Year: 2017

Feb
13

ACA Deathwatch: Healthcare and Snow storms

Posted by Joe Paduda on Monday, February 13th, 2017 | Comments

Happy Monday!  Up here in the northeast we’re still digging out from a major snowstorm that’s a long way from being over.

I’ll make a lousy analogy; that’s pretty much what’s happening in DC.  For local governments, getting the snow off the streets is the political test that ensures mayors another term, or ends their political career.

Healthcare is the national equivalent, with a rather important difference.  Unlike snow removal, healthcare is devilishly complicated.  It’s not just coordination of more plows, salt, drivers, and tow trucks.

Premium subsidies are one example.  About $9 billion goes towards helping poorer folks pay their deductibles, copays, and other costs.  Back when Republicans were in the opposition, they sued the Obama Administration to block those payments. If the suit were to succeed today, insurers would suddenly find themselves forced to:

  • come up with the $9 billion out of their own pockets or
  • terminate coverage for millions of members.

Not surprisingly, Republicans have apparently decided to keep paying the premium subsidies for the time being.

Kicking-the-can-down-the-road doesn’t do anything other than prolong the inevitable, which, stated simply, is this: Congressional Republicans are stuck.  It’s not possible to ensure poorer folks keep their coverage while reducing costs and de-regulating the health insurance markets.

Pre-election promises that voters can “Have their cake, Eat it too, and Not get fat” are coming up against the hard reality that healthcare is really complicated; and insurance companies, pharma, doctors, and healthcare systems are in business to make profits.

For insurers to be profitable, they have to:

  • enroll lots of people by charging premiums low enough to
  • get enough healthy people to join so they can pay for sick peoples’ care, yet
  • set premiums high enough to pay pharma and healthcare providers so those industries make a profit;

Without premium subsidies, lots of lower-income people can’t afford insurance, insurance companies can’t afford to insure those people, and more and more healthy people will drop coverage. Republicans’ apparent decision to maintain premium support will keep things calm for now.  The individual market looks pretty stable – rate increases have stabilized and enrollment, despite Republicans’ efforts to hinder sign-ups, is adequate.

Eventually the healthcare “snow” is going to pile up deep enough that Congress is going to have to start plowing.

Either that, or this…

What does this mean for you?

Don’t expect much REAL progress on healthcare legislation in the next month or two.  Or maybe even longer.

Got your shovel ready?

 

Feb
10

HealthWonkReview takes on Alternative Facts!

Posted by Joe Paduda on Friday, February 10th, 2017 | Comments

Steve Anderson’s HWR edition is one of the best I’ve read – Steve digs into alternative facts about ACA repeal, health care delivery, conflicts-of-interest, and work comp claims.

I’d emphasize a couple posts –

Charles Gaba’s got a great “app” for figuring out how many folks in YOUR Congressional district would lose coverage if ACA is repealed.

Louise Norris’ review of Trump’s executive order on ACA does what no one else could – explain what the order can, and cannot, do.

Steve – YOU THE MAN!

Feb
10

Other Effects; an occasional look at how the new Administration’s affecting workers’ comp

Posted by Joe Paduda on Friday, February 10th, 2017 | Comments

It’s not just ACA; the new Administration’s changes to OSHA, the Department of Labor, immigration policy, trade, and myriad other programs and policies will significantly affect workers’ comp.

This is the first of an occasional look at these “Other Effects”.

Farm workers

California’s produce growers are concerned that most of their field workers will be deported, potentially leaving billions of dollars rotting in their fields.  While others argue that farmers should not be employing undocumented workers, the farmers, most of whom appear to have voted for Trump, disagree:

“If you only have legal labor, certain parts of this industry and this region will not exist,” said Harold McClarty, a fourth-generation farmer in Kingsburg whose operation grows, packs and ships peaches, plums and grapes throughout the country. “If we sent all these people back, it would be a total disaster.”

Implication – if deportations begin, farmers will have to scramble to find legal residents to replace the 70% of current workers who are undocumented.  Labor costs will go up, and so will workers’ comp premiums.  Expect claims to rise as well, as the field work is very strenuous physical labor which most new workers will be unaccustomed to.

