Year: 2013

Mar
6

Obamacare – criticisms considered

Posted by Joe Paduda on Wednesday, March 6th, 2013 | Comments

Over the last week I’ve had several conversations with folks opposed to Obamacare/the Affordable Care Act.  Their criticisms are focused in several general areas:

  • it doesn’t do enough to control costs;
  • it is too expensive and we can’t afford it;
  • it is socialized medicine and violates our country’s foundational free market principles; and/or
  • it is intrusive and injects government into the doctor:patient relationship.

As I’ve said ad nauseum, PPACA (pronounce Pea-Pak-A) is so obviously a product of our vaunted-but-deeply-flawed political system that it should serve as a warning to all future legislators.  It was NEVER supposed to pass and become law as-is; if the Dems hadn’t completely screwed up the Senatorial election in Mass, thereby losing their veto-proof majority in the Senate and therefore had to pass the reform bill already passed by the House in the lame duck session, this conversation never would have happened.

Alas, it did, and here we are.

So, on to the complaints.

We can’t afford it.

C’mon, folks, as if the US health care system was affordable BEFORE Obamacare.  And, the recent announcement by Ala. Sen Jeff Sessions that the ultimate cost will be $6.2 trillion was flat-out wrong; his projections assumed the cost-control provisions of PPACA would be ended.  In fact, the Hill reported:

“the U.S. deficit will decline 1.5 percent as a share of the economy over the next 75 years, according to the GAO. Auditors attributed 1.2 percent of this improvement to the Affordable Care Act.”

Fact is, there are cost control provisions in PPACA, and unless they are repealed, they will reduce the deficit.  Two, the IPAB for one and ACOs, are promising – if only because neither has been proven. But I see another part of PPACA as likely the most effective; the mandate and prohibitions against underwriting.   If we all have to get insurance, and insurers can’t make money by risk selection and actually have to manage care (horrors!!), they’ll actually have to work on improving health, reducing morbidity, and improving the delivery of care – and eventually controlling cost thru their creative approaches.

Dirty truth folks, back in the old days (which includes every day up till 1/1/2014) health insurers spent most of their time/brain power/resources not on managing care, disease management, population health, or any other “health care” thing – but on underwriting. Nope, they worked hardest on figuring out first – who was likely to incur a claim, then second – how can we avoid insuring them.

That game’s over.  Now, insurers are stuck with all of us – healthy, fat, diabetic, blind, fit, gluten-free yoga enthusiasts, old, young, pregnant, single, whatever.  And if they are going to survive, insurers damn well have to figure out how to keep us – all of us – healthy and out of the doctors’ offices/ER.

Their game has changed more than anyone could possibly understand.

Why? Cause the heavy hand of government (that would be a government elected by us, folks) essentially said “enough of this crap.  Figure out how to control costs and improve health, or you’re out of business.”

The PPACA essentially changed – and leveled – the playing field.  The rules are clear.  And so are the penalties.  

Is it perfect? Hell no.  Is any legislation ever perfect?  Same answer.  But it is a LOT better than what we had before. Which, for those with short memories, was a completely out-of-control health system with declining numbers of insureds and rapidly rising costs.

 

Mar
5

Smart move, CWCI

Posted by Joe Paduda on Tuesday, March 5th, 2013 | Comments

With long-time CWCI President Michael Nolan slated to retire in May, the Board named Alex Swedlow to replace Nolan, passing the torch to one of the leading figures in workers’ compensation.

Alex’ research rigor, insight into nuances and intricacies of the industry, and unparalleled ability to make complex and complicated information understandable for lay people has served the workers’ comp industry very well.  From ground-breaking research on the influence of provider’s workers comp claim volume on outcomes to their latest research demonstrating the link between physician dispensing of drugs and longer disability/higher costs/poorer outcomes, Alex and his colleagues have kept CWCI at the forefront of workers’ comp research.

