Insight, analysis & opinion from Joe Paduda

Mar
17

Three-legged horses can’t run

Posted by Joe Paduda on Friday, March 17th, 2017 | Comments

If you cut a leg off your horse, it’s not going to run far or fast.  If you cut two legs off, it’s going to fall over.  And if someone else cut your horse’s legs off, you wouldn’t help them fix their horse.

Common sense, right?

So why is Paul Ryan et al complaining about ACA?

He and his fellow Republicans chopped not one, but two legs off that horse, and now they scream loud and long that that horse won’t run, so they need to shoot it and replace it with…what?

I bring this to your attention because it explains why there’s so much reluctance on the part of Democrats to work with their Republican colleagues on an ACA replacement. Put bluntly, Congressional Dems believe they got screwed and are really pissed off about that. So pissed off that they are more than happy to let the Republicans shoot themselves in the head all by themselves.

Here’s a quick summary of steps Republicans took that harmed ACA. (more here; a LOT more here)

  • Removed funding for risk corridors which kept co-ops and other plans alive
  • Didn’t expand Medicaid in 17 states
  • Hobbled ACA marketing efforts in multiple states
  • Sued the Obama Administration to block premium supports

I’ll leave aside the things the GOP could have done to help fix ACA, common sense stuff such as:

  • increasing the penalty for not carrying insurance to levels originally recommended by the Heritage Foundation,
  • fixing the “family glitch”
  • require insurers to operate in broad areas so they don’t cherry-pick only the most profitable locations, and
  • requiring full transparency from all medical providers.

If they had, ACA would be operating a lot better today, but Sen McConnell, Speaker Ryan et al weren’t interested in fixing ACA.  (In contrast, Democrats helped fix G W Bush and the GOP’s Medicare Part D plan when it was cratering)

The result of the Republicans’ successful efforts to hamstring ACA were made public earlier this week when President Trump did a photo op with several “Obamacare victims” including a Colorado woman who claimed her health insurance costs had tripled under ACA (note there’s no independent corroboration of her claim). Ms Couey said she’d had to switch insurers multiple times – while there’s no detail on this, it is likely more than one of her previous insurers went belly-up for one of several reasons.

(Warning, this gets pretty wonky) A big reason for Ms Couey’s issues – ACA had provisions specifically designed to help new insurers develop, grow, and become viable competitors – in local markets – in an industry dominated by behemoths. These provisions included “risk corridors”; financial vehicles designed to help health insurers entering markets by offsetting initial losses by transferring profits from their wealthier competitors.

The idea was to force competition into and help sustain that competition in a market where size is all that matters, where it is all but impossible for new, entrepreneurial competitors to start, much less succeed.

Those provisions disappeared, killed off by a Congress ostensibly interested in the competition and the free market.  Specifically, Sen Marco Rubio inserted the clause in the Cromnibus bill that prevented the Feds from moving money around to cover the Co-Ops’ losses in 2014.

Let’s remember that the risk corridor payments were to be budget neutral over the three year lifespan of the program.  The Rubio amendment (Section 227) forced CMS to shift that to a “pay as you go” model.

What does this mean for you?

If someone had chopped the legs off your horse, would you be eager to help them fix their’s? 

 

Mar
16

Health reform and Work Comp – more data is coming in

Posted by Joe Paduda on Thursday, March 16th, 2017 | Comments

The evidence is piling up; ACA is strongly associated with lower work comp premiums. Almost a year ago I attributed improvements in work comp’s medical expense trend to ACA; now, the impact is being seen in improving combined ratios particularly in states that fully adopted ACA’s reforms. (here’s a map of Medicaid-expansion states)

That view is now getting traction outside our little world, with the LA Times covering the issue earlier this week.

Premium decreases are now being seen in Medicaid-expansion states; here are a few examples.

  • Arkansas – 8.4% decrease
  • Michigan – 9.3% decrease in advisory rate
  • Montana – 7.8% decrease in loss costs
  • Nevada – 10.7% decrease in loss costs
  • Oregon – 5.3 % decrease
  • Vermont – 7.9% decrease

(I’ve purposely left out California, which has seen significant rate decreases however other factors beyond ACA are also affecting rates)

Of course, other factors are also in play here, including expanding employment and state-specific reforms. However, when you compare “ACA adopting states” with other states, the overall picture is compelling.

