Insight, analysis & opinion from Joe Paduda

Aug
23

Defining work comp medical cost ‘savings’

Posted by Joe Paduda on Monday, August 23rd, 2010 | Comments

In the course of my consulting practice, I see a lot of work comp medical bill review ‘savings’ reports. Over the last fourteen years (since founding Health Strategy Associates in 1996) I’ve collected, reviewed, and analyzed scores of savings reports from pretty much every vendor in the business – as well as many of the larger TPAs and insurers.
There’s some consistency in the business, but not near enough. That alone makes it hard to compare one vendor to another, much less benchmark one company’s performance against the industry.
Leaving that aside, there are a number of issues with most reports, issues that clients/insureds/policyholders would do well to consider when evaluating performance or comparing potential vendors.
1. Does the savings report include reductions below state fee schedule (SFS) and/or Usual Customary and Reasonable (UCR)? Many vendors don’t split out savings below SFS/UCR, instead lumping all reductions into one ‘overall’ category. This is either a) an oversight as any vendor should be willing and able to demonstrate their ability to reprice bills to comply with regulations, or b) a way to inflate savings so the naive buyer sees a bit percentage reduction and thinks the vendor’s doing a crackerjack job.
2. Does the savings report clearly identify the source of UCR data? There are several vendors out there that provide these data, and knowing which is important in evaluating performance.
3. How are savings percentages calculated? Do they include savings for duplicate bills or duplicate line items (they shouldn’t). Do they include all types of care, such as pharmacy and imaging? In many instances these services are outsourced to specialists, requiring the customer to combine results to get an overall figure.
4. For pharmacy, savings should be reported using AWP as the benchmark – if the vendor wants to include SFS, that’s fine, but AWP (and make sure they define the source) is the universal standard.
5. How is network penetration calculated? Is the basis the number of bills or dollars? Dollars are preferred, but may skew the numbers higher than number of bills, as network penetration tends to be higher for facilities (which have higher average bill charges).
6. Over time, have you seen a decrease in fee schedule reductions and an increase in so-called ‘nurse review’ or ‘bill audit’ or ‘professional review’ savings? Hint – if these are billed separately, there’s often an inherent motivation on the part of the vendor to lowball SFS reductions in favor of these ‘other’ reductions.
7. Semantics and definitions. Make sure there’s a clear and complete understanding of each and every term, including such seemingly-obvious ones as ‘bill’ – can be a ‘staple’, a single page, a date of service, or ‘up to x lines’.
What does this mean to you?
There’s lots more to this, but the message should be clear – don’t assume you understand the report, ask lots of questions, consider how the vendor gets paid, and don’t hesitate to ask the vendor to revise the report to give you the information you need the way you want to see it.
After all, you’re the customer.

Aug
20

Work comp claims systems – the state of the industry

Posted by Joe Paduda on Friday, August 20th, 2010 | Comments

It’s hard to overstate the importance of the claims IT system in workers comp.
Systems directly, and materially, affect: productivity; compliance; claimant and policyholder satisfaction; medical costs; litigation rates, expenses, and outcomes; administrative expense (both unallocated and allocated); claims cost; employee retention and satisfaction; and ultimately growth, revenues, and profitability.
To date there hasn’t been a comprehensive survey of claims systems providing insights and data on features, trends, user satisfaction, key attributes, cost, flexibility, connectivity, issues and problems.
That’s about to change.
Next month Health Strategy Associates will conduct the First Annual Survey of Workers Comp Claims Systems, gathering input from all stakeholders including IT executives, claims executives, managers, and desk adjusters. The results of the survey will be available early in the fourth quarter, with an executive summary available at no cost to interested parties.
Management responses will be gathered in a structured telephonic interview format, while an online survey instrument will be used to gather responses from desk-level experts. Input from the two groups will be compared and contrasted, and we’re betting there are areas where the folks ‘on the front lines’ see things a bit differently than the people ‘in the management suite’.
Sandy Blunt, former COO of the Ohio state workers comp fund and former CEO of the North Dakota state fund, is running the project, and we couldn’t have a better leader. Sandy’s been intimately involved identifying requirements, selecting systems, comparing vendors, assessing performance, and designing workflows. His leadership will ensure the Survey is as practical as it is timely.
If you are interested in participating in the survey, send an email to Sandy at SBluntAThealthstrategyassocDOTcom.
Participants will receive a detailed version of the Survey Report.
We anticipate this will become an annual Survey, one of the series of Surveys conducted by Health Strategy Associates as we continue to help work comp payers, providers, and stakeholders make more informed decisions.

