Insight, analysis & opinion from Joe Paduda

Mar
18

The post COVID service bump

Posted by Joe Paduda on Thursday, March 18th, 2021 | Comments

Now that things are sort of returning to “normal”, the investment community is again looking into the work comp services business for potential investments.

Couple things I’ve noticed in conversations with investors.

Some service entities are conflating revenue increases due to the “return to normal” with actual new business. In other words, these companies are claiming they are getting new business from new customers (or expanding their business with current customers) when really their existing customers are just seeing more claims as the economy bounces back.

While I get why service entities would want potential investors – and current investors for that matter – to think they are taking share from competitors, that’s a pretty short-sighted approach, may actually be counter-productive – and it’s also unethical.

Investors are going to look deep and hard at revenues to make sure the uptick in revenues is due to actual new business. These people are quite smart and very very good at picking apart reports and data, Companies that mischaracterize their business will find themselves hard-pressed to explain why dollars coming from old customers should not be counted as new.

Second, by characterizing revenues from recovering clients as “new”, service entities will have to explain why their former customers’ revenues aren’t returning. That has made for some very interesting conversations indeed.

What does this mean for you?

Don’t do stupid stuff. Like this guy.

 

 

 

Mar
17

COVID quick update

Posted by Joe Paduda on Wednesday, March 17th, 2021 | Comments

Quick takes on stuff you need to know – and most of it is good news indeed.

Eli Lilly has what may be one of the more promising treatments, a cocktail of two unpronounceable drugs showed strong results in a recently-completed double-blind trial involving 769 patients.  The bamlanivimab-etesevimab duo cut the risk of hospitalization and death by 87% versus placebo.

Unlike the hydoxycholoroquine “research” touted by the former occupant of the White House, this is real science by reputable scientists which shows the drug has a positive impact.

Other research indicates the Pfizer vaccine works to stop the Brazilian variant; since I’m getting my first shot – and it’s the Pfizer version – Monday, that’s good news indeed. Pfizer also believes its vaccine will work against the South African variant as well.

These are all good news, as economists believe an economic recovery is highly dependent on stopping COVID.  One stated: “The vaccine is truly incredible…. It’s the best kind of stimulus we could want.” Excellent podcast for your morning walk or pm drive is here.

Terrific research out of CWCI last week; in their annual meeting, Alex Swedlow, Rena David and colleagues provided a lot of information on what’s happened with claim counts, costs, claim duration, and treatment timing. One very bright spot – February saw a huge drop in COVID workers’ comp claims. Rena also reported that “many workers with non-COVID claims got faster treatment than before the pandemic…” A big chunk was via telemedicine, which hit 25% of office visits in April and May, then dropped to about 18% in October. [thanks to WCC’s Mark Powell for his reporting]

I’m hoping to interview Alex and will provide more intel in a future post.

What does this mean for you?

Science, people. 

Mar
11

The latest workers’ comp drug scheme

Posted by Joe Paduda on Thursday, March 11th, 2021 | Comments

CWCI released a report detailing the latest in what’s been a long line of schemes to manipulate workers’ comp regulations to suck money out of employers’ and taxpayers’ wallets.

CWCI’s Bob Young, Jackie Secia, and Steve Hayes conducted the research, which found opioid scripts dropped from three of every ten prescriptions in 2011 to one out of nine today. That’s the good news – or rather, great news.

The research also identified two drugs – fenoprofen calcium and ketoprofen as the other primary reason NSAID costs jumped from 14.2% of total drug spend to 23.5% in less than two years. Oh, and these meds aren’t wonder drugs that grow hair while curing low back pain and strengthening joints and rejuvenating shoulder cartilage…they are similar to aspirin, ibuprofen, and naproxen.

OK, here’s how the scheme works.

First, both drugs are exempt from prospective Utilization Review (also known as Prior authorization) requirements, so prescribers don’t have to get approval before prescribing, and dispensers don’t have to worry about getting paid. 

