Insight, analysis & opinion from Joe Paduda

Sep
8

Medicare – quick factoids

There’s going to be a LOT coming out in the next two months about Medicare, so it may help to know a few things about the program to help put it in context.
– We spent over a half-trillion dollars on Medicare in 2010.
– That’s fifteen percent of total Federal expenditures.
– 48 million people were covered in 2010.
– The health reform bill (aka the PPACA of 2010) is credited with reducing Medicare costs by by $424 billion (net ten-year savings) over the next ten years, certainly a step in the right direction.
– That equates to a 3.5% annual growth rate – almost two full points lower than projected per-capita growth in private health insurance spend.
– Despite those reductions, costs will get to within whispering distance of a trillion dollars in ten years.
– All those reductions don’t come without pain. In fact, Medicare’s Office of the Actuary projects Medicare reimbursement rates will be lower than Medicaid’s…a result that may well lead to providers abandoning the system.
– Some of that pain may start January 1st, when physician reimbursement is slated for a 29.4% across-the-board cut.
So. We have – on the one hand, huge costs that are getting bigger despite aggressive efforts to slash growth. And on the other, we have consequences that look pretty daunting – dramatically reduced reimbursement that will almost certainly lead to access problems for beneficiaries.
What does this mean for you?
There are no simple, easy, painless answers. Every time you hear someone talking about one aspect of the issue (physician payment, impact on the deficit, access problems, reductions in payments to Medicare Advantage plans) remember there’s another side to the issue, another perspective that almost certainly can make a well-founded and reasonable counter-argument.
he super committee and medicare – KFF report on implications


Sep
7

Work comp conference – Two months and counting

The biggest national work comp get-together is – hard to believe it – coming up in two months. While I’m somewhat conflicted about the location (I like Chicago a LOT more than Vegas…) the event is always well worth the trip.
This year I’ll be on the podium helping to kick off the conference – along with Davidson Pattiz of Zenith and Dave North of Sedgwick, two gentlemen who don’t always agree with everything I say or write (shocking, I know). The idea is I get to pontificate upon talk about what will affect workers comp tomorrow, the condition of the industry today, and some of the problems I see, and then Davidson and Dave get to tell you where and how I’m wrong.
This will be fun.
Lest you fall for the pre-conference hype, the three of us have specifically agreed to foreswear violence, conduct ourselves with professionalism and respect each other’s opinions.
Except if we really disagree.


Sep
6

Work comp drugs – What works in Washington…

There has been a lot of discussion about the WCRI report on Washington State’s workers’ compensation pharmacy costs. Unfortunately a good bit of the discussion has been rather simplistic, citing some of the findings without placing those findings in the correct context.
Washington’s workers compensation environment is unique. As one of the very few (that would be three) states with a monopolistic workers comp fund, the state’s regulatory reach and control over all aspects of workers comp is broad and deep. Simply put, Washington state can dictate terms to all participants including employers, providers, pharmacies, and other stakeholders, terms that the stakeholders must comply with. Moreover, providers and pharmacies in Washington do not need to concern themselves with eligibility issues, questions about coverage or payment or fiduciary responsibility. Compared to other states, this is a markedly different operating environment for providers and pharmacies.
News stories following the study’s release of the report stressed some of Washington’s cost-containment tactics, implying that other states could replicate these tactics and thereby enjoy similar benefits. However, neither WCRI’s news release or subsequent media stories stressed that Washington is a monopolistic state with a single payer system without the eligibility issues existing in states with multiple payers (carriers, third-party administrators and self-administered employers).
For pharmacies participating in the workers comp system in Washington, the single-payer system eliminates confusion and work associated with identifying their customer’s workers comp payer. The defined formulary and coverage policies ensure pharmacies’ ‘risk’ associated with dispensing medications to injured workers is quite low as pharmacies are all but assured that their bills will be paid. Moreover, pharmacies are tied electronically to L&I, further reducing their administrative expense and workload.
This environment could not be more different than the one in non-monopolistic states, where determining coverage is a complex and tedious task often requiring multiple phone calls and letters; ascertaining formulary compliance is difficult and uncertain; and pharmacies must assume substantial financial risk for medications dispensed to injured workers.
Given the differences between Washington and almost all other states, it is abundantly clear that what works in Washington will not work in non-monopolistic states. While simplistic solutions are often attractive, they are also often counter-productive.