It’s one thing to do great research; communicating the result of that research, making it understandable/approachable/usable for non-academics is an entirely different matter.  And that’s where Alex’ ability really benefits CWCI and the entire industry.  His dry sense of humor and straightforward presentation makes him a must-have for every conference.

I’d be remiss if I didn’t acknowledge the strides made at CWCI under Mike Nolan’s leadership.  He’s led the organization during a very tumultuous period marked by hard, soft, and rapidly-transistioning markets, keeping CWCI relevant and helping shape decisions in the nation’s largest workers’ comp market.

Kudos to CWCI’s board.  Smart move indeed.

(disclosure – I’ve counted Alex among my friends for several years, enjoy his company immensely, and will be speaking at CWCI’s annual meeting later this month.)

 

Mar
4

Mark Walls moves to Marsh

Posted by Joe Paduda on Monday, March 4th, 2013 | Comments

Good friend, colleague, and social media/marketing star Mark Walls is now at Marsh, where he’ll be “developing market research, insight, and other content for Marsh colleagues, clients, and prospects on emerging issues, trends, regulatory, and other changes that affect the workers’ compensation market.”

But mostly he’ll be doing what he does better than anyone; connecting people, commenting on current issues, generating dialogue, and taking positions.

This was a very, very smart move for Marsh.  They got themselves the guy who is arguably the best-known “brand” in work comp social media.  And they’re going to let him be himself: travel to and speak at conferences, help plan and participate in industry events; engage the industry and the various stakeholders.  The benefits for Marsh are incalculable; every time Mark posts, hosts, or toasts the Marsh brand will be there for all to see.

For Mark’s former employer, Safety National, this is a loss perhaps much bigger than they know.  Many in this industry associate SN with Mark; his work greatly improved their standing in the industry, opened many doors, and generated huge amounts of positive press.  Unfortunately, my sense is his bosses didn’t “get” Mark’s value to Safety National, did not understand how his market presence benefited the company, and as a result didn’t take full advantage of Mark.

That said, SN did encourage Mark’s activity and certainly benefited from that activity.  While many WC payers would have looked very skeptically on an employee engaged in social media, SN embraced that activity, generally supported it, and in so doing helped establish a presence for the company that is far wider and deeper than they’d have seen otherwise.

Mark’s WCAG group is the largest networked group in workers’ compensation.  He organizes several conferences, national as well as regional.  He’s a sought-after speaker and expert for media.  I have no idea what Mark is making at Marsh, but it’s a bargain for the return they’re going to get.

Congratulations Mark, smart move Marsh, and kudos to Safety National for getting this started.

Mar
4

WCRI’s research wrap-up

Posted by Joe Paduda on Monday, March 4th, 2013 | Comments

Only the thoroughly nerdy (and yes that includes your intrepid reporter) stuck around for the final session, a WCRI research sampler based on their CompScope research database for lost time claims from 2008-2011.

It’s not just medical benefits that vary wildly – indemnity benefits per claim ranged from almost $10,000 per claim in IN to $28,000 in NC.  The researchers broke this down into the various components and sub-components; temporary and permanent disability benefits.

This is NOT my area of expertise – so be warned.

One study looked at the Michigan workers’ employment after a lump-sum settlement of their claim.  19% of those claimants who didn’t have a job at the time of settlement found one within a year, most took their time.

Among those claimants who were working at their “pre-injury” employer, 41% left their job and were no longer employed a year later.  For those who had found a job at a new employer after their original injury, 75% kept that job.

About a third who had a job at time of settlement quit and weren’t employed a year after that settlement.

That’s it for me – time to get back get back to work.

Mar
1

WCRI Wrap-up

Posted by Joe Paduda on Friday, March 1st, 2013 | Comments

With a day and a drive to reflect on the WCRI conference, there’s much to be taken away.

Attendance was high.  Over the last decade, WCRI has become a must-attend for many payers and regulators, and as a result the number of service entities at the conference has grown steadily.  That’s good; all stakeholders need to hear what’s happening, share ideas, and debate solutions.

