Insight, analysis & opinion from Joe Paduda

Feb
6

The last Coventry earnings report ever

As Coventry prepares to become part of Aetna, Coventry’s earnings report marks the last quarterly report we’ll see from Allen Wise and Co.  As par usual, I’ll split my review into two parts; workers comp (of most interest to many readers) and the rest of their business in a future post.  There’s no earnings call scheduled, so no Q&A with investors or presentation from management to mull over…

First, overall it was a strong quarter for Coventry with revenues up 10% driven by big growth in public-sector programs; commercial membership declined slightly. Quarterly profits also rose, altho annual profits were down about 4 percent.

Today, it’s work comp.

As far as revenues a tough quarter for the work comp division, actually a tough series of quarters.  Revenues dropped each quarter, albeit slightly.  However, the total decline was over $14 million over the four quarters, and the year saw a drop of $26 million or 3.3 percent from the prior year.

There were several business losses over the last year that undoubtedly contributed to the drop in revenues.  ESIS switched PBMs from Coventry’s FirstScript to Progressive, and moved other services from Coventry as well.  The PBM move probably had the largest impact on the WC Division’s financials, as the entire pharmacy spend counts as top line for CVTY thus losing tens of millions of pharmacy has a big impact on reported revenues.  The loss may have been a wake-up call to management, as there have been some indications that FirstScript is working to elevate its game.  However, it has a ways to go to catch up to the offerings of its competitors, almost all of which have a pretty significant head start.

While that was a significant loss, it was likely a good deal smaller than one that has yet to be felt; the US Postal Service moved their PBM business from FS to PMSI.  The deal was done late last fall and it should hit the financials sometime early this year.

To the credit of the WC Division and boss David Young, they were able to add enough incremental revenue thru price increases and smaller account wins to mitigate a good chunk of the loss of the ESIS business  and other losses.

So, where does that leave Coventry work comp?

A recent re-shuffle will put the division under former-CFO-now-head-of-National-Business Joe Zubretsky. Interestingly, former Coventry CFO Shawn Guertin is now working for Aetna in a top finance slot.  Guertin’s experience with the WC business will likely be the subject of a discussion or two between these two gentlemen…

Zubretsky’s most recent public comments about work comp have been pretty positive.  I fully expect Aetna to embrace the business; it has less regulatory risk than their core business, zero insurance risk, and may have some strategic benefit as Aetna looks to the future of disability management. And let’s not forget the strong positive cash flow generated by the division, cash that will be sorely needed by mother Aetna as they continue to prepare for 2014.

Net is we can expect Coventry’s comp division to flourish under Aetna; there may be some changes but I’d expect them to be positive, and we may even see investment in the unit.  

 

 


Feb
5

What we nerds love…

is research that helps us understand why things are the way they are.

And while we rarely get to make out with supermodels like the guy in the SuperBowl ad (word is it took 45 takes to get it “right” (good for him!!),

Bar Rafaeli and…

we do get pretty excited about great research.  Which makes today a pretty good day.  Two studies were released – one from Washington on back surgery outcomes and complications and the other from CWCI discussing the use and cost of compound medications in worker’s comp.

First, Gary Franklin MD and colleagues published a study in the February edition of Health Services Research on the safety of lumbar fusion, an all-too-common procedure in workers’ comp.  Here’s my non-clinical take on the key findings.

