Year: 2017

Sep
14

Costs and benefits of disasters

Posted by Joe Paduda on Thursday, September 14th, 2017 | Comments

Disasters are good for the economy – sort of. They are also very likely to be really bad for people.

Combined, Harvey and Irma will cost about $200 billion – or 1.5% of US GDP.  That’s a huge infusion of capital and cash into the economies of Florida and Texas – and the other affected southeastern states.

Those dollars will go to pay workers, buy new equipment, replace ruined houses, buildings, furniture, technology, and infrastructure.

What’s not accounted for in the $200 billion figure is the cost – both personal and financial – that these disasters will levy on people involved in rescue, clean-up, and re-building.

One example – the bacterial and chemical stew pervading many areas in Houston will lead to immediate and long-term health problems for residents and clean-up workers alike. Living rooms, offices, factory floors, nursing home rooms, healthcare facilities, schoolrooms and firehouses – many will be polluted, requiring thorough cleaning and decontamination.

The real concern here is will the workers tasked with this job have the training, equipment, and clothing required to do this safely.

caption from photo reads: The #HurricaneHarvey clean up crews at our homes that were hired by management number about 200 and notice that none of them were given #Hazmat suits

Several factors are greatly concerning.

  • Texas doesn’t require workers’ comp
  • Companies are desperate to find workers, any workers, who will go into dangerous places and do very hard work in brutally hot and humid conditions
  • Labor brokers are notorious for subcontracting work like this, shaving every possible corner, and in the process hurting workers and dumping the cost of their medical treatment on the public sector
  • There are far too few documented workers available in either state to get the necessary work done quickly, so labor brokers are going to be recruiting undocumented workers.
  • Given today’s political climate and past history, those undocumented workers are far less likely to report and injury or illness
  • Lastly, an illness brought on by exposure to chemicals or bacteria takes days, weeks, months or even years to present, making it a lot harder for any injured worker to prove it was work-related.

What does this mean for you?

While responsible non-subscribers in Texas will do the right thing, many other non-subscribers will not.

Florida’s a different story, but both states must be vigilant to catch unscrupulous labor brokers.

Sep
13

Motivating sales people

Posted by Joe Paduda on Wednesday, September 13th, 2017 | Comments

Is a question asked over and over by pretty much everyone in this and other businesses, but it is especially important in workers’ comp services, where companies and sales people are fighting over what’s been a shrinking pie for years.

And, except in Florida and Texas, that pie will continue to shrink.

New research provides pretty compelling insights into what works, what doesn’t, and why.

Caution – this is ONE study, in a very different culture, of a in a company selling tangible products.

The high-level takeaway…Sales force compensation is a tricky issue, requiring decisions based less on intuition and conventional “wisdom,” and more on hard, quantitative data.

Details (paraphrasing here…)

Salespeople were assigned to groups each with different compensation arrangements. Some people received unconditional bonuses, which were given irrespective of their sales performance. Some received “conditional” bonuses, where compensation was tied to sales quotas under three different treatments: standard, punitive, and real-punitive. In the standard treatment, a salesperson was paid a bonus after achieving a weekly sales quota that was set 20% higher than what that individual had previously sold. The punitive treatment was identical except for the framing: We told salespeople that failing to receive a bonus was a penalty for failing to achieve their quotas. And in the real-punitive treatment, a draw system was used, where payments were made at the start of the week but then withdrawn for those who didn’t meet their quotas.

For the unconditional bonuses, the thinking was these would encourage reciprocity; Salespeople would work harder in appreciation for the firm rewarding them with higher pay. These bonuses were awarded under two different treatments: delayed and immediate. In the delayed treatment the bonuses were communicated to the salespeople at the beginning of the week, and payment made at the end of the week. In the immediate treatment salespeople were simultaneously informed of and awarded the bonus at the start of the week.

Perhaps not surprisingly, the conditional bonuses were, on average, more than twice as effective as the unconditional bonuses… they increased sales by an average of 24%.