Of course, it’s illegal for those farmers to employ undocumented workers in the first place, so their lobbying efforts – intended to convince the President to not do what he said he would do – amount to asking the Administration to not enforce laws currently on the books requiring farmers to comply with the E-Verify program.

What does this mean for you?

The President is doing what he said he would, surprising some of his supporters and delighting others.

Feb
9

Drones cutting occupational accidents

Posted by Joe Paduda on Thursday, February 9th, 2017 | Comments

One of the most dangerous jobs in America is power line maintenance.

Over 330 people were killed last year due to falls and electrocution while working on power lines, thousands more were injured. Now one energy company is employing sophisticated drones to monitor power lines, allowing workers to trade the sometimes-scary task of climbing way up a swaying tower in possibly lousy weather to check out a junction for a ground-based drone control and monitoring job.

According to an AES exec; 

“We find that using drones, we can reduce the number of hazardous hours that it takes to do certain types of maintenance. And we can also enhance the efficiency of the business.”

And AES is not just focused on aerial drones to reduce occupational risks.  It recently announced a program seeking unmanned methods of evaluating energy production and transmission equipment.  The risk here is intense heat; when something goes awry it often takes considerable time for the site to cool down enough for a human to enter and figure out what’s happened.  AES is looking for ways to use “unmanned technology” to get in quickly, assess the problem, and fix it.

measure is the company working with AES; they’re deep into multiple ways to use drones in heavy industry. For example…

  • shipboard workers using drones to check on container stability, possible fuel leaks, wiring and hoses
  • firefighters using drones heat-mapping capabilities to identify hotspots, vulnerable areas, trapped people
  • tower workers using drones to keep nesting birds at bay

What does this mean for you?

Fewer accidents, lower risks for workers, reduced worker’s comp premiums. 

And this is just the start.

Feb
8

Four questions for WCRI’s Dr John Ruser

Posted by Joe Paduda on Wednesday, February 8th, 2017 | Comments

I (virtually) sat down with WCRI CEO John Ruser PhD last week to catch up on his first year at the Institute and get a preview of next month’s WCRI Conference. (Registration is here)

MCM – Talk about the last year and WCRI’s accomplishments.

Dr Ruser – We are working to maintain and build on the momentum Rick [Victor, former CEO] created – a rigorous approach to our research agenda, addressing a series of issues in workers’ compensation. One we are focused on is the worker outcome surveys. This can add considerable value to the industry; it addresses access to care, satisfaction with care, Return to Work, Return to Functionality, and earning history post-injury.

We are excited about what’s coming up. We want to provide information in a more readily accessible fashion. We will be launching a new website; the current one is functional but it’s time to refresh. We will go live soon with a site that is visually appealing; the new website allows us to experiment with a blog and video and provides more readily accessible content that is easier to search.

MCM – Can you expand on that [making information more accessible]?

Dr Ruser – Our work is very scholarly; it is hard to digest sometimes, so we are focusing on producing new products to reach a broader set of stakeholders that aren’t researchers. These will be written in layman’s terms that are more approachable.

MCM – The annual conference is set – what are you most looking forward to?

Dr Ruser – The theme is Persistent Challenges and New Opportunities: Using Research to Accelerate the Dialogue. There have been lots of challenges and questioning of workers’ comp over the last few years. Is workers’ comp fulfilling its obligation to injured workers? We will address some of those issues, as well as discuss what the election means for healthcare in general, labor regulations and workers’ comp. We’ve invited veteran politicians and other experts to talk about what they see down the road.

We’ve been talking about opioids for years. Are we making progress, defined as reducing new pts and reducing duration? Our people have looked at this and we see lots of variation across states, but in many states there have been fairly dramatic declines in opioid dispensing (pharmacy and physician) even back in 2014.

We will also be focusing on alternatives to opioids, a variety of solutions to control pain aside from opioids – excited about this – research on marijuana and pain and biochemistry of that. Apart from sharing our latest opioid research, we will have a panel that talks about about a variety of different approaches, including mindfulness, and we have some policymakers will discuss medical marijuana and complexities involved [in dealing with marijuana].

There is a session on grand bargain and we are really excited about it.  Among the speakers are Dr. David Michaels now at GWU, who was behind record keeping changes and is the former head of OSHA is there, Northeastern’s Prof. Emily Spieler, Dr. David Deitz, and former AIA Workers’ Compensation executive Bruce Wood.