Sep
2

Medicare Fraud – what’s really happening

Everyone seems convinced there’s a ton of fraud in Medicare. And they may be right. What there wasn’t, for far too long, was much emphasis on finding and prosecuting the criminals stealing from taxpayers by defrauding Medicare.
Well, looks like that’s changed. This ‘story’ was first broken a week ago by Merrill Goozner, one of the more insightful observers of the health care scene. Here’s a piece from an OIG release quoted in Merrill’s post:
“Since their inception in March 2007, [CMS anti-fraud] Strike Force operations in nine locations have charged more than 1,000 individuals who collectively have falsely billed the Medicare program for more than $2.3 billion.”
CMS’ anti-fraud efforts are finally getting some press. For instance, prosecutions are up 85% over last year. Compared to five years ago, there’s been a 71% increase. It takes quite a bit of time to develop a prosecute a health care fraud case, as laws and regulations are quite complex and often confusingly contradictory; following the paper trail is difficult at best; and company ownership and fiduciary responsibility usually hard to identify and even more difficult to prove; thus it’s no surprise it’s taken a couple years for the Obama Administration to start to produce major results.
According to the piece in FierceHealthcare;
“The government prosecuted 903 cases of healthcare fraud, up 24 percent from last year, reports USA Today. The increased numbers come from more investigations under the close attention of the Federal Bureau of Investigation (FBI) and the Medicare Fraud Task Force, as well as the participation of whistleblowers. The FBI recently changed their focus to target criminal enterprises, including hospitals. In 2010, the government paid out $300 million to whistleblowers.”
Health care geeks may recall that the PPACA was supposed to deliver $4.9 billion in savings over ten years due to better controls over fraud and abuse. Looks like that was a ‘gimme’, as the GAO reported savings in 2010 alone were $4 billion.
These prosecutions often netted criminals defrauding commercial insurers as well as we taxpayers – one case in Puerto Rico nailed hundreds of crooks who stole $7 million from AFLAC.
Another CMS-led effort earlier this year resulted in indictments of 111 individuals for allegedly defrauding Medicare of $225 million.
That’s all to the good – perhaps as much for the ‘Sentinel Effect’ as for catching these thieves. Others who may be tempted to steal from the Feds or commercial payers may be a bit de-motivated when they hear about prison terms and hefty fines levied against others with the same idea.
There’s no question Medicare is a prime target for crooks large and small. After all, it’s a program that pays out billions each year, so there’s bound to be fraud. Commercial health plans, workers comp insurers, and other payers are certainly vulnerable and often victimized as well. Here’s hoping the recent press attention leads to even more attention on fraud, and more convictions as well.
What does this mean for you?
Are your SIU people tied into the CMS Strike Forces, sharing information and collaborating on investigations?


Sep
1

The Super-Committee; 83 days and counting

In MCM’s ongoing effort to keep our loyal readers apprised of things that will affect their businesses, it’s time to remind one and all that the Super-Committee’s budget cuts are due in less than three months.
Yep, in 83 days or so, six Republicans and six Democrats are supposed to come up with (at least) $1.2 trillion in cuts. If they don’t, automatic cuts will be triggered beginning in 2013, including a two percent cut in Medicare (and that’s assuming the pending SGR cuts hit on January 1…)
Couple of key points that bear mentioning;
1. the $1.2 trillion is spread over the next decade. Cuts could be back-loaded to minimize political fallout – and probably will be (if the group reaches agreement)
2. the automatic cuts take effect January 2013 – a lifetime away in political terms. Congress could do something else to prevent some of the automatic, or Group of Twelve cuts from occurring, modify the cuts, or pass a “fooled you, we were just kidding” law.
Back to the committee. As we’ve noted, it’s difficult to see how they can hit their target unless health care is addressed.
There’s no consensus on whether the twelve will manage to reach consensus or not. With an election year coming up, it’s hard to see how the GOP’s folks will agree to any kind of revenue increases, while Dems have been quite public about their intent to prevent cuts to entitlements. And if they don’t, as Steve Davis noted in an online piece on AISHealth, “Across-the-board reductions in Medicare payment could translate to more cost shifting by providers, which could lead to higher premiums charged by commercial plans and/or increased cost shifting onto employee-based coverage”.
That said, there’s some hope that statesmen-like traits will somehow take hold in the group and we’ll actually see them arrive at a grand bargain. If such a happy event occurs, expect to see:
– subsidies for Medicare Advantage programs cut
– a potential increase in eligibility age for Medicare recipients
– decrease in hospital reimbursement under Medicare
– means testing premiums for Medicare

You’ll note these are all focused on Medicare. Medicaid is unlikely to be cut dramatically – but then again, we just don’t know.
This all supposes the SGR cuts to physician reimbursement actually take effect on January 1 2012 – which is about as likely as our house getting power this week (no chance at all). If it doesn’t, there’s another $300 million or so in cuts that will have to be made.
What does this mean for you?
Watch carefully what happens with the Super Committee…It WILL affect you.


