Insight, analysis & opinion from Joe Paduda

Feb
18

Medicaid expansion will…expand.

Posted by Joe Paduda on Monday, February 18th, 2013 | Comments

As governors look more closely at the benefits – and costs (political and financial) of the Medicaid expansion slated to begin next January, more and more are deciding it isn’t such a bad thing after all.  Ohio’s governor has been pushing his supporters in this direction for some time, and Gov Kasich is joined by several of his fellow GOP governors including Michigan, Arizona, Nevada, New Mexico and North Dakota.  I’d expect Florida will also join the list; I listened to Gov Rick Scott uncomfortably listen to a Florida hospital CEO make his pitch in a meeting last fall, and a compelling pitch it was.

While this may be politically distasteful for some, it’s simply common sense, with a big dose of fiscal reality thrown in.  The reality is this: taxpayers from every state will finance the expansion, with their federal tax dollars paying for 100% till 2017 and 90% thereafter.  So, states that don’t accept the expansion will be providing funding for those that do.

Second, hospitals in particular are screaming for support.  For those who would decry Medicaid expansion as yet another entitlement we can’t afford, the hospitals respond that they are the ones hurt by this noble stance, as they’re providing care to the uninsured.  With the number of uninsured around the 50 million mark, those without insurance get much of their care at hospital emergency rooms.   Medicaid expansion will add about 8 million more people to the insured rolls, greatly lessening the burden on hospitals. It will also add about $300 billion over a decade to hospital revenue.

With those kind of dollars floating around there’s no doubt more states will join Kasich et al and agree to Medicaid expansion. 

So what does this mean?

A few things.

Providers will protest the low, and decreasing, reimbursement for Medicaid recipients. Something is far better than nothing, so safety-net providers will grudgingly accept the deal. The savvy ones – and there are many – will realize that fee-for-service reimbursement is a loser’s game, and push very hard to adopt and prove out different models of delivering care and paying for it.

This is a very good thing.

More coverage for more people lessens the need for providers to shift costs to private insureds, workers’ comp claimants, and auto/liability claimants.

 

 

 

Feb
15

California State Fund’s great work on opioids

Posted by Joe Paduda on Friday, February 15th, 2013 | Comments

70 doctors are writing one-third of the scripts for opioids in California.

Most of those scripts are for conditions where opioids are NOT appropriate treatment.

Those claimants that get opioids are off work 3.6 times longer; litigation is 60 percent higher, and their claim costs are twice as high as claimants who don’t receive opioids.

Hopefully you’re not so jaded by the flood of bad news about opioids that you yawn and move on to updating your facebook status; given the ongoing flood of bad news about opioids that wouldn’t be surprising.  Most fortunately, California’s state workers comp fund (SCIF), is on this issue like white on rice.

Here’s some of what SCIF is doing:

Kudos to SCIF for their assertive stance; it is great to see a payer take this on with a comprehensive and well-designed approach.
What does this mean for you?
If SCIF can do it, so can you.  And yes, the CA rules may be different, but there are ALWAYS things payers can do to address opioid overuse.

 

 

Feb
14

Variations in medical care – it happens in PT, too.

Posted by Joe Paduda on Thursday, February 14th, 2013 | Comments

There’s yet more evidence that treatment patterns vary significantly across providers.  Today’s evidence comes courtesy of two academic institutions and Medrisk, Inc. (consulting client) which reported significant differences in the type and duration of physical therapy provided to workers’ comp claimants.

The study looked at several variables contained in billing data: location of service, duration of care, type of care, and other data points; the data was case-mix adjusted.

There are several key takeaways:

  • corporate physical therapy centers billed for more visits and more units per episode than other practice settings.
  • there was a “large difference in treatment utilization between geographic regions regardless of practice setting, diagnosis, body-part treated or surgical intervention”
  • these corporate centers billed for “a lower proportion of physical agents indicating a greater use of those interventions supported by evidence-based guidelines (exercise and manual therapy) compared to other practice settings.”

These findings were consistent across diagnoses and after controlling for surgical v non-surgical cases.

Let’s look at the second takeaway.  It should come as no surprise that the type, volume, and delivery of medical care one gets varies a lot from region to region.  While one would like to think that the care we get is based on science, in many instances the care you receive depends more on where your provider was trained, the local standard of care, and the personal opinion of the treater than what has been scientifically proven to work.

