Insight, analysis & opinion from Joe Paduda

Feb
27

Wildly off-topic # 14 – the Russian “offense”

Last time we talked tanks

This time we’ll focus on Russia’s winter offensive. If you don’t have time, just skip to the takeaways at the bottom of this post.

credit Institute for the Study of War; I highly recommend ISW’s briefings

Quick take – the offensive isn’t going well. While Russia is making advances, they are measured in meters not miles, and are coming at horrendous cost in dead, injured, and captured Russian troops. The Russians did capture Soledar and have make barely measurable progress around Bakhmut and a couple other places but none of those are – in any way – changing the reality on the ground.

Which is Russia is screwed.

As we discussed in WOT #10, you need troops and equipment to fight a war.

The Russians lost a huge amount of equipment last year – hundreds of tanks, armored fighting vehicles, cannons, trucks, trains – equipment it cannot readily replace, if at all. If you want to attack, as Russia is trying to do in its winter offensive, you really need armored vehicles to penetrate opponents’ lines and break out into less well-defended territory. Dug-in defenses  – usually several lines deep – are very, very hard to defeat unless you can blow a really big hole in them and exploit the opening with fast-moving vehicles.

So, in what is eerily reminiscent of World War One, Putin the Butcher is throwing thousands of untrained men at Ukraine’s front lines. (If you want a taste of that, I highly recommend the book and film “All Quiet on the Western Front“.) Trigger alert – it is really awful and disturbing, and the German general is a bald version of Putin the Butcher.

PtB’s tactics are pretty awful…

  • untrained ex-prisoners and recruits from Russia’s far east are forced to attack Ukrainians positions.
  • they are slaughtered – because they have no idea what they are doing, have minimal weapons and ammunition, and are going up against entrenched, battle-hardened and well-supplied Ukrainians, but
  • in so doing, the Ukrainians reveal their positions, which are then bombarded with rockets and artillery and attacked by much more capable Russian troops.

That is NOT to say Russia’s “real” soldiers are invulnerable. Reports from the front indicate Putin’s “elite” units lost dozens of armored vehicles and hundreds of soldiers over the last few days…equipment and men which Russia cannot afford to lose.

Putin the Butcher has a seemingly inexhaustible supply of poor young men but they are a very poor substitute for modern military vehicles and artillery.

Takeaways

While others much more knowledgeable than I see this war grinding on for years, I’m hard pressed to agree.

Russia:

  • cannot replace most lost equipment,
  • is losing more and more of its irreplaceable, experienced and well-trained troops,
  • has not demonstrated its generals have any idea what to do,
  • is facing an increasingly better-equipped and far more motivated enemy, and
  • is losing the information and intel dimensions.

Like we saw late last spring, all is well until it is not, and then it goes really, really badly for Putin the Butcher.

all previous posts on this topic are here.


Feb
22

Budget facts

credit Prof Galloway

The budget hawks in DC are threatening to prevent us from borrowing money to pay our bills..if we don’t agree to some yet-to-be-defined and pretty massive spending cuts.

The total Federal budget for FY 2023 is $6.2 trillion.

About $3.7 billion is pretty much off limits. So, you may want to ask yourself, where are the cuts going to come from?

$1.5 trillion of our spending is for Medicare and Medicaid, and there are hundreds of billions more for the VA and other health programs. And the GOP recently said thy’d leave Medicare alone, and more states are expanding Medicaid (North Carolina appears to be next), so it’s hard to see where cuts would be deep enough to move the needle.

Defense cuts? Defense is $900 billion…Given China’s saber rattling, Russia’s belligerence, Iran’s new air force and movies towards nuclear arms, and the North Korean’s continued aggressive posture, that’s highly unlikely

Social Security? that’s $1.3 trillion, and the GOP has recently said they won’t cut it .(after saying they’d like to figure out how to privatize it…)

What does this mean for you?

Threatening cuts is really easy when you don’t tell anyone what you’re going to cut…because one person’s waste is another person’s income. 

 


Feb
17

Dinosaurs.

Far too many work comp industry CEOs are dinosaurs.

Their refusal to adapt to today’s labor market will ensure they fail their investors/policyholders.

Two things triggered this post.

