Over the last ten years, more than two thousand claimants have died as a result of drugs received as part of their "treatment' for their occupational injury or illness.

That's the conclusion reached by Peter Rousmaniere in his latest column at Risk and Insurance - and if anything, his estimate is on the low side. This isn't a criticism, as it is evident Peter is doing his best to avoid sensationalizing an issue that needs no exaggeration.

Peter bases his estimate on several different data sources, including a just-published article authored by Gary Franklin, MD, Medical Director of Washington's state workers comp fund. By my calculation, both Peter and Dr Franklin's estimates seem low.

A back-of-the-envelope calculation arrives at this figure - there were about 1750 narcotic-related workers comp deaths across the country in 2009 alone.

I base that figure on two data points.

1. Washington's research - about 35 claimant deaths in 2009 appeared narcotics-related.

2. Washington has about 2 percent of the nation's population.

Washington State has addressed the issue, and their solution has had a remarkable impact. This from the article by Franklin et al:

"By the third quarter 2009, there was a substantial decline in the mean daily long-acting opioid prescription dose among workers' compensation claimants in WA, followed by a dramatic fall in unintentional poisoning deaths related to prescription opioids in this population in 2010."

That's one state out of fifty.

What does this mean for you?

Identify doctors prescribing more than 120 morphine equivalents per day to claimants. Find out why, and if appropriate, take immediate steps to stop sending claimants to them.

Posted by Joe Paduda at 6:24 AM | Link to this post | Comments (1)

One of the most powerful firms in the physician dispensing business is sending hundreds of thousands of dollars to elected officials in Florida. [sub req] The donations, to individual politicians and their affiliated organizations, come as the Florida Senate is considering a bill that would limit reimbursement of physician-dispensed drugs to the cost of the underlying (non-repackaged) drug.

This morning Mike Whitely of WorkCompCentral reported Automated Healthcare Solutions "gave more than $32,500 to Florida state lawmakers and more than $500,000 to committees associated with conservative causes and candidates in 2011...", most of it in the last three months of 2011.

The timing is fortuitous, as Senate bill 668 was moving thru the legislative process last quarter, and is the subject of intense debate. Suffice it to say that passage of SB 688 would greatly reduce the income of companies in the physician dispensing/drug repackaging sector.

The physician dispensing bill made it out of one Senate Committee last week, albeit with a poorly-written and ill-advised amendment.

Writing in HealthNews Florida, Carol Gentry reported: "SB 668 survived its first committee in a 7 to 4 vote. But some senators who voted in favor said they may change their minds if answers to their questions aren't forthcoming by the time it gets to the Senate floor."

It's unknown if the flood of cash from AHCS will affect the votes of key Senators, or cause beneficiaries to use parliamentary procedures to block the bill. The forces allied in support of the bill include the Chamber of Commerce, most of the workers comp insurers, and many employers.

And, in an interview with Whitely, a spokesperson for AHCS said the company is not focusing on the issue, saying their donations are "not a means of affecting public policy".

Really. That's what she said. Evidently AHCS' half-million bucks - donated to key legislators with power over SB 688 - is not related to physician dispensing.

That being the case, I'm sure Florida's elected legislators will do the right thing, pass the bill, and thereby reduce Florida employers' work comp premiums by tens of millions of dollars.

What does this mean for you?

Yet another opportunity to watch the ugly, money-driven process that is politics at its worst.

Posted by Joe Paduda at 8:09 AM | Link to this post | Comments (0)

Looks like the rumors are based in fact; case management/bill review vendor Genex is up for sale.

The "official" news came yesterday (thanks to a good friend for the tip); "The Wayne, Pennsylvania-based company has EBITDA of USD 40m, the source and the first industry banker said. Bank of America has been mandated for the sale process, according to the source familiar. The sale process is in the early stages, with no first round bid deadline yet set, a third industry banker said."

With top line revenues estimated at $390-$400 million, it's not a terrifically profitable entity, but then case management is not known as a big cash generator. They've made a couple acquisitions lately, with Intracorp by far the largest.

Looks like Genex' owner, Stone Point Capital, may be entering the divesting phase. Recall SPC also has ownership in Sedgwick and Stone River/Progressive Medical, although the latter property was only recently acquired. As CIGNA is also an owner, they could be pressuring Stone Point to sell Genex; pretty much every health plan is looking for capital to invest in preparing for 2014, and CIGNA would get a chunk of cash from a sale.

Timing is good - valuations are up, there's lots of activity and interest, and a couple of big-money folks are looking for roll-up and industry integration opportunities. Genex would be a pretty interesting cornerstone for such a venture.

What does this mean for you?

Hold on to that hat - this isn't going to be the last big deal we'll see this winter.

Posted by Joe Paduda at 7:13 AM | Link to this post | Comments (0)

A couple days ago a shadowy equity "research" outfit that goes by the name Copperfield Research published what can only be described as a hatchet job, with CorVel the target.