MCM – What’s been the biggest surprise in your first year?

Ruser – [The] amount of support and respect that WCRI gets from the industry and our broad base of stakeholders, the recognition of the value and independence of our work, [we are] filling a void, [stakeholders have been] very supportive in general. Some disagree, but when they do they are respectful due to WCRI’s reputation.

Feb
7

Managing medical in Auto insurance – quick primer

Posted by Joe Paduda on Tuesday, February 7th, 2017 | Comments

Of late there’s been a resurgence of interest in managing the medical component of auto liability claims.  This happens every few years as insurers, entrepreneurs, and regulators look for ways to reduce costs and premiums.

The quick take – there’s not much opportunity here, and it doesn’t look like that’s going to change.

The details

With the exception of Michigan, which has no limit on medical benefits, almost all states have low minimum coverage requirements, often $5,000 – $10,000.  Some states – NJ, ND, MN, NY – have somewhat higher limits, and other state limits – e.g. UT – are lower.

If there’s an accident with bodily injury in a low-limit state, claims adjusters tend to set the reserve at the limit and do very little to “manage” the medical expense.  There are several reasons for this.

First, once the patient is transported to an ER, the bills pile up rapidly – diagnostics, specialists, medications, facility fees. (Mitchell’s latest report provides interesting detail on cost drivers; link opens pdf)

Second, most states don’t have fee schedules for auto medical care, so providers charge at or close to chargemaster rates – which are much higher than those for commercial health patients.

Third, this all happens before the auto insurance company is notified of and has accepted the claim.

Fourth, with rare exceptions, the insurer can’t direct the injured party to a specific provider or panel of providers.  Without that direction, providers are loath to offer any preferential pricing or other accommodations to the insurer or insured.

That’s not to say auto insurers don’t employ any medical management techniques. Independent Medical Exams, utilization review, medical bill audit, and nurse case management are tools that are occasionally used by payers seeking to ensure the care provided is appropriate.

Going forward, I don’t expect this to change.  While costs are up in some states, in my view that’s a temporary phenomenon.  Much more significant will be a massive reduction in injuries that is sure to follow widespread adoption of automated driving aids.

What does this mean for you?

Outside of Michigan and a couple other states, there’s not a lot of opportunity here.

Feb
6

ACA Deathwatch: Whoa, there, cowboy!

Posted by Joe Paduda on Monday, February 6th, 2017 | Comments

The news from the White House is the “replacement” isn’t going to appear until the end of this year – or perhaps sometime in 2018.

That’s a very good thing.

For those that have been following our ACA Deathwatch, that is no surprise.  In fact it’s a good thing, as the plans proffered by Ryan, HHS-Secretary-designee Price, and various other Republicans are short on details, conflict with Republican Governors’ wishes, and would result in major disruption to health insurance markets and imperil the Medicare Trust Fund.

There is no consensus among Republicans around key aspects of a replacement plan or the timing thereof. The White House’ latest announcement is at odds both with previous statements that the replacement bill would be released right after Tom Price’s confirmation as HHS Secretary, Speaker Ryan’s commitment to introduce a bill in March and Majority Leader McConnell’s promised timetable.

Here are the key problems facing the Repeal-and-Replace crowd.

  • ACA is NOT a bunch of totally separate and stand-alone laws, regulations, fees, taxes, policy requirements, and standards. The fees, taxes, and reimbursement changes provide funding for Medicaid expansion, Seniors’ drug costs, premium support, technology, guideline development, and hundreds of other initiatives, many close to the heart of really powerful constituencies.
    Republican leaders who once hooted at the length and complexity of the ACA bill are now learning that fixing healthcare is, shockingly, really complicated.
  • Republican Governors are quite concerned that a replacement will drastically cut funding they rely on for Medicaid, community health centers, public health, and other budget-critical programs. They expanded Medicaid based on a promise that the Feds would pay almost all of that cost; none of the plans currently under discussion live up to that promise.
  • AARP is marshalling its very large and very vocal membership to complain about higher premiums for the 50-64 year old group that would result from changing age bands and reductions to Medicaid that would hurt dual-eligibles.
  • Budget hawks are stuck because repealing ACA – or even just the taxes that are part of ACA – would lead to Medicare insolvency as early as this year.
  • Most troubling of all – loss aversion.  Now that people have coverage, they will be furious if Republicans don’t deliver on their oft-stated promises to reduce costs, preserve coverage, and expand choice.  And no, the attempts by politicians to wordsmith their way out of this commitment by talking about “healthcare access” and “access to insurance” will NOT placate voters who lose coverage.

