Category: Workers Comp

Jul
30

Where is the work comp insurance industry heading?

Posted by Joe Paduda on Monday, July 30th, 2018 | Comments

Work comp is doing very well – so well that one may want to be a bit nervous.

A couple things you should consider:

Today’s WorkCompCentral arrived with the news that the Hartford’s profits improved markedly last quarter driven in part by “favorable development” in its workers’ compensation business.

Essentially the Hartford determined that it had set aside more funds than necessary to pay for old claims, so a chunk of those funds were removed from “reserves” and became profits.

A bit further down in the Hartford’s filing came a bit more detail, detail that may be illuminating.  For example, “margin deterioration in workers’ compensation and a higher expense ratio” in the company’s middle market sector put a slight dent in that sector’s financial results..

Yet, while work comp renewal premiums for the small commercial sector were down, 4 percent growth in middle market revenue was “principally driven by workers’ compensation” new business.

So, we have better results than expected from old claims, tighter margins, higher expense ratios, and premium growth in a key sector. This may seem inconsistent – but it isn’t.

  • With lower premium rates come higher expense ratios – that’s just math.
  • Lower historical claims costs help reduce current premium levels; insurers may see this as lowering the cost of risk and therefore cut premium rates and/or offer discounts.
  • In turn these lower rates may generate more business especially from employers who want to buy insurance from top-rated carriers.

Quick aside…At Liberty Mutual, work comp accounts for 6 percent of net written premium. As a former Liberty employee, this is a pretty amazing statistic coming from the company that dominated US WC for decades.

From Liberty’s Q1 2018 earnings presentation

In the not-too-distant past, Liberty was at or very near the top of the largest writers of workers’ compensation insurance.  Not anymore.

This from Chubb’s Q2 2018 earnings call (thanks to Seeking Alpha):

Well, the macro picture, you have record low unemployment, which actually can play – cut both ways on workers’ comp. You have less experienced workers on the job, so you have to be careful. We’ve been seeing frequency up until now, frequency of loss has been down. Severity has been reasonably tame. And so overall loss cost trends have been good in comp. I think you have to – in my own mind, the market is reacting to that, the insurers, and comp has become more competitive. And I think you have to be careful that you’re not too aggressive, you overshoot the market.

Work comp premiums for the big carrier were down just under 6 percent this quarter over last, while YTD premiums were slightly higher.

I won’t attempt to link these data points to strategic moves; you can ponder those yourself.

Rather, my sense of what’s happening is some carriers are really trimming back their work comp books, others are growing it carefully, and all are waiting for an indicator that this historically-long-lived soft market is about to turn.

What does this mean for you?

We do know that very few – if any of us – will time that market turn correctly.

That’s the perspective of my alter ego…Captain Obvious!

Jul
27

Friday catch-up

Posted by Joe Paduda on Friday, July 27th, 2018 | Comments

I thought summer was supposed to be slow…

Sorry for lack of posts last two weeks – just slammed with client work.

here’s what I should have been posting on.

Economy drives employment drives workers comp

The economy boomed in the last quarter, with growth around 4 percent, a number we haven’t seen for four years.

Chart from Statista.

That’s the headline; the real story is less positive. Growth was partially driven by:

Here’s hoping things continue without overheating; forecasts aren’t so positive.

Implications – Lots of jobs open means higher wages and incentives for employers to keep workers on the job and get them back to work ASAP.

For those who just can’t get enough of the tariff issue – here’s the Harvard Business Review’s historical perspective.  Yes, I am a nerd.

Heat = more work-related illnesses/injuries

Deadly fires in Yosemite and California and Greece and Siberia and Sweden. A heat emergency in Japan. Temps in LA at record levels – even overnight. Scorching temperatures here in upstate New York.

Yes, climate change is happening. Yes, humans are the cause. And yes, it’s going to impact workers.

If the wet-bulb temperature (equivalent to that recorded by a thermometer wrapped in a moist towel) exceeds 35°C [95 degrees Fahrenheit], even a fit, healthy youngster lounging naked in the shade next to a fan could die in six hours.

Shifts in weather patterns are far more significant than overall global warming as they lead to very hot and dry conditions some places, hot and wet others, and exacerbate storm intensity among other effects.

Kudos to NCCI – they’ve been producing some highly relevant, much needed, and very useful research of late. Detailed, thorough, and diverse, and well worth your careful review.