I'm no fan of CorVel - their business model makes little sense, their pricing model for bill review/networks/ancillary savings appears designed to maximize their revenue, the quality of their services varies widely, and I've been generally unimpressed with their customer service and value proposition.

I'm even less enamored of the "research" and "analysis" done by Copperfield. This isn't a well-known research firm or trading outfit, I couldn't find anything definitive about Copperfield, what their business is, who works there, and why they publish "research". Others speculate Copperfield is the product of an individual engaged in short selling; making money when a stock price drops. I have no idea if that's the case, but that would help explain the CorVel research paper.

Whoever wrote the hatchet job quoted me extensively; that's why I find it necessary to speak out.

It is quite clear that Copperfield knows next to nothing about CorVel's workers comp business, or the work comp world in general, for that matter. Here are a few specific issues I have with their "report".

Copperfield cites the 2005 Broward County audit as an example of CorVel's problems - folks, that was seven years ago. Why did Copperfield resurrect that story? How does this support his claim that "Corvel operates in the gray area of legal and business practices?"

Copperfield raises the Silent PPO issue; CorVel's PPO, like every other PPO, probably has serious data issues and may publish inaccurate provider manuals as well. This isn't evidence of intentional fraud; as anyone who's ever been in the network business knows, the directory is obsolete the instant its published.

CorVel's bill review and related operation is cited as another example of possible malfeasance. Again, disagreement between bill repricers and providers is not exactly new news, and disagreements don't mean there's intentional fraud.

Copperfield can't understand how a work comp services company can grow while frequency declines. Boy, talk about a guy without a clue about comp. Severity is up, Copperfield, medical complexity is up, and many other services companies have also grown over the last decade - despite declines in frequency. Perhaps Copperfield's extensive research staff didn't find Sedgwick, MedRisk, PMSI, MSC, Express Scripts, Align Networks, York Claims, MHayes or any of the dozens of other companies, that have grown quite nicely over the last ten years.

He says "CorVel is paid based on the number of claims it manages and is often paid a percentage of the client's savings..." Well, not exactly. CorVel gets paid in a variety of ways for a variety of services; Copperfield's failure to delineate these various services and describe the associated pricing mechanisms shows a lack of attention to detail, or perhaps eagerness to avoid talking about issues that don't support his assertions.

Moreover, Copperfield's complete lack of professionalism is evident in his assertion that somehow CorVel's percentage of savings model is an outlier, unique and different. We all know that's far from reality. While I have voiced my objections to the model, the fact is it's all too common.

He also says no analysts are following the company - not true. There are any number of research reports on Corvel

Okay, those are the highlights. Now let me get snarky.

This guy just flat out can't write, yet he thinks he can. Here are a couple examples.

Discussing the Broward audit, he says it "succinctly details" information. Huh? That's an oxymoron, and a wrong one at that - the report has 211 pages...

Copperfield likens himself to perhaps the most attractive exposer of corporate malfeasance in recent history, saying "we feel a certain kinship to the Erin Brockovich's [sic] of the world..." I have no idea if Copperfield is the male equivalent but he certainly doesn't know the difference between the possessive and the plural.

In discussing the results of his(?) extensive research, Copperfield says "we have uncovered some alarming finding.[sic] There's that damn plural again...

If you really want a hoot, read his description of the work comp claims process on page 5. It is (unintentionally) hysterically wrong.

Finally, this knucklehead says "According to Joseph Paduda [that's me]...nurse case management is a low-margin." I know, I know, he just forgot to add "business." That's not acceptable for two reasons. One, if you're going to paraphrase or quote someone, get it right. Two, it shows a lack of attention to detail, an absence of care and thoroughness that may well extend beyond his inability to write.

What does this mean for you?

If Copperfield is selling short, he's already done well. And if you're reading his stuff and acting on it, good luck.

Posted by Joe Paduda at 6:58 AM | Link to this post | Comments (5)

I don't like these bills, and neither should you.

First, my perspective.

I'm a content provider and a copyright holder. I don't want anyone else taking my intellectual property without permission and/or compensation. This isn't just about MCM; I've also written a book (The Art of Sculling) that has been in print for twenty years, and while the revenue from that book is tiny, it is payment for my work and no one should be able to access that work without paying for it.

I get the movie producers', actors', artists, and musicians' perspective and agree with it.

The two bills currently before Congress are waaaaay too overreaching - sure they solve the problem of internet piracy. So would shutting down the internet. While SOPA/PIPA don't go that far, they do make innocent parties suffer for the acts of others.

Here's how this could affect me - and you, loyal reader.

Say someone posts a comment with a link to a copyrighted video, image, document, song; and the Feds get a complaint. Under SOPA/PIPA, they could legally shut down MCM immediately, and I'd have to spend tons of time and energy dealing with the issue before I could get MCM back up and running. That would harm me, and end your ability to access MCM.

