Insight, analysis & opinion from Joe Paduda
hosted by Health Affairs and authored by REAL journalist Christopher Fleming is up here for your perusing pleasure.
Posts from Hank Stern, Louise Norris, David Harlow, Roy Poses, and Tom Lynch are among the insights you’ll find at this latest Health Wonk Review.
I cannot believe we actually have to discuss presumptive GOP Presidential nominee Donald Trump’s health care plan.
Trump’s website calls for few specifics; most are recycled from other GOP positions while some directly contradict his past statements about healthcare or standard GOP health reform views. Moreover, he has been wildly inconsistent and often downright contradictory, often promoting then disavowing specific policy ideas in the same speech.
Notably, a couple positions contradict basic conservative ideology as well.
In fairness, buried in the dog’s breakfast that is Trump’s healthcare plan there are a couple good ideas.
With those rather major caveats, here’s what Trump says – as of this moment – about his plans for healthcare reform.
Rather than getting into an analysis of each of these “ideas”, let’s look at the overall impact.
First, the number of Americans without health insurance would immediately explode. About 21 million people have gained coverage under ACA; they would likely lose that coverage. Unless insurers can figure out how to comply with Trump’s requirement that insurers have to cover anyone regardless of pre-existing medical condition without going bankrupt.
If not, only healthy people would be able to get health insurance. Health insurers would immediately begin canceling and/or non-renewing and/or not offering policies for individuals, families, and employers with many health conditions/diagnoses. This is a matter of survival, as any healthplan forced to cover sick people would quickly find its costs exploding while healthy members fled to lower-cost healthplans.
This is fundamentally unworkable; you can’t require health insurers to cover people who aren’t forced to buy insurance, as only sick people will buy insurance.
Notably, there’s no mention of what Trump would do to address this.
Third, full tax deductibility of premiums makes consumers less sensitive to the cost of health insurance and healthcare, a violation of conservative free market ideology.
Fourth, health care providers would have to comply with an as-yet undefined governmental bureaucracy regulating “transparency”, with requirements around posting prices, updating same, making this information available to consumers, and enforcing these regulations. If anyone thinks healthcare providers would not instantly figure out how to game this, they’re hopelessly naive.
Finally, the American health care industry is in the midst of adapting to PPACA, a process that is well underway. The changes are monumental for every stakeholder.
Any individual with an IQ above that of your average tomato plant would understand that throwing the brake switch to stop a runaway train will kill most of the passengers.
The net – Trump’s ideas are either totally unworkable and/or widely discredited. He does not have an ideologically consistent, coherent or even remotely intelligible health care plan.
A while back I had the pleasure of interviewing Glenn Pransky MD, M.Occ.H., the director of Liberty Mutual’s Center for Disability Research. As I noted in a post a few months ago;
Glenn is the Director of Liberty Mutual’s Center for Disability Research; he is an occ med physician and has his Master’s in Occupational Health as well and has authored over a hundred articles, research papers, and book chapters. That’s all quite impressive; what really struck me is how approachable, genuine, and open Glenn is. [my use of his first name is intentional, Glenn is completely without pretension or ego.]
Here’s the first installment of the interview (note I captured this as accurately as possible however any errors are mine) :
MCM: How has the “condition of disability” evolved over the last 20 years?
GP: [There’s been an] Increase in the amount of health care treatment where it isn’t so clear that it makes people a lot better, along with growth in Social Security disability. More and more people seem to see themselves as permanently disabled.
Workers are staying in jobs longer because they have no resources to retire.
There are more employees with chronic conditions or who are in poor health; [there’s a] wave of baby boomers who are really unhealthy…less routine exercise in our working population. The Return to Work context of 20 years ago has changed, major shift in chronic musculoskeletal conditions is more prevalent today than it was 20 years ago – we are shifting from acute to more chronic disease state.
[Most recently there has been a] Shift from traditional jobs to non-standard work arrangements, contractors, out of house, gig economy etc. Non-traditional work situations are limited in terms of resources for RTW. The Upside is there is more focused problem-solving on RTW these days than before
MCM: What “causes” disability?