  1. an extensive conversation – or rather series of conversations – with the CEO of a very large payer whose workers are no longer required to work in office. When I asked about work from home, this eminently reasonable individual was mildly surprised, saying something like “of course we support WFH…there’s no reason for most of our folks to go to an office…they did just fine during COVID and like WFH so why change?” This person noted real estate and related costs would be reduced as would other expenses associated with an office-based work environment.
  2. A conversation with the estimable Bill Zachry, a person I am fortunate indeed to consider a good friend and mentor. Bill noted the challenges payers are experiencing finding and keeping adjusters.

It seems wildly obvious that WFH will help payers keep and find staff while lowering overall costs, significantly reducing ULAE (unallocated loss adjustment expense). Every payer C-suite has been on a cost-cutting rampage for several years in an effort to improve margins and adapt to declining frequency and shrinking rates.

In what can only be described as a logical fallacy, many payers are now “requiring” staff return to the office for more than an occasional day.

Good luck with that.

Most people do NOT have to work in an office, yet many CEOs refuse to accept that they – the Tyrannosaur Rexes of our time – cannot bend lesser beings to their will.

Sure, many workers are already back in the office, and some few prefer it. But most would much prefer not:

  • having to deal with child care emergencies by taking PTO;
  • commuting;
  • dealing with office politics;
  • wasting time at birthday parties, Monday morning “how was your weekend” chats, water cooler analyses of whatever sporting event, updates on officemates’ kids amazing (insert school/sports/music/theater/other), or the millions of other time wasters engrained in office-based work.

Shockingly, workers would much prefer to spend the 2 hours or so a day commuting with their family, or doing work, or exercising, or gardening or whatever.

And they’d rather save big bucks by ditching a car and its attendant insurance, license, tax, toll and maintenance costs; giving up the monthly commuting pass; not paying to park; having lunch at home and on and on.

To be sure there are arguments, some of them even reasonable, in favor of in-office work…yet the fact that most every organization survived COVID WFH is a rather compelling proof statement that WFH works.

What does this mean for you?

Mesozoic-era management will fail as will its proponents and the organizations they lead.


Feb
15

Workers’ comp > all other healthcare payers. Period.

and here’s why.

Work comp payers actually care about the patients recovery, return to functionality, ability, and productivity. Work comp HAS to…screwing up recovery = huge financial penalties in the form of claims that last forever, really costly settlements, and migraine-level headaches for all involved.

Whereas in group/individual health, Medicare and Medicaid (mostly), functionality is – at best, and then only rarely – an afterthought.

side note – if you think about it, how dumb is it that 99% of healthcare payers don’t really care whether the $4.2 trillion they spend on healthcare actually improves lives, helps patients stay active, supports functionality, and helps us live the lives we want to live?

answer – dumb as a box of rocks

WCRI’s latest in a never-ending stream of excellent research brought me back to this...researchers examined patient-reported functional outcomes after low-back pain, a far-too-common and sometimes really problematic diagnosis. [report is free to WCRI members and a nominal cost to non-members].

The research compared WC outcomes to those of other payers…and:

  • included patients covered by all types of payers,
  • totaled some 2.4 million patients (!),
  • covered almost 1.3 million PT/OT episodes of care, and
  • used patient-reported functional status specific to the low back pain issue (as captured by FOTO).

The researchers obviously put a LOT of thought into selecting the measure…they describe the process and rationale in detail in the report (ppg. 15 – 19).

credit WCRI

While it is important indeed to consider that workers’ comp patients’ reported functional improvements were not as high as some other payers – and we  need to understand why – that’s secondary to the fact that work comp’s primary focus – return to functionality – is way different from other payers’.

With extremely rare exceptions, no other payers focus on functionality, and almost none do across all patients with all conditions.

Kudos to Sebastian Negrusa, Vennela Thumula, Randall Lea, and Te-Chun Liu for their excellent work.

What does this mean for you?

Work comp gets beat up a lot…this is why – in one extremely important way -workers’ comp is superior to all other payers. 


Feb
13

After 10 days away from the keyboard – family vacation in Mexico and gravel bike race in California – it’s back at it.

shockingly the world kept turning while I was unplugged…

The estimable Charles Gaba has just updated his analysis of US healthcare coverage by payer. Charles’ work is the best I’ve encountered to date…he includes everything from Medicare and Medicaid to Exchange programs to Healthcare Sharing ministries (between 865,000 and 1.5 million, Indian Health Services (2.6 million)…

Here’s the all-in-one view…

Despite all  those gazillions of people with insurance, many hospitals are having real/awful/terrible financial problems. Hospitals’ average margin – according to Kaufman Hall – was -3.4% for the first 11 months of 2022.