WCRI’s growing use and acceptance of social media is impressive.  Andrew Kenneally was tweeting away through every session, and there were several other media folks there live blogging (including your trusty author).  They’ve gone out of their way to make our work easier, and the benefits for WCRI can be measured in the media mentions – which were likely in the gazillions.

From a content perspective, it was (with one exception) perhaps the best I’ve attended.  WCRI’s done an admirable job “freshening” their data: a past criticism was that the research was based on data that was quite dated, and therefore was not actionable.  The research we heard about this week reflected information from November 2011 – quite an improvement.

The discussion of guidelines was (generally) quite good – a solid explanation and background, a necessary albeit discouraging discussion of challenges getting docs to comply with guidelines, and a good synopsis of some key results in the non-WC world. There was also a review of some WC-specific results (I would have liked more results, but that’s a quibble). Prof. Wickizer’s summary was excellent, altho some of the citations were dated.

Some came away from that talk lamenting that they hadn’t heard much they hadn’t heard before.  I hadn’t either, but in fairness those I spoke with have very long and deep experience in this area; several could have given the talk themselves.  For many attendees, it was “new news”.

The focus on opioids on day two was absolutely on point.  I have the uneasy feeling most payers, actuaries, and rating agencies have yet to consider the financial impact of long-term opioid usage – and when they do it’s going to be really ugly.

OperationUNITE’s Karen Kelly gave a presentation on the human impact of opioid abuse that was terrifying.  In some counties in Kentucky, over half the kids are in households with NO PARENTS.  In one small elementary school, over ten percent of the kids had lost parents to opioid abuse. And there’s no question we in the workers’ comp world are contributing to this problem.

A colleague texted me during that session that IAIABC’s Executive Committee would do well to meet with Ms Kelly; they may well decide to reverse their decision and promulgate model language for opioids…

The following sessions detailed the cost, prevalence, and trends of opioid usage in WC.  Data on opioid usage was revealing, current, and actionable.

That was followed by two presentations by vendors – Paradigm (cat claims management) and Ameritox (urine drug testing).  Both were well-done, professional, and polished.  And totally inappropriate for WCRI.  The speakers discussed their company’s programs, provided details on their results, and shared their research, essentially marketing their services to the 350 attendees.  More to the point, their presence on the podium amounted to a subtle, if unintended, endorsement by WCRI. It would have been acceptable if their clients had presented; Paradigm has a long and successful relationship with the Travelers and Ameritox has many payer customers who have used their services for years.

Lest you, dear reader, think this is sour grapes, it is not.  As I’ve disclosed umpteen times, a competitor in the UDT space, Millennium Labs, is a consulting client.  If Millennium had asked me for my views on presenting at WCRI, I would have strongly discouraged their participation.  There are plenty of other venues where it is quite appropriate; the National WC and Disability conference, WCI, and RIMS are the top three.

WCRI is different.  And should remain so.

 

 

Feb
28

WCRI – Opioids part three – Treatment Guidelines

Posted by Joe Paduda on Thursday, February 28th, 2013 | Comments

Dr Dean Hashimoto’s talk on medical treatment guidelines covered what’s out there, what makes for good guidelines (my words not his) and what happened when MA implemented guidelines for chronic pain.  

We’ll focus on Massachusetts’ experience. (here’s a good synopsis of guidelines)  The state adopted those guidelines in part because there were an estimated 20 workers’ comp claimants were dying as a results of opioid poisoning (overdose).

Dr Hashimoto identified two impacts of Mass’ adoption of guidelines for chronic pain – these guidelines required use of the state prescription drug monitoring program, random drug screening, a written opioid agreement, and cautions when dosage exceeds 120 morphine equivalents per day.

While it is a bit early to assess results, here’s a couple preliminary findings:

  • “there was a leveling off of opioid prescriptions an deaths related to opioid poisoning.”
  • A WCRI study reported longer term use of opioids decreased from 11 percent of claimants to 7 percent after the guidelines were implemented.
Clearly evidence-based guidelines, effectively implemented, with strong UR features and “teeth”, work.  

