Author: Joe Paduda

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.

Jan
24

Justice gets closer for John Plotkin

Posted by Joe Paduda on Tuesday, January 24th, 2017 | Comments

Former CEO John Plotkin should not have been fired by SAIF, Oregon’s state workers’ comp fund.  That’s the ruling by a Marion County Oregon Judge, and led to SAIF’s Board of Directors offering Plotkin $1.7 million as a settlement.

It isn’t clear if Plotkin has agreed to the settlement offer; published reports do not confirm his assent.

Judge Claudia Burton’s ruling requires SAIF to give Plotkin his job back – but SAIF already has a CEO, and the Board appears extremely reluctant to return Plotkin to the corner office.

SAIF’s summary firing of Plotkin was not only illegal, it was grossly unfair to Plotkin, SAIF employees, SAIF policyholders, and the taxpayers of Oregon.  The evidence clearly shows – and the Judge agreed – that his firing was motivated by SAIF’s internal politics, the ambitions of Board members, and not by anything Plotkin did or didn’t do.

No, the case against Plotkin was fabricated, comprised of misquotes, misattributions, and outright lies on the part of his antagonists. The Board’s conduct was appalling at best.

I won’t restate the many issues with the Board, the history of this disgusting affair, or the damage this has done to employee morale at SAIF; Bob Wilson has masterfully documented this case. I encourage you to read his view on SAIF’s offer.

What does this mean for you?

Justice can be done, but Plotkin’s case demonstrates it can require a lot of money, an ocean of resolve and patience, and a lot of vocal support from other stakeholders.

 

 

Jan
23

Monday catch-up – management moves in work comp services

Posted by Joe Paduda on Monday, January 23rd, 2017 | Comments

Just when you think things are calming down in the work comp world, you get a week like last week.

Leading off, management changes.

First, sources indicated occupational clinic company US Healthworks laid off a sixth of its management staff, most in headquarters state California. This comes just six months after the company announced a major expansion in the Southeast with the acquisition of Lakeside Occupational Medicine Clinics.

The Lakeside deal followed a series of clinic acquisitions in other states over the last few years.

Acquired by healthcare giant Dignity Health for $455 million in 2012,word from these sources is USHW has not produced the desired financial results of late.

Couple major management changes in the work comp Pharmacy Benefit Management business.

OptumRx CEO Emry Sisson will be departing effective March 1, 2017.  Emry took the role after the Helios/Catamaran/Optum entities were combined; prior to that he shared the CEO slot at Progressive Medical and third-party biller Third Party Solutions with Tommy Young (Tommy left after the Optum acquisition).

Optum parent United Healthcare will be looking inside and out for a replacement. Knowledgeable sources within Optum indicate this was solely Emry’s decision and in no way driven by United or Optum.

Mitchell Pharmacy Solutions’ Brian Anderson will also be moving on; I’ve known Brian for over a decade and he is one of the most forward-thinking, innovative people in the industry.  He helped start the third-party billing business, so I do hold that against him :). Haven’t heard of a replacement yet and will let you know when I do.

Coventry Work Comp Services business is said to be coming back on the market.  Word is the “book” will be not be released until parent Aetna’s acquisition of Humana is resolved.

That may well take a while…

Evidently this was the subject of much speculation at the JPMorgan Healthcare conference last week.  Key to any transaction will be the status of Coventry’s provider network contract.  Industry followers will recall Aetna’s first attempt to sell the business ended rather abruptly when potential buyers’ bids were much lower than expected due to concern about Coventry provider network contracts.

Word is the vast majority of those contracts – and especially those with providers who have a lot of Coventry business – have been transferred to “Coventry paper”. This should make the company much more attractive.

Conflicting reports on whether Aetna will bundle all component parts or pursue a different path.

Finally, registration for NCCI’s Annual Issues Symposium is open, and AMCOMP’s annual meeting is set for mid-March in Las Vegas.  Agenda is here.

Jan
20

Finally.

Posted by Joe Paduda on Friday, January 20th, 2017 | Comments

New Hampshire and the Feds are going after opioid manufacturers with a vengeance.

NH State law enforcement has reached a $3.2 million settlement with fentanyl drug manufacturer Insys and is pursuing investigations against Purdue Pharma, Actavis Pharma, Janssen Pharmaceuticals and Teva Pharmaceuticals.

The FBI indicted six senior Insys executives last month on charges of racketeering.

And actions have been taken against the company’s sales force and/or prescribers in several other states as well.

Insys’ Subsys fentanyl drug was narrowly approved by the FDA for breakthrough cancer pain. In what has become an only-too-successful marketing strategy, allegedly Insys aggressively promoted Subsys for non-cancer treatment purposes.  Reports indicate only 1 percent of Subsys scripts in New Hampshire were written by cancer doctors.

The Granite State has the highest death rate from fentanyl overdose in the nation.

A Physicians’ Assistant in New Hampshire was allegedly paid speaking fees as a backdoor way of incentivizing him to prescribe Insys’ Subsys(r) a version of opioid fentanyl.

Reports indicate of the 100,000 doses consumed in NH, this one PA, Christopher Clough, prescribed 84% of them.

What happened in New Hampshire is directly related to Insys’ marketing practices.  Make no mistake, this was all about profits, regardless of the damage to patients, families, society, kids.

This from the NYTimes:

“As Subsys grows more mature, we expect the number of experienced patients to grow,” Michael E. Faerm, an analyst for Wells Fargo, wrote last year in a note to investors. “As the experienced patients titrate higher, the average dose per prescription should increase.”