That said, things steadily improved during the year…

In the tiny world that is workers’ comp, NCCI released its review of medical inflation…among non-hospital providers (docs, PTs, etc).

Thanks to the good work of Raji Chadarevian and David Colon, we know medical inflation among these providers was…minimal.

As in 1.5% per year over the last decade.

Final note. Facility costs are increasing.

Most payers are doing a really crappy job addressing this; their bill review partners/operations are woefully ill-equipped to ensure your dollars aren’t being Hoovered up by healthcare systems and hospitals.

And yes “most payers”includes you.

To date those increases have been matched by a $2 billion decline in drug spending – which, by the way, has also reduced claim durations (way lower opioid usage = way more claim resolutions).

Physician costs are pretty much flat, drug costs are way down, and facility costs are headed up…net is you need to PLEASE stop catastrophizing about “severity increases” and other nonsense.

If I read one more survey or interview or discussion of workers’ comp execs afraid of “rate inadequacy” or medical inflation or some other incredibly uninformed and wrong-headed and ignorant fear mongering I’m going to call them out publicly.

Just. Stop.

 


Jan
30

LWCC’s got it going on

I was fortunate indeed to attend Louisiana Workers’ Compensation Corporation’s annual provider meeting last week. Well attended, learned a lot, really enjoyed the people and the weather was really nice too.

I was blown away by their office building.

It was gorgeous…open, airy, beautifully appointed, welcoming, spacious, high ceilings and a terrific learning center and gym…it can only be wonderful to work in and it was a delight to experience.

But what really impresses me about LWCC is their people and culture – open and constantly learning, humble and very focused on doing the right thing. Unlike many other workers comp carriers, LWCC is about as far from arrogantly self-satisfied as it could be. I’ve seen way too many payers suffer from the “if it wasn’t invented here it didn’t need to be invented” syndrome, secure in the incontrovertible truth that they alone are the BEST.

They of course won’t listen or read this…why waste the time when you’re entirely sure you can’t learn anything from anyone? Especially not a single state carrier in a not-big state solely focused on a single line…

They might learn…if their customers take them down a notch or several, challenge them to compare their processes and outcomes using objective criteria, call them out on their arrogance.

It is clear that senior management really cares about LWCC’s people and are totally committed to doing the right thing. They listen hard and carefully, and respond to what they hear. And it shows; the passion and commitment to doing the right thing by every injured worker and every policyholder was front-and-center, evident in every LWCC person there.

They invest in marketing – which is really, really good. A cogent, really well-designed branding strategy designed to link LWCC to its home state, fresh and engaging graphics, a commitment to telling their stories, a leader who really understands marketing – which is NOT proposal writing, powerpoint editing, or letter writing. It is branding, content, design, strategy, pricing, research, community relations and more.

I don’t know of any other workers’ comp entity that does it as well.

What does this mean for you?

Most of the biggest payers in workers comp can learn a LOT from LWCC. 

 


Jan
26

CMS just reported US healthcare spending topped $4.3 trillion in 2021…almost $13,000 per person.

Meanwhile work comp medical spend for 2021 was likely around $32.5 billion…or 0.74% of US healthcare spend.

Government accounts for about 2/3 of total spend, among private employers Amazon has more health plan participants than any other company…

chart courtesy Mark Farrah and Associates

Old friends and colleagues Adam Fowler and Kevin Tribout’s latest edition of the Policy Guys podcast is up here. Honored to be part of the pod, especially with such distinguished hosts!

Off to Baton Rouge to get together with my friends at LWCC – looking forward to great food and better people.

 

 


Jan
25

Wildly off-topic #13 – Tanks.

Last time we talked about weapons…how many each side had, what’s been lost, and the challenges in replacing those weapons.

Today’s newsfeed arrived with the VERY welcome news that Germany has OK’ed supplying Leopard 2 tanks, and we will be sending Abrams tanks to Ukraine. The UK had committed to send 14 of its Challenger II tanks to Ukraine… Note that countries that use Leopard 2s have to get permission from Germany before sending them to Ukraine; with this latest announcement sources indicate Ukraine will get at least 100 Leopard 2s.