Bill Wilt of Assured Research kindly offered the following observations (more information is available here):

Assured Comment: American Health Care Act (AHCA) Likely Bad for WC Insurers

New 2016 data shows states maximally affected by ObamaCare outperformed WC industry

Newswires are on fire with analysis of the AHCA and its impact on the nation’s medically insured. Advocates point to the CBO’s estimate that it could reduce federal deficits by $337 billion over the ten years 2017-2026. Detractors, and there are many, focus on the CBO’s estimate that some 14 million Americans could lose healthcare coverage by 2021; climbing to 24 million by 2026.

New, 2016 industry data shows that the workers’ compensation loss ratio in states maximally affected by the rollout of the ACA (aka ObamaCare) have begun to outperform states minimally impacted by the ACA (see nearby figure). Our delineation stems from a recent New England Journal study which found that states expanding Medicaid and those introducing state-based exchanges saw the largest increase in the medically insured. In 2016, the WC loss ratios in those 18 states outperformed the 15 minimally impacted states by 440 basis points. The maximally-affected states also outperformed nationwide averages in 2016.

This new data comports with intuition and, increasingly, the anecdotes we pick up from industry sources. The ACA has likely been a contributing factor to the favorable trend in WC loss ratios. The evidence is significant: steadily declining WC loss ratios during the ACA-years, historically low medical inflation and favorable WC loss-reserve development. Most industry experts believe the expansion of the medically insured has resulted in less case shifting and less cost shifting (e.g., fewer fraudulent claims and comorbidities treated under WC).

The AHCA, in its current form, should have the opposite affect; it seems likely to lead to more WC claims and cost shifting – rising loss ratios. The nearly complete unwinding of the expansion in medically insured could accelerate cost-shifting, in turn putting pressure on WC loss trends and reserve margins. The initial wave of newly uninsured (14 million by 2018 according to the CBO) would result from the repeal of the individual mandate. We don’t have an estimate of the working population in that cohort but presume it’s meaningful. The second wave of newly uninsured (another 10 million) would result from changes in Medicaid enrollment. According to WC experts (link here to one prominent blog) some 81% of Medicaid families have at least one member of their family working. That presents plenty of cost-shifting opportunities.

We’d expect the negative impacts of the AHCA, if rolled out in its current form, would first appear in the states benefitting the most from the Affordable Care Act. Large states including California and New York are among the 18 included in our figure above – contact us for a complete listing.

WC rates across the nation have begun to decline – evidence that WC insurers discount favorable trends into their ratemaking. Regulators will probably have little tolerance for preemptive rate increases based on this evidence, but it will be interesting to see if the pace of rate decreases slow. If not, WC loss ratios will have almost surely found their bottom in 2016.

What does this mean for you?

Repealing ACA will be bad news for work comp premium payers, good news for service entities.

Mar
15

It’s about healthcare costs, NOT insurance premiums

Posted by Joe Paduda on Wednesday, March 15th, 2017 | Comments

What’s missing from the debate about AHCA and ACA is any discussion about what’s making premiums so damn expensive.  We are arguing over what we pay, not what we’re paying for.

That makes zero sense.

AHCA makes older folks pay more, and lets younger people pay less for health insurance. But it’s a zero-sum game; all of us are going to pay, we’re just arguing over who pays how much.

That’s not to say ACA was much better at “bending the cost curve”. Most real efforts (excepting Medicare physician reimbursement changes) were taken off the table during the negotiation process, so we were left with ACOs, medical homes, outcomes research, and “death panels” instead of:

  • federal drug price negotiation,
  • re-importation of meds from Canada,
  • requirements that new procedures demonstrate higher efficacy and lower cost,
  • stringent controls on medical devices, and
  • publication of prices and outcomes by provider.

ACA was – and is – an attempt to get insurers to compete for customers by lowering the cost of care. Some – Centene, Molina, Fidelis, and a few others – are succeeding, but the big commercial plans are mostly failing, resorting to hoary old “cost containment” techniques such as higher deductibles and copays instead of real innovation and effective branding and marketing.