Bob Wilson provides more insight:

"First, the government would have been able to force search engines to "delist" any website they suspected of these activities. The second would be to require ISP's (Internet Service Providers) to disable "Domain Name Service" to the suspected sites. The DNS service is essentially what allows the "domain name" that you are familiar with to work."

I get the intellectual property argument - I absolutely get it. But SOPA/PIPA are a heavy-handed, highly punitive, and poorly designed solution that would cause far more damage than necessary.

Sign the SOPA/PIPA petition, and let's stop this idiocy.

Posted by Joe Paduda at 7:23 AM | Link to this post | Comments (0)

Earlier this year, I predicted Florida would pass a bill limiting reimbursement for physician dispensed drugs. This morning, we made some significant progress.

Spent a good chunk of the morning watching the Florida Senate hearing on Sen Hays' bill that would peg reimbursement for physician dispensed drugs at what a retail pharmacy would charge for the same drug.

Automated Healthcare Services' lobbyist Tom Panza was up to speak in opposition. A passionate advocate for his client, Panza's speech was notable for its energy if not for its accuracy.

He conflated drug costs, saying that repackaged/physician dispensed drugs average price of $137 is the same as the average pharmacy price of $120. What Panza didn't say, and none of the Senators asked about, is drug mix. Physician dispensers almost exclusively dispense generics, which are much cheaper - on a per script basis - than brand drugs. And retail chains sell brands and generics - brands cost over $200 per script. Thus, Panza's claim that physician dispensed drugs only cost $17 more on average than retail was misleading and false on its face; in fact WCRI's recent report on pharmacy in Florida notes: "physicians were paid 35-60 percent more than pharmacies for the same prescription."

Panza also trotted out the hoary old chestnut that physician dispensing increases compliance, citing the statistic that 30% of scripts aren't filled - ignoring that this figure is a) dated; b) addresses group health and not work comp; and c) the main reason people don't fill their group health scripts is cost. And as we all know, comp claimants don't pay anything for drugs.

Panza also stated that physician dispensed drugs reduced litigation and increased patient satisfaction, without citing any data or research to support that assertion. Gotta respect his passion, even if his logic and supporting data (of which there was almost none) was suspect at best.

Lori Lovgren came up after Panza, and debunked his claim that prices were the same for physician and pharmacy prices. Sen Bennett was somehow confused about her response, or perhaps more accurately Bennett didn't like what he heard. Bennett's been vocal about his support for the egregious over-billing for drugs by physician dispensers. Sen Negron, another physician dispensing supporter, asked some unsubtle questions asking if insurers had any ownership of pharmacies or PBMs, which Lovgren did not answer - the answer, of course, is no.

While Lovgren was, or course, accurate, she wasn't a particularly effective speaker, and failed twice to make key points refuting Panza's claims. It's one thing to have the right information, but it's a whole different thing to present that information cogently and effectively.

Several other Senators seemed to focus on narcotics, and wanted to know if the pill mill bill had changed the financial picture, making NCCI's cost figures irrelevant. Lovgren responded that no, there was no significant impact on cost, but that didn't seem to bear much weight

A number of potential speakers from all manner of employer, taxpayer, and payer advocacy organizations waived their chance to speak but voiced support for Sen. Hays' bill (restricting overcharging for physician dispensed medications).

A physician advocated for physician dispensing said he couldn't dispense at the costs set by the Hays bill as he has to hire additional staff and buy software etc and therefore the bill killed physician dispensing

David Deitz, MD spoke directly to the physicians' claims that physician dispensing increases compliance, noting there are no studies supporting that claim. He also noted that Liberty Mutual does not oppose physician dispensing but rather repackaging. Another Senator cut off Dr Deitz, and the Committee did not allow any of the other dozens of supporters to speak. That's too bad, as Dr Deitz knows this subject very well.

There was some very brief discussion, but the bill passed out of Committee by a substantial margin

This is a big step, a critically important one, but only a step. There's much to be done to get this bill passed by the Senate and signed into law.

We'll keep you posted.

Thanks to Carol Gentry of HealthNews Florida for the head's up.

Posted by Joe Paduda at 9:29 AM | Link to this post

HWR's tech guru and all-around social media expert Julie Ferguson is this biweek's editor of Health Wonk Review.

There are lots of predictions and insights, and much discussion of reform and the Supremes.

Posted by Joe Paduda at 6:58 AM | Link to this post

Colleague Bob Wilson of WorkersCompensation.com has been delving deeply into the disaster that is North Dakota "justice", at least justice as applied in the Sandy Blunt case.

Bob's efforts have uncovered some amazing stuff...