This last is the key.

The political cost to Republicans of failing to deliver on an impossible campaign promise will be high indeed.  For now, they are going to push the deadline out as far as possible, perhaps pass a repeal-in-name-only bill, then wait till after the mid-term elections – or even the next presidential election – before doing anything serious.

What does this mean for you?

Republicans won’t pass and sign a true repeal bill for months.

 

 

 

Feb
2

ACA Deathwatch – quick update

Posted by Joe Paduda on Thursday, February 2nd, 2017 | Comments

After a few days of wonderful California weather and Golden State hospitality its back to work.

There’s been so much coming out of DC on all manner of topics healthcare has been somewhat under-covered.  No worries – I got this.

Quick take is Senate Republicans are no closer to a repeal today than they were a month ago. In fact, the “repeal clock” has moved backwards over that time as key Senate Rs have realized repeal is fraught with political landmines.

This bubbled up publicly when Sen Alexander, Chair of Senate HELP Committee and Sen Hatch got into a disagreement over Hatch’s push to repeal the tax provisions of ACA now, then work on a replacement later.

Hatch’s move would have effectively forced many insurers to drop their insureds’ coverage this year, as without premium support low-income insureds would have no funds to cover their share of the premiums deductibles, etc. Insurers would be faced with the need to either a) come up with the money themselves or b) drop out of coverage leaving insureds without coverage.

Alexander’s position was strengthened yesterday by multiple announcements from big insurers about likely withdrawals from the individual markets, as well as news that both the Senate and the House have scaled back plans to do a big bill to repeal and replace ACA.

What does this mean for you?

ACA Repeal is NOT a done deal.

Jan
26

HealthWonkReview’s Inauguration Edition

Posted by Joe Paduda on Thursday, January 26th, 2017 | Comments

Through election after election, HealthWonkReview has been your go-to source for the real impact on healthcare, health policy, access, coverage, and the rest of the story about the industry that accounts for one-sixth of our nation’s economy.

In preparing this edition, I was struck by how much better these blog posts were than pretty much any articles in the mass media (with a couple notable exceptions.).

The depth, understanding of core issues, knowledge of how various parts of ACA interact, and ability of the authors to explain all this in words everyone can understand is impressive indeed.

Louise Norris, Roy Poses, Andrew Sprung, David Harlow, David Williams – these are the folks you need to be following.

Repeal…

Andrew Sprung’s contribution is a welcome list of 7 ways the GOP could blow up ACA gains.  Or maybe not.

Andrew describes various paths to repeal and replace, dissects the problems, perils and promise of each, and handicaps the odds.  It’s a very, very insightful read.

Tick, tock…Louise Norris just keeps getting better and better; as a small-business insurance broker she is on the front lines AND understands the core issues affecting ACA and health policy.  Her entry this month discusses the Republicans’ plan to have legislation ready tomorrow – yes, January 27 – to begin the repeal process. 

A bit of background on the trump Executive Order that required the January 27 legislation comes from the estimable David Harlow.  A quick read, and a valuable one.

Friend and colleague Bob Laszewski’s wondering if the trump administration is prepping for it’s own “if you like your insurance you can keep it” fiasco.  In a great companion piece to the Norris and Harlow reportage, Bob asks a question the current administration likely didn’t:

if you take this new executive order to its logical conclusion, doing things like killing or easing the individual mandate or allowing for cheaper medically underwritten plans can’t have any effect other than making an already fragile Obamacare risk pool worse. Making the pool worse can only lead to fewer consumer choices, or no choices, or higher rates and bigger out-of-pocket expenses for those who remain in the Obamacare risk pool.

My entry this month compares the Republican position on repeal and replace to Wile E Coyote’s headlong charge off the cliff.  Beyond repeal and into replace, things could get pretty interesting – as Mr Coyote learns every episode, it’s not the fall that hurts, it’s the reality of the landing.