But it’s not that simple.

The researchers found that a conditional bonus could potentially demotivate salespeople over time: Salespeople’s performance was higher during weeks of a bonus treatment but lower in weeks after a bonus treatment. This result is consistent with past behavioral research that has found that too much extrinsic motivation may actually lead to a decrease in intrinsic motivation.

Unconditional bonuses tended to be more effective for salespeople with a higher base performance, which supports the idea that high performers generally have more goodwill toward the company and thus are more likely to reciprocate by increasing their selling effort.

Conditional bonuses were equally effective across all types of performers.

What does this mean for you?

Experiment with different approaches.  Avoid basing decisions on your gut; rely instead on data.

Sep
12

MedRisk is back on top.

Posted by Joe Paduda on Tuesday, September 12th, 2017 | Comments

Big doings at work comp physical medicine management firm MedRisk.

(MedRisk has been a client for over a decade)

Most significant, MedRisk is likely now the largest firm in the sector, passing OneCall’s Align Networks in total revenue. Two factors driving this result; Align dropped the ball on customer service, and MedRisk upped its game considerably.

As I wrote last year,

For years, [MedRisk] had the niche almost to itself, focusing its sales and service attention on corporate buyers. Along came Align Networks, a start-up that concentrated on the desk-level user, delivering stellar service to each and every adjuster and case manager.  Align was quite successful, eventually becoming the largest vendor in the PM management space.

A misstep by MedRisk helped Align.  Some years ago, MedRisk chose to outsource key functions, including some aspects of IT, billing, and outbound call center functions including patient scheduling. This did not go well, and the resulting dissatisfaction among desk-level users led some customers to switch from MedRisk to Align.

Confronted with the loss of business, MedRisk got back to basics.  The lesson was apparent; a dramatic change in customer service was critical. That involved a major shift in understanding about the central importance of the desk-level customer, the provider and the patient, and a recognition that those customers required, above all, personalized service.

MedRisk’s results prove the back-to-basics approach worked; the company has taken major market share from Align, and continues to add new business. Operations expanded, and the company had to lease new space to accommodate the hundreds of new workers.

Now, One Call is all-in on a technology solution, investing millions in a customized application intended to deliver on the “One Call” promise (currently the seven different services offered by OCCM have separate systems and processes). “Polaris” is slated to be “fully implemented” in Q1 2018, although it’s not clear what “fully implemented” means.

I don’t believe “automating” and off-shoring key customer-facing functions is the right answer, not in a high-touch business where adjusters, therapists, physicians, and patients all are key parts of the rehabilitation process.

While many MedRisk people made this happen – including COO (and fellow Syracuse grad) Michelle Buckman, CIO Vic Pytleski, and EVP Marketing Rommy Blum, the effort was led by President Mike Ryan.

Mike is one of the best-liked people in our industry, and most respected as well. Today, MedRisk will announce he is taking over as CEO from founder and Board Chair Shelley Boyce.

I’ve known Mike for years, worked with Shelley and her team for almost two decades, and am delighted for all. They traveled a long road and it is truly gratifying to see MedRisk back on top.

What does this mean for you?

It’s all about customer service.

Sep
7

Thursday catch-up

Posted by Joe Paduda on Thursday, September 7th, 2017 | Comments

Genex acquires Prium…

Good move by Genex, as Prium’s portfolio of services including physician review and pharmacy management ties in well to Genex’ current offerings. I’m a big fan of Prium CEO Michael Gavin – he’s one of the most thoughtful, intelligent, and measured people in our business…good news is he’s sticking around.

Kentucky’s making big progress on opioids

Thanks to WCRI’s Vennela Thumula PharmD for her study on how new legislation (HB-1) helped to reduce the number of new work comp patients receiving opioids.

The legislation required prescribers to check the Prescription Drug Monitoring database prior to prescribing opioids, limited opioid prescriptions, and implemented mandatory educational and patient treatment practices.

Key Takeaways

HB-1 immediately reduced opioids prescribed to patients in the first 12 months after the date of injury.