Second, neither drug is on the California workers comp drug fee schedule, so employers and taxpayers have to pay 83% of the “average wholesale price”. AWP is a number made up by the drugs’ manufacturers, and can be anything they want it to be. Over the last four years, the average cost of fenoprofen calcium (FP) sextupled (is now 6 times higher); ketoprofen’s costs jumped more than ten times.

So, some smart schemers figured out that they could make a shipload of money by a) jacking up the price of a drug that costs pennies to make, and b) convincing a few docs to prescribe it to workers’ comp patients.

FP and ketoprofen are the main reason “not listed” drugs suck up more of employers’ and taxpayers’ dollars than other drug categories.

graph courtesy CWCI

It’s not just California.

PBM audits we’ve recently completed found both drugs showing up in New York; I’d expect they’ll appear in other states soon enough.

There’s a lot more we need to know – who’s pushing these drugs, why are docs prescribing them, what does the supply chain look like, are FP and ketoprofen also gaining traction outside of workers’ comp.

That said, we know enough right now to know we’ve got a big problem on our hands.

What does this mean for you?

Every PBM program must have an early warning capability to identify emergent drugs, and an ability to adapt quickly to ensure abuse is minimized. 

 

 

 

Mar
9

COVID, Claims, Employment, Opioids, and Physical Therapy – WCRI’s got it all

Posted by Joe Paduda on Tuesday, March 9th, 2021 | Comments

One  of the top work comp events is three weeks away – WCRI’s annual research conference kicks off on March 23 and continues the following day.

Registration is here.

I connected with John Ruser PhD to get the scoop on what we’ll learn at the Conference; here’s an edited version of our interview.

1)    We now have data to help us understand how the pandemic has affected workers’ comp. What are some of the key findings you and Dr. Fomenko will be discussing?

We have data over the first half of 2020, that is, the early part of the pandemic, which shows where claims were rising by state and industry. We show how COVID claims were associated with the severity of the pandemic in each state and with presumption laws in effect at that time. There was a large drop in non-COVID claims in the second quarter. We will address how these claims were linked to locations where the pandemic was more severe and employment dropped the most. We will also address the mix of medical-only versus lost-time claims. In the second quarter of 2020, there was an increase in the proportion of lost-time claims, likely due to COVID-19 claims that were much more likely to have more than seven days of time away from work, while non-COVID claims also had longer duration.

Regarding non-COVID claims, we continue to see the same distribution by type of injury, e.g., sprains and fractures, not a shift to fewer soft tissue claims – there were fewer of those but they were more severe.

We will also talk about how the pandemic affected the provision of medical care, that is, to what extent there were delays in the provision of care, particularly for elective surgeries.

2)    As we’ve tried to understand the impact of the pandemic, one of the biggest challenges has involved data – what should we be collecting, how fast can we get it, what sources are most useful, and how can we best use data to understand a novel situation. How has WCRI adapted to quickly understand what’s happening during the pandemic?

We accelerated data processing to accommodate for COVID-19, not necessarily getting data faster, but rather processing and analyzing it more rapidly. Our report on the impact of COVID-19 on claim composition is also shorter due to the need to focus on higher priority topics in a shorter period of time. While there is a need to have rapid and timely data to understand the early impact of the pandemic, there are still a lot of questions you can’t answer with quick data. Other fundamental questions will be answered with more mature data, specifically issues including long haulers, impacts on the injured worker of surgery delays and disruption in provision of care, and other longer-term impacts that are not so apparent now.

3)    Dr. Thumula and Dr. Savych will be discussing the latest research on prescription drug usage; our understanding of the impact of drugs on claims has evolved rapidly. What do we know now that we did not a few years ago?