Aug
30

Goodnight Irene

We dodged a bomb.
Here in New England, it always seems the greater the media coverage around weather events, the less dramatic the impact when the actual events hit. Fortunately Irene was no exception. That’s not to minimize the impact of Irene and especially the devastation in Vermont and upstate New York; reports indicate the damage far inland far exceeds what those of us on the coast experienced. While we are without power – and likely will be for another week or so – that’s a minor inconvenience in comparison.
The silver lining of Irene’s dark cloud is the impact on insurance markets. While irene’s bill won’t be large enough to turn the market harder, it’s likely to have more of an additive effect, coming as it did on top of the tornadoes, tsunami, and flooding earlier in the year. The sum of all these events will certainly help to firm up the P&C market and not just in property lines. Insurers are looking for any reason to increase rates and this latest event may well push a few more to tighten underwriting and raise premiums.
We would do well to remember we are nowhere near the end of hurricane season; Irene has relatives that may come calling this fall and they may be nastier still.


Aug
25

Mark Walls and Greg Krohm on the future of work comp

The last two speakers at IAIABC were Safety National’s Mark Walls and IAIABC Executive Director Greg Krohm.
Mark’s major concern is health reform will lead to access problems, especially with specialists such as orthopods and neurosurgeons. This may lead to delays in care for work comp patients.

Comorbid conditions are also problematic,
driven by obesity, diabetes, and other lifestyle/choice related issues. Work comp has to pay for these conditions, albeit indirectly due to longer disability and more costly medical treatment.
Medical costs are a huge problem, and quality of care is the desired goal. Mark noted there are several related factors, including the number of ‘bad docs’ in the comp system. 4% of docs in Louisiana accounted for 70%+ of medical costs; Mark also cited Alex Swedlow’s data on over-prescribing of opioids in California and physician dispensing of medications as additional evidence of the difficulty in controlling costs when physicians are more interested in making money rather than treat appropriately.
Other cost drivers include use of Actiq in workers comp, a drug that is only approved for cancer pain. Mark pointed out that the state of Washington and Texas have dramatically limited the use of Actiq in their respective states, and called for other states to take similar action.
Greg – who will be retiring as Executive Director at the end of this year – closed the meeting. His forecast was positive and pretty cheery, as he believes disability will be reduced, frequency will continue to decline, and workers will get good care quickly and their wages replaced in full and rapidly.
Greg’s been a very effective leader, and his replacement will be filling mighty big shoes.


Aug
25

Work comp’s future – IAIABC’s closing session

Three speakers in the final IAIABC session focused on the future of workers comp and factors affecting same. Allen Hunt of the University of Wisconsin started out discussing the factors contributing to the current deficit. In a nutshell, he doesn’t see the deficit as much of a problem. To support that statement, he shared a slide indicating the deficit was pretty much under control until the Bush tax cuts, wars, and economic downturn, and even after accounting for those issues the deficit just isn’t that significant when considered as a percentage of GDP.
Taxes aren’t high relative to our industrial competitors; overall tax revenue as a percentage of GDP is well under the OECD average of 44.8%; US tax revenue is 26.1%.
What really surprised me was the growth in the number of disabled workers, which has more than tripled since 1981 and is rapidly nearing a million working-age Americans.
Dr Hunt shared a good bit of information about the economy and changes thereto over the last thirty plus years and closed with his predictions for the future of work comp. The takeaways are this
– the injury rate (frequency) will continue to decline – declining employment in blue collar industries, better disability and claims management will drive the rate down for the foreseeable future.
– the underwriting cycle will continue – this is the soft/hard market cycle known all too well to us old-timers.
– Dr Hunt believes there are lot of WC claimants who are finding their way into the Social Security System and this may well continue.
– the percentage of 25-54 YO men who are not working has grown from about 2% in 1967 to 8% in 2003. More and more people are being pushed out of the economy – for whatever reason.
Dr Hunt’s top threats are:
– Political polarization and focus of political gain over solving problems
– Medical cost containment has been a failure
– Wage and employment trends aren’t looking good – the number of workers is not increasing, and given the slow employment recovery it will take another eight years to get back to pre-recession employment levels
– Over-reaction to the deficit threat – Hunt believes strongly that this has been much ado about very little.
– OASDI (Social Security) costs – can be dealt with if taxes are increased by a very small amount.
– commitment to work – Dr Hunt closed by saying we are all soft now…