Both the percentage of patients receiving opioids and the amount of opioids decreased by more than 15 percentage points.

Major surgical patients weren’t significantly affected by HB-1; not much change in prescribing to these folks.

Patients with back sprains and similar diagnoses had far fewer opioid scripts.

Thanks to Andrew Kenneally, Communications Director of WCRI, for the head’s up…

Opioid marketing practices

Kudos to Sen Claire McCaskill, D MO, for publicizing opioid manufacturer Insys’ alleged efforts to get approval for fentanyl product Subsys through misrepresentation. McCaskill’s report included an:

audio recording of conversations between an Insys employee and pharmacy benefit manager representatives related to a Subsys prescription for Sarah Fuller, who later died from an alleged fentanyl overdose. This recording suggests the Insys employee in question repeatedly misled Envision Pharmaceutical Services to obtain approval for Ms. Fuller’s Subsys treatment—heavily implying she was employed by the prescribing physician and misrepresenting the type of pain the patient was experiencing.

Sarah Fuller

This follows other reports of Subsys’ unethical and potentially illegal marketing practices, where other Subsys reps said they called payers, saying they were from doctors’ offices and were seeking approval for the drug.

Hell is too cold for these people. 

Finally, a very revealing piece in HealthAffairs provides more insight into just how powerful big healthplans are:

insurers with market shares of 15 percent or more (average: 24.5 percent)…negotiated prices for office visits that were 21 percent lower than prices negotiated by insurers with shares of less than 5 percent.

Differences in providers’ and insurers’ bargaining power are a major contributor to variation in commercial health care prices

Workers’ comp folks – you’re lucky if a generalist work comp PPO’s market share at a practice is 3 percent…

Back out onto the campaign trail!

Sep
5

Big changes a-coming in workers’ comp.

Posted by Joe Paduda on Tuesday, September 5th, 2017 | Comments

Here’s what I see coming.

Quick take – what happens this fall and winter will bump up premiums, injury rates and claims costs.  

Insurers will see rising premiums, claims service entities more work, and some insurers and re-insurers’ bottom lines will be hit hard.

Companies focused on servicing work comp patients in Texas and Florida are going to be very busy.

Hurricanes are the “why”

Harvey, Irma, and as-yet-unnamed storms are likely to make this the worst of all hurricane seasons – and we’re nowhere close to the end of the season.

Harvey alone may cost close to $200 billion. With Irma – now a Category 5 hurricane with winds over 175 miles per hour – storm tracks favoring a Florida landfall, we could be looking at a second blockbuster bill. (note cost projections are all over the map

There are huge implications for the workforce – starting with public safety workers, moving to clean-up crews and workers making emergency repairs. Then comes re-building: residential, public, commercial, and industrial construction, plus repairs to infrastructure.

Remediation will follow and take years. The huge petro-chemical operations around Houston mean waterways and land will be seriously polluted.

And, hopefully, big changes to storm and climate change mitigation planning, which will require major investments as well will mean billions in spending and lots of work for construction workers

Roads, water and sewage systems, rail, power generation and transmission, pipelines, ports and terminals, communications infrastructure all were hammered by Harvey and Irma may be just as brutal.

Implications.

Higher payrolls – Hundreds of thousands of workers will be needed today, next month, and for years to come. They will be working in high-frequency, high-severity jobs, and many may be poorly trained and supervised. And good, experienced workers will be costly due to supply-and-demand.

It’s highly likely tens of thousands will be undocumented; our governmental leaders will have to decide whether they are going to strictly enforce immigration laws or turn a blind eye. 

Labor fraud – I’m betting a large percentage of clean-up and construction workers will be undocumented, which means a likely explosion in labor fraud. Unscrupulous employers will bid on clean-up work, knowing they can screw immigrants out of pay and those workers have no recourse.

Higher injury rates – inexperienced workers putting in massive hours in dangerous places doing dangerous work = lots of bad injuries, plus exposure to nasty chemicals and pollutants.