One different angle is their ongoing work to highlight the good done by the  workers comp industry every day. Today’s installment is another example of this; there’s a lot more recognition that work comp is about the patients and employers.

Well done.

Opioids in the Federal workforce

Thanks to the great folks who handle my social media, website, and all that technical stuff I don’t understand at all, we’ve got video of testimony before the House Committee on Education and the Workforce.

 

Jul
25

Doing diligence on a potential acquisition

Posted by Joe Paduda on Wednesday, July 25th, 2018 | Comments

When they buy a company, investors are betting the story they’re told is accurate, that it fairly represents future opportunities and risks.  They’re betting on management – the people who built the company, that they’re who they appear to be – honest, insightful, decisive, well-connected.

When they get it right, it’s rewarding indeed. But when they don’t, it may be career-limiting.

Investors do diligence – often a lot of diligence – to make those bets as sure as possible. But, most investors aren’t expert in the specific niches occupied by the companies they are buying, so they rely on “Subject Matter Experts.” These are long-time industry people who know the ins and outs; probably know the business and its management; understand markets, regulations, and where things are headed; and have the contacts and relationships who will help give them the real story.

In the ten years or so I’ve been doing this, I’ve learned a lot. Here are a few takeaways.

Dig Deep into the Details

The proof is in the details. Dig deep into the stuff that drives the financial results. Investors are really good at financial analysis, but they don’t understand what drives those finances. Things like procedure codes, billing processes, discount arrangements, fee schedules, workflows and systems connections are where the business succeeds or fails.

Example – Read the actual provider contracts. What do they cover? What are the rates? What is the time frame? Compare the contracts to those provider’s bills – do the billing results match the contractual terms? Is the patient a member of a contracted customer? Did the customer do what was required to “earn” the discount?

If the seller won’t get into those details, you’ve got to ask why. Either A) they don’t have that information available, which is troubling in and of itself, or B) they have it but don’t want to share it, which is also troubling, and/or C) they are paranoid their “secret sauce” will become not-so-secret.

Push, and push hard. Make very sure your client knows exactly why this information is critical.

Pay attention to…

Overnight successes. Businesses that sort of float along, then experience a sudden jump in profits and/or revenues need extra-careful analysis. The seller will claim this was all part of the plan, they built carefully, invested heavily, and now are seeing the benefit of that strategy.

Perhaps…and perhaps there’s been some deep cost-cutting, a change in how they determine what’s revenue and when they can recognize it, a shift in accounting for old receivables, a new billing process. That’s not to say those things are inherently bad, they just may not reflect anything more than a one-time bump, or they may not be sustainable, and/or their suppliers (in many cases these are healthcare providers) may decide they don’t like whatever’s changed.

Vague claims. Stuff like “we keep all our customers”, “our program is clinically based” – where’s the supporting documentation? If the seller says it, they should be able to back it up convincingly.

The SME’s job

The seller will do a fine job of “selling”, my job is to be the realist.

In my view, my job is not to blow sunshine up the buyer’s shirt, but rather to find the potential issues, problems, roadblocks, and concerns and clearly illustrate what they are, the potential implications, and how much of a problem they represent.

There’s a lot of pressure on investors to do deals. They’ve taken millions of investor dollars into their funds, and need to park it somewhere. As potential deals become scarcer and more expensive, the pressure increases.

Strive to be just a bit on the skeptical side, and you’ll serve your client well.

Stick to what you know

I’m often asked “would you invest your money in this business?”  To which I reply, “Look at my investment portfolio and you’ll see why I’m the wrong person to ask about investments.”

Point being, buyers value companies for reasons that escape logic, or at least what I think of as logic.

For example, there’s CorVel. Why this company has a price:earnings ratio of 30 is beyond me. Revenue growth is minimal, operating income grew 10 percent in 3 years…hardly a growth company worthy of that multiple. But hey, what do I know.

Instead, focus on the business itself – let the investors figure out what it is “worth” – they understand valuation, I don’t.

Be clear about your biases

As you know all to well, dear reader, I have strongly held opinions. You should too. Be very careful to support your opinions with facts, based on data, supported by logic. Be transparent to your client.

That doesn’t mean you don’t share your views, just be clear about what they are, and on what they are based. That allows the client to assess how they should value your view on that issue.