That said, the final point – that treatment in line with evidence-based medical (EBM) guidelines is more common in corporate settings is…intriguing.

Increasing the use of treatments for workers comp claimants that are in line with evidence-based medical (EBM) guidelines is a primary goal of many payers, regulators, and other stakeholders; WCRI’s just-published review of state workers’ comp regulations provides ample evidence of this trend.  While there could well be reasons the use of treatments supported by EBM were more common in corporate-based settings, the discussion in the report appears to address some of the key factors; delay in initial treatment, severity, and acute v chronic status.

Let’s be sure to recognize that these findings are general, overall, and based on statistical analysis.  Undoubtedly there are clinic-based, private, facility-based, and other PT practices that are quite focused on EBM and rigorous in their application.  And, to reiterate, there may well be sound and valid reasons for the differences noted by the stdy authors.

What does this mean for you?

1.  Good to see research focused on this key area of workers’ comp; with 15 to 20 percent of medical dollars spent on physical medicine, the more we know, the better.

2.  Payers should talk to their network partners to find out what type of care their PT providers deliver.  If they don’t know, find a network that does.

Feb
13

Medical malpractice and physician dispensing

Posted by Joe Paduda on Wednesday, February 13th, 2013 | Comments

So, here’s a question for you.  Given the patient safety issues inherent in physician dispensing of repackaged drugs to work comp claimants, are medical malpractice liability carriers considering this issue when underwriting coverage?

If not, why not?

Here are some of the problems with physician dispensing…

  • as research from CWCI and WCRI illustrates, prescribing patterns often change when dispensing rules and reimbursement change. If a patient is harmed, and the prescribing pattern changed before that event, is there added risk for the carrier?
  • the doc often has never seen the patient before, so they don’t know what medication the patient is taking, their medical history, or situation. If they dispense meds, they have to do so without full insightinto
    • the patient’s medical history
    • current drug regimen and possibly dangerous drug-to-drug interactions
    • other treatments the patient is receiving from other providers
  • most dispensing docs only give drugs to their workers comp claimants. So, if a workers comp claimants gets meds and has a problem, and a group health patient with the same diagnosis is treated differently, the plaintiff’s lawyer is going to ask, why? what was the motivator?
  • in many states, docs can and do dispense addictive drugs – opioids particularly.  There’s obviously a financial incentive for the doc to dispense meds to a patient, and if and when one of the doc’s patients is diagnosed as an addict, the plaintiff’s lawyer may well raise the financial incentive as a possible factor.
  • if the doc is dispensing opioids to a patient, and those opioids are being diverted, is there an issue?

And that’s just what I can think of off the top of my head.  I’m guessing underwriters and risk managers can come up with a few more…

 

Feb
12

Variation in hospital results – how to use the data

Posted by Joe Paduda on Tuesday, February 12th, 2013 | Comments

It has long been known that there’s wide variation in the type, quantity, and outcomes of medical care across providers.  A new report – research done by Dartmouth, and funded by the Robert Wood Johnson Foundation – looks at variations in re-admission rates among and between hospitals, and provides some striking insights.

The researchers used 2010 Medicare data; the overall results indicate one of eight surgical patients were readmitted within 30 days of discharge.  Non-surgical patients were readmitted more often; one out of six was back in within 30 days.

According to the report, the “issue of patients being readmitted to the hospital is considered important because many are avoidable and, as the report notes, can occur because of differences in patient health status; the quality of inpatient care, discharge planning, and care coordination; the availability and effectiveness of local primary care; and the threshold for admission in the area.” [emphasis added]

CMS recently began reducing reimbursement to hospitals with high levels of readmissions – which will make it really important for those hospitals.

So that’s kinda interesting, but not really. Here’s what’s really interesting.

The good folks at Dartmouth have published the re-admit rates for all hospitals, and you can download the spreadsheets.  Now before we go picking the best hospitals based only on their numbers, let’s look a little deeper.

Looking at two hospitals in my home state of CT, one can see the readmit rate for St Vincent’s in Bridgeport is much higher than Middlesex Hospital’s.  One answer may lie in the population; Bridgeport is a lower-income area than Middlesex, and likely has a much higher proportion of patients without adequate primary care and/or insurance.  Dartmouth provides some insight into this – 82% of patients discharged from Middlesex after congestive heart failure treatment saw a primary care provider compared to only 60 percent at St Vincent’s.