What does this mean for you?

We’re about to see the most significant change in workers’ comp in decades.

Sep
1

Labor Day Special Edition

Posted by Joe Paduda on Friday, September 1st, 2017 | Comments

Happy Labor Day Weekend readers!

Make sure to thank the folks who work hard every day to make our lives better – teachers and support staff, building trades, healthcare workers, factory folks, agriculture and food workers, public safety, transportation, public works, and everyone else we often take for granted.

Here are a few articles of interest…worth thinking about as you watch parades, cook up your masterpiece on the grill, and enjoy the opening of the College Football season.

What’s been top-of-mind for me is how we’ve commoditized our workers, thinking of them as “expense” instead of an “asset”.  One of the most reprehensible anti-Semitic, racist, nasty people in business – Henry Ford – recognized employers need to pay their workers enough to buy the goods they make. Somehow we’ve forgotten this, along with the truth that workers are people, have intrinsic value, and deserve to be treated as such.

The best employers I know think of their workers as assets, not expenses. They know that when people feel valued and respected, those people do amazing work.

Here in upstate New York, one of the best employers I’ve ever come across is Tessy Plastics, a privately held company with about 900 workers that makes everything from those tiny plastic thingies that close ziplock baggies to surgical stapling devices used in gall bladder surgery.

Facing the loss of their largest customer fifteen years ago, Tessy relied on its workers to bounce back and become an amazingly successful company. I know a lot of Tessy employees, and they love what they do, work incredibly hard and smart, and as a result Tessy is doing very, very well.

We all can learn a lot from Tessy.

On the other hand, there’s a lot of worker risk and abuse out there.  First up, a reminder of how some workers are mistreated, abused, and oppressed by scummy bosses.  Thanks to workerscompensation.com for the heads’ up.

Law enforcement officials in New Jersey busted a company that was allegedly taking advantage of undocumented workers, cheating them and their clients in multiple ways, including money-laundering.

The explosion in the Arkema chemical plant outside Houston is another reminder of the risks faced by workers, risks that almost always are ignored by all of us until something catastrophic happens. Fortunately none of the 60 workers were at the plant when the storage trailers started exploding, but public safety workers were.

For those looking to help out with donations, the Greater Houston Community Foundation is one site that’s been thoroughly vetted.

Have a great weekend!

 

Aug
31

Will Harvey be a disaster for recovery workers?

Posted by Joe Paduda on Thursday, August 31st, 2017 | Comments

Friend and colleague Peter Rousmaniere penned a terrific piece in workerscompensation.com on how and why Harvey may expose huge holes in the workers’ compensation “system” in Texas.

here it is in its entirety- thanks Peter and WorkersCompensation.com!

Harvey brought 50 inches of rain and a thick dossier of irony to the workers’ compensation system in Texas. This natural disaster, like others have in the past, will challenge an economic safety net like workers’ comp to deliver assured and complete response.

 

Special factors at play in Texas may trigger a combination of grief, schadenfreude, and uncertainty.

 

Already hundreds if not thousands of employers in the state are gearing up for a surge of business in cleanup and repair. Can employers and workers depend on workers’ comp? Well, it depends. The catastrophe struck in the state with the greatest contradictions in how the workers’ comp system is supposed to work.

 

Are the cleanup and repair workers actually eligible for workers’ comp coverage?

 

In any other state, in any other year, the simple answer is yes. But in Texas, employers do not need to participate in the workers’ comp system. The opt-out program (technically, its non-subscriber program) covers very many small employers. How they respond to work injuries may be anyone’s guess, including themselves, since being outside workers’ comp means the employer is accountable to no one. Though they are supposed to file an intent to opt-out, the state is lax in enforcing that. The employer can drop off an injured worker at a community hospital and not pay a cent for the worker’s medical care. It need not pay a dime for wage replacement.

 

The employer can, to be sure, be sued for negligence. But what lawyer is going on a fool’s errand to sue for negligence a dry wall contractor with somewhere between 2 and 10 employees depending on the jobs at hand?

