Insight, analysis & opinion from Joe Paduda

Jan
25

Dumbest law of the month…#2

Okay, this isn’t a law, rather a school board ruling.

But it is so amazingly, blindingly, completely stupid that it beggars belief.

Last June the duly-elected Escambia County School Board  banned 8 dictionaries and encyclopedias because they…wait for it…contain depictions or descriptions of sexual conduct.

Who knows if these vile, disgusting, immoral books contained anything problematic…but under Florida’s “Don’t Say Gay” law, one parent – yup, just one – can force a school to pull a book from its shelves and conduct a lengthy review to ascertain if it is – according to some made-up criteria – inappropriate for that school.

So, let’s see…what could qualify?

  • A parent kissing their spouse?
  • Reproduction by an earthworm?
  • A trout laying eggs?
  • A medical textbook describing intercourse?

Those are all “sexual conduct…

That’s not the worst of it. Under Florida’s law, ANY parent could force a school too pull ANY book – which could include…the Biblewhich does reference various activities that could be construed as “sexual conduct”.

What does this mean for you?

Don’t let your kids go to Escambia County schools.

 

 


Jan
22

What should happen in workers’ comp – but probably won’t

I’ve finally figured out that what I think should happen often doesn’t.

So, here’s my take on the 5 things that SHOULD happen in worker’s comp this year but likely won’t.

  1. We won’t hear more caterwauling about “rising medical costs”.
    Ha. The latest NCCI research indicates execs still don’t understand what’s really happening with medical costs – despite NCCI’s diligent efforts to educate same.
  2. Work comp execs will embrace innovation.
    I wrote about this three years ago here. Basically,

    1. execs got to be execs by avoiding anything remotely risky.
    2. The industry is making billions in profits so why try anything new.
    3. Frequency and premium rates are declining, so why try something for a declining business?
    4. And worker’s comp is mandatory in 48 states, so they’ll have to buy it from someone.
  3. Buyers will stop asking about/measuring/caring about medical “savings”.
    I’ve written about this a gazillion times…here’s one example. The net – it’s really easy to show a reduction below list price – we Americans have been trained to do just that.
    Even when it makes zero sense…follow the link to get why there’s a horrendously ugly sport jacket here…

    Oh, And, this industry is pretty lazy.
  4. The industry will wake up to human-caused global warming. 
    Ha. Nice to see that some pundits have finally raised this as an issue – but jeez people it’s 2024, and we’ve KNOWN we are boiling the planet for decades. Nope, there will be minor moves, with little public discussion among or by work comp execs.
    Why?
    Great question.
  5. The industry will seriously embrace behavioral health, take major steps to understand this as a disability driver, and seek out meaningful solutions.
    Sure, some have – and kudos to them for doing so – And kudos to good friend, colleague, and mentor Bill Zachry, David Vittoria of Carisk, Dr Les Kertay, and others who have been leading the charge.
    But let’s get real folks…disability is as much- if not more – mental/emotional/
    psychological as physical, yet far too many payers don’t want to accept that blindingly obvious truth, scared of “owning the psych”.”
    You already own it.

    (Carisk is an HSA client)

 


Jan
19

Good news Friday…

The best possible news hit the wires yesterday – there won’t be a government shutdown next week.

The House – in a bipartisan vote – passed a continuing resolution (aka CR) to keep current funding levels in place till early March, giving the House and Senate time to negotiate on 12 individual spending bills.

The really good news is this passage:

  • was bipartisan, with 207 Democrats and 107 Republicans joining together to pass the CR
  • did not result in a move to oust current House Speaker Mike Johnson (R LA) (a similar bill cost then-speaker Kevin McCarthy R CA the Speakership)

While it is way too early to celebrate a new era of bipartisanship and congratulate the radicals on both ends of the spectrum for their maturity, and

…it is mind-blowing that we now celebrate a near-government shutdown as “good” news, 

Given recent history this does count as good news.

What does this mean for you?

That said, we cannot continue governing like this.  Thoughtful, principled compromise must return to Washington.


Jan
18

Hospitals are…

a) in desperate financial shape, on the verge of bankruptcy…

b) doing quite well thank you, enjoying very healthy profits…

c) both.

