Insight, analysis & opinion from Joe Paduda

May
24

UPDATE – Just amazingly dumb.

UPDATE – this story gets ever more bizarrre; Business Insurance had a piece describing how employees at the party were snorting salt.
Right, that was my reaction as well; wha…SALT?? UP THEIR NOSE??
what the heck were they thinking? And is it somehow better that the folks in the pictures were inhaling salt and squeezing limes into their eyes rather than snorting coke?
Jeez, I thought I’d seen sales folks do some dumb things but we Americans can’t hold a candle to the Germans!
For those interested in photo documentation, click here. Note – the photos are from a German tabloid, and their standards for what is suitable for publication may be different from what you’d expect…
several credible sources , including the company itself, indicate >HM Insurance rewarded their top sales personnel (men, I assume) with a night to remember in the Gellert Thermal Baths.
What made this so special was not only the setting; the Gellert Baths are one of the more historic sites in Budapest; or the cost, a reported 83,000 Euros; or the sponsor (an insurance company!!). No, what made this unique was the reward for those reps who consistently performed.
budapest-gellert-pool_chop1n.jpg
(photo credit to adventurouskate.com)
Twenty prostitutes were there to personally congratulate the top sales staff, conveniently positioned in four-poster beds located around the edge of the central pool.
I kid you not.
Here’s how one attendee remembered the soiree:
“Anyone could go to one of the beds with one of the ladies and do what he wanted. The ladies were marked with stamps on their forearms after each such meeting. So it was recorded how often each lady frequented.”
“The ladies wore red and yellow wrist bands. One group were there as hostesses, and the others were to fulfill any and every desire,” he added. “There were also ladies with white wrist bands. They were reserved for the board and the very best salesmen.”
So, not only were they idiots, they were misogynistic idiots.
What’s almost as amazing as the fact that this occurred at all is the somewhat blase’ way the company is addressing this now.
Then again, maybe that’s just brilliant PR.


May
23

Work comp TPAs; more consolidation

A well-placed industry exec shot me a note late last week re yet another TPA deal; Ohio-based Avizent will buy FARA, a Louisiana-based TPA.
Terms weren’t available, but there’s a bit of an outcry over the deal from some folks in Louisiana. Evidently FARA recently took over administration of the State’s Office of Risk Management as part of Gov Bobby Jindal’s privatization initiative. The deal was worth some $68 million to FARA (there was an increase of some $7 million that sparked heated comments by at least one LA legislator).
That increase seemed to fall just within the boundaries of the law, which enable an agency to increase funding up to 10% of the original contract value.
There are a couple other potential deals out there now; xChanging (formerly Cambridge) is rumored to be close to a sale to one of two very large TPAs.
I’d expect more to come in the not-too-distant future.
Much more.


May
19

Gingrich on health care

For several years, Newt Gingrich was one of the more interesting voices in the health care policy world. He joined obscure policy entities, developed interesting ideas, promoted the use of technology as a BIG part of the solution, wrote a book, and sat on committees dedicated to improving quality.
That was then, this is now.
Interestingly, many of the ideas Gingrich now assaults he supported less than a decade ago.
Some of the people he decries he sat next to on policy panels and publicly praised.
Here’s an excerpt from an excellent piece by Michael Millenson:
“Gingrich-as-health-wonk for years advocated reforms such as “data-driven reimbursement” informed by best practices, a national electronic health network and a focus on prevention and wellness. All those items — and others Gingrich supported — are contained in the HITECH Act, part of the budget stimulus package and the Affordable Care Act…
a former colleague of Newt’s on [the National Commission on Quality Long-Term Care] is now one of the Obama administration’s most prominent health care bureaucrats, Dr. Donald Berwick. Back then, New Newt must have listened and learned, since in his book he praises Berwick’s quality improvement work. But today’s Old Newt told Fox News’ Bill O’Reilly that Berwick’s appointment as head of the Medicare program was just another example of Obama’s “secular Socialist machine.”
And yes, this is the same Newt Gingrich who’s now backtracking as fast as he can from his scathing comments about Paul Ryan’s Medicare plan.
I know, I know, this is just politics.
I know, I know, the ‘news’ that a politician is being hypocritical and intellectually dishonest is NOT news.
I wish it was.