One advantage of spending decades in a business is you just know stuff, you see things and instantly have a sense that this is BS, or wow, this is innovative, or huh, that doesn’t look right. You can’t exactly put your finger on it, but it’s there.

Your client is paying you for those decades of experience, the judgment it brings, and must know how you arrive at a conclusion, statement, or opinion. Telling the client that something just doesn’t feel right is fine – but understand they’re going to push you hard to figure out why.

Tomorrow, a couple other things I’ve learned

What does this mean for you?

It’s critical to be critical.

Jul
23

Sloooooow progress in California’s work comp system

Posted by Joe Paduda on Monday, July 23rd, 2018 | Comments

That’s the quick takeaway from a review of CWCI’s just-published report on drug prescription management in the Golden State. (there’s a lot more to this study than this…)

As cognoscenti (a fancy word for nerds) know, the utilization review (UR) and Independent Medical Review (IMR) processes were intended to help ensure patients got the drugs they needed quickly, were protected from dangerous or potentially unsafe drugs, and prescribers would learn what was likely to fly and what wasn’t.

This last was based on decades of experience in healthcare, observing what happens when evidence-based guidelines protected by utilization review processes to encourage/require compliance are put into place. In most every other instance, providers adapted their care models to meet the standards, and after a flurry of appeals at the outset, things settled down a lot.

But, well, hey, this is workers’ comp…

The first two (better care and patient safety) seem to have worked pretty well, but up till now, it appeared that WC prescribers were militant non-learners as the volume and type of UR/IMR requests just didn’t taper off.

My assessment of CWCI’s report is (equivocation alert) prescribers MAY BE changing their behavior – a wee bit. 

Here’s what’s driving my optimistic take (from CWCI):

After the formulary took effect last January, prescription drug requests declined from 44.5 percent to 40.7 percent of all UR decisions in the study sample – a relative decline of 8.5 percent.

I mean, how could one not dance in jubilation, right?

Well, perhaps prescribers have decided to not keep pushing that stone up the hill. Or perhaps it’s just a temporary hiatus.

I’m going to remain optimistic, and you should read the entire report because there’s lots of good info in it.

What does this mean for you?

Less hassle, better care. We hope.

 

Jul
12

Workers’ comp drugs – its NOT about the cost

Posted by Joe Paduda on Thursday, July 12th, 2018 | Comments

The reaction to yesterday’s news that pharmacy costs have dropped by over a billion dollars was a bit disappointing – and missed the key takeaway.

That is – we’ve made a ton of progress, and we still have a long way to go.

Instead, some asked “where are the savings going?”, claiming employers and patients aren’t benefiting from the reduced cost.

A Kansas legislator was among those positing that question; perhaps he was unaware that Kansas employer’s premiums dropped 7.6% this year. Kansas’ results mirrored the nation’s and other states:

Of course, there are many other reasons rates and premiums are dropping across the board:

  • a nine-year long economic expansion;
  • a solid job market;
  • continued decline in claim frequency and anecdotal reports of a drop in total claim counts;
  • better control of medical costs; and
  • lots of capacity in the insurance market

are the most significant contributors.

Another critic complained that “the savings are going into insurers’ pockets.” There is some truth to that, as workers’ comp insurer profits remain at near-record levels despite the continued decrease in premiums.

(Re increased benefits for patients, that is a state regulatory issue as indemnity benefits are almost all driven by a formula involving cost-of-living benchmarks)

But the key point is this – work comp has done great work eliminating opioids – and that is wonderful news by any standard.

As CompPharma’s report details, a key driver of the drop in drug costs is lower opioid utilization. That is very good news indeed; fewer patients are getting opioids, and other reports indicate dosages and treatment duration are declining as well. Moreover, the drop in opioid usage in work comp is far greater than the overall decline in drug spend, indicating we are doing a far better job than the rest of the insurance world despite the difficulties inherent in managing drug utilization in comp (no economic levers to influence consumer behavior, few states with pharmacy network direction, widely varying regulatory environments).

For fifteen years I’ve been interviewing the people most responsible for addressing the opioid crisis in work comp. While costs are important, without exception these professionals see their job as improving patient care, reducing the risks and dangers inherent in opioid prescribing, and helping patients recover quickly.

Their relentless focus is leading to healthier patients and lower costs for employers.