For instance, the same state that spent hundreds of thousands of dollars prosecuting Sandy Blunt for giving a few thousand dollars of incentive presents such as balloons and chocolate chip cookies and five dollar (five dollar!!) gift cards to employees also used a Predator drone to nail some farmers for keeping six of a neighbor's cows on their property.

Yep, that's a $154 million aircraft used to get $6000 worth of beef.

There's a new definition of RoI; it's no longer "return on investment" but Reminder of Idiocy.

Alas, some of the good bad folks of NoDak don't see that as a problem, instead choosing to hurl imprecations (for you NoDak Sandy-Haters that means "say nasty things") at Bob for his ignorance and temerity (again, for NDSHers, that means "unmitigated gall"; oops, that won't work...how about "excessive boldness"?).

Net is, they've been pretty awful, and not very articulately awful at that. Lots of "oh yeahs?" and "yo mama" type stuff, so much so that Bob had to shut down comments before the offenders sprained their brains tying to decipher his multisyllabic retorts.

But Bob says it better than I can. Go read his "People's Republic of North Dakota" piece and see for your own self.

And don't forget to sign up for the Friends of Sandy Blunt afterwards...

(Now before all the GOOD folks of NoDak pillory me, I know you're out there, admire you immensely for standing by Sandy, and appreciate your support for the guy. I'm also sorry you have to live on the same planet with those jerks)

Posted by Joe Paduda at 3:53 PM | Link to this post | Comments (2)

Today's WorkCompWire has a great piece authored by PMSI CEO EIleen Auen on the differences between work comp and group pharmacy management.

Among Eileen's points are:

- "Group health benefits generally focus on sickness and illness while workers' compensation focuses on workplace injuries and returning individuals to work. Although a fairly obvious difference, it underlies many of the other differences that make workers' compensation unique, including drug mix." (I'd add that work comp ONLY covers drugs specifically for treatment of the occupational injury or illness).

- "The types of drugs used. Because of the focus of care, the medication mix in workers' compensation is much more focused towards pain management rather than illness management."

There's quite a bit more on differences in clinical management, formulary, and financial incentives, and how these effect prescriber and patient behavior.

Well worth the read, especially if you're an investor type trying to understand the WC PBM industry.

(Note PMSI is a member of CompPharma, and Eileen is a good friend)

Posted by Joe Paduda at 12:43 PM | Link to this post | Comments (1)

Mitt Romney's comment " I like to be able to fire people" has been turned against him by his GOP Presidential candidate opponents, with Gingrich and Rick Perry (remember him?) using it to illustrate Romney's "out of touchiness" with regular Americans.

Of course they're taking it way out of context. All who try to beat Romney will - a time-tested way to win is to use your opponent's words against her/him; if he makes it thru as the GOP Presidential candidate, expect the Dems to feature that prominently in key states.

But there's a deeper message here - yes, Mitt is out of touch - but no, not for the reasons cited by his opponents.

Romney clearly doesn't understand that most of us can't fire our insurance companies. A piece in the Columbia Journalism Review makes this point: Can you really fire your insurance company? The answer is that it's darn difficult even in Massachusetts--the land of Romneycare.

For those covered by large employer or union plans, what you've got is what you've got - and if we don't like it that's too bad. Of course, many large employers offer several choices, so these folks have better options than those of us who don't work for large employers - which happens to be most of us.

If your coverage is thru a small employer, your selection is most likely limited to one plan. While your employer probably shops the plan every few years, the only one who can "fire" his/her insurer is the employer. And that supposes the insurer doesn't fire the employer first by raising rates to the point where the employer has to move to another health plan.

Those of us (that includes your faithful scribe) who get their coverage thru the individual market face even more limited choices (depending on where you live). If your health status changes while insured, it will be very tough for you to get a new insurer to take you on - and if they do, expect to pay a lot more for a plan that doesn't cover your pre-existing conditions for some period of time (how long that period lasts depends on your state).

The net? While we'd all love to be able to fire our insurance company, most of us can't.

And under Mitt's health reform plan (such as it is), your ability to get coverage would be even more limited.

Of course, Mitt may have been paying a compliment to his potential opponent in the fall Presidential race - under PPACA (health reform), individuals can fire their insurance company, small employers may well have more choice (and the cost of that insurance will be less for many employers).

What does this mean for you?

Mitt is definitely out of touch - we can't fire our insurance companies, but they sure can fire us.

There's lots more detail on Federal limits on pre-ex here.

Posted by Joe Paduda at 7:37 AM | Link to this post | Comments (1)

Physician dispensing in Florida is back in the news, as we await with bated breath the outcome of this session's legislative battle.

On one side is the Florida Medical Association and Automated Healthcare Solutions, the Miramar company that provides software, billing services, and otherwise enables the physician dispensing industry.

On the other is the Chamber of Commerce, most of the state's work comp insurers, and several large employers seeking to correct a loophole in the law, a loophole that has enabled dispensers and their facilitators to suck over $50 million out of employers' and taxpayers' wallets to pay for drugs at inflated prices.

