With extremely rare exceptions, workers’ comp payers – and PPO networks – are doing next to nothing about “quality”.  An illustration.

Let’s compare two hospitals near Jacksonville Florida.

Using publicly available, free data (thanks to RAND), Baptist Medical  is pretty good; it has 4 out of 5 stars on the CMS Hospital Star Compare rating system – the most widely accepted quality rating metric.

Over the bridge is an HCA facility – Orange Park Medical Center – with 2 stars, below average on CMS’ scale.

Both facilities are in multiple workers’ comp PPOs…none of which indicate the large gap in quality between the two. Or any other quality measures for any other facilities.

You’ll note there’s a cost difference as well. And no, you don’t get what you pay for.

The higher-rated facility costs less –  Baptist gets paid about 2.6 times Medicare’s rate for care delivered by private insurers, Orange Park is 4x Medicare.

What does this mean for you?

Want to show you care about the quality of care delivered to injured workers? Send them to good facilities.

 

 

After a brutal three weeks of 12 hour work days, finally came up for air late yesterday. The water is receding, so should be able to get back to my posting duties on a regular basis.

Let’s get right into it.

COVID’s mutations are likely to put off a full recovery till late summer or even fall.

While quite rare, viruses mutate during replication – genetic material gets shuffled around, mixed up, and re-ordered. In most cases the result is pretty minor, or “fatal” to the virus’ replication (as viruses are not technically “alive”, “fatal” isn’t exactly the right term, but close enough.)

Mutations are even rarer for the coronavirus.

So that’s the “good news”.

The bad news is this – with hundreds of millions of people infected, each producing hundreds of millions of individual viruses, there are lots of opportunities for the virus to mutate.

That’s why we now have at least three separate instances of a mutation that appears to make COVID more transmissible. While only one – the UK variant – appears to be slightly more deadly, the overall impact is not good.

Even more worrying, these mutations also appear to make antibodies (one of the immune system’s tools to attack viruses) and perhaps one of the vaccines less effective.

The good news is the Moderna and Pfizer vaccines appear to work almost as well against COVID mutations as they do against the “original” virus. So far.

Meanwhile, vaccinations in the US are few and far between. With only one out of 12 Americans vaccinated to date, we have lagged far behind the world leader – Israel – which has vaccinated over a third of its population.

Amazingly, there are idiots seeking to stop or prevent COVID vaccinations; these people are complicit in the deaths of the 440,000 Americans who’ve died from COVID. (photo credit halperry)

What does this mean for you?

1.  Wear an FDA-approved N95 or KN95 mask. Not a cloth mask, not a bandanna, not a “surgical mask. (Thanks Mary!)
2. Prepare for at least six and maybe nine more months of COVID. It stinks and no one likes it and all that – we all need to suck it up, stop whining, help each other out, and power through.
3. If you can, help out the less-fortunate. Be kind and be generous.

 

The good.

David Colon and Raji Chadarevian of NCCI have produced an excellent summary of COVID’s impact on workers’ comp medical treatment.

Colleagues Brittni Moore and Vicky Mayen have authored a companion piece that provides an early projection of 2020 financials. While not COVID-centric, there’s no doubt COVID is a main driver of the 8.1% decline in private carrier premiums. Moore and Mayen also note final premium totals may well be lower due to pandemic-driven declines in payroll.

As we projected back in the summer, profits remain robust. The pandemic-driven decline in claims plus carryover from inflated pricing due to the opioid factor are likely chief contributors.

A few takeaways from the COVID study:

• Among COVID claims that had medical expenses, one-fifth had an inpatient stay. Note that this is only for accepted claims WITH medical expenses.
• Among those claims with an inpatient stay, one-fifth – or 4 percent of all claims with medical expenses – were in an ICU at some point.

graphic courtesy NCCI

My takeaway – medical costs are relatively low.

Meanwhile Johns Hopkins University researchers studying Accident Fund data report there’s only one industry likely to be significantly impacted by occupational claims for COVID – you guessed it, healthcare.

The highlight – “This suggests that the vast majority of workplaces will not be subject to a high frequency of COVID-19 related WC claims over the course of the pandemic.”