May
18

AWP isn’t going away

Average Wholesale Price – the much-declaimed pharmaceutical pricing metric – is not going away anytime soon.
Certainly not this fall, and very likely not next fall either.
AWP is published by several firms, including Wolters Kluwer. WK’s version, branded Medi-Span, was supposed to be sunsetted later this year, a result of a legal settlement. That is not going to happen, for the simple reason that buyers, sellers, pharmacies, PBMs, payers, Medicaid agencies and pharma can’t find a suitable alternative.
As WK stated, “Wolters Kluwer Health intends to publish AWP (or a similarly determined benchmark price) until relevant industry or governmental organizations develop a viable, generally accepted alternative price benchmark to replace AWP.”
While stakeholders did agree on using WAC (wholesale acquisition cost) as a potential substitute, WAC is suitable primarily for brand drugs, as it does not apply to multi-source (generic) drugs. It also suffers from some of the same problems as AWP – WAC is the “list price” and doesn’t reflect rebates, discounts, allowances, or other price concessions. That means, it really isn’t the actual price – here’s how one knowledgeable group put it:
“Wholesale Acquisition Cost” prices are currently available for many, but not all drugs. WAC may be susceptible to the same concerns that rendered AWP ineffective: it is a manufacturer-reported value not readily amenable to audit, and there is no reason for confidence that it could not ultimately be inflated well beyond any actual market price. Particularly since it has been defined in federal law as an “undiscounted list price” WAC would require continuous adjustments (markups or markdowns) by states based on acquisition cost surveys.”
There are also other AWP publishers which are not affected by the legal settlement. Gold Standard, and Thomson Reuters have not revealed any plans to stop publishing.
What does this mean for you?
AWP is here for the foreseeable future; it’s pretty flawed, but it’s better than any of the alternatives out there today.


May
17

Work comp claims systems – the webinar’s coming up

From the “shameless commerce division” of Health Strategy Associates, LLC – a Webinar reporting on our First Annual Survey of Workers Comp Claims IT Systems is coming up later this week – Thursday from 1:30 – 2:30 pm eastern, to be exact.
The Survey obtained input from front-line folks and execs in claims and IT, and we’ll be comparing and contrasting responses to show where there’s a disconnect/differences in opinions between the two groups. You’ll also find out about:
– decision processes,
– what execs are looking for in their new systems,
– the limitations of their current systems,
-pricing methodologies, and
– respondents’ opinions on vendors.
You can sign up by clicking here.
The webinar will be conducted by myself and Sandy Blunt; all attendees will get a detailed copy of the Survey Report as well.
From the Survey, here’s one not-surprising-and-quite-revealing item:
88% of the front-line representatives and managers said their current system is NOT fully integrated with their bill review and utilization review system (75% wish that it was); conversely, 68% of the executive leadership responses state that their system IS fully integrated with their bill review and utilization review system.
Lots more to present on Thursday at 1:30 eastern.


May
16

Health Reform’s impact on Medicare

There’s been a good deal of complaining about the future costs of health care under reform, some of it justified, some not. In particular, the release of the Medicare Trustee’s report last week noted that the date when Medicare intake is lower than outflow has gotten nearer due to the poor economy.
There’s a misconception here.
Reports indicate “The Medicare hospital insurance fund will be exhausted in 2024, five years earlier than last year’s estimate, government accountants now figure.” That’s NOT what the report says. In reality, the HI fund will not be exhausted, but rather insufficient to pay ALL projected hospital costs. In 2024, it will be able to cover 90%, slowly decreasing to 75% in 2048 than back up near 90% in 2085.
However, even that overstates the problem, as it is highly likely the IPAC’s provisions will kick in to reduce costs well before then. I’d also note that the Medicare Actuary predicted reform would add thirteen years to the HI fund’s adequacy; the new figures cut that to an eight year addition due to reform.
As Maggie Mahar pointed out:
“Today [last Friday, actually] the Trustees affirmed that “projected Medicare costs over 75 years are about 25 percent lower because of provisions in the Patient Protection and Affordable Care Act.” The Trustees highlight one plank in the ACA that will save tens of billions by reducing “the annual payment updates for most Medicare services (other than physicians’ services and drugs.)”
Here, the Trustees are referring to the provision in the legislation that shaves Medicare’s annual increases in payments to hospitals, skilled nursing facilities, home health agencies, and other institutions by 1 percent a year, for ten years, with the goal of spurring them to become more efficient. This means that if, in a given year, hospitals normally would receive an adjustment from Medicare that raised reimbursements by 3%, under the new law their reimbursements would climb by just 2%. (Note: this provision does not apply to doctors, only Medicare Part A providers.) Over the decade, the Congressional Budget Office estimates that this change will save $196 billion.”
This is not to say Medicare’s cost problems are nonexistent – far from it. We absolutely have to get costs under control. The ACA is part of the answer; increasing revenues and reducing expenditures are two other parts of the solution. Of course, we can eliminate the need to increase revenues if Medicare starts negotiating drug prices and Congress eliminates some of the dumber provisions of the Medicare Modernization Act.