They will bring together a couple of different WCRI studies, looking at the relationship between opioid policies and utilization in workers’ compensation and off-label prescribing. Regarding opioids, what is new is measuring the impact of policies on changes in opioid utilization, including prescription drug monitoring programs and prescribing limits. The session will also cover the rise in workers’ compensation of off-label prescribing of gabapentinoids and topical dermatologicals. Physician dispensing will also be addressed.

4)    WCRI had to change how it operated due to the pandemic and restrictions. Talk about how that happened, what the impact has been, and what you see changing over the long term.

Everyone is remote. There is a skeleton crew in the office every day to handle day-to-day stuff but nearly all work is done at home; we are fortunate that we had an emergency operations plan in place and had upgraded IT recently. On March 12 we had a staff meeting, planned a March 13 dry run of the operating plan, and planned to come back Monday – the dry run turned into a year working from home. We had to learn how to do work via video and maintain cohesion, handle staff meetings, and run social events. We have done several webinars – one with Judge Langham had 1,600 registrants.

 

We have been able to participate in more conferences and events, and with our virtual conference, we will reach a lot more people. Registration numbers are exceeding what’s normal for an in-person conference. Since the conference is virtual, we have been able to secure speakers we normally may not be able to get since the time commitment is less, such as

  • Katharine Abraham ─ who ran the Bureau of Labor Statistics (BLS) and is a former member of the President’s Council of Economic Advisers ─ will talk about the economic impact of COVID-19;
  • Jewel Mullen – former principal deputy assistant secretary for health and acting director of the National Vaccine Program Office in the U.S. Department of Health and Human Services ─ will talk about vaccines; and
  • Director John Howard of the National Institute for Occupational Safety and Health will be speaking on the future of work and work safety.

 

Our conference will be a blend of recorded sessions and live Q&A.

5)    More broadly, do you see the rest of the economy changing significantly ─ and for the long term ─ as a result of the pandemic? What does this mean for labor, employment, and workers’ comp?

Two plus years out, things will likely be different – we might anticipate more work from home and not as much business travel, and some structural changes such as more online shopping. The question is what will the magnitude of change be? Dr. Abraham will talk about that and what the future will look like. She ran the BLS and is well versed in the data. She’ll talk about the prospect of long-term unemployment and scarring effects of that. She will also talk about the extent to which changes in education might impact labor market prospects in the future.

 

 

Anything else you want to add?

 

We hope to see you at our conference, March 23 and 24. In addition to drawing upon the diverse perspectives of highly respected workers’ compensation experts and policymakers from across the country, we will be presenting our latest research findings. And it’s virtual, so you can attend from the comfort of your home or office. It is also shorter with four sessions per day in the afternoon from 1-4p.m. ET. Registration is free for WCRI members, state legislators, and members of the press, and $175 for non-members. To learn more and register, visit https://www.wcrinet.org/news/events/37th-annual-wcri-issues-research-conference.

Mar
8

Data ≠ Insight, Questions ≠ Answers

Posted by Joe Paduda on Monday, March 8th, 2021 | Comments

Data is great, but it is no substitute for seeing the world through someone else’s eyes.

That’s my takeaway from a great piece in today’s Harvard Business Review – timely indeed as it comes on the heels of Friday’s post re the decline in service at many workers’ comp “service” companies.

The piece discussed a financial services firm looking to better understand what their customers actually wanted; the firm “conducted a series of client interviews structured in a way that allowed the customer to do the talking and the company to do the listening.”

Here’s a smack-to-the-head finding:

the questions they’d been asking [in previous surveys] were built on managers’ perceptions of what clients needed to answer. They weren’t constructed on what clients wanted to express. This resulted in data that didn’t reflect clients’ real requirements. The list of priorities obtained via client interviews compared to management’s assumed client priorities coincided a mere 50 percent of the time. [emphasis added]

A smart tech exec said we:

“…focus on what customers want to accomplish, not necessarily how they want to accomplish it.” [emphasis added]

That’s point one.

Which leads directly to Point Two – You cannot just do what the client says they want you to do.