Aug
19

Implementing Health Reform – Health Wonk Review reports

Posted by Joe Paduda on Thursday, August 19th, 2010 | Comments

Now that health reform is the law of the land, the focus has turned to implementing the law itself. As anyone knows, the real work, and the real impact, is in the details, the definitions, the requirements and operating guidelines.
And that’s what this edition of HWR is all about.
Fundamentals
Let’s begin this edition of HWR with a quick review of the fundamentals – starting with Tinker Ready’s reminder that “All health care is local.” Actually she’s channelling Atul Gawande in her report on his talk at the National Quality Colloquium this week. Gawande’s summary of why that’s the case is a very helpful reminder as we contemplate implementing reform.
My contribution to this edition asks the rather uncomfortable question “Managing health care costs – whose job is it?” WIth health plan associations whining about the lack of cost controls in the reform bill, one has to ask – exactly what function do health plans perform? If they’re asking the government to control costs, what is their purpose?
Friend and colleague Gary Anderberg is guest-posting over at Workers Comp Insider this biweek; Gary’s post is similar to Tinker’s in that his focuses on health insurance, and the services covered by insurance, are really ‘risk management tools’ to help maximize productivity. True True True, and a wonder more don’t think the same way…
On the “Good News’ front,“Congratulations If You Were Born Between 1952 and 1964” takes a look at the recently released report that shows health reform just extended the financial solvency of the Medicare Part A Trust Fund by 12 years. Brad Wright also stresses that we’re not out of the woods with the cost problem–2029 isn’t that far away–and we need to realize that this isn’t a problem we can solve, as much as it’s a tension that we have to figure out how to navigate.
In that vein, the always-insightful Jason Shafrin tells us the real story re the impact of reform on state budgets – not too good, but not too bad, either.
Reactions to reform
The opposition to reform continues to make its case; Anthony Wright documents the ongoing efforts by Anthem Blue Cross of California to stop California’s health insurance exchange. Anthony opines Anthem’s actions “should be a clarion call for California consumers about why we need to advance these bills, this year.”
In a related post, Roy Poses digs deep into Wellpoint’s rate increases, and finds out that the employee tasked with announcing the increases had serious concerns, concerns that may have led to her termination. As always, Roy finds the truth and does some of the best reporting in the blogosphere.
These last two stories are particularly important, because as Aaron Carroll warns us, insurance companies are very good at what they do. Which in this instance is risk selection. Talking in this case about Medicare HMO enrollment, Carroll elaborates:
“Somehow the private insurance HMOs figured out a way to get the healthy people to jump ship out of the another plan into theirs!
Not only that, but people who left the (private) HMOs and went back to the (public) Medicare used 180% more care after leaving than the people who stayed. Somehow the private insurance HMOs figured out a way to convince the sicker people to jump ship back to the public plans.”
Jaan Sidorov notes that “the odds against prevailing against a Presidential veto are..questionable and the waste of political energy would be atrocious.” But Jaan does think that the bill can be improved, and offers serious ways opponents should move.
The always -informed and -informing Maggie Mahar thinks the liberals/progressives who are hoping the anti-reform folks succeed (as it will usher in a single payer system) are basing their hopes on faulty assumptions, namely that Americans will like a Medicare-for-all plan. Maggie notes “A great many Americans have employer-based insurance that they like–particularly if they work for large companies. They don’t want to give it up for an unknown government plan.”
Maggie adds: “we’re all lucky that large companies are covering so many people with benefits that are, on average, rich and comprehensive.”
EHR, benefits, and babies
One of the keys to health reform is widespread adoption of Electronic Health Records; David Blumenthal and Dr Don Berwick (yes, the same Don Berwick who runs CMS) document the significant progress being made in that direction, emphasizing the new regs on ‘meaningful use’. Anyone remotely involved in EHR should read their post…
But before we adopt those EHRs, make sure to shred the patient records – or suffer the consequences described by David Harlow.
Implementation is all about the details – and there are bazillions of them, all critically important to those directly impacted. Jay talks about maternity coverage, and the absence of clarity about same in Colorado – even though all plans are supposed to provide coverage as of 1/1/2011…
Ryan opines that health plans authorized by the Feds should cover birth control, but only because we own the consequences if we don’t.
All carrot and no stick – Innovation in insurance – oxymoronic to some, just plan moronic to others (sorry, couldn’t resist). Our old friend and colleage David Williams writes about the problems realizing the potential of Value-Based insurance Design, noting “in practice most VBID programs encourage the use of high value services but don’t discourage the use of low value services.”
Important in their own way
Kinda-but-not-really related is this piece from Adam Fein of DrugChannels, who broke the story about CMS’s quest for a vendor to survey retail prices, payment, and utilization rates for pharmacy – as well as wholesale pricing. Could this lead to a substitute for AWP? Dare we hope?
Joanne Kenen reminds us why the ER is no place for palliative care, providing insights into what happens there – and more importantly – why.
John Goodman calls Medicaid “the most abusive health plan of all” in his post. Goodman bases his claim on states revising Medicaid enrollment and eligibility requirements, calling them ‘rescissions’. Ed. note – the reason most of these folks lost their coverage is the states where they lived ran out of money to fund Medicaid. Tax increases would’ve solved that ‘problem’…
Finally, over at InsureBlog, Mike Feehan says health plans should keep their reserves, no matter what Consumers’ Union thinks.