  1. Outcomes  – defined for this study as complications within 90 days of a fusion – for workers’ comp patients were not nearly as bad as I thought they’d be. Surprisingly, they were somewhat better than the average!
  2. However – and it’s a BIG “however”, that may be due in part to the Washington state fund (L&I)’s tough stance on authorizing fusions.  In turn, that was based on priori research that indicated fusions had generally poor outcomes.  So, L&I’s numbers for outcomes may have been better because they do a good job of winnowing out those claimants more likely to have poor outcomes.
Pretty cool, eh? Gotta love the power of the monopolistic carrier.
Well, here’s some not-so-cool news.
Eileen Auen, CEO of PMSI and Alex Swedlow and his colleagues at CWCI have co-authored a study examining the cost and trends associated with compound medications in California. (disclosure – both are friends and I was a reviewer of the draft report)
And the results are about as appealing as Ms Rafaeli’s ad-mate.
For the blissfully-unaware, compound medications are concoctions of various real and pseudo-medications fabricated by parties evidently more interested in sucking money out of employers and taxpayers than healing patients.  There is precious little evidence supporting the use of these medications for the kinds of conditions suffered by workers’ comp claimants; nonetheless they are inordinately popular among a subset of providers.
California instituted controls on the use of compound meds 1/1/2012, the thinking being these “controls”would reduce compounds in comp.
The good news is compounds dropped from 3.1 percent to 2 percent of scripts.
The bad news is while there were fewer compounds dispensed, the cost of each went up over 68 percent, so compounds’ share of drug costs increased from 11.6 percent to 12.6 percent.
That’s right – fewer compounds cost more money.
How’d that happen?
Well, compound prescribers and dispensers quickly figured out how to game the “controls” by adding more ingredients and more of each ingredient to each compound.  
There it is, another example of unintended consequences.
What does this mean for you?
Unscrupulous providers will quickly figure out how to game regulations/controls that are not well-developed and carefully considered. Better to do something right than to do it quickly.

Feb
4

Rapid change in California’s health system

The pace of change  – mergers, consolidations, physician/hospital affiliation, new construction and shifting of services – in California’s health care system is fast and accelerating.  Several area-specific reports just out from the California Healthcare Foundation provide a great overview of the changes in specific markets, and are well worth study for any payer working in the Golden State.

In a quick review of CHCF’s report on San Diego a few things jump out.

  • Hospital systems’ profitability is generally increasing rather substantially, this in a period when many are investing big bucks in new plant and equipment.  Margins for several systems are into the double digits.
  • Lots of investment is occurring in the wealthier (read – privately insured) areas, such as La Jolla.  No surprise that.
  • Safety net providers are benefiting from federal largesse, using funds to expand services to low-income communities and add medical home capacity as well.

For Los Angeles, the title of the report says it all “Fragmented healthcare system shows signs of coalescing.”  Whether it’s physicians aligning with health systems, hospitals joining together, or health systems merging, there’s lots of efforts to get bigger, increase service areas, and expand services themselves.

Unlike San Diego, LA is a pretty fragmented market, with too many hospital beds, no dominant systems or facilities, and many systems looking to consolidate the market.  Kaiser is the only system with a double-digit share of hospital discharges at 11.8%.  And, also unlike SD, margins for many facilities are negative to just barely above break-even.  There are exceptions; Cedars-Sinai had a 7.6% operating margin in 2010 and UCLA’s was almost twice that.

The study indicates that one driver of the relatively poor financials in LA may be an over-supply of hospital beds at 205 beds/100k people vs the state average of 181.

There’s a wealth of useful information in these studies.  Payers of any stripe doing business in California would be well-advised to read them carefully, and consider the implications for their future.  


Feb
1

Work comp hospital costs – what WCRI’s report says, and what it means

The good folk at WCRI have produced a very useful – and very timely – analysis of outpatient facility costs, cost drivers, regulatory mechanisms, and trends in 20 key states.  Timely because the upcoming changes to Medicare and Medicaid’s hospital reimbursement bode ill for workers’ comp, and doubly timely because payers are seeing significant increases in facility costs in many states.

There’s a lot to consider in the study, here’s what struck me.

  • States without fee schedules are way more costly than those states that have outpatient facility fee schedules based on a fixed amount (not percentage-of-charges) reimbursement methodology.
  • States with percentage-of-charges “fee schedules” are about as costly as states with no fee schedules at all.
  • Even states with fee schedules based on a fixed reimbursement can be problematic; Illinois is a great example as it has the highest costs of all 20 study states.
  • Changing or modifying fee schedules appears to drive changes in billing patterns, which are supposed to be based on actual services delivered.

What stands out most is the overall trend.  Costs went up over the study period, sometimes a lot, other times there was an initial decrease after a fee schedule change went into effect after which an upward trend resumed.  And while some methodologies seem to do a better job controlling cost inflation than others, all can be gamed.

Cap reimbursement on a per-procedure basis, and watch utilization go up.

Base reimbursement on a lower percentage-of-charges, and miraculously charges escalate dramatically.

But start with low costs, and those low costs will likely persist; the ten lowest cost states in 2006 were still in the bottom half in 2010.  Yes, some had moved a notch and others down, but no state moved more than two slots.

What does this mean for you?