The problem with most account managers, and managers of account managers, and customer service goals, and the execs that are responsible for customer happiness/retention/success is they focus on what the customer says – not what they mean.

You know way more than your customer does about your business, your abilities, the supply chain, workflows and processes, which regulations apply and which don’t. You probably know a lot more than your customers’ execs do about:

  • how their IT systems work and don’t,
  • workarounds and the impacts thereof,
  • how and why front-line workers are negatively impacted by archaic processes and management approaches,
  • how your work product is accessed and integrated into outputs, and
  • how you could simplify processes and speed things up and reduce errors.

Your job is to do that – not to do what the customer says, but to deliver what they really need – not what they say they need.

[As one who has conducted dozens of surveys over the last two decades, this will force me to re-think how we do this…]

What does this mean for you?

Asking the right questions is about identifying the problems your customers want to solve.

You – not your customer – are responsible for figuring out how to solve those problems.

 

Mar
5

It’s not that hard, people.

Posted by Joe Paduda on Friday, March 5th, 2021 | Comments

Over the last few years I’ve been involved in multiple engagements with workers comp payers where their “vendors” just weren’t performing.

Responsiveness was…poor.

Problem solving was more client-blaming than taking responsibility.

“Proactive” was a word used in stewardship reports and entirely absent from actual account service.

Platitudes.

Excuses.

Sure, every service entity has problems – I’ve dropped the ball more than once myself. And there’s no question a client’s performance may be part of the problem and/or expectations may be unrealistic.

That’s not what I’m seeing, rather consistently poor performance seems to be OK with the execs at some service providers. My sense is there are two general problems. First, some service companies focus on what’s important to them, not to the customer. Increasing revenue, raising prices, selling other services, pulling back on commitments/turnaround times, adding fees for services that were previously part of the package – all are seemingly more important than just making the customer happy.

I recall a site visit to a client’s then-vendor where a senior exec proudly pointed to a wall of accolades for employees. The exec voiced delight at the many notes lauding employee performance. I looked closely…every one referenced an employee adding services, billing more, creating revenue. None referenced a delighted customer, a happy patient, an employer with a solved problem.

Is this what your customers are doing when the video feed is off?

“Success” = more vendor $.

Second, execs – and their subordinates – are not listening to customers. And if they do, all they are listening for is opportunity to sell more stuff. The execs are NOT asking how the client is doing, what they are focusing on, what problems the client is facing, where the client is heading – and what the vendor can do better and how they can improve.

Is this your client?

Many vendor execs aren’t seeking to understand what makes the individual they are working with successful, how they are measured, what is important to them.

Most recently this may be driven by COVID’s impact on claims volumes and the trickle-down reduction in medical services producing fewer visits, fewer medical services, fewer bills, less need for UR and case management and everything else.

But this was happening long before COVID hit.

What does this mean for you?

Understand and solve your customers’ biggest problems, and do it without adding to their workload.

Or fail. 

 

Mar
4

Drug prices are going up…or not.

Posted by Joe Paduda on Thursday, March 4th, 2021 | Comments

Optum’s work comp folks inform us that prices for some brand name drugs went up in January. The list includes medications that often appear on Medicare Set-aside cost projections – including some new-to-the-market meds that are pretty expensive.

As in $34.50 per pill expensive for Vivlodex, indicated for osteoarthritis and pain and almost 50 bucks per tablet for Vimovo, also for arthritis and pain.  As in a 5% increase for OxyContin, 10% jump for Nucynta, and 5% for a brand form of Opioid Use Disorder medication suboxone.

Two takeaways.

First, at least two of these meds should/must be replaced with generics.

