With payrolls plummeting and premium dollars poised to follow suit, workers’ comp payers are looking for the proverbial nickels in the couch cushions.

While pharmacy costs have been declining for years, there are several ways payers are losing money by overpaying for drugs.

Here’s one.

Almost all work comp payers pay for drugs based on a discount below AWP. Generics get a much deeper discount than brands, perhaps 45%+ compared to 13% or so. That being the case, you’re getting a much better price on all your generic meds.

Well, perhaps.

First, what is a generic? Again, seems straightforward, but thru the miracle of legalese, it can be anything but. I’ve seen many a PBM-Payer contract where the definition of generic was, well, opaque.

there’s a definition in there somewhere…

A “generic” is a generic… right…?

Well, no. Among the generic definitions I’ve seen are:

• a generic drug is a medication the contains the same chemical substance as a drug that was originally protected by, and is no longer protected by, chemical patents.
• a generic drug is a medication listed as a generic by a compendia (such as Medispan’s GPI, or generic product identifier)
• a generic drug is a medication with an “O” or “Y” identifier
• a generic drug is a medication available from multiple manufacturers

And, that definition was buried in the dense print on page XXX, while the pricing referring to generics was somewhere else, and the process and timing of linking the two, and the data source for the actual prices were either nowhere in the contract or buried somewhere else.

Unless you a) know exactly and precisely what the definition should be; b) read and understand the entire contract so you can connect a definition to a pricing level to a pricing basis/compendia/source; c) have the expertise, staff, resources, and time to monitor the actual pricing you are getting, you don’t KNOW if you are overpaying for “generics”.

What does this mean for you?

Do you know what you don’t know?

Things that are keeping me awake at night (besides the normal problems associated with being a 61 year old guy)

The number of people without health insurance will increase – a lot, driven by:

• 10 million have lost their jobs – as of last week – and those lucky enough to have good health insurance will be hard-pressed to pay health insurance premiums much less deductibles and copays.  This from the Economic Policy Institute, “EPHI” is Employer provided health insurance”; link to interactive site is here
  
• Many service workers don’t have employer-sponsored health insurance; some might qualify for Medicaid after a layoff unless they stay working part time or have other income. For those who live in the 17 states that haven’t expanded Medicaid, it’s even harder to qualify.
• The Trump Administration is refusing to open the Federal Insurance Exchange to allow people without health insurance to sign up – but pretty much every state-run exchange has already done this.
• The Trump Administration is still trying to overturn the ACA, which would kill Medicaid expansion, eliminate the requirement that insurers cover young adults (between 18 and 26) on their parents’ insurance plans, and allow insurers to discriminate and upcharge people with pre-existing medical conditions.
• more on this issue here.

Note – in yesterday’s press conference, President Trump did make some vague comments about possibly using Medicare and/or Medicaid to pay for COVID treatment. Here’s the quote:

“I’m not committing,” said Trump. “I have to get approval. I’ve got a thing called Congress. It’s something to look at and we have been looking. “

This would require a massive change to Medicare and/or Medicaid laws, followed by an equally massive change in lots of regulations, followed by…who knows what.  Reality is, there are way better ways to address this.

Back to the growth in the uninsured and implications for COVID:

• some/many will not get tested for COVID as they can’t afford treatment and are terrified of debt.  Some of these folks will continue to work because they have to, which increases the likelihood they’ll spread the disease.
• hospitals and other healthcare providers – which are already struggling financially because they aren’t doing profitable surgeries for privately insured patients – are going to be delivering a lot of care to people who can’t pay for it.

Net – fewer people with decent health insurance will mean more people will get infected, and the healthcare delivery system is going to have serious financial problems.

A modest proposal.

Here’s a fix.  The federal government makes COVID testing and treatment a federal benefit for all residents (yes undocumented people too) and reimburses providers at Medicare rates.

This would:

a) alleviate the huge financial pressure on hospitals, EMS, and all healthcare providers;

b) increase the number of people tested; and

c) get us back on track sooner than if we do nothing.

Well, the WORST thing about this damn pandemic is I can’t do my annual April Fool’s post.  So, instead of actually working, I’ve been trolling twitter for the best COVID tweets and the inter-webs for great stories.

This story wins the prize…

 

Ok, now the twitter-verse’s take on Covid!

 

 

Dad joke alert…

Sports fans…

A new sport!

 

 

Zoom meetings ain’t new after all…

Snark alert

The COVID shutdown’s impact on nature

Hoarding alert!

 

 

Sorry!