Aug
18

Medical foods and workers comp

Posted by Joe Paduda on Wednesday, August 18th, 2010 | Comments

The good folks at CWCI just published a research report (The Cost and Utilization of Compound Drugs, Convenience Packs and Medical Foods in California WC) documenting the rise in spend on medical foods, repackaged drugs, and compound drugs from 2006 – 2009; the highlight is these categories accounted for almost 12% of drug spend in California in Q1 2009.
A couple of the findings that jumped out at me…
– the average amount paid per compound drug as $728 in Q1 2009.
– medical food reimbursement hit $233 per script that quarter
– a new category, ‘co-packs’ has emerged as a significant therapy; these are combinations of drugs with medical foods dispensed as a single unit.
The story of drug costs and attempts to address same in California is fascinating, with lessons aplenty for regulators and payers.
– A drastic reduction in the fee schedule was followed by explosive growth in repackaged drugs.
– Regulatory changes finally addressed that issue, but meanwhile the use of narcotic opioids increased six-fold, likely negatively impacting disability duration as well as increasing cost.
– New entrants into the therapeutic armamentarium, entrants that are foreign to many adjusters, case managers, and work comp execs alike, are growing in importance, requiring regulators and payers alike to understand their impact and develop policies for coverage and reimbursement.
The list of medical foods includes Theramine, Gabadone, Sentra, Apptrim, Trepadone, and others, with Theramine (pain) and Sentra (sleep aid) accounting for over half of the volume in California. Medical foods are pretty new to me; according to the Orphan Drug Act (1988 Amendment), a medical food is “a food which is formulated to be consumed or administered enterally (orally) under the supervision of a physician, and which is intended for specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.”
I’m no pharmacist or clinician, and am certainly not able to comment on the efficacy of medical foods or specific medications. For a primer on medical foods, click here.
There does appear to be evidence supporting the use of medical foods for treatment of pain, osteoarthritis, and other conditions, with one medical food, Limbrel, the subject of large, double-blind, placebo-controlled clinical studies in the United States and Japan. According to one source, “Limbrel administration has resulted in statistically significant improvement in all primary clinical endpoints (functional mobility, functional stiffness and functional joint discomfort).”
What does this mean for you?
If your P&T Committee hasn’t looked at medical foods yet, you may want to add it to the agenda for the next meeting. It is highly likely we’re going to see more of these scripts, and far better to be ready than to have your adjusters making decisions completely unprepared.