VivlodexTM is a brand version of meloxicam, which is available in a generic form at a tiny fraction of the cost. drugs.com indicates pricing is about 13 cents per tablet…

meloxicam oral tablet 15 mg is around $13 for a supply of 100 tablets

Similarly, there are also generic substitutes for VimovoTM -which is simply a combination of naproxen (aka AleveTM) and omeprazole (aka PrilosecTM). The “substitute” would be to buy these two over-the-counter medications…

[Embarrassing disclosure time – I consulted for Vimovo’s manufacturer for a while till I figured out what the drug really was. Ouch. Lesson learned.]

Second, the price increases noted in Optum’s post do NOT reflect rebates. These can amount to 1/3 or more of a brand drug’s retail price, dollars that flow to the PBM and other entities on the supply chain.  As we’ve learned, all the news about drug price increases must be considered in the context of rebates.

courtesy Adam Fein PhD’s Drug Channels

The left most column reflects rebates etc paid to commercial insurers/PBMs etc

What does this mean for you?

Ask about rebates. There’s beaucoup bucks there.

 

Mar
2

The CDC’s Opioids for Chronic Pain Guidelines; Myths and facts

Posted by Joe Paduda on Tuesday, March 2nd, 2021 | Comments

After my posts last week it is clear there’s a lot of misinformation and misunderstanding about the CDC’s opioid and chronic pain guidelines. At MCM we take the old-school approach to these things; we focus on the facts.

So, here they are.

The CDC’s guidelines mandate strict limits on dosage and require tapering  for patients on long-term opioids.

False.  As Dr Beth Darnall of Stanford University noted recently;

some health care organizations and states have wrongly cited the 2016 CDC Guideline as a basis to substantiate prescribing “dose-based limits” or to mandate that physicians and prescribers taper patients taking long-term opioids to specific thresholds (eg, < 90 mg, or < 50 mg). Such dose-based opioid prescribing policies are neither supported by the CDC, nor do they account for the medical circumstances of the individual patient. [emphasis added]

Further;

The CDC [issued] a clarifying statement that derided the misapplication of the opioid guideline and discouraged the dose-based policies and practices that fall outside of its scope, as well as use of the guideline to substantiate tapering.

The Guidelines for Prescribing Opioids for Chronic Pain were developed in secret.

False.  The process fully complied with CDC and AHRQ requirements and standards, and the results were shared with the public and public comment sought prior to promulgation of the final guidelines in 2016.

The Guidelines aren’t working; look at all the opioid-related deaths.

False.

  1. The big increase in drug poisonings (technical term for overdosing) is driven by a rapid increase in the use of synthetic opioids, both prescription and non-prescription. The synthetic opioid death rate increased over 1000% from 2013 to 2019, with the biggest increase in the western US. Fentanyl and Tramadol are examples of synthetic opioids
  2.  There’s been a small but measurable decrease in the death rate (4.4 to 4.2) from prescription opioids that correlates with the guidelines’ publication date.  Of course, correlation is not causation, but clearly the guidelines have been impactful.

3.  Further, when you count the deaths due solely to prescription opioids, the drop in the prescription opioid death rate is even more remarkable. The bold line is prescription opioid-only; the guidelines were introduced in 2016.

The net is those who claim the guidelines are somehow “failing” are conflating law enforcement issues with public health issues, and are ignoring the very real post-guideline decline in deaths from prescription opioids.

The guidelines are killing people.

The guidelines are just that – guidelines.

The guidelines do NOT require or mandate dosage restrictions or tapering. Blaming the guidelines – and those who developed the guidelines – for physicians not following the guideline’s explicit recommendations is wrong, and does nothing to solve the problem of bad legislation and poor physician behavior.

Here’s what the CDC actually said:

Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. [emphasis added]

There are a lot of anecdotal reports of patients unable to get prescriptions renewed or otherwise forced off their opioid regimen, many with awful consequences. Yes, the guidelines did suggest/encourage/support these tools in certain circumstances, but – as you can read above – these are NOT requirements and require clinicians to evaluate and balance risk and harm.

What does this mean for you?

