Sep
30

ICD-10 codes you could not make up

Courtesy of good friend and esteemed colleague Alex Swedlow of CWCI, I give you the new diagnoses you do not want to appear on your medical chart.

(For a serious review of ICD-10 and workers comp, click here for CWCI’s analysis)

First up, the tragic Y93.D1: Accident While Knitting or Crocheting. Note, needlepoint and lace-making are separate and, well, distinct.  One wonders what kind of injury…burnt lip from ingesting overly hot Earl Gray?  

Known colloquially as the “Lincoln Diagnosis”, I give you Y92.253: Hurt at the Opera.  I know, technically not an opera, but hey, close enough!

Here’s one that doesn’t sound so fun – V97.33: Sucked into Jet Engine.  I think I saw something like that in an Indiana Jones movie…but it may have been a propeller, so…never mind! 

Among the candidates for most unlikely code ever to appear outside of a blog, I present V91.07:  Burn Due to Waterskis on Fire.

From Adam Fein, a candidate for the coveted “developed after coders read The Martian” award – V95.44 (“Spacecraft accident injuring occupant”)

Then there’s this, which makes one wonder if even the ICD-10 coding geniuses thought there could be a sequel – W56.22: Struck by Orca, Initial Encounter. 

From there to something that we kinda sorta always knew in the back of our heads was definitely a medical problem, but now we KNOW it ’cause there’s an actual code! Z63.1: Problems in Relationship with In-Laws.  

Our oldest daughter is getting married next summer…I’m hoping this isn’t prescience…


Sep
29

Causation and Correlation and the fallacy thereof

There’s a big difference between “causation” and “correlation”.  Just because A is around when B happens does not mean A causes B.  It could be that A’s friend C is actually the instigator, and A and C happen to hang out together a lot.  Or let’s say B is graffiti at the subway. A can only get out of school on Saturdays which is the only day B occurs because that’s when the graffiti school has their practical exercises.

Or, to be a bit more complex, when Justin Bieber was born, cholesterol scores began to decrease.  Until, that is, Facebook was invented, which reversed the decrease, thereby proving the Beebs is not as powerful as Facebook!

justinbeiber

Did you know that the more mozzarella consumed in the US, the more civil engineering degrees that are awarded?

Did you know that the age of Miss America strongly correlates with the number of murders by steam, hot objects, or hot vapours?

And the more the US spends on science research, the higher the number of suicides by suffocation strangulation, or hanging… (damn science!)

For those consumed by marriage in Kentucky, know that the marriage rate is closely tied to the frequency of death by falling out of a fishing boat.  Perhaps a fishing honeymoon involving moonshine is a time-honored tradition in Kentucky…

Now you know…

But seriously folks, even esteemed medical journals sometimes screw this up – HealthNewsReview highlighted one such faux pas last week in the British Medical Journal of all places.

According to HNR, a BMJ piece about SSRIs and crime stated:

‘Use of selective serotonin reuptake inhibitors (SSRIs) increases the rate of violent crime among young adults.’

The piece SHOULD have said “there is a correlation between SSRIs and an increased risk of violent crime among young adults.”

See the difference?  A statistical correlation does not mean one causes the other. In fact, it could be that violent youths are more likely to be prescribed SSRIs, or the crimes studied were committed in an area where psychiatrists prescribe SSRIs a lot more often than in other areas, or any one of dozens of other reasons.

I bring this to your attention, dear reader, because there’s far too much sloppy reporting out there that confuses correlation with causation, often by folks that should know better.  

What does this mean for you?

Think critically.  Always.  


Sep
24

Pay to Play – who’s at “fault”?

There are plenty of candidates – work comp TPAs who solicit fees from service vendors, vendors who offer to pay fees to get on a “preferred” vendor list, individual buyers with their hands out.

But when you get right down to it, the folks that are most at fault are also the ones most affected – employers.