This is especially striking as healthcare outcomes in the US are pretty awful, and research clearly proves spending more on physician care does NOT produce better outcomes. In fact, all credible research indicates the US lags well behind other developed countries in terms of health outcomes.

Link between health spending and life expectancy_ US is an outlier – Our World In Data

We pay more – a lot more – for health care than other countries.

So, here’s the solution – but one our politicians won’t pursue because they can’t afford to piss off the healthcare lobbying industry.

Cut what we pay for medical care, drugs, facilities and other services, and reduce the volume of services we pay for.

What does this mean for you?

Medical care drives premiums, and if we don’t deal with medical care, we’ll never control what you and I pay for insurance and taxes.

 

 

Mar
14

AHCA, CBO, and Workers’ Comp

Posted by Joe Paduda on Tuesday, March 14th, 2017 | Comments

There’s lots of news out there about the Congressional Budget Office’s scoring of the Republican healthcare reform bill known as AHCA; we’ll narrowly focus on what passage of AHCA would mean for workers’ comp – and highlight what’s missing from every other analysis of the CBO report.

Briefly, I’d expect case-shifting and claims-shifting to workers comp to increase significantly, resulting in higher work comp expenses for employers, and more business for the work comp service industry.

Here’s why.

The expansion of Medicaid and the individual mandate covered about 13 million more workers than pre-ACA; 81% of Medicaid recipients’ families have at least one member working. When workers who have health insurance get hurt, they are less motivated to claim it was on the job. And, if they are hurt on the job, work comp doesn’t have to pay for non-occupational medical conditions (e.g. dealing with hypertension before doing surgery).

The newly insureds are also working in jobs with higher claim frequency than average.

Some argue that the high deductibles and copays common in some insurance plans negates my argument; I respectfully disagree.  That’s because the newly insureds are poorer than average, thus they are much more likely to either:

  • get premium support payments from ACA which also cover deductibles and copays or
  • be covered by Medicaid, which has no cost-sharing (except in Indiana).

Since ACA was fully implemented in 2014 we’ve seen historically-low work comp medical trend rates, a strong indication that ACA is a major factor in lower work comp costs.

The CBO has projected:

  • 14 million will lose health insurance next year
  • 7 million more by 2020
  • another 5 million will lose coverage by 2026
  • most of those losing coverage would be older
  • deductibles and copays would be higher than under ACA

(credit Washington Post)

All of these projections are bad for work comp; older workers’ injuries are more expensive, and the higher deductibles and copays, along with a big drop in Medicaid coverage, would financially motivate workers to “claim shift.”

(credit Washington Post)

So, those losing health insurance would be:

  • much older
  • more likely to be employed in higher-risk jobs
  • more likely to be currently covered by Medicaid

What’s missing

…from all of the press reports and analyses of the CBO report is a discussion of how providers would react to passage of AHCA. That’s in part because the CBO report (full copy here) doesn’t address the issue.

Insurance coverage is just part of the story; doctors, hospitals, pharma and other providers are going to be hugely affected by a big decrease in their customer base.

More on that tomorrow.

What does this mean for you?

For work comp payers, higher claims and higher medical bills.

 

Mar
13

Are you the frog in the pot?

Posted by Joe Paduda on Monday, March 13th, 2017 | Comments

At some point the frog figures out the water is getting too hot – but by then the heat has sapped so much of its strength that it can’t escape. It’s morbidly funny – except if you’re the frog.

Our economy is changing so rapidly, many businesses, “thought leaders”, regulators, legislators, and other actors are going to be shocked when they find their long-held beliefs – and the businesses based on them – are no longer valid.

More succinctly, ignorance kills, and there’s a LOT of ignorance out there.

How much of your business relies on blue-collar employment? If you are a work comp insurer, case management company, adjusting firm, or loss prevention entity, likely a lot.

If you are a worker in that business, times are changing rapidly indeed.

If you had a job laying communications cables, wireless technology killed it. If you bolted pipes together in an oilfield, a machine can do it faster better cheaper – and with no injury risk. If you inspected pipes to look for possible weak spots, a robot can do that way more effectively and efficiently than you can. If you analyzed data in the field to figure out precisely where to drill to find possible natural gas reserves, a computer is about to replace you.