We have a very long way to go. While lots of work from lots of people has helped dramatically reduce the initial (or even more problematic second) opioid script, the much tougher challenge is helping long-term opioid patients reduce and end their use of the drug.

Some payers are making solid progress; you can hear from four of them at IAIABC’s annual meeting this fall. I’ll be moderating an intensive review of how these payers are successfully helping patients reduce opioid consumption and get back to being themselves.

What does this mean for you?

Congratulations on making major differences in many patients’ lives. Now the hard work begins. 

 

 

 

Jul
11

A billion dollars and better care

Posted by Joe Paduda on Wednesday, July 11th, 2018 | Comments

Work comp drug costs have dropped by over a billion dollars over the last eight years.

What’s even better news is this has been driven largely by sharply lower opioid utilization.

The bad news is there are still far too many patients suffering from Opioid Abuse Disorder brought on by massive overprescription of opioids.

Across all 29 workers’ comp payers surveyed by CompPharma, drug costs dropped almost 10 percent last year compared to 2016. (Total US drug costs decreased last year by 2.1 percent)

The results come from our annual Survey of Prescription Drug Management in Workers’ Comp, a project now in its fifteenth year.

Payers cited clinical programs as the primary driver of lower opioid and total drug spend. A key takeaway come from payers’ views of formularies:

many respondents did NOT want to abandon their internal formularies in favor of a one-size-fits-all blanket formulary. These payers noted patients are all different, their needs evolve throughout the course of treatment and recovery, and therefore their pharmacy needs would change as well. While they were in favor of managed (state-mandated) formularies for initial fills, they want flexibility to adapt to the patient’s condition and needs without putting undue burden on the prescriber and pharmacy to comply with prior authorization requirements.

The public version of the Survey Report is available here for download; respondents received a more detailed version of the Report.

As the author of the Survey, I’d be remiss if I didn’t thank the respondents who have provided data and their views and opinions over the last 15 years. Their willingness to share their insights and perspectives has gone a long way to helping improve patient care.

I’d also note that work comp Pharmacy Benefit Managers have been largely responsible for reducing employer’s drug costs and opioid overuse. Another way to put this – PBMs have dramatically reduced their revenues by improving their customers’ and patients results.

 

Jun
27

The trade “war” and workers’ comp

Posted by Joe Paduda on Wednesday, June 27th, 2018 | Comments

Responding to the European Union’s new import tariffs, Harley Davidson will be shifting some production from American factories to its plants in Brazil, India, and Thailand in an effort to keep it’s bikes affordable.

A store in Paris

Motorcycles aren’t the only US product suffering from the not-quite-yet-a-trade war. Orange juice, cranberry juice, peanut butter, bourbon, tobacco products, steel, jeans, and playing cards are among those that are incurring at least 25% import duties.

Farmers and those in the “food chain” may be the next to feel the pain. In response to Trump’s tariffs, Beijing has said that it will retaliate by imposing duties of fifteen per cent on a wide range of American foodstuffs, According to the New Yorker the products affected include: “soybeans, cashews, almonds, apricots, strawberries, and other fruits. Pork products, which are very popular in China, would be hit with a tariff of twenty-five per cent.”

Harley-Davidson’s move was driven by the European Union’s increase of import duties, aka tariffs by 25%. This was in response to President Trump’s higher import duties on certain EU products.  With the new EU tariff raising prices by an average of $2200 per bike, HD management is now eating the losses in order to keep market share in Europe until the company can ramp up production overseas; this quote from HD is from The New Yorker:

“Increasing international production to alleviate the EU tariff burden is not the company’s preference, but represents the only sustainable option to make its motorcycles accessible to customers in the EU and maintain a viable business in Europe,”

Farm products have already been hit by trade war fears; corn and soybean futures are at a two-year low. While there’s a lot driving those prices, the short-term outlook for farmers, wholesalers, farm-equipment manufacturers and others in the ag value chain are not good.

China buys over $20 billion of US agricultural products every year, and is moving to buy more from Brazil and other countries as US goods will be much more expensive with the import duties.

Our neighbor has 1300 acres of soybeans and corn, so this is pretty real to us.

One company that’s getting hit from both sides in this trade thing is John Deere. The company’s steel prices are up while future demand for its products – both here and overseas – is in doubt. According to one analyst,

Deere & Company could end up seeing years of depressed US agricultural sales, because it may take farming households years to recover financially.

