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Consolidation in the real world – implications for workers’ comp

There’s been a lot of mergers and acquisitions in the work comp arena, and certainly more to come.

But the activity in our little corner is minor indeed compared to what’s happening in the “real world” – group health, Medicaid, and Medicare. Make no mistake, these transactions will affect work comp.

You’ve probably heard of some of the activity among payers;

When these deals are completed, there will be three giant health insurers; United, Anthem, and Aetna.  All will have major operations in the Health Exchanges, Medicaid, Medicare, and employer-sponsored health insurance. Anthem, which owns many Blues plans, will have more local dominance in specific markets while Aetna and UHG are bigger players in the employer marketplace.

What you may not be tracking is the provider consolidation – which is equally frantic.  Just a few examples from the last few months:

The ongoing seesaw of market power is playing out nationally and locally – but the local scene is much more relevant for workers comp payers.  Local health systems negotiate with these big payers, with both sides coming to the table from positions of strength.  If Aetna wants coverage in southeastern PA, UPenn-Lancaster must be in their network.  For UHC to compete for employer and/or exchange business in New Jersey, they’ve got to have access to facilities and docs controlled by the two entities listed above.

The bruising battle over access, rates, and exclusivity is what’s driving the move to narrow networks. Health plans have to deliver more patients to specific health systems or those systems will not negotiate on price.

The best way to ensure increased patient volume is to make a deal exclusive – and we will see more and more narrowing of networks as competition heats up among the big three health insurers.

What does this mean for workers comp?

Work comp is incidental to Medicaid/Medicare/group/Exchange business. Health systems are going to get squeezed in these deals. Health plan execs will look to several reimbursement sources to make up margins; out-of-network care being most important but workers comp will be considered quite attractive as well. Comp is quite profitable, particularly as it drives orthopedic and ancillary revenue, services which have traditionally high margins for hospitals.

The other consideration is the care that is delivered via a health system or facility is billed under a hospital fee schedule. And, there can be a facility charge in addition to the physician fee. 

The net is work comp will be seen as a great source of very profitable patients.

2 thoughts on “Consolidation in the real world – implications for workers’ comp”

  1. You probably read my two articles about Humana, so I won’t reiterate the issue. This consolidation will make things worse.

  2. What will the corporatization of these facility and physician practices do to outcomes? Will profits be ever more important than results? Will physicians spend even less time with patients as they become well-educated piece workers? In the county where I live there are 2 large corporate owned/operated mega-clinics. In my suburb, one of these operates and there are only 1or 2 physicians who are not employed by these clinics. If I appear at the mega-clinic with a sore throat, my physician will see me for 2 minutes, the nurse practitioner for up to 5 minutes. After a cursory exam at which no history beyond when I began feeling sick is taken along with a cursory review of any medications I might be taking, I’m sent downstairs or across the hall to have another department do a throat culture regardless of whether I exhibit any symptoms of strep, maybe some blood work, and then down to their pharmacy to fill a prescription for antibiotics, whether I need them or not. But when the bill comes, there are charges for up to 10 professionals, multiple lab charges, etc. A simple sore throat will be billed out at over $300 or more and I will have spent approximately 6 minutes with a medical professional overall. If I’m unlucky and the reason I had that sore throat was because it was the first symptoms of throat cancer, the mega-clinic likely wouldn’t diagnose that until it reached a critical stage unless I went back repeatedly and demanded more and more services, exams and tests because they don’t bother to conduct anything more than a cursory exam and history.

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Joe Paduda is the principal of Health Strategy Associates



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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