Oil rigs are increasingly automated. Even if we continue on this disastrous push to increase use of carbon-based energy, it isn’t going to do much to help blue-collar workers. Rigs that used to need 20 workers now do just fine with 5. One Texas oil producer added over 200 new wells – without hiring a single additional worker.

Coal production is falling because natural gas is much cheaper and easier to use – but coal mining jobs are disappearing largely because of automation.  Studies indicate 40% – 80% of mining jobs are at risk due to automation.

I’ve posted before about the coming demise of the long-haul trucker, one of the few blue-collar jobs that still provides something close to middle-class pay and benefits.

And don’t think those workers are going to jump industries and become construction workers.  Even if Congress and the President are able to pass a huge infrastructure bill, there will be fewer jobs than you might expect.  Even construction is being automated…

Think these guys and gals are likely to get hurt?

What does this mean for you?

How far out is your business forecast, exit plan, or “equity event”?

 

Mar
10

WCRI 2017 – California’s outcomes post reform, and plans for the next round of reform

Posted by Joe Paduda on Friday, March 10th, 2017 | Comments

One last post on last week’s excellent WCRI conference; Alex Swedlow CEO of CWCI provided a brief but information-rich profile of California – an Altered State.

The good news…

  • Medical trend has flattened
  • Fewer spine surgeries
  • Fewer Opioid scripts
  • $1.3 billion in system wide savings

One problem that seems almost specific to California – cumulative trauma claims. These claims are particularly problematic in the LA county area – and are outliers in terms of disability duration, cost, indemnity payments.  Moreover, cumulative injury cost are driven by LA county AND attorney involvement.

Medical treatment costs have been essentially flat for five years – due in large part to adoption of an RBRVS-based fee schedule.

The FBI’s involvement in tracking down miscreants in the spinal surgery industry may have been helpful in reducing overutilization of that much-criticized procedure.

Opioid spend has declined for the 5th consecutive year – kudos to the work comp PBM and payers who’ve done this. There’s also been a 26% decrease in cumulative MED over the first two years of the average claim.

This is very good news.

But, as Alex noted, we’ve only moved from the disastrous to the miserable, as opioid use is still far too high.

Overall, while a reduction of 8 percent in medical trend is welcome news, this happened before in the previous attempt to reform California work comp.  After an initial similar reduction, costs zoomed up, necessitating more reform.  So, while Alex is hopeful that trends are positive, he is wary indeed.

A few more key data points

Loss Adjustment Expense is just about equal to indemnity payments and is the highest across almost any comparison group.  And, this expense load has increased dramatically over the last couple of years. Medical cost containment expenses are a big part of this; the data presented was preliminary and thus can’t be cited yet but suffice it to say that costs account for a huge portion of overall medical expense.

Drugs

Rx spend accounts for 12.4% of medical spend but average expense for first 24 months after a claim is incurred is just under $2000 – this has decreased over the last few years.

A formulary is in the offing and it looks like the go-live date of July 1 2017 will happen. While the intent is to improve care and reduce cost, there will have to be strict enforcement for the hoped-for results to actually become real. One of the key issues unresolved is the formulary doesn’t address the difference in the price per pill of identical drugs – the variation can be wide indeed. This is an area that regulators have been focused on, yet none of the current solutions – change in fee schedule or adoption of a formulary – has addressed.

IMR and UR

Only 4.3 percent of medical care sought by treating providers was modified or denied, refuting claims made by other media outlets that there was wholesale rejection and denial of needed care thru the IMR process. Fortunately 99.4% of compound drug rejections were upheld – and over 90% of opioid denials.

What does this mean for you?

Things are getting better in California, but some of the “solutions” offered by regulators are misguided and will actually increase frictional costs. I’m going to dive into this in a post next week.

Mar
9

ACA Deathwatch: Republicans should hope AHCA doesn’t pass

Posted by Joe Paduda on Thursday, March 9th, 2017 | Comments

I’ll stipulate to this – ACA needs major fixing. See below, and multiple past posts, for my take on what’s needed.  Unfortunately that doesn’t look likely.  The internecine warfare among Republicans over the American Health Care Act was inevitable, and will not be easily resolved.