A couple other stats looked interesting; the data for surgical re-admits for UPMC facilities indicates they do a pretty good job keeping readmits down – and therefore overall quality is likely better than most (again this is just one data point).  Similarly, patients discharged after a heart attack from Geisinger’s Wyoming Valley facility have a high incidence of primary care follow up – compared to other facilities in PA (58 percent v 48 percent.  However, they’d be just above average in Wisconsin (54.4 percent).

What does this mean for you?

While there’s a LOT to digest here, I’d suggest one use would be for network direction.  Identify the hospitals with statistically better results, assess them for confounding factors, and think about how best you can direct patients/injured workers to those better-performing facilities.

 

 

Feb
11

Time’s running out; schedule your Obamacare RFID chip implant today!

Posted by Joe Paduda on Monday, February 11th, 2013 | Comments

After my post last week on some crappy journalists’ mis-characterization of an IRS memo as an admission by the Obama administration that family premiums would be $20,000 in 2016, I received an email from a reader about an even better story.

Seems the nut-o-sphere is rife with claims that anyone signing up for health insurance will be implanted with an RFID chip containing their medical and financial records.

I kid you not.

This is yet another complete mis-characterization by people looking for any reason – real or not – to find fault with PPACA.  (there are plenty of reasons without resorting to outright lies…)

This BS intentionally mis-reads the PPACA’s Medical Device Registry language – which is clearly intended to track medical devices to “facilitate analysis of postmarket safety and outcomes data.” This language – which looks pretty simple and quite clear is mis-interpreted to imply that we all are going to get a chip implanted somewhere on our persons.

What does this mean for you?

Please do a bit of fact-checking before sending on emails…

 

 

 

Feb
8

Medicare, MSAs, the SMART Act, and your taxes

Posted by Joe Paduda on Friday, February 8th, 2013 | Comments

I’ve long avoided getting into the Medicare Set-Aside issue for a bunch of reasons; it’s highly esoteric, requires deep knowledge, is ever-changing, can get pretty nasty and getting educated about MSAs would come with a high opportunity cost – I wouldn’t be able to do any real work for a couple months.

But never one to waste an opportunity to stick my neck into the noose, here goes.  First, my admittedly ill-informed view.

CMS’ failure to a) make rational decisions pertaining to future costs and treatment and b) provide intelligent guidance to P&C payers is a travesty. 

For CMS to assume that any current treatment will continue forever, at current prices, with current (brand) drugs, when any sane person knows that is absolutely NOT going to happen, is nuts.

Passage of the SMART Act helps address several key problems, but there is still much to be addressed before insurers can feel comfortable settling claims – comfortable that they aren’t getting screwed, comfortable that CMS isn’t going to come back and ask for more money, comfortable that the process, methodology, and calculations are actually somewhat stable – if not rational.  Certainty is the goal here, and we’re still well short of that.

Leaving aside the debacle that has been CMS’ attempt to implement a law passed by Congress (with little guidance as to how to actually implement Congress’ wishes), there’s a different issue that deserves mention – why MSAs?

Their purpose is to ensure that taxpayers don’t have to pay for care that should be covered by another entity.  And I’m very much OK with that.  As a taxpayer and contributor to Medicare’s funding, I don’t want my tax dollars spent on care that should be paid for by someone else.  I doubt anyone does.

Therein lies the rub.  Reality is, for decades, we taxpayers have been footing the bill for medical care consumed by workers comp claimants, to the tune of tens/scores/hundreds of millions of dollars (pick one).  That was great for those on the hook for WC claims and premiums, not great for taxpayers.

So, on the one hand, I think everyone (except maybe CFOs at and owners of P&C carriers) supports the IDEA of the Secondary Payer Act.  On the other hand, making the idea a reality has been a(n) mess/disaster/embarrassment. But on the third hand, it is necessary.

I know, commenting on something so obvious may seem like a waste of pixels.  But it’s good to know CMS is actually trying to save taxpayers’ dollars.

Now if they could only figure out how.

 

 

 

 

Feb
7

WCRI’s Annual Meeting; what you can expect

Posted by Joe Paduda on Thursday, February 7th, 2013 | Comments

WCRI’s annual meeting is coming up at the end of the month in Boston; this conference always delivers a deep dive into key issues facing workers’ comp.  The brain trust at WCRI have made several changes to the conference over the last few years, most notably the data on which their research is based is much more current and covers more states.