Watch FS changes in your key states very carefully, but don’t hold out much hope that any big changes will dramatically impact costs over the long term.

 


Jan
30

Physician dispensers are getting desperate

Oh this is getting fun!

Earlier this week WorkCompCentral published a column ostensibly written by a physician attacking me for exposing the dangers, both physical and financial, inherent in physician dispensing of repackaged drugs.  I say ostensibly because the column reads like it was ghost-written by one of the industry’s shills, perhaps one of Ron Sachs’ interns. (Ron’s the guy physician dispensing company AHCS hired to call reporters to tell them they were suing me).

By the way, I LOVED the column.

It was an amazing combination of pronouncements from an arrogant-beyond-belief doctor, with a really nasty and personal attack on me, my motives, and my ethics.

Alas, it was so poorly done, with so many logical fallacies and nonsensical arguments based on nothing more than fact-free opinion that I can’t believe a real doctor actually wrote it.  After all, doctors are supposed to believe in science; you know, research, medical evidence, facts, logic supported by data – those kind of things.  Yet the column didn’t have any of those, instead it was a mishmash of unsupported claims based on “our experience”, and never directly addressed the key issues I raised in my piece, e.g. retail pharmacies have much more complete access to patient data, and docs who dispense don’t.

(btw, a Summit on Physician Dispensing will be held in Boston on February 25/26.  Sponsored by PMSI and Progressive Solutions, the Summit is free of charge and is held the day before WCRI’s annual conference – in the same hotel.  This is an invite-only event; there are a few slots open.  Email me at jpadudaAThealthstrategyassocDOTcom for details.

The ostensible author, one Dr Rafael Miguel, offered not a single shred of evidence to support his claims of better outcomes and enhanced quality of care. When not denigrating pharmacists, mischaracterizing my statements, and accusing me of profiting from defeating physician dispensers (more on that below), Dr Miguel/the intern hid the total lack of data supporting his claims behind the omnipotence of the god in the white coat, as if his title is proof enough and we non-physicians should meekly listen and obey.

You can tell the physician dispensing industry is in desperate straits when they use surrogates to question the motives of their opponents, fabricating reasons why anyone would dare interfere with their ability to suck money out of taxpayers and employers by charging outrageous amounts for the drugs they prescribe – and dispense – to workers’ comp claimants.

That’s known as “diversion”; when you can’t refute a critic, yell really loud about what a bad person they are.

Well, let’s look at Dr Miguel.

Dr Miguel is a dispensing physician using Rx Development Associates.  A quick check of their website reveals frequent mention of one of the key benefits of physician dispensing; additional revenue for the physician.  RxDA also touts how easy it is to sign up and use their system to generate big profits, “without interrupting or burdening staff members.”  That’s in direct conflict with Dr Miguel’s assertion that physicians “must recover the costs and time to provide this service to workers compensation patients.”

Let’s look at Dr Miguel’s scripts.  He’s dispensed fluoxetine, etodolac, omeprazole, and gabapentin, among other meds. One of those scripts, omeprazole, is commonly used for heartburn.  Omeprazole, also known as Prilosec, can be bought over the counter for about a buck a pill; Dr Miguel charged about $10  pill.  That’s not opinion or hyperbole, it’s fact.  Miguel charged about ten times more for the drug than it would have cost over the counter.

Dr Miguel/the intern contends docs can’t buy drugs for the same price retail pharmacies do, and that’s why they have to charge so much more.  Again, he offers no evidence of this.  In fact, if Dr Miguel had tried, he could have found repackaging companies clamoring to sell him drugs at very low prices.

Finally, allow me to address Dr Miguel/the intern’s questioning of my motives, and contention that my efforts to combat physician dispensing are “what can only be described as an attempt to fatten Mr. Padudas personal bottom line.”

  1. As I have noted many times, I am co-owner of CompPharma, an association of workers’ comp PBMs.  It makes no difference (financially) to me if  physician dispensing dies off, explodes, or just stumbles along. I don’t get a nickel more or less.
  2. My public battle with the industry and its advocates has cost me tens of thousands of dollars in legal fees not to mention hundreds of uncompensated hours.
  3. Yes, PBMs will benefit if physician dispensing ends, but I am not a PBM, nor do I own a PBM, nor do I get paid based in any way on their volume of business.
What Miguel/the intern can’t understand is some people just have principles, standards that they live by, ethics that require them to speak out when they see others doing wrong.
And physician dispensing of repackaged drugs is wrong.