That’s because there’s no consensus among Congressional Republicans on what healthcare reform should look like, who should pay for it, or what the priorities should be – access, coverage, cost control, less government intrusion, lower taxes, budget deficits are all in play, and many conflict. There’s also palpable and well-justified fear of the conservative infrastructure, a force including media outlets, think tanks, consultants, donors, and fringe groups that is extremely vocal, very powerful, and critical to the political future of individual Republicans.

Outside the reliably Republican world there is even more danger lurking.

What’s not being reported is this – If AHCA passes, the Republicans are in deep trouble.  10 – 15 million Americans will lose coverage (and loss aversion is powerful indeed).  Insurers will drop out of many markets overnight.  Hospitals, especially in rural America, will get crushed due to lower reimbursement and higher bad debt. Trump voters who believed him when he said he’s lower costs and improve insurance are going to be disappointed indeed. Deficits will go up.

Thus Republicans are in a can’t win situation; they have to deliver on impossible campaign promises, and if they do, voters will blame them for loss of coverage, higher prices, and anything and everything related to healthcare.

While Republicans battle amongst themselves, the medical provider community – AMA, AHA, American Nurses Association – just about every national interest group has come out firmly against AHCA. Insurance companies are warily walking the fence, not willing to provoke a tweetstorm but concerned indeed that AHCA will pass and their risk pools will crater. Seniors are up in arms, outraged that they’d have to pay more (!) for insurance if younger people don’t subsidize their needs.

There is a possible compromise bill, Cassidy Collins does offer some hope as it would likely garner support from both sides of the aisle if it gets any attention – and a lot of modification along the way.  But that is a very big “if”.

While all have different and specific issues, the net is this: AHCA will not lower the cost of care, and will increase the number of Americans without health insurance by at least 10 to 15 million people at the outset.

If AHCA passes, that number will inevitably increase as insurers’ risk pools experience worsens when fewer young people enroll, driving up costs for older folks. The death spiral in the individual markets will accelerate until…something happens.

There’s no question ACA needs fixing.

  • An excellent start would be to re-fund the risk corridor program killed by Sen Rubio in 2015 when he was able to force thru defunding of risk adjustment in the budget agreement.
  • Adding a public option to markets with limited choice would provide an insurance backstop, much like residual markets in workers’ comp.
  • Increasing the penalties for failing to carry insurance is another wise step.
  • Replacing deductibles with co-insurance requirements would help ensure people could afford the care they need while making sure the high-utilizers think long and hard about their medical care.
  • Requiring all to take greater responsibility for personal behaviors that increase health risks should be front and center. Obesity, substance abuse, medication adherence and failure to utilize preventive medicine should all be addressed

The intractable problem is cost. AHCA focuses on insurance markets, subsidies, eligibility, and credits.  It does nothing to address what drives cost – the massive waste due to unnecessary care and inflated prices for drugs, services, devices.

What does this mean for you?

AHCA won’t pass, a fate Republicans should be forever grateful for.

 

Mar
8

WCRI – What’s happening with medical?

Posted by Joe Paduda on Wednesday, March 8th, 2017 | Comments

Hospitals are losing work comp share. You would think that’s good news as non-hospital care is much cheaper.  But that may well be wrong. 

The hospital info was the headline from Carol Telles’ kickoff presentation Friday morning at WCRI’s Annual Conference. Workers’ comp patients are using less inpatient hospital care AND care is moving from hospital facilities to ambulatory surgery centers.

This isn’t specific to work comp.  Care has been moving from inpatient to outpatient to non-hospital facilities for decades.  Way back in the eighties – when I started my career in what was then known as “cost containment” – the big effort was to reduce hospital length of stay and admission rates. Over the last thirty (gulp!) years we’ve seen massive shifts in the location of care, as procedures that once HAD to be done on an inpatient basis – think back surgery – moved to outpatient facilities.

The result – outpatient/ambulatory facility use for all payers grew dramatically over the last 30 years, while inpatient admissions actually decreased over that period. This despite the aging and fattening of America.

For work comp patients, this trend persisted across all states – but this did NOT result in lower cost. In fact while the decrease in inpatient admissions was in the low single digits, costs per admit increased on average 24%. This makes sense. As providers and payers have moved patients to outpatient locations, only the sickest and most risky patients have required inpatient treatment. Unlike ambulatory surgery centers, hospitals have a broad array of emergency and life support resources needed.

