Insight, analysis & opinion from Joe Paduda

May
12

Medicare Set-Asides – current data says…

At the closing session at NCCI, Barry Lipton reported on their research on MSAs, research based in large part on 2200 files provided by Gould & Lamb. In 2011, CMS approved $1.1 billion of MSAs…

Key findings

  • MSA dollars account for 40% of the average proposed settlement
  • half of the MSA dollars are for prescription drugs
  • the differences between proposed and CMS-accepted MSA settlement are largely due to drugs”
  • only 20% of submissions are for claimants <50
  • 29% of submissions are for more than $300,000;
  • but, most submissions are for much lower amounts;
  • so 62% of costs are for the 29% that are for more than $200k.
  • The highest initial submission approval rate was about t50% before 12/12; during 12/12, the approval rate zoomed up to 92%.  this happened to be the same month where processing vendors changed…
  • median processing time has dropped dramatically to 41 days in Q4 2013
  • Median MSA approved amounts have been very stable at around $42,000 over the last four years.
  • recall CMS doesn’t cover off-label use of drugs, so any non-cancer claims with opioids are going to require full funding of future projected spend

The net – from my perspective, if you have an addicted claimant, CMS is going to want a lot of dollars set aside.


May
9

Work comp’ declining frequency rate – will it continue?

The geekiest part of NCCI is the research workshop that takes place after lunch on the second day – you know the people attending are committed if they are in Orlando on a Friday afternoon listening to economists…

Harry Shuford discussed the “mystery of declining claim frequency”, an oft-described trend that some believe will end at some point while others think it may continue ad infinitum.

While there has been a cynical pattern over the last 90 years, the overall decline has persisted since 1926 (using manufacturing claim rates, the only ones that go back that far).  That said, the decline steepened after 1990 and has continued to this day, and it is consisted across all states, industries, occupations, demographics, affected body parts…

Why?

Harry and his colleagues looked at a lot of factors to determine their correlation with injury rates and similar data points.  The correlation isn’t due to the decline in manufacturing in the US; the decline has happened globally and across all sectors of the economy, not just manufacturing.  

Harry then showed a graph of international work-related fatalities (across 120+ countries) which showed a similar decline trend, with a bit of leveling in the late eighties followed by a steeper decline till 2006  and an even more rapid drop after that.  On average, there’s been a 4.3% annual decline over the last 30 years.

The death rate decline also mirrored the increase in per-capita income, albeit at a lower rate (3.6%).

And it was, if not entirely consistent, at least similar across geographic regions.

Net – two drivers: time, perhaps driven by pressures to improve productivity; and as a country gets wealthier, there’s a decline in the injury rate.

The takeaway – the trend has been in place for 80 years (at least) and will very likely continue into the future.

What does this mean for you?

Frequency will continue to decline.

 


May
9

NCCI – Work comp legislative and regulatory trends

The last session on Thursday focused on regulatory and legislative trends  – primarily focused on state issues.  There’s also a session on the impact of ACA on work comp; that’s something I’ve spent far too much time on – that and the fact that lead speaker Mark Walls just looks fabulous after his make-up session in the green room has me in the reg/leg session.

Mark did spend a bit of time on ACA, citing concerns and issues including that unicorn of workers’ comp; the oft-described but never adequately documented “Monday morning injuries”; that employers are increasing deductibles and copays as a result of ACA; that he doesn’t believe that people with insurance are healthier than those without; and that a lot of people still aren’t covered.

Much as I like Mark, I have to disagree with him on most of these issues.  For reasons why, see here, here, and here.

Mark also touched on issues as diverse as unionization among Division 1 athletes, medical marijuana, opt out, and the potential need to change the basis for premium calculation from payroll basis to risk class.

He made a pretty compelling case for consideration of the latter, noting that this would reflect the changing way many employees are compensated and not penalize companies for seeking to pay higher performers more – and differently.

Lori Lovgren and Ann Bok followed Mark with the top five issues in work comp.

One of the more interesting is their work in estimating the potential impact of regulatory or legislative changes on work comp premium rates.  They get these requests from a variety of stakeholders in many states; an example was their estimate that eliminating physician dispensing up charges in FL would reduce costs by about a percentage point.

Don’t expect to see much in the way of legislated change this year as it is an election year, and elected reps won’t want to upset constituents while they are campaigning. That said, the potential issues NCCI is seeing include:

  • changes to reimbursement and fee schedules
  • medical cost containment e.g. employee choice of physician
  • benefit changes
  • claims administration issues

Among the rate changes coming are several rather significant ones:

  • Missouri – 11.6% increase
  • Hawaii – 6.2% increase
  • Virginia – 4.1% increase
  • Oklahoma – 14.6% decrease
  • West Virginia – 8.9% decrease
  • SD, KY, ME, and IN – decreases around 8%

 


May
8

Bob Hartwig – drinking from the firehose

The always-entertaining and enlightening Bob Hartwig of the Insurance Information Institute was next on the podium – he violates a bunch of “presenting rules” (chiefly talking really fast) and is thereby proof that you can be a very good and very effective presenter by doing what works for you.