This will supply roughly one brigade – and is about 1/3 of what Ukraines’ leaders say they need.

These are “main battle tanks” [MBTs], a term describing very heavy, very well armored vehicles with very powerful cannons. Unlike the other armored vehicles already sent to or on the way to Ukraine, MBTs are much more likely to survive an IED, land mine, rocket or artillery attack.

Highlights…

  • Leopard 2 tanks are very capable; well armored and with a very powerful cannon, highly mobile, durable and simpler to maintain than the US Abrams tank
  • there are thousands of them in more than 19 armies

  • The US Abrams is equally if not more capable, BUT…
    • guzzles fuel (although it can use jet fuel, gasoline, or diesel)
    • requires a lot more maintenance
    • is really heavy and thus harder to transport

Timing

These will not be there tomorrow…however I’d bet NATO countries will be sending tanks from their current units rather than pulling mothballed older versions and going through what could be a long and difficult process of upgrading them and preparing them for battle.

Then there’s spare parts, fuel, ammunition, training, repair and maintenance  personnel and facilities and transport. These are massive, very complex vehicles that require a lot of care and feeding.

Experts contend that Ukraine’s Army has shown itself quite able to learn complicated weapons systems quickly; it’s use of the HIMARS rocket system, artillery, and anti-ship missiles has been pretty impressive.

What does this mean?

This is a major move, one that will definitely improve Ukraine’s chances of retaking territory. 

That said, like any tool, it comes down to how well it is used. 


Jan
23

Hospital profit margins – a bipolar mess

For profit hospitals have very solid operating margins.

Some Not for profits are really struggling…others are doing just fine thank you.

credit FierceHealthcare.

That’s the headline – the question is…why? and what does this mean?

First, a little more explanation…

From the Kaiser Family Foundation’s report

So far this year [2022], operating margins among the three largest for-profit health systems in the country have met or exceeded pre-pandemic levels. HCA and Tenet in particular have had high operating margins.

the largest for-profit systems have had operating margins that exceed pre-pandemic levels. [emphasis added]

Also, most hospitals and systems saw declines in investment income; as this falls outside their core business, we are focusing on operating income which excludes investment and other categories.

Why?

It appears that the more profitable hospitals/healthcare systems:

  • saw surgical and other profitable service line volumes return to or exceed pre-pandemic levels
  • better controlled staffing costs; contract staffing costs (traveling nurses and other clinicians) were a major factor for several not-for-profit hospitals
  • benefitted from non-healthcare operations (insurance for UPMC) and financial gains from mergers (e.g. Intermountain Health)
  • increased prices for commercially-insured patients (this is an assumption although there’s this…)

The merger thing continues to be a major influence, with $45 billion in transactions in 2022 across 53 deals… again the results aren’t consistent as some systems really benefited while others did not.

Meanwhile, the American Hospital Association continues to call for higher reimbursement and other federal intervention to help hospitals financials.

For my workers’ comp readers…

Look at the costs of providing care at an HCA hospital vs some of the not-for-profit hospitals in your service areas. You will very likely find HCA’s costs are several times higher than not-for-profits’. 

Oh, and they are waaaay higher in Florida

More on this here.

What does this mean for you?

Don’t use HCA or Tenet facilities. 


Jan
18

Why hospital costs are going up

Because they can.

Healthcare  – and more specifically facility-based healthcare – is a very mature industry and – with one huge exception – exhibits all the hallmarks of such…continued widespread consolidation, shuttering of marginal locations and elimination of unprofitable business lines and centralization of core services.

The “huge exception” is margin compression and price reduction. When any other sector matures, competition becomes fierce and prices come down.

Not so in healthcare, where pricing is opaque at best, and more often opportunistic if not downright predatory.

Over the last 70 years, the percentage of hospitals in health systems has grown by a factor of ten. Unusual indeed is the standalone facility.

That decades-long trend continued in the 2010s, although the pace slackened somewhat as there were fewer hospitals to acquire.

The net is this – most healthcare markets are pretty consolidated, which means one or two systems have pricing power.

Those systems use that power to force ever-higher reimbursement from commercial payers – and workers’ comp.

What does this mean for you?

Facility costs are going up.

 


Joe Paduda is the principal of Health Strategy Associates

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