Aug
24

Work comp claim reserves – not good, but not too bad either

Yesterday’s PropertyCasualty360 reported on FitchRatings’ latest views on the status of reserves in the Property and Casualty (P&C) insurance industry. For those new to this world, ‘reserves’ are the funds set aside to pay the future costs for claims.
Reserves can be “adequate”, which means the dollars set aside look to be enough to cover future liabilities; “deficient”, which means there aren’t enough funds; or “redundant”, which means they are more than adequate. In Fitch’s view, “U.S. property and casualty loss reserves remain within an adequate range as of year-end 2010, and the potential for large deficiencies emerging in the near-term is limited”.
That’s good news, but before you start smiling, know that another analyst views reserves as “deficient”.
So, who cares?
Well, you should.
If reserves are adequate, insurers won’t need to charge new policyholders more to make up for losses already incurred. If they are deficient, rates are going up. And if they are redundant, than new customers may well get a discount, as there is ‘extra’ money lying around to help cover their claims.
It’s not quite that simple, but you get the picture.
What is notable is where the two analysts agree: both believe workers comp is under-reserved. Keefe Bruyette Woods says the deficit is $2.3 billion and Fitch did not provide a figure in their release.
With work comp reserves at the end of 2010 totaling about $115 billion, that’s a deficiency of about 2%.

What does this mean for you?
Another sign that the market may be firming. Or at least not softening any more.


Aug
23

Off to IAIABC…

OK, vacation’s over, and mail box is (almost) cleaned out. So here’s what’s happening this week.
The annual IAIABC conference is underway in Madison Wisconsin. The International Association of Industrial Accident Boards and Commissions is the trade group for the people who regulate workers comp in the US, Canada, and several other countries.
Among the sessions is one on the origin of workers comp in the US – which, fortuitously, occurred in the same town. This will be a great opportunity to take a step back and reflect on what WC is all about, how it has evolved, and think about where it needs to go. And how it can get there.
IAIABC Executive Director Greg Krohm has an editorial in yesterday’s Milwaukee Journal-Sentinel on the subject; here’s an excerpt.

Worker’s compensation was developed in an era when organized labor and employers were at each other’s throats. Labor was pushing for higher wages and better working conditions. Management wanted to rid itself of never-ending lawsuits from work accidents. Both sides, despite their heated arguments, came together to compromise and build something that was better for both sides.
This pragmatic spirit of cooperation in worker’s compensation is especially ironic given the supercharged political climate in Wisconsin of late.

I’m on a panel Thursday discussing the issue of addiction in workers comp. The experts are Gary Franklin MD, medical director for Washington state Labor and Industry (their work comp state fund). Gary’s been a driving force behind Washington’s effort to address addiction in work comp. Tom Jan DO will lead off the panel; Tom’s a pain management doc with extensive expertise in addressing addiction in comp on the patient level. He brings a real-world, street-level perspective that adds much needed perspective; often we policy geeks get too ‘intellectual’ about a problem that destroys lives and families.
This is also the week of the Florida Work Comp Conference; one of the largest in the country with a wealth of good information along with lots of ‘entertainment opportunities’. The quality of the show is even able to get people to Orlando in August…
Meanwhile there’s another news item that work comp payers should be watching.
On the economic front, work comp insurers and TPAs are a bit happier these days as employment seems to be reviving somewhat; payrolls were up in 31 states last month and the overall jobs picture brightened. The upper midwest led the charge with Michigan employers adding 23,000 jobs. To put this in context, things have been pretty dark on the employment front lately, so even a bit of light is welcome. We’ll get a bit more perspective soon as there’s a jobs report due out on Thursday that will help indicate if things are in fact improving or if we’re just bumping along…


Joe Paduda is the principal of Health Strategy Associates

SUBSCRIBE BY EMAIL

SEARCH THIS SITE

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.

 

DISCLAIMER

© Joe Paduda 2025. We encourage links to any material on this page. Fair use excerpts of material written by Joe Paduda may be used with attribution to Joe Paduda, Managed Care Matters.

Note: Some material on this page may be excerpted from other sources. In such cases, copyright is retained by the respective authors of those sources.

ARCHIVES

Archives