 

regular COVID jokes…

– People with a cold – “I just want to stay in bed and do nothing, I feel terrible”  People with Corona Virus – “I feel terrible, I think I will go skiing in Austria, visit the Eiffel Tower and maybe do some white water rafting in Camino de Santiago”

– To the people who bought 20 bottles of soap leaving none of the shelves for others, you do realise that to stop getting Coronavirus, you need other people washing their hands too.

– During self isolation.. Dogs: “Oh My god, you’re here all day and this is the best as I can love you, see you, be with you and follow you! I am so excited because you are the greatest and I love you being here so much!

Cats: “What the hell are you still doing here?”

– Mexico is asking Trump to hurry up and build the wall NOW!

 

Tomorrow back to our regular broadcast…

 

 

 

That’s “During Covid-19”; hopefully we’ll be “AC” soon (After Covid-19)

I’ve been spreading so much doom and sadness it’s time to make amends.

OK, here’s some tips and advice from a person that’s been working from home for 20 years.

1.  You will get a LOT more done at home than you do at work – if you are disciplined.  Fewer people to chat with, run into in the hall, and engage in non-work conversations means more time – and more ability to focus.
2. Keep your cell phone on the charger, and use a wireless headset.  That way you won’t run out of battery, and you can pace around while you are on the phone. You’ll find that is way better then sitting at a desk or table – and way healthier too. Put that headset on the charger whenever you aren’t using it.
3. Turn the email off for several periods during the day so you can focus on the task at hand. Unless you’re waiting on a time-critical email, being off the grid for an hour or so at a time isn’t a problem.
4. Prioritize your tasks – now that you have more control over your daily work, make very sure that you do the stuff that’s important first. As a former professor told me many times, “Do the important stuff, THEN the urgent.”  Best way I’ve found is to write a list, then number them in order of importance – and stick to it.
5. Don’t worry about background noise from dogs, kids, partner or spouse. We are all in the same situation.
6. Respect those directly affected by COVID-19 and preparations for same. They may not have time for idle chitchat, when they ask for something it’s probably important, and they are really stressed.

Finally, it’s entirely okay to call people and talk business, ask for things to get done, check on progress, and otherwise carry on. This will pass, and in the meantime life has to go on.

What does this mean for you?

There’s a lot to be said for getting back to “normal” even when that “normal” is different than it was last week. 

 

A dozen years ago, there were lots of relatively small companies delivering specific services to work comp payers.

There were 10 PBMs.  5 bill review application and more diagnostic imaging vendors. Dozens of case management companies. Scores of IME firms.  The same for DME, home health, transportation/translation, and UR.  Lots more TPAs too.

Today’s landscape is dramatically different.

3 PBMs have significant market share.

Conduent is the largest BR app provider, with Mitchell second and Medata gaining share; their competitors were acquired.

There’s one major dx imaging firm.

A dominant IME company.

There’s been vertical consolidation (think Examworks rolling up the IME business) and horizontal mergers (One Call buying PT, DME, home health, dental and T&T companies; Paradigm buying case management, network, and niche service firms, Mitchell/Genex doing the same).

Sure, there are smaller companies, many of which are flourishing – think HomeCare Connect, MTI America and Carisk (the latter two are HSA consulting clients).  There are much larger ones – think MedRisk (HSA consulting client) – that focus on a single service. These companies identified a niche, and/or developed a unique capability and/or deliver exemplary service – simple in concept, brutally hard in execution.

What’s happening in the workers’ comp service industry shouldn’t be a surprise to anyone with a lick of business sense; comp is a shrinking business, with flat medical costs and fewer claims every year.

For an excellent summary, read this Harvard Business Review article.

Point being there are two distinct ways to survive and even thrive in a rapidly consolidating industry – get big, get efficient, lower costs – or focus narrowly and/or deliver exemplary service.

In either case, a relentless focus on identifying and solving customers’ problems will determine if you live or die.

Both models have big issues and challenges;

• cybersecurity is a huge challenge for small companies with limited resources;
• efficiency does not and cannot mean lowering customer service standards; and
• buyers (managed care and claims execs) value different things than front line workers – but you have to please both.

What does this mean for you?

If you’re wondering where you will be in a few years, wonder no more. There will be fewer service companies delivering fewer services to a smaller group of ever more demanding payers.

 

 

After weeks of speculation – most of it pretty accurate – it’s official.

In one of the more impactful transactions we’re likely to see this year, CVS/Aetna has agreed to sell Coventry Workers’ Comp Services to Mitchell/Genex. Terms haven’t been disclosed. Press release is here

The deal isn’t official until it’s passed thru any and all regulatory hoops. I doubt very much there will be any problems as the current Administration isn’t interested in doing much of anything to interfere with business.  Sources indicate current Coventry leader Art Lynch will report up to Peter Madeja; as noted here before I’m a big fan of Peter’s.