Aug
17

The cost of forgoing care

Posted by Joe Paduda on Tuesday, August 17th, 2010 | Comments

A new report documents the impact of the recession on the health care system, and for many Americans, the news is proof of what they know all too well – higher deductibles and copays are reducing their ability to access care.
The report [fee req] does not document whether the forgone care would have been necessary/appropriate/supported by evidence-based guidelines, and it is likely some of the forgone care was unnecessary. That said, it’s only ‘some’, and it is highly likely Americans with slimmer benefits, or no benefits at all, are skipping visits, medications, therapies, and operations that will over the long term will have very serious implications.
According to a piece in the NYTimes, the researchers reported “We find strong evidence that the economic crisis — manifested in job and wealth losses — has led to reductions in the use of routine medical care.” 26.5 percent of respondents reported reducing their use of routine medical care since the start of the global economic crisis in 2007.
The report adds more weight to the increasing evidence that the recession, coupled with the unique American health insurance system, has had a significant impact on Americans’ ability to access care.
The importance of primary care in prevention is well documented; [opens pdf] timely use of primary care tends to reduce the need for interventional procedures such as CABG, thereby reducing cost and improving long term quality of life. Delaying or forgoing primary care will likely have the opposite effect, increasing future health care costs.
Impact on workers comp
Over the short term, this ‘side effect’ of the recession will likely increase work comp costs and extend disability duration, as more injured workers will have poor health status due to forgone care. If diabetics aren’t controlling their blood sugar, asthma sufferers have more acute episodes, and hypertensives are taking their meds every other day, it is going to be more difficult, costly, and time-consuming to help these claimants recover functionality.
Over the long term, health reform will reduce work comp costs as many more individuals will have coverage. But until 2015 (or so), we won’t see this positive influence.

Aug
16

Managing health care costs – whose job is it?

Posted by Joe Paduda on Monday, August 16th, 2010 | Comments

We’re learning a lot from Massachusett’s experiment in universal coverage – and some of the lessons are rather enlightening.
Take this one.
According to Bestwire, Lora Pellegrini, president of the Massachusetts Association of Health Plans, said something along the lines of “That’s the problem with the new U.S. health care reform law… it offers millions of uninsured Americans access to health insurance but doesn’t address underlying medical costs, which are contributing to costly premiums.” [not a direct quote]
Wait.
Isn’t that your job? In return for getting millions of new members, aren’t health plans supposed to figure out how to manage care and control costs?
If health plans rely on the government to help control costs, exactly what value do they deliver?
In fairness, Ms Pelligrini noted the market share of some provider groups is a significant factor in insurers’ inability to negotiate favorable rates. There’s no question negotiating power has shifted back towards providers, and that shift is contributing to higher costs for health plans.
Doesn’t seem to be hurting profits, though; the industry is enjoying a stellar 17.4% return on equity after seven publicly traded health plans reported earnings above expectations.
Try as I might to sympathize with insurers, their complaints are besides the point.
Suppliers in any business seek to maximize profits. Smart buyers will figure out how to find more cost-effective suppliers, develop alternative supply chains, or in very tight supply markets even resort to vertical integration, setting up their own suppliers.
I see no reason health plans can’t do the same. There’s far too much ‘old thinking’ among health plans; they remain overly concerned with the size of their network directory, believing large provider networks are essential to success.
Clearly, nothing could be further from the case. Some health plans are beginning to experiment with smaller, more exclusive networks, and I have no doubt the lower costs will make them much more attractive than the ‘old school’ huge networks with high costs due to broad access. No, success will come to those payers who creatively figure out how to work closely with selected providers, establishing partnerships, paying fairly, sharing information, and providing feedback.
Otherwise they’re just administrators, and not very efficient ones at that. If health plans are going to rely on the government to control costs, what, precisely, are health plans for?