His view is historical trends indicate we are a few years away from a return to the bottom side of the insurance cycle.  I hope that’s true, but I’m less sanguine.

On the overall economy, he’s predicting growth of around 3% in GDP over the next few years along with a drop in the unemployment rate to below 6 percent (possibly) before the end of the year.  That would be good news – for work comp – indeed especially as it comes on top of the addition of over 9 million jobs since April 2010 (even more in the private sector).

Other good news:

  • hours worked per week are up to almost pre-recession levels
  • average hour day continues to slowly increase, it’s up 14.4 percent since the beginning of the recession.

Growth is going to come in high-frequency industries; construction manufacturing and energy will be big drivers. Construction employment alone is up 565k since January of 2011; we’re still over 1.6 million jobs down from the height just before the crash, altho that was a bubble-driven number.

Manufacturing employment is up 640,000, and those workers are making more stuff than just before the recession, even though there are fewer of them.  That means productivity is higher.

Of course, health care employment is up dramatically as well, and will grow faster than any other sector – adding 3 million new jobs over the next 8 years.  Energy exploration, production and transport will be another big driver.  Employment in this sector is higher than any time in the last 28 years and is going to increase even more.

The net?  Lots more employment in high wage sectors are ‘unambiguous positives for the workers comp sector.”


May
8

The 2013 workers’ comp State of the Line

With long-time top actuary Dennis Mealy’s retirement, NCCI tabbed Kathy Antonello to fill his very big shoes.

On a personal and professional note, it is GREAT to see a woman in a historically-male profession in such a prominent role (says the father of two professional women).

The public introduction of Ms Antonello to the work comp industry is happening now with her presentation on the State of the Line, perhaps the most-anticipated report in the industry.  Here are a few of the highlights:

  • Total P&C premiums for 2013 were up 4.6 percent.
  • The P&C 2013 combined ratio was 96%, a decline of 12 points from 2011 and 10 from the 1985 – 2012 average.
  • Work Comp premium was up 5.4% – $2.3 billion over 2012 and over $8 billion (almost a third) from the low point in 2010.
  • Work comp’s operating gain shot up to 14 percent, a huge jump from last year’s 5.6% and far above 5.3 percent – the average over the last 23 years.

Ms Antonello got into a lot of detail about various components, ALAE, ULAE, various margin calculations, and premium drivers, and did so with humor and polish.  Among the key drivers employment is perhaps the most important.  I’ll leave the rest of the details to those who want to download the full presentation. (available at no charge, registration is free as well)

She also provided a view into some cool new data visualization tools NCCI has developed, tools that help explain trends over time and the impact of various factors.

So here’s the $64 billion question – is a soft market nearing?  Will some see these strong results as a reason to double-down on work comp, write as much business as possible in as many states as possible, and thereby start a decline in effective premium rates?

States such as California, Arizona, Colorado, New Jersey, Florida, and Connecticut – where premiums grew by double digits – may be especially attractive to new entrants and some current writers.  

Add to those factors the news that premium rates approved for 2014 increased less than a point, and a report from Goldman Sachs that work comp premium increases are moderating, and the likelihood of a softer market looks a little higher.

What does this mean for you?

The work comp industry has never been unable to enjoy success for very long.  Just as we are starting to see daylight, there are some potentially-troubling indications that the market may soften.


May
8

The work comp outlook is…balanced

That’s the one-word synopsis of the state of the line from this year’s NCCI conference.

I’d be a bit more positive; especially because the combined ratio is down 7 points to 101.

Premiums up for the third year running, and claim frequency continues a long-term decline with another 2 point drop in 2013.  

NCCI indicates medical costs have grown at a rate of 3 percent.

Even investment income is still robust at 14 percent. The result – operating margins are improved as well.

With the latest news indicating employment growth is accelerating after a long winter, the issues identified by NCCI as problematic, namely lagging employment, the potential non-renewal of TRIA, and the potential impact of the PPACA look like pretty small potatoes compared to all the good news.

In his kick-off presentation, NCCI CEO Steve Klingel took pains to note the statistics are national, and individual carrier experience varies quite a bit due to their reserving practices, the states they write work comp, mix of business and other factors.

Klingel noted RAND’s just-released report on TRIA makes a strong case for renewal of the Terrorism Risk Insurance Act; he also opined that state-specific judicial determinations can and will have significant impact on work comp.

Mr Klingel also delved into issues surrounding Big Data, data security, and the impact thereof.

If you aren’t here, you’re one of the few.  The place is packed.


May
7

Insurance saves lives and costs money – and we’re surprised?

That’s the finding of a massive study of the impact of health reform on mortality rates in Massachusetts.  The death rate declined by 3 percent after universal coverage went into effect in 2006, and the carefully-constructed study found that the decline was mostly among the poor.

By any measure, that’s a huge win.

For the green-eyeshade folks, a decline in death rates means more productive years for more people leading to more economic production, altho they’d balance that against the costs of caring for those folks. For those of us who are a bit more “human”, it is even better – longer lives for more people means more time with our loved ones.