May
13

M&A – what’s happening next in the work comp world?

While there weren’t a plethora of deals announced at RIMS last week, that’s not due to a lack of activity.
The pending changes to tax rates (without another extension, capital gains will go up at the end of 2012) make it imperative that deals get closed before 12/31/2012. But it’s not just the tax code that’s driving activity. The continued soft market and drop in frequency during the recession have been particularly tough on TPAs; many work comp service companies are also hurting, while others look to be nearing the end of their initial run and readying themselves for the ‘equity event’.
Among TPAs, xChanging is nearing a deal to sell its former Cambridge TPA. A couple of suitors are still in the mix, both are big TPAs looking to get even bigger. Expect this to get done within a month or so, and at a price that will surprise.
The Align Networks deal is moving forward as well, with the field of potential acquirers now narrowed down. Financial suitors are rumored to be quite interested, but there remains interest from some looking to combine Align with other assets. I’m speculating here; my guess is it will be a financial buyer smitten by the company’s rapid growth and rosy outlook.
Unless… someone buys both Align and Universal SmartComp and puts them together in a bid to topple MedRisk (current HSA consulting client) from its long held position as the dominant player in the work comp physical medicine sector. I don’t see how that would work as the business/operational models are markedly different. Moreover, a lot of the ‘value’ of the assets lies in their network contracts, which would be redundant in any deal.
There are a couple of other deals rumored to be in the offing, but nothing verifiable as of yesterday. We’ll keep you posted.
Finally, there were rampant rumors at RIMS that one of the big PBMs was about to be sold; not true.


May
12

Family health insurance costs near $20 grand

Actuarial consulting firm Milliman reported recently that the average American family’s health insurance costs are now over nineteen thousand dollars. Costs have more than doubled in the last ten years.
CORRECTION – Families are paying over $8000 towards the cost of insurance – “$4,728 in employee contributions and $3,280 in employee out-of-pocket cost…”
Think about that.
If medical inflation rates stay the same, we’re looking at the cost of family health insurance hitting $30k a year in six and a half years.
And over $40,000 four years after that.
Of course, trend could accelerate…
If there’s any good news, it is that under health reform, both insurance premiums and out of pocket costs won’t be as much of a killer for those at lower income levels. Out of pocket costs including deductibles will be indexed to income, as will premiums which will be subsidized for those with incomes below 4 times the poverty level (about $88,000 in today’s dollars).
thanks to Jane Saransohn-Kohn for the heads up.


May
11

Examworks – questions I hope someone asked

Update (correction re revenue figures) While flying home from LA yesterday, thru the miracle of airplane wifi I got a note from a colleague stating “MES contributed $13.2 million in revenues in the first quarter of 2011. MES had approx. $129 million in revenues for 2010 (a run-rate of approx. $32 million per quarter).
Am I reading this right??” the net is not exactly, but the earnings report does raise. Few questions.
For those not immersed in this tiny little business, Examworks is a rollup of IME firms, companies that contract with independent doctors to do Independent Medical Exams, primarily for workers comp insurers. Among several other acquisitions last year, Examworks bought MES for some $175 million in cash plus $10 million in assumed debt plus 1.4 million shares of Examworks stock (worth about $25 million) for a total of about $210 million .
If their new acquisition generated about forty million for the first three months of 2010, (deal closed 2/28, so the $13 million was for one month) the obvious question is “was it worth $210 million?”
My colleague was referencing yesterday’s earnings release which was followed by a press conference/call last evening. I didn’t hear the call, so don’t know what was said (will see the transcript by the end of the week). As my investment portfolio demonstrates quite convincingly, I’m no Warren Buffett. But I do know a bit about this business, have helped on a few private equity deals, and can operate a calculator with some facility.
MES’ 2010 EBITDA was about $23.4 million. So, Examworks paid a 11x multiple for MES, a rather princely price. Especially given the Q1 revenue figures.
So, if I was on the call – which I was not – I’d want to ask:

How’s that MES deal?
Have you been able to negotiate more favorable rates with your physicians, and if so, how much lower?
What savings are you seeing from synergies? What kind of synergies have you found?

Here’s hoping someone did.


Joe Paduda is the principal of Health Strategy Associates

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