Oldsters will recall that Aetna tried to sell Coventry at least twice.  Both times the deal didn’t happen because the owners didn’t understand the critically important issue – who owned the network contracts.

After the last debacle, Aetna went back and converted (almost) all the Coventry provider contracts to Coventry paper, so the network contracts convey with the sale of Coventry. Since it’s the network that drives the majority of profits, this was a have-to.

In addition to the network itself, Coventry has a bunch of other assets – PBM FirstScript, a bill review business, case management and UR, and other stuff.

Takeaways.

Data is a huge asset, and one that should create a lot of value for Coventry and its customers. As the largest network, one of the largest bill review entities, and with decades of transaction history, the company has the information it needs to build a much more effective network…effective defined as “one that delivers lower net cost for its customers.”

In an HSA survey of 15 big payers’ views of provider networks, Coventry garnered the top spot in terms of market acceptance and respondent ranking. It is certainly the largest in terms of share despite chronic under-investment by owner Aetna.  Now that Coventry will be owned by a workers’ comp entity run by people who know workers’ comp, I’d expect a pretty significant investment into the core asset – the PPO.

That will undoubtedly include building and staffing a network contracting and management capability – from scratch. Certainly M/G will be able to use Aetna’s technology and perhaps contracting/credentialing resources for some time, and equally sure M/G will do everything possible to build that network management capability quickly and well.

If they do it right, customers should see improved results in the form of lower facility costs.

The First Script PBM is the next biggest asset.  It has also suffered from underinvestment for years. Given the continued decline in work comp drug spending and the need for millions to invest in PPO network infrastructure, it wouldn’t be surprising if the new owners focused their interest elsewhere.

Genex’ bill review operation is a big player, and the addition of Coventry’s BR operation will add even more scale. One question – what to do about the BR platform?  Coventry is a big Stratacare user which presents a bit of a dilemma as the new owner is a direct competitor.

Then there’s case management, UR, and other related services.  These can be readily integrated into Genex’ current service portfolio and will strengthen the company’s breadth and scale. Expect Genex to leverage this to expand relationships with national payers.

Implications

The transaction marks the latest in a long list of mergers and acquisitions in the workers’ comp services business. We are nearing the end of a decade-long consolidation – there are just not that many large assets left, the industry is not that interesting due to structural issues, and fewer assets = higher prices.

Payers should see better results from a Coventry network run by people who understand work comp and are willing to invest big dollars into building a much more effective network.

Conduent’s leadership may be thinking thru implications as well as there’s a bit of channel conflict.  As the largest (by market share) WC BR application vendor is rumored to be in this for the long haul, I strongly doubt Conduent will be having second thoughts about partnering with the largest WC PPO.

 

Three pictures tell the story of the biggest problem in workers’ comp medical cost management.

A reminder that facility costs are the biggest chunk of medical spend from Kaiser Family Foundation.

A seemingly-unrelated graphic illustrating the status of Medicaid expansion; blue states expanded Medicaid under ACA, gold-ish states did not.

States where work comp facility costs have risen the most – courtesy WCRI.

This from Captain Obvious – Hospitals in states that failed to expand Medicaid are using workers’ comp as a financial lifeline.

What does this mean for you?

What’s your solution?

Two Republican-appointed judges on a Federal appeals court struck down a key provision of the ACA.  So what?

Well, if you or a family member are a bit heavy, have high blood pressure, are pre-diabetic, had a bout of cancer, may need long-term care, make less than $103,000, are pregnant, pay attention.

Another judge will decide if the entire ACA or parts of the very broad law are struck down. Among the provisions at risk are:

• guaranteed coverage for pre-existing medical conditions
• guaranteed healthcare for your kids up to age 26
• long-term care benefits for you and your parents.
• no lifetime caps on medical benefits
• reduced premiums for families that make less than $103,000
• financial support for small business’ healthcare premiums
• coverage for prescription drugs and behavioral health
• limits on what insurers can charge older folks
• Medicaid expansion in two-thirds of the states

SOME of the pre-existing health conditions that would not be covered if the ACA goes away…

This would have different effects in different areas… click here to get an interactive map.

What’s puzzling is the Republicans who want to blow up those protections have no plan to deal with the consequences. The end of all or some of the ACA will have huge effects on families, and there’s NO plan to help families when this happens.

What does this mean for you?

Check the list up top.

More on potential implications here.

A detailed discussion of the lawsuit and where things stand is here.