 

Further, the employer can legally threaten to fire the injured worker, or his co-workers, if anyone threatens to file a suit or so much as complain about having to make up his or her own work injury benefits. Intimidation is legal in opt-out.

 

Typically, in other states, when workers try to cover their work injury medical bills with their health insurance plan, the plan sends a team to the workers’ comp insurer to recover their medical spending. But Texas in this regard is not typical. Opt-out employers don’t have insurers.

 

And, Texas has the largest percentage of the population of all 50 states that do not have health insurance. (When almost every other state’s uninsured population plummeted due to Obamacare, Texas’ did not.) A lot of the cost is likely paid by the worker or out of hospital free care.

 

What about the undocumented workforce?

 

“Where are those undocumented workers now that we need them?” the construction industry may be asking. It has, according to press reports, grumbled months ago about Trump’s immigration enforcement. A 2013 study by the Workers Defense Project estimated that half of the construction workforce in the state is undocumented. These workers concentrate in low skilled assignments — such as hauling destroyed carpets from flooded homes, clearing out debris and carrying in building materials. In other words, the work created by Harvey.

 

We can disagree on the wisdom of stepped-up immigration enforcement and on the best long term solutions for the country’s eight million undocumented workers. But consider the facts on the ground. As Voltaire was reputed to have quipped, at 5 PM we are all economists.

 

Here is the problem: If Homeland Security continues to root out undocumented persons, how are the contractors who depend on them going to hire them? And if hired, in today’s climate of enforcement would an undocumented worker of employer covered by workers’ compensation rationally ever want to file a workers’ compensation claim out of fear of being discovered and deported?

 

Major disasters find a way to exacerbate unresolved stresses that preceded — in land use, economic relations, public policy. This was the case in the Chicago fire of 1871, the Triangle Shirtwaist fire of 1911, Katrina, and now with Harvey. Is the state of work injury benefits in Texas a model or a monster?

You can reach Peter at pfr@rousmaniere.com

Aug
25

There’s no BIG problem in work comp pharmacy – and that’s scary.

Posted by Joe Paduda on Friday, August 25th, 2017 | Comments

In the fourteen years I’ve been surveying work comp payers on their views on pharmacy, I’ve never seen so little consensus among respondents on emerging issues.

In past years compounds, physician dispensing, opioids, price inflation, and new drug introductions have all been named by at least a plurality of respondents. Not so this year.

Here are some of the 24 respondents’ concerns:

legalization of marijuana – lots of talk about it but concern is what do you do about it, how do you handle it, pay for it, authorize it, etc. so many unknowns and little understanding
state regulations and how to bring information on those changed regulations and how to operate under the new regs back to adjusters and case managers at the desk level and to PBMs
I’m concerned we’ll see branded topicals increasing over the next few years despite a lack of efficacy and inflated prices. teracyn, speedgel, etc aren’t useful
advent of all new formularies, no one has grappled with legacy claims in that environment, thinking is formularies will get docs to taper it off – docs who prescribe all this don’t know how to taper, so finding the right docs and facilities is a real issue for legacy claims
acquisition of comp pbms and consolidation of the work comp PBM industry
Physician Dispensed Drugs and non-controlled home delivery – not just cost but formulary and safety and quality of care
what interventions can they do to to affect drug pricing, especially some of the drugs that have minimal alternatives
more problematic than opioids is the combination of benzodiazepines and sleep aids
watching very closely Evzio, naloxone prescribing practices as part of CDC
still a soft market so anything you can do to reduce costs is important

While payers are seeing good success in reducing opioid utilization and total drug spend, there are a host of troubling issues out there.

Here’s why this is a big issue.

Payers are all too used to getting screwed by unethical and very creative profiteers intent on sucking money away from employers and taxpayers by exploiting loopholes. Branded topicals, “independent” mail order pharmacies and novel drugs are all great examples of these tactics, often hidden under and supported by claims that these promote healing and health despite a total lack of supporting evidence.