Aug
12

Health plan enrollment is up, but that’s just part of the story

Posted by Joe Paduda on Thursday, August 12th, 2010 | Comments

Mark Farrah and Associates’ latest report indicates health plans enjoyed a nice bump in enrollment in Q1 2010 from the previous quarter, with the entire increase coming from ASO (large, administrative-services only plans that are sold to larger employers) business.
In fact, risk-based insurance plans (more commonly purchased by smaller employers) saw a significant decline in enrollment in Q1 of 0.6%, or 890,000 members. According to MFA’s report, ” WellPoint added 565,000 new ASO members in 1Q10, but lost 400,000 fully insured members. UnitedHealth saw gains in both segments.”
What’s happening here?
It’s no surprise that the economy has hammered employers small and large, but smaller employers are more ‘flexible’ when it comes to benefit plans. They can choose to drop or add coverage much more quickly and with fewer repercussions than big firms. In fact, large employers almost never drop their coverage, while the percentage of smaller employers offering health insurance has been shrinking steadily for years.
The actual decrease in employer coverage (at least as it appears in MFA’s highlights) is masked somewhat by increases in Medicare Advantage PFFS plans, which grew significantly for CIGNA; there’s much of the Medicare PFFS story still to be written as Coventry completes its exit and other health plans work thru their respective strategies.
Year over year, Medicare Advantage plans have seen significant growth, with membership up by 600,000 members, despite a drop in the number of insurers offering MA options.
Meanwhile, medical trend numbers are looking better, contributing significantly to the jump in profits enjoyed by most of the major health plans. Contributing to the increase in 2009 was a drop in pharmacy expense, which was somewhat offset by a 1.2 point increase in the percentage of medical expense paid to hospitals.
Ok, so net it out.
Health plans are continuing to restructure their books of business, winnowing out the unprofitable or potentially-unprofitable members, states, and coverage types. The nice bump in profits isn’t surprising, but the hard work is yet to begin.
That hard work is changing from a risk selection to care and cost management business.

Aug
10

California’s compound med bill – half a loaf is worse than no loaf at all –

Posted by Joe Paduda on Tuesday, August 10th, 2010 | Comments

California’s Senate will be considering AB 2779 today, a bill that would (among other things) require Prior Authorization of compound medications for work comp claimants. While there’s no question compound meds are a big issue, the bill would do nothing to solve the Golden State’s larger problem – out of control drug utilization.
(thanks to WorkCompCentral for the heads up)
Here’s the issue.
The work comp drug fee schedule in California is pegged to Medi-Cal, resulting in the lowest reimbursement for drugs in the nation (with the possible exception of WA).
Pharmacy Benefit Managers (PBMs) operate on the difference between what they pay the pharmacy and what their customers pay them. In California, that delta is tiny, if not negative. If PBMs don’t have any operating margin, they can’t afford to allocate clinical resources to deal with prior auth requirements; they’ll lose even more money in an effort to help their clients. That’s neither appropriate nor good for the long term health of the comp business in California.
To those who claim the low fee schedule hasn’t caused any problems, I’d suggest a thorough read of CWCI’s excellent discussion of the explosive growth of narcotic opioids among comp claimants. Here’s the brief takeaway – California slashed the work comp pharmacy fee schedule just about in half six years ago. Since that time, the number of scripts per claimant has increased 25% and costs per claimant are up 31% (CWCI stats). And that’s not the worst of it. Schedule II narcotics have gone from less than one percent of scripts to almost six percent, a six-fold increase.
But what does that have to do with a bill designed to attack one of the emerging cost drivers – compound meds? Isn’t the proverbial half a loaf better than no loaf at all?
No. While the bill enables payers to deny compound meds for medical necessity (a relatively easy call, as I don’t know of any evidence-based guidelines that recommend compounded medications, PBMs simply can’t afford to develop the workflows, do the research, hire the clinical staff, and manage and monitor the intake/referral to the adjuster/approval-denial/appeal processes. This is a lot of work, requires careful planning and implementation, and must include clinical staffing – nurses, pharmacists, and in some cases perhaps physicians.
We’ve seen the impact of the low fee schedule on total costs – they’ve gone up. What we haven’t seen is the impact on injured workers – many more are now on narcotic opioids, with some undoubtedly suffering from all the complications linked to these potentially debilitating and addictive drugs.
AB 2779 piles more work on top of an already overburdened industry, while doing nothing to address the underlying problem.
A major step in the right direction would be for California to de-link the comp fee schedule from Medicaid. That would give PBMs the pricing stability they need to help their clients regain control over drug costs.
For a detailed discussion of Medicaid’s suitability for work comp drug pricing, click here.