As I see it there are two main issues:

  1. Repeal without replacement is a budgetary and political minefield.
  2. Congressional Republicans aren’t even close to agreeing on what a replacement bill would look like

One of the big changes might be block grants for Medicaid – where the Feds just give each state a chunk of money and the state gets more flexibility in how they spend it.  There’s a LOT of detail around this, but at least in Massachusetts, it may not be much of an issue.  David Williams posits that MA is in a pretty different place than most states, one where a full-on total repeal of ACA wouldn’t be a big deal.  That’s because Mass has been in the forefront of these changes, and things are working pretty well.

Federal changes…

OSHA is going to be a different animal altogether in the new administration; perhaps more akin to a cuddly panda than a persistent bloodhound. Julie Ferguson details how the agency is already shifting to a more “employer-friendly” mode.

Julie’s post also digs into the administration’s claim of a “dramatic expansion of the federal workforce in recent years.” and resulting hiring freeze and consequences thereof; quoting a source that finds there has been no federal workforce expansion and that “employment by the federal government as share of all US employment is relatively low compared to most of the last 70 years.”

That’s a fact, not an “alternative fact”, or what we would call a “lie”.

Peter Thiel is the focus of Roy Poses’ ire this month, and that ire is well-placed.  The trump advisor supported one “Jim O’Neill, one of Mr Theil’s business associates, for this position [of head of the FDA], despite Mr O’Neill’s apparent complete lack of experience or training in medicine, health care, public health, or biomedical research, and Mr O’Neill’s obvious conflicts of interest.”

Other news of note

Brad Flansbaum’s penned a piece on healthcare CFO and CEO ratings at The Hospital Leader. Interesting take on how administrators – who currently are not being “rated” – perhaps should be. Brad provides his views on a few evaluation standards; good to see the proverbial shoe being placed on another foot!

And the ever-wonderful Hank Stern informs us that healthcare inflation is not limited to this side of either pond; costs are going up in other countries too – driven there by a demand for private care.

Jan
25

Michelle Buckman – one of work comp’s good people

Posted by Joe Paduda on Wednesday, January 25th, 2017 | Comments

Ok, I’m biased. But there’s no question Michelle Buckman is one of the really good – and very talented – people in the industry.

Not only is Michelle a fellow Syracuse University grad, she’s also COO at MedRisk, a long-time HSA consulting client.

Michelle started out in MedRisk’s marketing department before she moved into operations. That’s where she made her mark – and continues to do so. A little history is needed here.

Responding to customer concerns, MedRisk decided to internalize ALL customer-facing functions just after Michele joined the company. While Michelle, a graduate of Syracuse’ famed Newhouse School of Public Communications, didn’t have much in the way of formal business training, she most certainly understood interpersonal relations and communications. She put that expertise to good use, building a department with 165 highly trained and very motivated college graduates focused solely on helping each and every patient, provider, employer, adjuster, and case manager they work with. (Lots more detail on this here.)

Michelle worked very closely with IT under Vic Pytleski to develop applications, programs, and technology that would enable quick access to lots of information – and a way to report and monitor activity critical to continually improving results.

Regrettable Turnover (losing people you’d like to keep) among MedRisk’s Customer Advocates is 9 percent annually.

9 percent.

After the Customer Advocacy Program went into effect, duration of PT care decreased 15 percent.

Michelle and her colleagues have built a department staffed with highly trained, well paid, happy employees doing a really good job and materially improving results.

And all these folks are located here – in Pennsylvania, to be precise. Instead of “keeping expenses low” by outsourcing or offshoring jobs, Michelle et al viewed this from the customer’s perspective.  By approaching it from that angle, they were able to focus on what’s most important to any company – serving each and every customer as well as you possibly can.

The focus is NOT on “how can we squeeze another nickel out of operations?” but rather “what can we do better to make our customers’ lives easier and our patients healthier?”

That focus was the easy part. The hard part is to operationalize it, to make it real, to keep that tight focus, to recruit, train, incentivize, motivate, measure, and manage the people who make it work. It’s easy for consultants (and I am one) to talk about what organizations need to do.

It’s a whole different thing to actually do it – and not only keep it going year after year, but to continue improving.

What does this mean for you?

What’s really needed is not a degree or experience or training, it is a deep understanding of what’s important, and the passion and dedication and persistence to deliver.