The answer is…C.

For-profits – HCA, Tenet et al are doing great, while (most/many) not-for-profits are really struggling, with some on the verge of/going into bankruptcy.

Why?

Very briefly, for-profits (there’s lots of nuance here, but generally);

  • don’t take Medicaid patients,
  • have very strong orthopedic and cardiac surgery practices which are very profitable;
  • do their best to avoid/transfer/not care for the uninsured.

Not-for-profits…

  • include inner-city and rural facilities that must take Medicaid and
  • serve as primary care providers for the indigent and uninsured and
  • deliver lots of babies and provide general med/surgical services which are marginally profitable

What does this mean for you?

Hospitals of all types are looking to maximize revenue, especially from very profitable payer types.

Is that you?

 

 


Jan
15

What’s REALLY going on with inflation?

A couple subscribers have been pushing back on my take on inflation; essentially their position is that “real people” (as opposed to “fake people”?) are suffering from pocketbook issues, issues that I do not understand.

Well…lets – very briefly – dig into “pocketbook” issues.

First, here’s the latest Consumer Price Index figures from last month courtesy of the US Labor Department…this looks at price changes from December 2022.

But that’s just one year…looking further back, food prices have indeed increased a lot  – almost 20%. – since 2019.

Some food producers claim inflation is the driver, forcing them to increase prices to keep up with inflation,

But there’s solid evidence many food companies are just jacking up your prices to jack up their profits.

This from NYT

  • PepsiCoprices for its drinks and chips were up 17 percent in the latest quarter … its third-quarter profit grew more than 20 percent.
  • Coca-Cola reported profit up 14 percent from a year earlier, thanks in large part to price increases.
  • Chipotle Mexican Grill’s prices are now nearly 15 percent higher than a year earlier, reported $257.1 million in profit… up nearly 26 percent…

From BonAppetit

From TIME:

  • Conagra Brands—one of the largest consumer packaged goods companies in the U.S.—announced that it had posted a nearly 60% year-over-year profit increase between December 2022 and February 2023. The Chicago-based company, which makes a long list of grocery staples including Chef Boyardee, Hunt’s, Slim Jim, Reddi-wip, and Marie Callender’s frozen meals, reported a net income of $342 million, up from $219 million in the same quarter a year prior.
  • Tyson Foods, the largest meat company in the U.S., more than doubled its profits between the first quarters of 2021 and 2022.
  • remember the huge price jump for eggs? According to TIME, “Cal-Maine Foods, the largest egg producer in the U.S., reported that its revenue doubled and profit surged 718% [in Q1 2023] because of higher egg prices.”

What does this mean for you?

If you’re going to point fingers, make sure you know who to point at.

 


Jan
12

Good news Friday!!

With all the craziness in the world, its easy to miss some of the good things that are happening…stuff that makes life just a little better.

The gubmint is actually making progress…on those incredibly annoying junk fees.

Overdraft and other banking fees

The Consumer Financial Protection Bureau is finalizing regs that will protect us from bank overcharge fees.  In 2022 banks took $7.7 billion from customers.

A big percentage of those hit with overdraft fees are poorer folks – the ones who get hit with a $35 charge for buying a few groceries. The new regs will really help  those folks.

Retirement junk fees

There are potential conflicts of interest for retirement plan advisers, conflicts that might encourage advisers to recommend an investment that isn’t in your best interest.

From USNews…

the Administration is pushing changes in “three specific areas to lower fees for Americans preparing for retirement. These are related to closing loopholes in the purchase of any investment product, advice given about IRA rollovers and recommendations for 401(k)s and other company-sponsored plans.” [emphasis added]

Colleges and junk fees..

Colleges and universities have gotten pretty darn good at sucking money out of students’ accounts with some pretty outrageous stunts.

From USNews:

Student flex fees are a target..some colleges are keeping left over funds after graduated.

SHOCKER!

Congress may actually get something done...I know, who woulda believed it. A bi-partisan effort to address stupid- and unconscionably high insulin costs, appears to be gathering steam.

From WaPo:

their bill would extend Medicare’s $35-per-month cap on insulin prices to individuals with private insurance, rein in the business practices of prescription drug middlemen and make it easier for new generic and biosimilar drugs to enter the market. [emphasis added]

What does this mean for you?