The former Insys sales representatives said they were paid more for selling higher doses…

What a great business. A highly addictive drug creates more revenue for the manufacturer and for sales reps as patients need more and more and more to get “relief” – or get high.

New Hampshire has subpoenaed other large opioid manufacturers who have refused to comply with the demand to provide materials. It’s highly likely Purdue, Teva et al will be compelled to comply when higher courts rule.

What does this mean for you?

A bittersweet moment indeed, but at long last corporate crooks are being criminally charged for their actions that killed people to create profits.

Here’s hoping they are convicted and sentenced to long terms at awful places.

 

Jan
19

Beware of “astroturf”

Posted by Joe Paduda on Thursday, January 19th, 2017 | Comments

As “Astroturf group” is one that looks like a “grassroots” organization that is actually founded, funded, and an advocate for a large organization.

Big pharma is infamous for the practice; one great example is the American Pain Foundation, an opioid-peddling outfit masquerading as a patient advocacy organization (thanks to WCC’s Elaine Goodman for the reminder).  The APF was shut down after an expose by ProPublica’s Charley Ornstein and Tracy Weber.

The APF is instructive.  90% of its funding came from big pharma and medical device companies.

Endo, J&J, and Purdue Pharma of OxyContin fame were major backers.  This is the same Purdue that pleaded guilty to federal criminal charges in 2007.  Sadly no Purdue executives went to prison despite thousands of deaths and millions of addicts from opioid over-prescribing.

And ruined communities – this was once a trailer occupied by a heroin dealer in Kentucky. (Credit HuffPo)

burnt-house-64a18ea387dc25ab789335b313810e57

APF got both the Joint Commission – THE healthcare facility accreditation organization – and the Federation of State Medical Boards – to send letters and publish “guides” and other materials promoting pain as the “Fifth Vital Sign”, a brilliant marketing ploy that required physicians to ask about – and treat – pain.

Their reach extended into the Veterans Administration and hundreds of other organizations. The Fifth Vital Sign campaign, backed almost exclusively by opioid manufacturers, created the opioid disaster we are living thru.

This is not yesterday’s news – it’s happening today.  In many state capitals the opioid industry remains a powerful and insidious force promoting opioid use.

The damage done is incalculable – hundreds of thousands of dead people, millions of addicts, destroyed families, devastated communities.

montvilleopioidvigil

Why discuss this now?  Because big business is ascendant.  With the incoming administration focused on reducing regulations and oversight across pretty much every industry we will undoubtedly see Astroturf groups proliferate.

What does this mean for you?

Our families and our towns cannot afford another opioid epidemic.

Jan
18

ACA Deathwatch: the GOP’s “repeal”

Posted by Joe Paduda on Wednesday, January 18th, 2017 | Comments

If you are confused and frustrated with the Republicans’ moves to repeal and replace ACA, rest assured they are way more frustrated – and more than a little concerned – than you are.

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Here’s what’s going on.

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

Republicans are working to finalize a bill that would defund major parts of ACA. There is NO consensus among Republicans on the details of this bill – and won’t be until at least January 27 (don’t be surprised if the replacement bill isn’t ready till well after January 27…). This won’t require any Democratic support as it is a budget bill. The GOP will own the bill – and the bill’s repercussions.

Earlier this week the CBO gave us a taste of what a repeal without credible replacement would look like, and that taste was bitter indeed.

  • 18 million would lose health insurance within twelve months
  • Premiums would jump by 20 percent to 25 percent immediately

BTW the CBO’s Director was appointed by Republicans in 2015.

If the GOP moves forward with repeal without a replacement bill – which looks highly likely – it will get hammered by Democrats in what will be reminiscent of the Tea Party’s assault on Democrats during ACA’s passage. Dems will turn the tables on Republicans, and with voters primed to fear losing coverage, the message will resonate.

The GOP’s problem is simple – ACA funding is very complex and cutting funding (which is how Republicans are “repealing” ACA);

  • decreases the number of people with insurance and/or
  • increases state government budget deficits and/or
  • increases the federal deficit and/or
  • hurts Medicare, and/or
  • hurts hospitals, and/or
  • hurts insurers.

There’s intense lobbying going on as device manufacturers, hospitals, governors, insurance companies, the very wealthy and other special interests seek to protect themselves.

While Republicans do have “plans” to replace ACA, they do NOT have consensus on “A plan”.  There’s a plan from HHS Secretary nominee Tom Price, another from Speaker Ryan, other plans based on prior GOP bills, plus lots of ideas from GOP-affiliated think tanks and lobbying groups. Make no mistake, there’s a lot of ideological division among Congressional Republicans.

When the GOP does write a replacement bill, it will be scored by the CBO.  A part of that scoring has to do with the definition of health insurance. Up till now, CBO used the ACA’s definition; now that ACA is going away, it will revert to the previous definition.  Not to get too deep in the weeds here, but that’s NOT good news for the GOP.

The dilemma facing Republicans is simple; there’s no way they can deliver on their promises to ensure people don’t lose coverage, reduce costs, and improve access.

Republicans are about to pull a Wile E Coyote, running full speed off the cliff. Given Democrats’ amazing ability to turn certain victory into crushing defeat by losing the messaging battle, the GOP may make it to the other side unscathed.

What does this mean for you?

The CBO is the key.