The real problem with Opioid Guidelines is states, insurers, and other entities – as well as prescribing physicians – failing to use the guidelines as intended.

reminder to commenters – valid email addresses are required, and disagreements are welcome as long as they are supported with credible citations.

 

Feb
25

Worker comp payers – hold on to your purses and wallets

Posted by Joe Paduda on Thursday, February 25th, 2021 | Comments

Two news items hit the virtual desk this morning; hospitals will lose more than $50 billion this year, and consolidation among hospitals and health systems is continuing, isn’t improving quality, and is increasing health systems’ leverage over payers.

The bad awful financial picture for hospitals comes after a pretty bad 2020, a year in which operating margins were slashed in half.

Of course financial problems are the main driver behind consolidation as health systems with stronger balance sheets take over struggling competitors. Physician practices hammered with revenue declines driven by far fewer patient visits, fewer elective surgeries, and more uninsured patients are also being acquired by health systems.

For payers – especially for workers’ comp payers – the balance of power has shifted to providers. With control over many hospitals and thousands of physicians, systems like Sutter Health in California can dictate terms to huge group health buyers.

I find it ironic indeed that the online ads next to the reporting on the consolidation problem in general and Sutter Health in specific include this one. Payers’ ability to control costs in consolidated health care markets is…challenging at best.

What does this mean for you?

If you operate in Alabama, Florida, Louisiana, Arkansas, Kansas and a bunch of other states, your facility costs are going up. 

Feb
23

CVC acquires a majority stake in MedRisk

Posted by Joe Paduda on Tuesday, February 23rd, 2021 | Comments

International private equity firm CVC Capital Partners will acquire a majority stake in workers’ comp physical management company MedRisk.

The Carlyle Group is the current majority shareholder and will retain a “significant stake” along with MedRisk senior management.

I could not be happier for my many friends at MedRisk; they built a company from a start-up in 1994 to it’s current position as the dominant provider of physical medicine management in work comp.  The speciality network business essentially started with founder Shelley Boyce’s idea that grew from a business school paper (that earned a less than stellar grade). In 27 years, Shelley, Mike Ryan and their colleagues grew Medrisk to a company with hundreds of employees ensuring almost 400 thousand injured workers have received the best possible rehabilitative care.

I know the CVC people well; they are thoughtful, incredibly smart, understand healthcare, and have the resources to ensure MedRisk has whatever capital it needs to continue its growth.

Lessons learned

Focus – While pretty much every other work comp services company (except for PBM myMatrixx) was diversifying, MedRisk stuck to its business. The work comp physical management business is a big one at almost $5 billion, offering plenty of opportunity for growth. This focus enabled MedRisk to concentrate on doing one thing very, very well, instead of distracting management with ventures into “potential opportunities.”

A relentless focus on service also paid off very well. I wrote this some years back:

For years, MedRisk had the niche almost to itself, focusing its sales and service attention on corporate buyers. Along came Align Networks, a start-up that concentrated on the desk-level user, delivering stellar service to each and every adjuster and case manager.  Align was quite successful, eventually becoming the largest vendor in the PM management space.

A misstep by MedRisk helped Align.  Some years ago, MedRisk chose to outsource key functions, including some aspects of IT, billing, and outbound call center functions including patient scheduling. This did not go well, and the resulting dissatisfaction among desk-level users led some customers to switch from MedRisk to Align.

Confronted with the loss of business, MedRisk got back to basics.  The lesson was apparent; a dramatic change in customer service was critical. That involved a major shift in understanding about the central importance of the desk-level customer, the provider and the patient, and a recognition that those customers required, above all, personalized service.

Management – Investors invest in management. MedRisk’s management team is second to none, and has only gotten better with the addition of Danielle Lisenbey as President. CEO Ken Martino stays on as does Executive Chair Mike Ryan and most of the great people who made MedRisk what it is today.

 

 

Joe Paduda is the principal of Health Strategy Associates

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