Employers are the ones who demand ever-lower per-claim fees from TPAs, and TPAs who want their business have to play that game.  Truth is, it is impossible for any claims organization to deliver professional, solid, responsible claims handling for $1200 per lost time claim. They have to make their money somewhere, and that “somewhere” is with more fungible, less visible, claim-specific services.

Case management, utilization review, bill review/network access are just a few of the categories that escape close scrutiny yet add up quickly.  Many of these services are categorized as medical services and thus hit the file as non-administrative.  That category is almost always all but ignored during audits or file reviews, and thus is ripe for…margin making.

Before you start yelling about the dastardly TPAs and their evil ways, stop and consider why they do this.  It’s pretty simple; if your core service is commoditized and you’re constantly under rate pressur, you’ve got to do something to stay in business.  So, you find other ways to generate the dollars needed to deliver the level of service your customers demand.

I place the blame squarely at the feet of employers and their brokers and consultants.  There’s just not enough effort to really understand how TPAs differ, why one costs more and what their value propositions are.  It’s too easy to plug all the numbers into the spreadsheet and not try to figure out why TPA A does things this way, and TPA B does it this other way.

Nope, claims is claims.

There’s another reason employers have to accept a big chunk of the blame.  Many know fee splitting occurs, but don’t have the energy/motivation/ability/professionalism to pursue it.

What does this mean for you?

Is this acceptable?

Note – I heard from more than one colleague who wants me to “name names”.  It is NOT my responsibility to do that.  I’m not harmed by nor do I benefit from the practice of fee splitting.  Moreover, don’t act like this is “new news”; this is hardly a revelation.  It has been going on for years, and everyone knows it.

I will admit to being quite frustrated with stakeholders who somehow feel I – and others – need to try to fix problems with the work comp world, problems neither of our making nor solvable by anyone other than those affected by them.

As our son’s high school lacrosse coach often said – you’re either a finger or a thumb. The finger assigns blame to someone else, while the thumb points back to you.

Are you a finger, or are you a thumb?


Sep
23

Pay to Play – the corporate version

Monday we discussed the sleazier side of work comp services sales – payer decision makers with their hands out and the creative ways they profit from their positions.

Today, it’s back to a topic we covered years ago – fee sharing between services companies and payers – mostly TPAs.

It is no secret that almost all TPAs profit from managed care services – some by providing those services with internal resources, others from access fees paid by external vendors for the privilege of working with the TPA, still others do both.

That’s not a problem; TPAs have to make a profit, and their per-claim fees are under constant pressure from employers and brokers looking to demonstrate their ability to negotiate ever-better deals from their TPA.

Those per-claim fees are easy to measure, negotiate, and display.  What’s much tougher to track are the costs of add-on services; bill review, network access, PBM, specialty managed care, case management, UR, litigation support, investigative services, MSAs, and on and on.

Almost all claims use some of these services, some use all.  And when they are provided by external vendors (or internal suppliers, for that matter), the employer pays more.  Again, that’s fine – these services add value (in most instances) and are needed.

What’s not fine is not disclosing the fee-splitting arrangements between the TPA and service providers.  Actually, let me refine that – what’s not fine is telling employers no such splitting occurs when it does.  Some TPAs tell their customers that they get paid by vendors, and aren’t going to disclose those payments.  Again, that’s OK – employers know they are paying “extra” to the TPA for claims and related services, and they know they won’t find out how much “extra” that is.  Caveat emptor.

And that happens – a lot more than you’d think, and in very creative ways.  There are per-service fees, IT connection fees, rebates of fees, marketing fees, you name it – all kinds of descriptions of charges that increase costs for employers.

Some TPAs tell their customers there are no such arrangements, either outright lying or dissembling by creatively avoiding the question. They do this by interpreting the question as literally as possible. Thus the TPA can say “no we don’t get paid commissions” because the vendor pays the TPA an “IT connection fee.”

Kind of like Bill Clinton and his definition of “sex”.

So, what’s an employer to do?  I’ll address that in detail later this week.

 


Sep
21

Pay to Play – yes, it’s still here.