Government gets stuff done…


Jan
9

MedRisk acquires Medata

MedRisk and Medata just announced the former has acquired the latter.

Pretty interesting move…note I’ve worked with Medata in the past and worked with Medrisk for decades – and still do.

The official release is below – here’s my take.

Synergies

Data – Medata has a wealth of data on all types of medical services; MedRisk has data on millions of (physical medicine) episodes of care. Together, there are several potential benefits:

  • More information is good, helping identify best practices and providers with – and without – good outcomes. This will help improve patient outcomes.
  • Medata has data on post-PT costs, medical care, provider usage and other very useful information. This will help MedRisk better understand care delivered after a therapy episode and identify opportunities to improve return to work, transitional duty practices, and issues that may arise post therapy.
  • Network development – Medata has a wealth of information spanning decades on  physical therapy, occupational therapy, and chiropractic services’ prices, reimbursement, utilization and trends. These data will further help improve MedRisk’s network and enable it to provide better information re provider performance in- vs out-of-network.
  • These benefits will be felt soonest by mutual customers, but over time will improve results for each company’s unique customer base.

Efficiency

MedRisk is the largest manager of physical medicine in work comp and does a LOT of bill review in that space. Now that it owns a BR company, BR costs should decrease, improving margins albeit it on the margin.

With bill information coming into Medata, MedRisk will be better able to identify out-of-network therapy and where possible and appropriate either enroll the therapist if credentialing approves or divert the  patient to an in-network therapist. This will improve patient outcomes, increase payers’ network penetration and likely reduce cost of care.

Here’s the press release…

MedRisk acquires Medata to further improve the claims experience for customers, patients, and providers

 

King of Prussia, Pa. (January 9, 2024) — MedRisk, the leader in managed physical rehabilitation in workers’ compensation, has announced its acquisition of Medata, one of the leading providers of cost management and clinical solutions in the United States.

With this acquisition, customers of both companies will have access to expanded care management and cost containment offerings in workers’ compensation.

“We are excited to add Medata to our team,” said Sri Sridharan, MedRisk CEO. “This will further enable us to deliver superior claims outcomes and experience for our customers, for the patients we serve every day, and for our provider partners. In addition, we will now be able to leverage our inventory of data from both organizations so we can deliver unique insights and additional innovative solutions.”

Based in Irvine, California, Medata provides the most comprehensive cost containment and document management solutions in the workers’ compensation and auto liability industries.

“We are thrilled to become part of MedRisk,” said Medata President Tom Herndon. “Our companies recognize customers want greater alignment among their service partners, and this change strengthens our foundation and will drive investment into product innovation. Together, we will leverage our collective resources to continue delivering exceptional products and services to our customers.”

“For 30 years MedRisk has focused on creating a better experience for patients, our customers, and the entire industry,” said Mike Ryan, MedRisk Executive Chairman. “The addition of Medata is a natural and exciting step forward for us to further accomplish that mission.”

About MedRisk

Based in King of Prussia, Pennsylvania, MedRisk is the nation’s largest managed care organization dedicated to the physical rehabilitation of workers’ compensation patients. For more information, please visit www.medrisknet.com or call 800-225-9675.

About Medata

Based in Irvine, California, Medata provides the most comprehensive cost containment and document management software and solutions for the insurance industry. The company serves insurance carriers, self-insured companies, third-party administrators, state funds, and public entities in the workers’ compensation and auto liability industries. For more information, please visit www.medata.com or call 800-854-7591.

# # #

Media Contact:  Helen King Patterson, King Knight Communications, 813-690-4787, helen@kingknight.com


Jan
9

Prior auth – are you flying blind?

A pending CMS rule may lead to major changes in the use of Prior Authorization, changes that would reverberate across all payers – Medicare, Medicaid, group health, Exchange plans and workers’ comp.

Remember work comp is the flea on the tail of the healthcare elephant:

  • WC is 0.7% of total US medical spend and
  • a tiny portion of most providers’ patients and
  • the draft regs have no exemption for workers’ comp.