Aug
9

From the ‘completely off topic’ file…

Posted by Joe Paduda on Monday, August 9th, 2010 | Comments

In the almost six years I’ve been publishing MCM I’ve never strayed this far off topic. Except for the annual April Fool’s day fun (consider yourself warned), this is all about stuff somehow related to managed care, health policy, insurance…
Try as I might, I just can’t come up with a link here. Except for the very very distant possibility of a workers comp claim.
So here’s what’s got my attention.
Just a few minutes ago, a flight attendant, fed up with a &^@&*(?! of a passenger, ran to the exit door, pulled the emergency escape hatch, inflated the slide, and jumped out of the plane.
Yes, the plane was on time, and no, it hadn’t been sitting on the tarmac broiling in the sun with backed up potties.
Fortunately, JetBlue 1052 was on the ground in New York [scroll to the bottom and read the comments; some are hilarious] when Steven Slater, the flight attendant in question, pulled the cord.
Wait, this gets better…
Turns out Mr Slater was reacting to a passenger who had jumped up just after the plane had landed, started to get his bag out (you’ve undoubtedly been on a plane with one of these jerks), refused to stop when Slater asked him to. In fact, the passenger’s bag fell out of the overhead and smacked Slater on his head.
Slater didn’t go nuts then – he actually asked the passenger for an apology. Instead of doing the right thing, the guy (ok, it might have been a woman, but we all know it wasn’t) cussed Slater out. Whereupon Slater got on the PA, screamed a few choice words (reportedly “To the passenger who called me a m—f–er, f— you!…I’ve been in the business 28 years. I’ve had it. That’s it”) over the squawk box, and exited the craft.
I kid you not.
Perhaps Mr Slater can claim work comp from an injury that discombobulated his sense of propriety…

Aug
9

Narcotic usage – too much, or too little?

Posted by Joe Paduda on Monday, August 9th, 2010 | Comments

Just in case you thought the problems with abuse of powerful prescription drugs have been overstated, here’s a wake-up call.
The CDC’s Director is taking this very seriously, saying: “Overdose with prescription drugs is one of the most serious and fastest-growing problems in this country.”
The problem is showing up in a doubling of Emergency Room admissions due to prescription drug abuse, driven primarily by oxycodone, methadone, and hydrocodone.
Narcotic use is rampant in workers compensation as well. Studies by NCCI and CWCI point to the frequent use of narcotic opioids for workers comp claimants, with the explosive growth in California particularly troubling.
One of the issues in comp is that unlike group, most Medicare Part D plans, and to a lesser extent Medicaid, claimant copays are nonexistent. There’s no financial skin in the game, as medications are free.
Another potential contributor is the potential street value of these drugs; while there isn’t conclusive documentation of the percentage of scripts that are diverted, the ‘sense of the industry’ is that diversion is not uncommon. Add to that the desire on the part of some states to reduce the work comp drug fee schedule to match Medicaid, and there’s no surprise use is exploding (if PBMs can’t afford to manage utilization, utilization isn’t managed).
Here’s what some of these drugs are reportedly worth on the street.
The estimated street value of one 40-milligram OxyContin pill is about $40; another report indicates an 80mg dose is going for $30 in the northeast.
Actiq runs about $25 a dose.
Duragesic patches range from $20-$75 depending on brand, location, and dosage.
So, narcotics are ripe for abuse, there’s a big – and very profitable – secondary market for them, and use is growing. That’s one side of the story.
The other is the inability of many legitimate pain sufferers to get adequate treatment.
Research published by Oregon State University indicates “at least 30 percent of patients with moderate chronic pain and over 50 percent of those with severe chronic pain fail to achieve adequate pain relief.”
Some think the inability of those with chronic pain to get treatment thru standard channels is a big component of the overall narcotic diversion issue.
What does this mean for you?
Like so much else in health care, there are no clear problems or easy solutions. This is more evidence of the complexity of one small part of the challenge.

Joe Paduda is the principal of Health Strategy Associates

SUBSCRIBE BY EMAIL

SEARCH THIS SITE

SEARCH THIS SITE

Health Wonk Review Archives

CATEGORIES

Categories

ESSENTIAL
BLOG READS

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.

OTHER BLOGS
I LIKE

BLOGS TO WATCH

INDUSTRY NEWS

INDUSTRY ORGANIZATIONS

 

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

HEALTH STRATEGY ASSOCIATES

About Joe Paduda
Engagements
Strategic Planning
Operational Improvements
Sales Improvements
Investor Guidance