Now, the bad news.

Long Haulers are COVID patients with persistent and often strange symptoms that can persist for month. Possibly related to an immune response gone awry, these conditions include (quoting the NYT):

• fatigue,
• pain,
• shortness of breath,
• light sensitivity,
• exercise intolerance,
• insomnia,
• hearts that race inexplicably,
• diarrhea and cramping, and
• memory problems.

While most patients improve over time, one researcher estimates about one in ten have issues that persist for months.

What does this mean for you?

We have a lot to learn about COVID.

Premiums and injury claims are way down; profits remain really high.

Those are the key takeaways from just-released analyses of COVID’s impact on comp from NCCI and WCRI (WCRI report free to members, fee for non-members).

That’s also what Mark Priven and I predicted last summer. I highlight that not to crow but rather to point out that these findings were quite predictable. And others’ grave concerns about COVID hitting profits were completely off the mark.

First, the qualifiers.

• NCCI’s report includes private carrier data reported by NAIC through September 2020. Things got a lot worse late in the year, so it is highly likely premiums and injury claim drops increased somewhat.
• WCRI data covers results from 27 states during the first half of 2020

Claim decreases

WCRI’s data shows a stunning decline in non-COVID claims (MO and LT) across the 27 states from Q2 2019 to Q2 2020…a 30% + drop in the vast majority of states.

Not surprisingly, the decrease in LT claims – while still dramatic – wasn’t as large.

The net – overall, claims dropped by more than a quarter in the vast majority of states.

Also, WCRI found that the severity of the outbreak was strongly correlated (my word not their’s) with the decline in non-COVID claims.

Implications

• TPA revenues suffered as claim counts declined
• Medical management revenues in the second half of 2020 almost certainly dropped significantly (compared to 2019). Fewer new LT claims = fewer bills, fewer network encounters, less need for case management and UR

What does this mean for you?

• With COVID infections exploding – and the criminally inept vaccine rollout – we will almost certainly see a reprise of Q2 2020.
• You can expect this reprise started in December and will continue thru April.

 

First – stay careful and smart – this is NOT the time to take risks; hospitals in many states don’t have room in their ICUs or ERs. Drive carefully, mask up (see below for info on the most protective mask), and DO NOT hang out indoors with people outside your “pod”.

To that point..

“Excess” death counts are used to better understand the real impact of COVID. In California, the pandemic is not only leading to tight capacity in hospitals, it is correlated with a significantly higher death rate, especially among Blacks and Latinx people.

This isn’t surprising; people of color are:

• less likely to have health insurance and
• thus are in generally poorer health;
• more likely to live in urban areas with denser populations;
• have less access to testing; and
• more likely to work in “essential” industries and in “essential” jobs that place them at higher risk.

This from an NYC physician:

As a physician in an urban pediatric ED, I have worked with families who fear losing their jobs and medical coverage or exposing their children because they cannot work from home; families who feel abandoned by their primary care clinicians after their offices closed down; and families with language barriers or limited internet access precluding their use of telemedicine services, which are not always covered by insurance.

Also notable – the group that had the highest increase in excess deaths was people under 24 years old.

It’s not just California. A national study of excess deaths among 25-44 year-olds showed just over a third were from COVID.

Workers’ comp claims

COVID-related claims in California hit an all-time high last month.

A quarter of all claims in November were COVID-related.

BUT…claims are down by almost 17% for the year.  One out of every six claims disappeared…

double But – only (!) one of every 10 projected claims didn’t happen. (claims counts are on a decades-long structural decline)

Other key metrics:

• about 1/3rd of all COVID claims are denied
• over half of all WC COVID claims are for people under 40
• to date, one of every eight claims is COVID-related

CWCI has led the way in reporting, documentation, and accuracy in all things COVID claim related.

Insurance execs are concerned.

As well they should be. The fine folks at NCCI report that COVID is the top concern amongst the insurance execs they polled.

I still don’t get fears about  presumption (the number 2 concern). COVID claims are cheap, resolve relatively quickly, and rarely become cat claims. Yes a very small percentage of patients may become Long Haulers, but even then they don’t/won’t represent a lot of dollars.