Juxtaposed against that finding is the increasing evidence that health care costs are going up.  That’s no surprise; a lot more people have coverage and they are using health care services.  The early indicator comes from pharmacy utilization; giant PBM Express Scripts reports there are more scripts going out these days and some of this MAY be due to more coverage, altho this is expected coming out of a recession as well. There appear to be more hospital admissions as well (again not surprising; people who didn’t have insurance couldn’t get knee/hip replacements and now that they have insurance they’re lining up to get those things fixed).

Notably, utilization, not prices, is by far the biggest inflation driver.

In total the VERY EARLY data suggests consumer purchases of health services was up almost 10 percent in Q1 2014.

That said, it would be hard to find anyone  – at least anyone who gets math – who didn’t think health care costs would go up as more folks are covered.  In fact, projections way back in 2009 called for just such a bump.

So there you have it.  People who get insurance who didn’t have it use a lot of health care services.  Longer lives are associated with higher health care costs.

At least for now.

I’d hazard a guess that health plans are working their collective fannies off to hold down costs and thereby remain competitive in the battle for members.  A safe guess, as all the news I’ve seen indicates this is precisely what’s happening.

What does this mean for you?

The free market – a well- and intelligently-regulated one – will deliver better outcomes at lower cost.  And that’s exactly what PPACA is supposed to do.

 

 


May
6

Xerox’ acquisition of Stratacare and Bunch; done deal

Minutes ago, Xerox officially announced it is acquiring ISG Holdings, parent of Stratacare and Bunch, for $225 million.

In its announcement, Xerox claimed that the company is now the “leading provider” of work comp bill review services; that looks like a reasonable claim as the combined entity processes around 23 million bills via outsourced bill review and SaaS (where the payer does the actual processing using Xerox’ application).  There’s no question adding Stratacare to the company’s current CompIQ platform makes it a much more formidable competitor.

It also further consolidates a business in dire need of consolidation.  There are now four significant players; mcmc, Medata, Mitchell, and Xerox.  (what’s with all the “M” names??)

(I don’t include Coventry in the mix as their BR 4.0 application is rapidly approaching obsolescence.)

As I noted last week, “While Xerox will now own two platforms, I’m thinking we will see current CompIQ customers converted to Stratacare.  CompIQ has not been having all that much success of late, so this may well rejuvenate what was becoming an also-ran in the bill review space.” I’d add that it makes no sense for X to continue to support two applications, however they will have to do so until their contractual obligations expire, and perhaps a bit longer if customers demands are firm enough.

Xerox is reaching out to customers today, and my educated guess is they are discussing:

  • if and when customers can expect to be converted to one or the other platforms;
  • other benefits that X can bring to the party, such as document management and off-shore processing;
  • staffing and account service plans, although it is likely too early to say anything definitive, so expect something along the lines of “business as usual”.

What I find interesting about this is Xerox’ decision to not only stay in the work comp service business, but to invest a couple hundred million now, and likely millions more in transition costs.  It makes sense; comp is an industry crying out for automation and streamlining of business processes, which is precisely what Xerox does.  There’s a lot of opportunity, especially when comparing work comp to other health-related businesses such as insurance, Medicaid, and Medicare.

Xerox can take much of what it learned there and use it to strip cost and inefficiencies out of work comp – and we all know there’s a LOT of both.  We’ll see how this develops, and if  they really make a push in this sector or are content to just muddle along.  I’d bet they make the push…

I’d be remiss if I didn’t touch on Bunch.  What used to be a leading light in the managed care space has dimmed appreciably.  The purchase by ISG some years back was puzzling, and the rationale didn’t get any clearer as time went on.  Bunch has lost business in its target market and failed to replace those lost customers with new ones.  I just don’t get why they bought Bunch; there may well have been some sound strategic reason, but the follow-thru was noticeably absent.

What does this mean for you?

Wait and see.  The next couple of months will tell the tale; as always actions are credible, words are (much) less so.


May
5

When it comes to understanding how the ACA will affect your business, you have to separate the politics from the practical.

In this case, remember that “Politics are national; health care is local.”

The pundits (and I’d have to include myself in this category at times, altho I’m an amateur at best) use the national enrollment numbers to declare victory or defeat. That’s fine for a parlor exercise, but practically, the national data matters not one whit for health plans, providers, and work comp payers.

No, for business folks, what matters is what’s happened/happening in their state, and more precisely their operating area. In some states (Vermont – 280% of projections, California, Michigan, North Carolina – 155%), enrollment is robust.  In others (Ohio, Arkansas, West Virginia) enrollment is well under projections.

Medicaid expansion, state-based exchange success or failure, and the political environment greatly affected enrollment; politicians in some states actively discouraged/tried to prevent ACA enrollment while in others the exchange was a mess (e.g. Oregon).

Regardless, the higher the enrollment, the more likely you will see ACA impact;

  • the health care provider community,
  • adoption of different care delivery and reimbursement models,
  • more or less incentive to cost shift to work comp,
  • and access to key specialists.

Current state-specific enrollment data is here.

What does this mean for you?

Depends on where you do business…


Joe Paduda is the principal of Health Strategy Associates

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A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.

 

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