Pay to Play – charging work comp service vendors to do business with payers – was a big part of the industry a couple decades ago.

It still is.

Way back when, bagel boys and babes looking for files to service would bring goodies to claims offices; food, trinkets, tickets to the Red Wings game, you name it. Anything transportable was fair game. Didn’t matter if they were repping drugs, DME/HHC, case management, or investigation services, the boys and babes would load up their cars each morning before heading out to do their rounds.

There was also some pretty smarmy activity back then – big parties with lots of booze and entertainment at local/regional claims meetings, even envelopes left on adjusters’ and claims managers’ desks.

Most of the really obvious activity has gone the way of the green screens. Now that work comp payers have limited access to claims offices – and many have home-based their adjusters – the “retail sales” folks have a much tougher time getting access.

Alas, pay to play persists, its just moved up the corporate ladder.  That’s not to say there weren’t unethical practices in past years – there most certainly were.  What’s changed is awareness and top-down vendor management.  There is much more control of many vended services from payer HQ, allowing payer execs more insight into what’s happening at the adjuster level.  As a result, the locus of decision making has (partially) shifted from the desk level up the corporate ladder.

Now, we see P2P occurring in two ways – overt fee sharing, where vendors pay commissions/rebates/fees to the payer, and the much-less-talked-about, but nonetheless far-too-common direct payment to decision makers.

We will discuss the payer payments later this week…for now, the focus is on the decision maker payments.  Note I’m NOT talking about social events – golf outings, dinners and the like, relationship-building events long accepted, commonly practiced, and openly acknowledged. No, this is about highly unethical if not outright illegal payments and practices, such as:

  • untraceable gift cards, bought with cash, given to payer decision makers.  One decision maker demanded cards to “help his boys with their college expenses.” He asked (and likely still does) for cards for specific retailers as the price to get a meeting with him to even discuss a vendor’s services.
  • consulting fees paid to the decision maker’s significant other.  This is happening today, with the vendor forced to keep the cash flowing to keep the referrals coming.

I don’t believe work comp is any better or any worse than any other industry – there are always going to be scummy sleazebags with their hands out, creatively enriching themselves at the expense of their company, their claimants, their employer and/or taxpayers.

I do believe we need to do a much better job ferreting this out, and payers bear a big part of the responsibility.  When a payer discovers a decision-making exec has been lining their pockets at the expense of vendors they rarely (actually never) make this discovery public.  In hiding their embarrassment, the payer abrogates their societal responsibility – and ensures they will get screwed again.  Until and unless payers prosecute and/or publicly discipline these sleazebags we aren’t going to see it stop.

In fact, given what’s been going on over the last two years, it looks like it’s more widespread than ever.

What does this mean for you?

Time to stand up to sleaze.


Sep
18

Friday catch-up

Here in the East summer is still in full force, no matter what the calendar says – but the work load has ramped up now that school is back in session and 2016 planning is well under way.

Two items of note that came across my virtual desk this week…

The latest data indicates premium increases for the benchmark silver plan in 13 key markets average 3.1% for those without subsidies, 1.0% for subsidized plans.  Premiums decreased in 4 markets and increased in 9.

Access to care post-reform implementation doesn’t seem to be too problematic – at least not according to primary care providers.  80 percent said their ability “to deliver high-quality care” had stayed the same or improved; 20% said it had worsened.

The connection between diet and health is clear and strong, as is the relatively poorer health status of poorer people.  A compelling piece discusses why the less-affluent have lousy diets – and it isn’t because they like Big Gulps and Cheetos.  Here’s a key excerpt:

…participants are, by virtue of their qualifications, extremely pressed for cash. They eat fewer meals as a result, and select for more caloric foods, which tend to be less healthy, in order to adjust. Starch-heavy meals, fattier fare, and sugary foods all tend to be cheaper.

Part of it, however, might also be driven by the absence of free time to cook foods which require longer prep times (often vegetables). Convenience, in other words, can be a diet killer.