I spoke with WCRI’s Executive Director, Dr Rick Victor yesterday about the conference and what attendees can expect.  Here – paraphrased – is what I learned.

The conference begins with an extensive review of treatment guidelines and unnecessary care, featuring a presentation by Prof. Thomas Wickizer of Ohio State on the evidence of the impact of treatment guidelines.  As payers confront growing medical costs and higher utilization, there’s a lot of interest in guidelines. But not all guidelines are created alike, and how they are implemented can be just as significant as how they are developed.  When I asked Rick what attendees can expect, he gave a very brief answer: “like the other discussions, evidence.”

What will be especially useful is evidence from both the WC and non WC worlds, and how UR does or does not compliment the guidelines; in addition the plusses and minuses of different approaches will be discussed and compared.

Recent WCRI conferences have included more coverage of external influences on workers’ comp; that continues this year with a discussion between former VT Gov. Howard Dean and Sen Judd Gregg (R NH) about the political dynamics affecting workers comp and healthcare. I asked Dr Victor what led to this expanded focus on external factors.

His response: “In 2008 the world shifted in fundamental ways that affected the lives and fortunes of most Americans.  You can’t really address WC effectively without talking about the impact of the financial crisis on people.”  He went on to promise not to depress everyone again with another “surprise”, so this year the external factors discussion will focus on solutions. He went on to say “The problems are well understood, so now we need to talk about how to get out of it.  Two people with different perspectives but both very thoughtful and experienced will help us understand where the leverage points are in the political process for meaningful change, and provide their prognosis.”

Finally, there will be a thorough discussion of the Opioid Epidemic, focusing on the urgency and scope of the problem both nationally and in workers’ comp.  Topics covered will include prescription drug monitoring programs, opioid guidelines, education and prevention, and the treatment of dependency.

The net – this year’s WCRI conference looks to be a don’t miss event.  Be there.

 

Feb
6

IRS, health care premiums under ObamaCare, and right-wing distortions

Posted by Joe Paduda on Wednesday, February 6th, 2013 | Comments

There’s a bunch of nonsense circulating on the web claiming the Obama Administration has said the average family premium under Obamacare will be $20,000 in 2016.

The sources, primarily lousy journalists, right-wing ideologues and wingnuts (Betsy McCaughey), are either:

a) unable to read and understand basic English; and/or

b) quite willing to distort, mis-inform, slant and obfuscate.

The kerfuffle began with a lengthy IRS memo released last week.  [opens pdf] Ideologues took one sentence (page 70, third paragraph) out of the document and claimed it said something which it absolutely did NOT.

The nut-o-sphere mis-read the IRS’ statement and interpreted an example as the IRS’ estimate of cost.

IT IS NOT.

If you read the para at the beginning of the relevant section, it reads “The following examples illustrate the provisions of this section.”  Note the use of the words “example” and “illustrate”.

In fact, no one knows what the premium for a bronze-level plan for a family of 5 will be in 2016.

Now that we’ve thrown out that trash, let’s talk about family premiums, shall we?

First, let’s be precise about definitions. Employers’ costs are almost always lower than individual coverage, so be precise when talking about costs – are they for individual coverage, Medicaid, or employer-based plans.

Second, most individuals/families with incomes below 400% of the Federal Poverty Level will have a subsidy so their “cost” on the individual (or small employer” market will be less than the “list price.”

Third, the cost for a medium cost area is about $19,138 for a family of four for the Silver plan with no subsidy. If you make $80 grand, your cost – after the subsidy – is $11,528.

Fourth, my family – with four covered, all of us healthy, and no subsidy now or later, is paying $756 in premiums for a policy with an $11,900 deductible TODAY. That’s $20,972 TODAY. I can’t wait for Obamacare, as our costs will go DOWN and coverage vastly improve if the IRS’ figures are correct.

The best resource for calculating cost is the Kaiser Foundation’s calculator –
http://healthreform.kff.org/subsidycalculator.aspx

Unfortunately this is yet another example of ideologues taking statements out of context to advance their own agenda. Of course I didn’t read news of this revelation about Obamacare in the credible press; they ignored it because it isn’t a story. There is no story here. Unless it is about distortions for political gain.

This first came to light (for me) in the Workers’ Comp Advisory Group’s forum; not sure why it was there.

Joe Paduda is the principal of Health Strategy Associates

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