Concern about rate adequacy is even more puzzling.  Rates have been too high for years, driven largely by declines in opioid-related costs and disability. While that may change w the uptick in opioids, to date we’ve seen nothing that indicates the long-running gravy train that is workers’ comp is headed off the tracks.

What does this mean for you?

Prevention is the best cure – the most protective cloth mask is a two-layer woven nylon version.

If you don’t have one, use your regular mask this way:

See you next year.

 

Defying statutory requirements, logic, common sense, good government, fairness, basic math and the facts, Florida’s workers comp regulators just hammered the state’s employers, taxpayers, and physicians.

This is NOT yesterday’s Three Member Panel meeting, altho it bears a striking resemblance…foregone conclusion after a lot of theatrics

In a regulatory process resembling a Soviet show trial, the Three Member Panel slammed through a reimbursement scheme that will raise costs for employers and taxpayers while making sure Florida’s docs are among the lowest paid in the nation.

Allow me to list a few of the TMP’s many errors.

1. The TMP failed to comply with the law that established the TMP, which reads in part:
   “Paragraph 440.13(12)(d), F.S. further 4 states: In establishing the uniform schedule of maximum reimbursement allowances, the panel must consider: 1. The levels of reimbursement for similar treatment, care, and attendance made by other health care programs or third-party providers; [note that several organizations gave the TMP data comparing WC reimbursement to Medicare and others; the TMP ignored it] 2. The impact upon cost to employers for providing a level of reimbursement for treatment, care, and attendance which will ensure the availability of treatment, care, and attendance required by injured workers…”
   The TMP said the scheme would reduce facility costs by 23%, citing an NCCI analysis that indicated the revised hospital fees. HOWEVER, the comparison data used in the analysis was from 2019, when hospitals were able to game the system by over-charging work comp patients. After a court ruling some months ago, many payers started denying outlier payments – and that continues to this day. [edit after hearing more from NCCI]
   Thus, the comparison does NOT reflect the actual difference between current and future costs due to the TMP’s new reimbursement scheme.
2. The TMP refused to even consider the impact of rampant price-gouging by facilities with high charges on employers and taxpayers. This is very well documented, yet somehow escaped the TMP’s consideration.
3. An incredibly naive comment by one TMP member illustrated his total ignorance about medical costs in work comp. According to a piece authored by William Rabb in WorkCompCentral, “worker representative” Jason Robbins said that in his experience, since few workers end up in the hospital, it’s not a big deal. [Why read WCRI studies when you can just rely on your own “experience”?)
4. The estimable Mr. Robbins also noted excess insurance protects the insurers from high costs. Of course, employers and taxpayers have to pay premiums to excess insurers, which are driven by facility costs, a reality that appears to have escaped Mr. Robbins.
5. Then there’s the hospital lobbyist noting that the law doesn’t require reimbursement to be “reasonable”…looks like the TMP bought into HCA attorney Jennifer Hinson’s opinion on what the law says.  Attorney Hinson’s opinion is – to be kind – not supported by the actual law, which states:
   “The uniform schedule of maximum reimbursement allowances must be reasonable, must promote health care cost containment and efficiency with respect to the workers’ compensation health care delivery system…”[italics added]
6. Even the employer “representative” on the TMP, one Tamela Perdue, also voted in favor of hospitals. Perdue is an attorney employed by Sunshine Health, a Florida health insurer owned by Centene.
   I’m a bit surprised Perdue is a) on the TMP and b) voted; there’s a potential conflict of interest here as her vote favoring hospitals could be seen as a favor to hospitals in Sunshine Health’s network.

Finally, there’s a wealth of research indicating Florida’s reimbursement of physicians is way too low.  Rather than take a stand on this, the TMP just said it wasn’t anything they could do anything about.

Leadership at its finest, no?

What does this mean for you?

This is a not-very-well-hidden tax on Florida employers and taxpayers.

[note – I asked the Dept of Workers’ Comp for comment; as of this time they did not respond]