Before you criticize SNAP and belittle recipients, read the article.

California will have a drug formulary within 18 months.  Expect this trend to expand pretty quickly. There are at least a half-dozen states seriously considering formularies with several others beginning to explore the concept and implementation thereof.  One is North Carolina; I’ll be speaking at the NC Industrial Commission’s annual conference next month on the topic.

One observation – expect formularies and the rules and regulations that support enforcement thereof to evolve quickly from the Y/N model to a much more sophisticated form.

Got to get back to it – September is a very busy month!


Sep
15

California’s going to have a work comp drug formulary

And that is good news indeed.

WorkCompCentral reported this morning that the state legislature passed the enabling bill late yesterday; the Governor will sign it.

California will join four other states that have formularies in place today, and it is highly likely others will follow suit soon.

As good as that is, please do not make the all-too-common mistake of declaring victory and moving on.  The formulary bill is just the first step.  Here’s what has to happen to make a formulary actually work for all stakeholders.

  • UR – binding utilization review processes and rules that require compliance.  Otherwise you have speed limits with no police or laws to enforce them.
  • Flexibility – enable payers and PBMs to use rule-based processes and procedures to ensure patients get the drugs they need and aren’t dispensed drugs that may be harmful or counter-productive.
  • Specificity – blanket Y/N formularies are blunt instruments – allowing percocet for all claims just isn’t good medical care.  Instead, the formulary should be disease/condition/injury specific.
  • Timing – Texas’ phased-in rollout of their formulary made a lot of sense.  Handling new claims differently from legacy claims is appropriate and sensible.
  • Assessment – Monitor, track, and report on changes in prescribing and dispensing patterns, single out potential irregularities, identify problems and publicize same.  Fortunately, California has the best state-specific reporting and analysis entity; CWCI will be instrumental in this process.

What does this mean for you?

Wait…are we seeing actual progress in workers’ comp?  Hope springs once again!


Sep
11

Friday catch up

A crazy week indeed.

Here’s a few of the more striking things that happened while we were all doing our day jobs.

A minute in an ER costs 82 cents. Surgical ICU; $1.43.  Orthopedic OR; $12.  A terrific piece in the NYTimes about what seems to be a simple question; how do what does it cost hospitals to provide a service, test, or procedure? Turns out that this is an amazingly difficult question.  But one hospital system has done pretty impressive work on this – the University of Utah Heath Care system.

This is really, really important, because knowing what things/services/time costs has helped the hospital figure out how to reduce costs and improve care.

What’s amazing is few hospitals have ever tried to do this…

An intriguing story in Insurance Thought Leadership by Valen Analytics’ Bret Shoyer dives into the insurance market cycle question.  Shoyer opines that these cycles have been driven not by solid business reasons, but by market over-reaction.  Well worth a read.  The logic is compelling, the graph more so.

Examworks execs sold a bunch of shares, contributing to a drop in the stock’s value. I’m still mystified by the popularity of Exam among investors…

The CDC has announced $20 million in grants to states to encourage those states to “work with insurers to help providers make informed prescribing decisions, and take action to combat this epidemic” according to HHS Secretary Sylvia Burwell.  The funds will be used to enhance PDMPs among other services.  This is good news indeed; if insurers and PBMs have access to and contribute to state prescription drug monitoring programs, they will be much better positioned to prevent inappropriate dispensing of opioids.

More states considering formularies for workers’ comp (a very good idea); this am’s WorkCompCentral identifies at least a half-dozen that are deep into the process.  The list, in an article penned by WCC’s Steve Sadin on North Carolina’s progress towards a formulary, adds SC and NE to the list that previously included CA MT ME TN and LA.  OH WA OK and TX currently have formularies.

OK, time to wrap up the week and get ready for the weekend!

 


Sep
10

HWR – the selfie edition is up

There’s been a boatload of health policy stuff out of late – PPACA, pharma pricing, narrow networks – you name it.  read all about it here – courtesy of Steve Anderson at MedicareResources.org.