Here, excerpted for brevity's sake, three recent articles:

An editorial in the Palm Beach Post says this:

[In late 2010, the GOP majority in the Senate was poised to end the loophole by overriding a veto of a bill by past Gov Charlie Crist]:

By late 2010, however, Automated Healthcare Solution had given nearly $1 million to the Republican Party of Florida. The company also gave big to the political action committees of new Senate President Mike Haridopolos and new House Speaker, Dean Cannon. Physician groups had given. The override never happened.

Meanwhile, Alan Hays [author of a bill to close the loophole] had moved from the House to the Senate. Last year, he introduced the loophole-closing bill again. It had no House companion, and went nowhere. This year, Sen. Hays is back with a similar bill, SB 668. There is a House bill, HB 503. It has passed one committee, by a vote of 14-1.

For those who oppose his bill, Sen. Hays said, "It's all about how many millions they can make from gaming the system." Indeed, the estimated savings from closing the loophole are now $62 million. In August, the Workers Compensation Research Institute reported that "the average payment per claim for prescription drugs in Florida's worker compensation system was 45 percent higher than the median" of other states the group had studied between 2006 and 2008, all because of repackaging. Recall that unexpected rate increase in 2009.

Those who profit from it claim that the current system helps workers take medicine more faithfully and get back to work quicker. In fact, SB 668 would not prevent physicians from dispensing drugs. They just would have to charge based on the normal fee schedule. They couldn't rip off the system.

Automated Healthcare Solutions' main argument against this bill is the $160,000 it has donated to the Republican Party and the $10,000 it has donated to Rep. Cannon's PAC, the Florida Freedom Council. The Florida Medical Association has donated, and its ex-lobbyist is Sen. John Thrasher. He chairs the Rules Committee, and can stop any bill from reaching the floor.

This isn't Special Interests vs. The Little Guy. Florida's major business groups support the bill. Still, the biggest thing wrong with Tallahassee is that certain groups use lobbyists to get certain favors that help a few people but hurt the state overall. You've heard Gov. Scott and most legislators claim that they want Florida to be more business-friendly. So cozy up to this bill. Confound the skeptics.

Friend and colleague David Depaolo has a post in Work Comp World:

"Our WorkCompCentral news story calls AHCS a software firm, but that is not an accurate representation - the company manages physician dispensing of drugs with automated systems to control inventory, repackaging, and claims management to help ensure top dollar reimbursement to the physician...

According to news reports, companies controlled by AHCS executives Dr. Paul Zimmerman and Gerald Glass gave $100,000 to a committee that supported Scott during the 2010 elections. Five companies affiliated with AHCS sent $500 checks each to Scott's campaign, according to the publication Health Care News Florida.

The FMA seems to be tightly integrated with AHCS. FMA spokeswoman Erin VanSickle referred questions by WorkCompCentral on FMA's stance on the bills to Alia Faraj-Johnson, an outside media consultant for AHCS."

And WorkCompInsider adds this -

"A Tampa Bay news report talks about how the state's pill mill crackdown was held up by proponents of doc dispensing, including AHCS principals: "The two Miramar workers' compensation doctors have helped pump about $3 million into the political system through a dozen companies in the past year."

On the other side of the issue comes this from Stanley T Padgett, an attorney who is also "CEO of FPP Health Solutions, LLC ("FPP"). FPP is the exclusive Pharmacy Services Provider to the FMA [Florida Medical Association];

"Dispensing provides patient convenience, better patient compliance and better medical outcomes. It also provides an additional revenue stream [emphasis added] to offset the constant onslaught of government and provider reimbursement cuts for physician services."

Stanley T Padgett's argument is that compliance increases with physician dispensing, but nowhere in his article does he reference the fact that the vast majority of physician dispensing in the Sunshine State is for work comp patients. In fact, Stanley T Padgett only discusses patients with chronic conditions, specifically hypertension - a diagnosis that is extremely rare in comp. We'll also ignore his unfounded assertion that somehow compliance will increase if docs dispense medication (there are many reasons for non-compliance, and asserting that it's more convenient to get your pills from a doctor than from one of the three pharmacies on the next street corner and therefore physician dispensing will reduce medical costs in Florida by over $10 billion is just laughable.

If, as Stanley T Padgett claims, the purpose is to "provide patient convenience, better patient compliance and better medical outcomes", then why, pray tell, don't those docs dispense drugs for Medicare, Medicaid, and group health patients?

What does this mean for you?

It's crunch time, folks. If you want to end this outrageous assault on employers and taxpayers, tell Florida's Governor and legislators to back Sen. Hays' bill.

