate as many people as possible, this year there will be both live (3/8) and virtual (3/10) conferences.  Register for both the live and virtual meetings here:  https://www.cwci.org/conferences.html; the virtual meeting will combine recordings of the live sessions with a live Q&A.

There’s a lot on the agenda related to legislative targets including access to care/MPNs, presumptions, med/legal & QMEs as well as the usual claims monitoring report (COVID/Non-COVID claim dynamics, utilization, pharmacy).

Michael Marks, a most insightful attorney will tie together the theme (“Are We There Yet”) with a comparison of the original grand bargain to our current state.

Not to be outdone, NCCI’s out with their latest economic briefing; highlights include:

  • Unemployment rates at or below 4% in December and January indicate that the US economy is nearing full employment.
  • Job losses are now concentrated in just two major sectors: Leisure and Hospitality, and Education and Health Services. (With family members in healthcare, I know first hand why so many are quitting)
  • January’s employment numbers showed no effects of the Omicron surge…deferred jobs hit in February is unlikely.

The Conference Board forecast that the US economy will grow by 2.6 percent (year-over-year) in 2022. I’m no economist (yippee!) but I’m betting we’ll see significantly higher growth – which will positively effect employment, wages, and thus workers’ comp and group health premium growth.

What does this mean for you?

Things are getting better. 

Feb
14

Hospital CEO pay ≠ Outcomes

Posted by Joe Paduda on Monday, February 14th, 2022 | Comments

An excellent piece by Merrill Goozner highlighted – among other things – the disconnect between not-for-profit hospital CEO pay and their hospital’s ability to control costs. 

Merrill cited the Lown Institute’s analysis of hospital performance, DEI results, outcomes, cost and pay equity

Since 1996, hospital costs have risen about 2 1/2 times faster than overall inflation…

Why?

Quoting Merrill..

You’d think the boards of trustees at the nation’s non-profit hospitals, which account for 80% of all staffed beds in this country, would be up in arms over top management’s inability to keep prices and thereby patient costs under control. At the least, they might want to incentivize their chief executive officers and other C-suite staff to take cost control seriously.

Nope.

up to 40% of a CEO’s bonus depended on measures that directly affect hospital finances.

Not for profit hospitals are a BIG part our healthcare problem; most don’t care about rising healthcare costs, and they don’t tightly link CEO compensation to clinical outcomes.

Now I know why I had to pay $355 for ear wax removal.

What does this mean for you?

Hospital leaders’ and their boards’ priorities are not ours. 

Subscribe to Merrill’s posts here.