 

Feb
28

WCRI and Opioids, part three – Interventions – a successful community approach

Posted by Joe Paduda on Thursday, February 28th, 2013 | Comments

Operation UNITE’s Karen Kelly led off with some of the most disturbing data I’ve ever seen on the impact of opioids in Kentucky and the country.

  • average age of first drug use is 11.  Eleven.
  • in some counties, 50% of children are being raised with no parents in the home.
Operation UNITE is doing terrific work in Kentucky – sponsoring treatment, supporting narcotics enforcement and interdiction, buying drug lock boxes for homes, education of kids and others, sponsoring summer camps, building community coalitions, and drug-free workplace training – among many other initiatives.
And their work is paying off – there’s been a year over year decrease in dispensing of all controlled substances by 11.7% in their area.
There are a wealth of resources available on their site, from videos to educational materials  to news and updates on progress in the battle against opioid abuse.
(I’m moderating a session at the National Rx Drug Abuse Summit with Washington state’s Gary Franklin MD and Amy Lee of Texas DWC  addressing opioids in workers’ comp at their annual meeting in early April.) There are several other sessions addressing opioids, detailing what works, what doesn’t, strategies and results.

 

Feb
28

WCRI on Opioids – Part Two – Opioids in WC

Posted by Joe Paduda on Thursday, February 28th, 2013 | Comments

Senior researcher Dr. Dongchun Wang’s presentation delved into the details, looking at data from 300,000+ non-surgical lost time claims, with scripts filled thru March 2011.  I emphasize non-surgical, as its entirely understandable that a patient just out of surgery would get some opioids to help them deal with post-surgical pain for a few days.

Takeaways…

  • Why are so many non-surgical claims getting opioids?  With rare exceptions, opioids are NOT indicated for these types of claims. Who’s prescribing these drugs and why is this allowed?
  • Building off yesterday’s discussion of variation in prescribing patterns, we’ve seen huge variations in prescribing patterns – dosage, duration, long-term vs short term usage.
  • The volume of opioids received per claim varied by a factor of four among the study states – lowest in Iowa, and highest in NY (on a morphine equivalent basis)
  • In four states, more than ten percent of claimants who received opioids were still getting scripts six months later – and remember, these are non-surgical cases.  While only 3% of AZ claimants were using drugs for more than six months, 17% of those in LA were…
  • 24 percent of drug claimants were tested in 2009/2011; a big improvement over the 14 percent from the previous two-year period – but still abysmal. (disclosure – Millennium Labs, a drug testing firm, is a consulting client)
  • As bad as that rate was, it was better than the use of psychological evaluations which should be done prior to prescribing – only 7 percent of claimants had psych evals…

 

Feb
28

WCRI – Opioids part one, the overview

Posted by Joe Paduda on Thursday, February 28th, 2013 | Comments

Dr Karen Mack of CDC led off this morning’s discussion of opioids with a review of the opioid crisis and provided a lot of data on death rates, usage trends, and mortality trends. Pretty scary stuff.

The most compelling slide shows a strong correlation between opioid sales and overdose death trend rates  which, if not parallel, are certainly quite similar.  Encoouragingly, the rate of treatment has actually accelerated over the last few years at a rate that is much higher than opioid usage trends.

Here are a couple takeaways.

First, I was surprised that there were multiple “ooohs’ from the audience when Dr Mack presented info that I would have thought we all knew – e.g. currently there are enough opioids sold in the US to keep every one of us doped up for a month. Ok, I know I’ve been up to my eyeballs in this issue for several years, and others haven’t spent the time on this that we research nerds do.

But.  Come on folks!  This should NOT be a surprise.  The issue has been front-page news in most newspapers, featured on many news broadcasts, discussed by politicians, media, celebrities, not to mention the issue is so pervasive it’s hard to find someone who doesn’t know someone else who’s been directly harmed by opioids.

This is the single biggest issue in workers comp. Kudos to WCRi for dedicating most of day two to the issue.  

Now let’s stop talking about the problem and get moving on solutions.