 

 


Jan
29

Marketing is NOT sales or communications or…

The lack of effective, or even decent, marketing in the work comp services and insurance industry is all but universal.  It is also damaging – to the industry as well as to individual companies.  And it is dumb.

The value of a brand is well-documented;

A brand is build by marketing – which is NOT communications or proposal writing or trade shows or parties at trade shows or trinkets given to adjusters.

Marketing – BIG M MARKETING – is all of those and more.  It starts with defining the value you bring to a specific segment.  It requires a simple and clear statement of that value so that potential buyers understand how it relates to them, and that must resonate.  And it continues from there.

But the purpose of this post is not to provide a primer on marketing or branding, but rather to call attention to the dearth of effective marketing.  My sense is this happens because most leaders just don’t get marketing – they think it is soft, fluff, a waste, a nice-to-have, when in reality it is a have-to-have.  Companies have to stand for something, mean something, and that “something” isn’t what the leader THINKS it is, it is what the market thinks it is.

How do you know if you have effective marketing?  Obviously, or perhaps for some less than obviously, market research.  What do users/buyers/influencers think of your company ?  How do you know?  No, how do you REALLY know?

Objective and well-designed market research.

Allow me to close with an example of what effective marketing can do.

I give you Joe Paduda. (forgive the use of the third-person)

A consultant in the industry, known by a few folks eight years ago, mostly former co-workers and colleagues, Paduda is now quite well-known throughout the industry. He has keynoted the two largest conferences, is a sought-after speaker and expert, almost four thousand people subscribe to his blog, and many seek to curry favor with him, or avoid pissing him off.  His client list is extensive, he does not work cheap, and he regularly turns down projects.

The “Paduda brand” drives success.  Smart, insightful, opinionated, honest, fair, objective with deep understanding of the industry and strong strategic sense.  A tendency to be bleeding-edge (not politically, altho some would disagree, but rather too far in front of trends) and occasionally, and pretty publicly, wrong.

Marketing – via the blog (thank you Julie Ferguson!) and public relations (thank you Helen Knight!) is the driver of my success.

If I can do it, so can you.  All it requires is consistent commitment, a willingness to spend money, and a relentless focus on building and strengthening your brand.

What does this mean for you?

Success – or lack thereof.


Jan
24

A tale of two states – Idaho and Florida

Yesterday came the welcome news that the good – and smart – folk in positions of authority in Idaho have drafted work comp regulations designed to prevent outrageous up-charging for physician-dispensed repackaged drugs.  Approved by both Legislative houses, the rules will shortly go into effect.  Idahoans are fortunate indeed to be in a state where they can proactively prevent a problem by implementing regulations, and don’t have to pass legislation to save taxpayers and employers dollars.

Oh, if that were only the case in Florida.  

Two bills have been introduced by allies of physician dispensers that purport to address the issue.  Both require physician dispensers to pay a $15 “rebate” to employers for each physician dispensed script they bill.  Why, you ask?

They say that physician dispensed drugs’ average bill is only $15 higher than the average retail pharmacy bill, so the $15 covers their higher costs.

They are, of course, lying.

First, physician dispensing companies get docs to dispense by telling them they can make another $50 grand (or more!!) a year giving drugs to work comp claimants.  You can’t make fifty grand if you only make $15 more per script – unless you dispense 3,333 scripts a year…

Second,  physician dispensers almost exclusively dispense generics, which are much cheaper – on a per script basis – than brand drugs. Retail chains sell brands and generics – brands cost over $200 per script. Thus, the claim that physician dispensed drugs only cost $15 more on average than retail is misleading and false on its face; in fact WCRI’s recent report on pharmacy in Florida notes: “physicians were paid 35-60 percent more than pharmacies for the same prescription.”

Of course, it is highly likely that the sponsors received thousands of dollars in contributions from those dispensers, who spent over $3 million in the last election cycle to ensure they could keep sucking money out of taxpayers’ and employers’ wallets to buy jets and fancy Italian sports cars – and generate fat profits to their investors – ABRY Partners being the most visible.

To our friends in Idaho; Yippee-Kai-Yay!

To those in Florida; Illegitimi non carborundum.