The proposed rule is now under review after public comments; there are a wealth of implications and potential issues including:

IT

  • requirements re new APIs (electronic links) in PA IT applications including payer and provider interfaces  – idea being to streamline flow of information between payers and providers
  • payer-to-payer data exchange requirements – essentially linking payers together so a specific patient’s entire health record is kept by its current payer (given patients’ high propensity to switch payers, this will be darn challenging.
    • work comp would have to integrate with many other payers...
  • build automated processes for providers to determine if a PA is required –  idea being to reduce confusion as to what procedures do and do not require a PA

PA processes

  • tight time frames for PA processes and possible reduction to 48 hours for expedited requests
  • mandatory requirement for payers to include a specific reason for denials
  • mandatory reporting for most providers

There’s a lot more to this…I’ve just scratched the surface here.

What does this mean for you?

if you aren’t paying attention to what’s happening in the larger healthcare world, you’re flying blind.

Make no mistake, what CMS does – whether its fee schedules, interoperability requirements, Medicaid eligibility, drug pricing, reimbursement policies, network adequacy or PA changes – affects you.

 


Jan
5

Good news Friday!

After a holiday hiatus, time to get back to covering some of the good news out there…

Big news – the US economy grew by almost 5 percent in Q3 2023...a rather stunning performance.

Growth was expected to slow to about 2.7% in Q4  – which is also good news as this will likely presage interest rate cuts by the Fed.

Which leads to this…

Implications

Confident consumers spend. Spending creates jobs. Lower interest rates improve construction hiring and durable goods purchases. 

AKA…a virtuous cycle.

Have an excellent weekend!


Jan
4

Stuff you may have missed…

Spinal cord stimulators...Don’t work.

More specifically, multiple high-quality studies found little evidence of pain reduction, no impact on disability, no impact on opioid use, and a relatively high risk of complications (about one in five patients required device revision or removal)

Just as bad, the SCS industry fought back with highly questionable tactics: this from JAMA reported in MedPageToday:

 “Industry-funded critics of independent studies often do not follow the usual route of scientific discourse…

Rather than respond to the journal where the original study was published, critics frequently publish in journals where they are the editors and can control the discourse (15 of 18 letters criticizing the independent studies cited in this article appeared in journals with industry-affiliated editors)…

The journal can then choose to paywall the subsequent response from the independent authors, giving critics the last word.”

and criticisms are typically narrow (but they didn’t look into the benefits for left handed red heads who speak Swahili!) and/or specious.

The net – science indicates the risks of SCS are high indeed, while the benefits of SCS are sketchy at best.

FDA approves test to assess opioid addiction risk

From the FDA

“The AvertD test is intended to be used before patients who are being considered for a 4- to 30-day prescription for acute pain (e.g., for a planned surgical procedure) are first exposed to oral opioids. It is not intended for patients being treated for chronic pain.”

Excellent news indeed!

The test is NOT yet available…check here for more info.

Net – get your Medical Director(s) on this post haste to determine coverage policies and reimbursement.

Opioid settlement dollars

are in high demand, with a bunch of companies coming up with very creative ways to stick their heads in the trough. Spiderman-type cord wraps for police, locking pill bottles, safe disposal envelopes are among the pitches governmental entities are getting for their opioid settlement dollars.

Two points – 

  1. addiction counseling, behavioral health, and other patient care is what is needed – and where dollars should go.
  2. illicit fentanyl is the big problem now – expensive locking pill bottles and disposal envelopes are marginally useful.

Texans may see rolling blackouts this winter, with implications for businesses, public safety employees, utility workers and essential workers.

In October ERCOT – the state’s power regulator, “… issued a request to increase [electricity producers] power capacity ahead of winter’s peak load season in Texas but canceled the request after it only found an additional 11 megawatts out of the 3,000 it was looking for.”

Power producers pointed to ERCOT’s request as too little, too late; University of Houston Energy Fellow Ed Hirs: “Just simply throwing some money out and hoping that people could bring a coal-fired power plant back out to operational capability within a period of weeks was really, ridiculously, ambitious.”

It’s not just Texas…with changing winter weather patterns driven by climate change other states are also at risk of similar blackouts.

 


Joe Paduda is the principal of Health Strategy Associates

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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.

 

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