In past years when doctor dispensing, the opioid crisis, or compounds were top-of-mind for most respondents, the industry joined together to come up with solutions. That obviously isn’t the case today, leaving patients exposed to crappy providers interested only in profits coming up with myriad ways to game the system.

What does this mean for you?

It’s not the one big problem that’ll get you, it’s the many small ones you may not even notice.

Aug
23

Big news in work comp pharmacy

Posted by Joe Paduda on Wednesday, August 23rd, 2017 | Comments

Finishing up the Annual Survey of Prescription Drug Management in Workers’ Comp this week (I hope!).  24 payers responded this year – TPAs, Insurers, State funds, and very large employers. Each provided specific data about their pharmacy programs, data which provides remarkable insights into what’s really going on.

Something jumped out at me that I had to get out immediately…

Two big takeaways – drug spend dropped by almost 10 percent…

while opioid spend decreased even more – almost 14 percent.

Wrap your head around that.

Work comp PBMs and payers succeeded in eliminating one of every seven dollars spent on opioids; yes, overall drug spend was down a full 10 percent, driven in large part by lower utilization of opioids.

When opioids are eliminated, the drugs needed to counteract their awful side effects – everything from constipation to sexual dysfunction to gastrointestinal distress to depression – are reduced as well.

The programs, processes, analytical resources, clinical staff, research, and patient outreach that’s driven this stunning result are largely PBM-delivered (with some notable exceptions).  These services are clearly improving the quality of care delivered to work comp patients, while reducing costs for employers and taxpayers.

A shipload of opioids has been taken out of circulation, eliminating the possibility of diversion, misuse, or abuse.

What does this mean for you?

Healthier patients, lower costs, reduced disability. 

 

Aug
22

Reducing opioids CAN reduce pain

Posted by Joe Paduda on Tuesday, August 22nd, 2017 | Comments

Yes, patients can be weaned off opioids AND reduce their pain levels.

That’s the conclusion of a Vox article providing an excellent, detailed, and thorough review of a study published in the Annals of Internal Medicine Vox (thanks to Health News Review for the head’s up).

Here’s the abstract’s conclusion…

Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue LTOT [long term opioid therapy] and that pain, function, and quality of life may improve with opioid dose reduction.

Let’s parse this out.

The AIM study was based on a review of 67 clinical studies; it wasn’t “primary research.” Researchers found most of the studies on this issue had either a poor methodology or low sample size. And, relatively few were even of “fair” or “good” quality.

The 12.000 pain patients in these studies volunteered to taper off opioids; they were obviously motivated and wanted to make the change. So, it’s not possible to use this research when thinking about how to address non-volunteers as “involuntarily pulling patients off the drugs (may not) lead to similar outcomes.”

And this…

Crucially, the studies also looked at what happened when these reductions in opioid doses were paired with alternative treatments, including alternative medicines like acupuncture, interdisciplinary pain programs, and medication-assisted treatment for addiction. This is very, very different from a situation in which a patient is taken off opioids and effectively left stranded without any other form of care.

Conversely,

[the CDC concluded] there are simply no good long-term studies looking at the effects of opioids on long-term pain outcomes, while there are many studies showing that long-term opioid use can lead to bad results in other areas, including addiction and overdose.

Here’s a major point made in the study and Vox article – we HAVE to stop looking to opioids as a first-and-only line of treatment for pain.

the lack of access to non-opioid strategies may be one big reason that doctors resorted to opioids in the first place. The drugs offered an easy answer — if ultimately an ineffective one — to the many problems doctors faced, including patients who had complicated pain problems that physicians didn’t fully understand and tight schedules driven by the current demands of the health care system that made it hard to take the time to work through a patient’s individual problems. [emphasis added]

AND, we HAVE to allow/encourage/pay for alternative treatment.

What does this mean for you?

Suggest different initial treatments for pain, and get creative when helping patients who want to get off opioids.