Not surprisingly, hospitals are pretty unhappy about this. They are losing healthy, easy, well-insured patients to doctor-owned facilities, but get to keep treating the risky, low-health-status Medicaid and uninsured patients. Over the years, hospitals’ patient population has gotten more expensive to care for and less likely to have good outcomes.

What this means for workers’ comp

To fight back, hospitals are getting much better at revenue maximization.

In English, that means they get as much revenue from vulnerable payers as possible to offset lower reimbursement for unprofitable patients. And you, work comp payer, are about as vulnerable as it gets.

While fee schedules in some states (Maryland for example) generally protect work comp payers, most states’ fee schedules ensure work comp is very lucrative indeed for hospitals.

And no, your PPO isn’t helping.

Work comp PPO discounts may look ok, but the actual cost of treatment has been ballooning in many states. Payers THINK they are doing fine when they see the “savings” below fee schedule, but many aren’t focused on the real problem – how much they are paying.

What can you do about this?

Direct care to providers that deliver the best value, defined as cost divided by quality.

 

 

Mar
7

ACA Deathwatch – (some) Republicans reveal their bill

Posted by Joe Paduda on Tuesday, March 7th, 2017 | Comments

Good morning all – it’s going to be a busy day in health reform land – so here’s the latest.

Republicans have released their long-secret healthcare plans; don’t get all excited as it’s going nowhere, mostly because Congressional Republicans aren’t all behind it.

This legislation will have to pass the House and Senate.  It will not pass the Senate as is, because four Republican Senators have publicly stated they will not vote for the bill due to concerns over Medicaid coverage.  Three other Republican Senators have expressed concern with the cost of the bill, and appear reluctant to vote in favor.

For the bill to pass, at least 7 Democrats would have to get behind it- which is highly unlikely.

Republicans will not ask CBO to score the bill – thus we don’t know what the impact on federal deficits would be.  There’s also no estimate of how many would gain or lose insurance.

And, Freedom Caucus members in the House are denigrating the bill as “Obamacare Lite”, demanding a “clean repeal” instead of a replacement.

So, this is mostly an academic exercise, but does provide a starting point for the GOP.  Here are the key points from the bills, with my quick take appended:

  • Eliminates subsidies, replacing them with age-based tax credits ranging from $2000 to $4000
    MCM – this does little to help lower-income Americans; the current subsidies haven’t been enough to drive participation, so these lower amounts won’t do much.  Also, these aren’t income-based, so it amounts to a giveaway to wealthier Americans who don’t need the subsidy. UPDATE – late change to the bill adds income levels that would change credits.
  • Eliminates premium-support and deductible/copay funding 
    MCM – these subsidies help poorer Americans pay for deductibles; eliminating them is a major concern of insurers, and several insurers have said they will immediately move to end coverage without the subsidies
  • Roll back Medicaid expansion, capping payments to states
    MCM – Anathema to many GOP Governors and several Senators from expansion states.
  • Delays the Cadillac Tax
    MCM – this would reduce tax receipts, leading to higher deficits
  • Ends most of tax provisions of ACA, reducing taxes to wealthiest Americans
    MCM – this will result in higher federal deficits, a key issue with at least three R Senators
  • Eliminates the individual mandate requirement and tax penalties for failure to maintain coverage
    MCM – this would likely reduce the number of young members who subsidize older and sicker people, leading to higher costs for older members.
  • Requires people to maintain coverage or be subject to a 30 percent penalty.
    MCM – Many would likely face this penalty as 24%+ of people 26-64 have a pre-existing condition, and those who lose employer-based coverage would have a tough time paying the entire premium themselves without a job
  • Ends all federal funds to Planned Parenthood
    This troubles some Republicans as PP provides a lot of healthcare to lower-income women.

The legislation is exposing splits among and between Republicans on ACA and health reform.  Republicans opposed ACA, but for diverse reasons; costs too high, mandate, tax provisions, Planned Parenthood.

But there is no unity around a solution.  It’s easy to rally opposition to a complex issue; many Democrats have been pointing out problems with ACA for years. It’s far harder to come up with a new solution because everyone has different priorities and ideologies.

What does this mean for you?

The ACA Deathwatch clock moved forward a bit – but not much…

Joe Paduda is the principal of Health Strategy Associates

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