 


Jan
22

In workers’ comp, it’s the tail that’ll kill you

More than 10% of workers comp medical costs are for claims more than 20 years old.

And that percentage may well increase.  That’s the finding from NCCI’s latest research, courtesy of Barry Lipton, John Robertson, and Dan Corro. There are a few striking findings well worth considering:

  • Diseases were the largest contributor to costs, followed by complications from medical care.
  • Drugs (38%), home health, implants/orthotics/prosthetics and other supplies make up 58% of costs compared to 16% of costs for claims less than 20 years after injury.  Notably, the authors predict that drug costs for today’s injuries 20 years out may well account for more than 50% of total spend.
  • About a quarter of drug costs were for opioids – drugs that are not indicated for musculoskeletal conditions.
There is a wealth of information in the report, information that should be carefully considered by any and all payers with a significant number of legacy claims.  And, those payers with claims that look like they may well be around in 20 years.
Here are my top four takeaways.
  1. How new claims are handled has a dramatic effect on where they are in 20 years. The vast majority of those claimants should probably NOT be on opioids; the fact that they are indicates a) they will likely never get off and b) the reason they are not closed is very likely because they are taking opioids.
  2. There are two very different types of home health/DME; the commodity-type for relatively young claims that need a cane crutch or wheelchair for a few days and the legacy claims that need a van, home mods, and nursing assistance forever. Huge implications that are NOT well understood by most vendors and buyers.
  3. Far too many claimants get far too much care in hospitals, when they may well be better served in a less-intensive inpatient facility.  Hospitals LOVE workers’ comp; it is very profitable and there are few controls on length of stay.  Payers would be well-served to figure out how to use less hospital care.
  4. Payers should also carefully examine medical records for patients suffering from complications due to medical care.  Poor medical care, lack of diligence on the part of treating providers, and flat-out malpractice are likely contributing to higher claim costs.
And kudos to NCCI for conducting this research.

 


Jan
21

Bear mauls stoned worker, judge adds insult to injury.

Let’s start off the week with another warning on the perils of marijuana.  Specifically, if you try to feed grizzly bears while stoned, they may try to eat you.

And that would be a compensable injury.

This actually happened in Montana – thanks to Kristie Wolter for providing the details.

Here’s the scene – at a tourist bear park, a guy ostensibly there as a volunteer – but getting paid – goes into a bear pen with food and gets mauled, escaping only by crawling under the electric fence.  Goes to hospital, then files a WC claim.  Park owner says the guy’s a volunteer so no WC, guy gets lawyer, goes to court, and judge renders opinion.

Which says, in part:

“[Bear park owner] Kilpatrick’s testimony that he gave Hopkins money on multiple occasions, “out of my heart” coincidentally while Hopkins was performing “favors” for Kilpatrick at the bear park is not credible. There is a term of art used to describe the regular exchange of money for favors – it is called “employment.” [emphasis added]

Further, Kilpatrick asserted that Hopkins’ decision to get stoned was a/the major contributor to Hopkins’ injury.

Again, the judge:

“Hopkins admitted to smoking marijuana before arriving at work on the morning of the attack, I cannot conclude based on the evidence before me that the major contributing cause of the grizzly bear attack was anything other than the grizzly. It is not as if this attack occurred when Hopkins inexplicably wandered into the grizzly pen while searching for the nearest White Castle. [emphasis added] Hopkins was attacked while performing a job Kilpatrick had paid him to do – feeding grizzly bears. The fact that the grizzly attacked Hopkins while he was performing this job is not exactly a “man bites dog” event. When a grizzly bear is sighted on a trail in Glacier National Park, the trail is closed to all hikers, not just the hikers who may have recently smoked marijuana. Kilpatrick installed multiple electrified fence lines at the bear park to separate the grizzly bears from all customers, not just the customers who may have recently smoked marijuana. When it comes to attacking humans, grizzlies are equal opportunity maulers; attacking without regard to race, creed, ethnicity, or marijuana usage. Hopkins’ use of marijuana to kick off a day of working around grizzly bears was ill- advised to say the least and mind-bogglingly stupid to say the most. [emphasis added]

And there you have it.  Our workers’ comp system protects even the mind-bogglingly stupid.  

One can only hope Mr Hopkins protects his progeny from similar disasters by not having any.


Joe Paduda is the principal of Health Strategy Associates

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