Posted by Joe Paduda at 6:16 AM | Link to this post | Comments (1)

Today's' WorkCompCentral arrives with a solid piece[sub req] from Greg Jones detailing the current work comp insurance market environment, which III's Bob Hartwig characterizes as "firming"; rates are up but not (yet) into the double digit territory which is Hartwig's definition of "hard".

It's been a long five or six years, rates are at historic lows in many states, and the hardening is spotty - some states (Texas) are still seeing rates that are flat or nearly so, while others (Florida) are looking at big increases.

For now, the question is not "when will the market harden?", rather it is "how fast and how much are rates going to increase?"

TPAs are hoping the answer is "very soon and a lot", and most insurers are as well - especially the ones who have reserve deficiencies...

What does this mean for you?

Realism in pricing is good, even though prices are up for employers, the recent pricing was simply too low. If it had continued, real damage would have been done to lots of insurers, and we'd be looking at insolvencies and a very hard market coming very quickly.

Posted by Joe Paduda at 7:20 AM | Link to this post

Okay, here's the last of my predictions for the work comp business 2012...

7. The physician dispensing cost control bill currently pending in Florida will pass.

After several years of political intrigue, huge campaign contributions from companies making enormous profits from physician dispensing, and continual efforts by good actors in the system, outraged taxpayers and employers will finally succeed in limiting reimbursement for drugs dispensed by docs to the original underlying price of the non-repackaged drug.

I hope. And so should you.

That won't' be the end of the issue; Maryland, South Carolina, and other states are also battling to limit this latest and greatest abuse of the comp system. Even if we win in Florida, there will be many more battles ahead.

8. More payers will diversify their provider network partners.

As Aetna winds up its work comp network operation, payers' interest in exploring other network options will increase. Following the lead of Broadspire and ESIS and enabled by technology that makes it easier than ever to mix and match provider networks, we'll see several other large payers award more network business to more network companies. Expect firms such as Anthem, HFN, Horizon, Cofinity, Rockport and Prime to gain share.

That doesn't mean anyone should count Coventry out. They are the oldest, largest, and most entrenched, and are working hard to address network gaps that will arise when their relationship with Aetna finally ends (which is still a long way away).

9. York Claims will finish the year well on its way to becoming a top-tier TPA.

Through savvy deal-making, a pretty intelligent sales approach, and what is by several accounts a strong focus on doing the right thing for the employer (and not just generating fees for York), York has transformed itself from what was a not-very-good TPA a decade ago to a well-regarded and very well run organization. York's robust technology and strong market share in key sectors (especially governmental entities in several states), coupled with the expertise they've added as a result of acquisition (I'm especially impressed with the JI Companies deal) bodes well for their future.

Perhaps I should modify the headline - York already is a top tier TPA in terms of capabilities; these capabilities will drive them towards the top tier in terms of revenue and market share.

10. Oklahoma will eliminate the requirement that all employers have workers comp insurance.

There are moves afoot in several states to reconsider the work comp mandate, but none have more traction than the one in OK. Whether it's because they share a long border with the only state that doesn't require comp (Texas), many of their larger employers also have big operations in Texas and like the opt-out there, or there's something more ephemeral, a sense that work comp as currently constructed doesn't work the way it should anymore, Oklahoma may well be the next state to allow employers to opt out.

There's already a study group authorized by the State Senate that's looking into the feasibility of the change; their findings should be released in the next few weeks. that will be just in time for the next legislative session which starts in February.

This may not become law in 2012, but I'd expect some movement that allows some employers to opt out, perhaps in a pilot program as early as next year.

Well, there we have it. Oh, there's one more..

11. My annual April Fool's post will generate some controversy, tick off a few people, and generally cause consternation among those who either don't have a sense of humor or can't read a calendar. It will also not get me in as much hot water as some others because I have to vet it through my PR department...

Posted by Joe Paduda at 10:45 AM | Link to this post

I'm finishing up compiling results from the most recent survey of pharmacy management in workers comp, and had to take a break and get this out.

I just totaled up the responses to the question "How much of an issue are opioids in workers comp?"

The average response was 4.8 on a 1 to 5 scale, with 5 "extremely significant".

This is the highest score for any question in the eight year history of the survey.

Moreover, respondents are deeply concerned about the increased risk of addiction and dependency inherent in widespread and prolonged use of these highly addictive drugs. They rated their level of concern at 4.4.

Respondents were from a variety of payers: state funds, large private insurers, TPAs and smaller regional carriers.

Kudos to WCRI, NCCI, and CWCI for raising awareness of the issue.

Next step is to put solutions in place.

Posted by Joe Paduda at 3:38 PM | Link to this post | Comments (4)

With the release of WCRI's latest report - this on on outpatient facility surgery costs - I'll have to leave the next and last wave of crystal ball gazing to tomorrow. That'll ensure it has a full charge before I polish it up one more time for some serious prognosticating.