So, what does this have to do with workers’ comp?

Insurers and employers are enjoying the latest in a string of really, really good years. 2017’s combined ratio was a stellar 89, the best result we’ve seen in two decades. While premiums were down marginally last year, the pre-tax operating margin hit 23 percent, a level we haven’t seen in recent memory.

All this really really good news has been driven by a nine-year long recovery, a continuation in the structural decrease in claim frequency (and likely total claims), and relatively low medical inflation.

The very strong labor market helps a lot; re-employing injured workers is a lot easier when there are lots of job openings and employers work really hard to get injured workers back on the job to meet demand.

One would do well to remember what happens when good things come to an end. Claims jump up, possibly driven by workers scared of layoffs deciding to report that nagging pain. Employers stop hiring, afraid to be stuck with lots of idle workers when demand drops off.

If the current trade conflict gets any more heated, we’re headed for a nasty trade war, one that will have deep and lasting effects on every sector from steel to transport to agriculture to tourism.

What does this mean for you?

Trade wars will hurt the economy and hammer workers’ comp insurers. Companies serving the claims sector may well see an uptick as claim frequency and claim duration increase.

 

 

Jun
21

Why we’re not solving opioid addiction

Posted by Joe Paduda on Thursday, June 21st, 2018 | Comments

The reason opioid abuse disorder (OAD) is such a huge problem is because no one’s figured out how to a) fix it while b) making a shipload of money.

Sure, there are “solutions” that address bits and pieces including:

  • urine drug testing identifies patients who aren’t taking prescribed drugs and/or are taking other licit or illicit medications;
  • Medication Assisted Therapy (MAT) can and does help many wean off opioids without going thru withdrawal;
  • inpatient or outpatient detox is essential for some OAD patients;
  • physical therapy and exercise is helpful for many; and
  • cognitive behavioral therapy (CBT) is essential for many patients.

But many patients require many of these services, while some do fine with one or two.

There is no single silver bullet.

What we aren’t doing is funding community-based treatment facilities and providers. This is essential because OAD is a long-term chronic disease, and patients need follow up and support for years.

The real issue is three-fold – treating OAD usually requires dealing with the patient’s chronic pain as well; OAD is a lifetime disorder; and every patient is different.

The terror of withdrawal coupled with the dread of chronic pain is hugely difficult to overcome. Patients are justifiably terrified of both, and this fear must be addressed throughout the treatment process. This is a long-term process likely involving different treatment modalities delivered by diverse providers.

Some patients respond to MAT, others do not. Some have family support systems, others are pretty much on their own. Some respond to PT and exercise, others are too afraid the effort will trigger a resurgence of pain. And the only way to find out what works for Patient X is to keep trying different approaches, providers, modalities until you find something that works.

No one has cracked the code, come up with a set process, solution or approach that works for most patients. Until someone figures out how to make gazillions fixing people with substance abuse disorder, I don’t expect the nation will make real progress.

That does NOT mean there aren’t real successes happening every day.

California’s State Fund is one of the leaders, delivering remarkable results through a careful, methodical approach.

Here’s the key – OAD can be a lifetime issue. Do not fear this, rather accept it as reality. It’s far easier to throw one’s hands up at the difficulty of it all rather than dig in and get going, but it’s also what led to hundreds of thousands of workers comp patients with OAD.

What does this mean for you?

Those who are in it for the long haul are going to be the difference makers.

Jun
6

What do these acquisitions mean?

Posted by Joe Paduda on Wednesday, June 6th, 2018 | Comments

Two just-announced acquisitions are an indicator of where things are in today’s work comp services world.

Tech firm Mitchell (recently bought by Stone Point (!) thanks for correcting me JT!) will acquire IME and peer review firm MCN.  Based in Seattle, privately-held MCN is one of the larger independent firms in that space, has a national network of 13,000 physician reviewers and a solid customer list. Brian Grant MD founded the company 30+ years ago and built it into a firm serving the auto, comp, and disability insurance industries.

This deal adds depth to Mitchell’s already-extensive utilization review/peer review offering, and adds cross-selling opportunities that should help the company compete with Examworks.