The report is typical WCRI - carefully researched, stuffed full of appendices, state-specific information, methodological discussions and data dissection. Fortunately authors Rui Yang and Olesya Fomenko have provided a quick summary of major findings for those who don't want to read all 123 pages. We'll get to them after a (very) quick synopsis of the methodology.

For trending purposes, Yang, Fomenko, and assistant Juxiang Liu analyzed payments for the 2003 - 2009 service years for knee and shoulder arthroscopy, surgical episodes common in workers comp, thereby taking into account fee schedule, coding, negotiated, and network discounts. The cost differentials were based on 2009 data.

- It will come as no surprise that states with no fee schedule, or one based on percentage of charges - had higher costs in 2009. And, those costs increased more over time than states with fees based on standards such as APCs (Ambulatory Payment Classification groupers)

- Illinois had the highest costs, 45% above the median (recall that work comp is already a v very profitable payer, so paying 45% more than median means WC is really profitable business for facilities)

- Massachusetts had the lowest cost, at 40% of the median. However, Mass had the highest rate of increase over the six year period at 85%.

- Notably, Maryland, the only state that sets costs level across all (well, mostly all) payers was the second lowest cost state at around 55% of the median.

- looking at arthroscopic knee surgery, Maryland's FS rates were $928, about an eighth of Illinois' at $7.713. For shoulder surgery, IL's outpatient FS rates were more than twelve times higher than Maryland's...

So, a couple of observations.

1. the information is a couple years old, and therefore doesn't factor in changes since then. There's no way WCRI could as many changes don't make their impact felt for some time. That said, I'd note that Illinois' new FS is 'more of the same', using a percentage reduction below charges that, as the study shows, won't control costs.

2. the average cumulative trend rate from 2003 - 2009 was 38%, not terribly different from the overall CPI for similar services (6% per year). That's encouraging, if you're average. Texas' increase was 73%...

3. With the expansion of Medicaid, pressure on hospital reimbursement from Medicare and the rapid increase in the number of uninsured, workers comp's unenviable position as the best payer in the business is ever more firmly established.

And a conclusion.

Fee schedules and network discounts based on a reduction off charges DO NOT WORK, if "work" is defined as controlling costs.

If "work" is defined as making money for network companies, they work really, really well.

Posted by Joe Paduda at 8:33 AM | Link to this post | Comments (1)

My crystal ball blanked out yesterday after revealing the top three predictions for 2012; it recharged overnight and looks ready to continue this morning. I'll see what it shows and hopefully, before the light dims, we'll have a clear picture of what the new year will reveal.

4. Attacking opioid addiction and dependency will hit the top of many payers', regulators', and employers' agendas.
Led by reports and publicity from notables including Gary Franklin, Medical Director of Washington State's work comp fund, Alex Swedlow of CWCI, WCRI and NCCI, there's been a tremendous awakening among stakeholders to the human and financial cost of opioid abuse in workers comp. The quicker payers are already moving from "oh my it's a big problem" to "here's the plan to fix it."

It's about time. The damage caused by rampant over-prescribing of opioids is immeasurable. Devastated families, dead claimants, rising insurance premiums, increased crime, completely unnecessary disability and higher costs for employers and taxpayers are the result.

Identification of claimants at high risk for addiction and treatment of those individuals must - must be a priority. Intelligent payers will stop ignoring the problem or hoping it will go away, and work to a) prevent more overuse and b) help those already addicted/dependent to get healthy.

5. Now that Illinois is starting to approve Preferred Provider Programs, there will be lots of interest followed by disappointment that they really don't do much to control over-utilization.

I know, this is a gimme. The good folk at the Illinois Department of Insurance have been forced to come up with regulations to implement legislation that is about as convoluted as it could possibly be. Unfortunately, claimants who are interested in gaming the system will use the loopholes in the PPP system to get what they want when they want it from the providers they want to get it from. The PPP will only really work for claimants who weren't interested in gaming the system.

Unfortunately the PPP isn't much of a solution.

6. As work comp premiums begin to rise, we're going to see a renewed interest in loss control, risk management, and medical management.

With rate increases coming in California, Florida, and Massachusetts (among other states), employers are going to have to dust off those yellowed risk management plans, recall the basics of loss prevention, and perhaps re-hire the loss control pros they laid off over the last few years when their services weren't 'needed'.

Look for the big consulting houses, and smaller boutique firms, to emphasize their loss control expertise and capabilities; mono-line (and heavily-work-comp-focused) carriers will also tout their knowledge and ability to help employers control comp program costs.

The ball is dimming, and client work calling...time to put the sphere back in the charger.

We'll conclude tomorrow.

Posted by Joe Paduda at 7:08 AM | Link to this post | Comments (1)

There's a lot happening in the work comp industry: a hardening market; frequency ticking up; consolidation/mergers/acquisitions and buyouts; legislative and regulatory changes; and management moves. And all this against the backdrop of a very big election year.

So here's what I'm going to be watching for.

1. Health reform will impact workers comp.

I have no idea what the Supremes will do when they rule on the constitutionality of the PPACA, aka health reform bill. Their ruling could kill the law, leave it alone, or eliminate the individual mandate. But no matter what the official decision is, the health financing and delivery industries have changed dramatically over the last two years, and that change will only accelerate over the next two.

The rapid consolidation of health care providers, growth (via acquisition) of delivery systems, and acquisition of providers and provider-based managed care plans by payers is changing the landscape, as is the expansion of Medicaid. Health plans KNOW they have to change their models, get bigger, invest billions in technology and solidify and strengthen relationships with providers, regardless of whether reform survives or not.

All health plans are very tightly focused on those strategic imperatives. As a result workers comp, long a sideline, has been relegated to a position of insignificance, with one exception - Anthem. I'd expect to see the Big Blue continue to expand their work comp presence, but they'll be the only one to keep pushing. The rest are too busy worrying about the 98% of the business that is group, Medicare and Medicaid.

For comp, network discounts will diminish, That doesn't mean medical costs will increase, as discounts don't always, or even most of the time, equal savings. Network options will change, and we'll see more piecemealing of networks as other payers follow the lead of Broadspire and now ESIS and diversify their network relationships.

2. M&A in comp is going to accelerate.

There was a lot last year, but 2012 is going to be the year of the deal. With the pending changes in capital gains slated to kick in a year from now, several private equity-owned companies getting well past the three year horizon (and a couple past five), some long-time entrepreneurs looking to ride off into the sunset, and what appears to be an uptick in valuations, it's a no-brainer.

3. Comp rates will go up.

Well, this already started, but it bears repeating. After a way-too-long soft market, it's about time pricing sanity returned. Higher work comp premium rates will drive business to TPAs, encourage risk managers to, well, actually manage work comp risks, increase vendor business (think UR/case management, PT, bill review, and networks) and generally help all of us in the industry.

Three more tomorrow...

Posted by Joe Paduda at 5:24 AM | Link to this post

It's increasingly evident that the way-too-long soft market in workers comp is coming to an end - if it isn't already over.

The latest news comes from MarketScout (reported by Mark Ruquet in PropertyCasualty360.com), which indicated WC rates were up three percent in December, the highest increase among all P&C lines.

Earlier, Moody's noted that reserve releases (insurance companies deciding they have too much money set aside to cover future claim costs) for work comp claims had pretty much ended, and ISO reported P&C insurers' net income for the first three quarters of 2011 had declined by two-thirds from the same period in 2010.

This comes as welcome news to insurers, brokers, TPAs, and has implications for work comp services companies as well. And while employers may not look forward to paying higher premiums, they have to realize they've been enjoying a long period of low rates and great availability, factors which have reduced their expense significantly over more years than anyone could have expected.

For TPAs, many of whom have been hanging on by a thread while waiting for employers to once again look hard at self-insurance, this couldn't come any sooner. Word is there's been an uptick in proposal requests from employers.

For companies such as York (which just completed another acquisition of JI Companies late in December), Broadspire, Gallagher Bassett, and Sedgwick, this could well be the start of some nice, profitable growth. That is, if they don't decide to cross the stupid line when it comes to pricing.

What does this mean for you?

Congratulations, you've made it through the longest soft market in recent history.

Posted by Joe Paduda at 6:21 AM | Link to this post | Comments (3)

The first edition of Health Wonk Review for the year is up at the OHP blog - a well-organized and quick review of what happened while you were otherwise engaged.

Posted by Joe Paduda at 6:15 AM | Link to this post

Nothing drastic, so no, we're not going away or selling the site to the New York Times, and despite rumors to the contrary, MCM has not been acquired by a very large TPA.

No, we've added a feature that should make the blog an easier read on mobile devices - blackberries and iPhones and Droid phones too. Just click on the box on the right hand side of the home page and voila'. We've heard from a couple readers that it's a bit tough to read posts on their handhelds, so hopefully this will help out.

Or, even simpler, add this link to your favorites - it's a direct connection to the mobile feed.

We're looking at making some blog upgrades later this year - if you have any usability gripes or issues, let us know and we will keep those in mind as we plan our next iteration.

Also coming in the next week are posts on:

- results of the eighth annual Survey of Prescription Drug Management in Workers Comp

- a review of Paul Starr's new book on health reform in America

- an analysis of Rick Santorum's health care record

- the new NCCI report on aging and workers comp injuries.

Vacation was great, and it's good to be back.

Posted by Joe Paduda at 9:07 AM | Link to this post | Comments (1)

A very funny edition of HWR is up at Health News Review, Gary Schwitzer's always insightful blog on health news.

Well worth the visit!

Posted by Joe Paduda at 7:01 AM | Link to this post