Strategically, the acquisition both broadens Mitchell’s non-bill review business and strengthens its offerings outside the auto casualty space, changes that lessen Mitchell’s reliance on auto and work comp review.  Given the long-term uncertainty about those businesses, the transaction makes sense – especially if the company focuses on disability, a space not subject to the impact of autonomous vehicles and the structural decline in work comp claim frequency.

One source indicates the price was in the 12x earnings range; that could not be independently verified.

In an unrelated transaction, TPA SUNZ bought case management firm Ascential Care in a deal announced on WorkCompWire this morning.  SUNZ sells high-deductible work comp plans to professional employer organizations (PEOs), staffing companies and larger employers.

I’d expect Ascential’s case management to be more tightly integrated with SUNZ’ claims management processes. Employers with loss-sensitive plans almost always buy into proactive, rapid use of clinical staff when claims arise. Getting case managers involved – when appropriate – can avoid problems and help patients feel like their employer is working to help them recover.

Ascential CEO Rich Leonardo is staying on and will continue to lead the business and SUNZ is investing in more staff to meet client needs.

Takeaway

For the umpteenth time time, workers’ comp is a very mature industry (as is auto).  Service companies looking to grow have to either:

  • take share from competitors;
  • buy other, similar businesses;
  • buy related businesses; or
  • expand into other markets.

Mitchell is growing by acquisition, adding more depth to its current medical management operation.  SUNZ is capturing more of the services delivered to current customers, thereby keeping those dollars inhouse.

What does this mean for you?

If you want to grow, see above. If that’s going to be hard to do, think about who may want to buy you.

Jun
5

BWC Ohio picks a new Pharmacy Benefit Manager

Posted by Joe Paduda on Tuesday, June 5th, 2018 | Comments

Several weeks ago Ohio’s state work comp fund – the Bureau of Workers’ Compensation – selected a new PBM to replace OptumRx.

This has me thinking more broadly about the vendor-customer relationship and how that’s evolving.

First, buyers are getting smarter. BWC’s former and current pharmacy directors (John Hanna and Nicholas Trego respectively) are not just pharmacists, they have become expert in pricing, auditing PBM transactions, understanding contracting language, and negotiations.

According to WorkCompCentral’s William Rabb, BWC learned it was paying OptumRx millions more than it should have after conducting an audit earlier this year.  Quoting Rabb:

an audit showed that the current PBM, OptumRx, failed to keep drug prices below the maximum allowable cost as required.

The audit is here.

Without getting too deep in the weeds here, allegedly OptumRx was supposed to keep generic drug prices at or below a Maximum Allowable Cost, or MAC. However, the audit indicated OptumRx failed to do that, resulting in BWC paying about $5.7 million more for generics than it should have.

Seems straightforward, but this can be hard to figure out as the list of drugs subject to MAC list pricing is often not disclosed.  That is, the PBM has a “proprietary” MAC list which it does NOT have to share with its customer.

Obviously this makes it hard for the customer to figure out if it is paying what it should.

Second, major issues don’t just pop up out of thin air; its unlikely BWC first expressed concerns a few months ago.

Moving an $84 million pharmacy program – or any big service – is no easy task; there’s a ton of systems programming to be done and tested; patients to be switched from one PBM to the new one; adjusters and case managers to train; financial arrangements to be agreed upon; pharmacies and employers to educate; and myriad other tasks.

Payers do NOT make changes unless they have no other choice due to the switching cost, potential business and patient care disruption, and internal stress involved in moving to a new PBM (or any other service type).

Service providers need to ensure that their senior managers and front-line staff understand their customer’s situation, concerns, needs, and plans.  Equally important, senior management must empower their client-facing staff, giving those staff the ability to fix problems, highlight issues, and marshal resources needed to meet clients’ needs. (I’d note that Optum’s work comp PBM recently brought Kaye Lewis back on board to run account management; Kaye is universally well-regarded and one of the best in the business; I had mistakenly said Kaye was working with OptumRx which focuses on the broader health marketplace. I regret the error. )

Third, vendors need to own up to and deliver on their commitments to all involved.  Quibbling over contractual terms, arguing over this clause or that, or word-stretching to avoid doing what the customer or the customer’s advocates need done reflects short-term, myopic thinking.

Sure, you may be “right”, but you’ll win that battle and lose the war.

What does this mean for you?

These days customers are harder and harder to come by, so when you get one, make darn sure you keep them. Listen, anticipate, deliver, and be flexible.

And most of all, meet their needs.