GP: A lot of factors. It starts with a health condition that limits [the person’s] ability to work. Whether it becomes a work loss is due to other factors; whether there are accommodations available, the treating physician’s focus on disability prevention, and whether there is reassurance that the injured worker’s RTW will be safe and supported.
For everyone who’s disabled according to Social Security there’s someone working full time that means there is more [to the disability] than the health condition. Work is better for people, as prolonged disability is bad for your health. Research indicates that even when controlling for the patient’s medical condition, when working age people are out of work, they become sedentary, depressed, detached, and mortality increases.
There are significant opportunities [to mitigate disability]; early positive contact w the injured worker makes a difference; work accommodations offered for temporary alternate duty reduces TTD days by 30%, supervisor response “how can I help”, how can we accommodate” can make a difference of 20% reduction in TTD…Also having a formal policy and consistent approach to it makes a difference.
For insurers- early contact and problem solving research in Australia shows this reduces TTD days.
MCM: What is the role of medical treatment and treaters in disability; causation, prevention, and mitigation?
GP: Providers that are focused on RTW are better for patients and deliver the best outcomes when they practice EBM and communicate w patients on this; there is good evidence that this improves RTW. There are a series of studies from Bernacki in JOEM – more recent ones from WA COHE program…when patients get medical care that does not have a strong evidence base, disability is prolonged. Opioids are a great example.
More to come from Dr Pransky – my quick takeaway is this:
Disability is NOT a medical condition.
I’m up to my eyeballs in the 13th (!!) Annual Survey of Prescription Drug Management in Workers’ Compensation; the response from payers willing to devote time to the project has been gratifying indeed.
Previous Survey reports are available here; note these are the Public versions; respondents get a much more detailed and comprehensive version.
A bit of background first. I conduct these surveys telephonically, speaking to the individual at the insurer/self-insured employer/state fund/TPA/trust who is directly responsible for the pharmacy program. In addition to asking their opinions and views, we get data on a variety of key metrics including:
A few early findings.
Much more to come; when the Survey Report is done I’ll post a link.
Enjoy the weekend!
Utah’s is 16 deaths per 100,000 residents.
New Hampshire? 18.2.
West Virginia leads at 24.7.
Rhode Island is well into the double digits at 14.2.
Texas is among the lowest at 2.5, as is Nebraska at 2.8.
For 2014, the national death count was almost 19,000. You can check every state here.
19,000 people died from prescription drugs – pills that a doctor prescribed for a patient. Not heroin, not crystal meth, not Ecstasy. Pills a drug company marketed, many of them supposedly “abuse-deterrent”. Pills a stockholder profited from.
I bring this to your attention, dear reader, because the news these days includes some signs that we’re making progress, that opioid scripts are down and things are improving.
They are NOT.
In fact, don’t be surprised if the death count in 2015 hits 22,000. That’s just a number, but it’s a number built on dead sisters and brothers and cousins and best friends, dead moms and dads and kids and BFFs and girlfriends and hunting buddies.
What does this mean for you?
Please don’t relax one bit. Keep the pressure on, keep the focus tight, keep demanding answers, and above all, be aware,
Now that Hillary Clinton is the Democratic Presidential nominee, it’s time to delve into her health policy platform. The quick recap is she is looking to expand and build on ACA, tweaking various parts and pieces to fix legislative errors, incent states to participate, and reduce out of pocket costs. (we discussed this in yesterday’s Blab; you can watch it here.)
Expand Medicaid
Clinton would offer 100% funding for any state that expands Medicaid for at least three years, then tapering down to 90%. This would likely encourage more states to take the step; Florida and Nebraska are two where elected officials are under increasing pressure to make the move.
Remove the family glitch
A drafting error doesn’t allow taking an employee’s family into account when determining subsidies for insurance bought via the Exchanges. Clinton would offer tax credits to offset those out of pocket costs for eligible families. The tax credit proposal is a convoluted way to fix what should be done via correcting the original language.
Allow near-seniors to buy-in to Medicare
More an idea than an actual policy position, Clinton is talking about allowing “people 55 or 50 and up” to voluntarily pay the entire “premium” to join Medicare. With much to be fleshed out, this looks to be a response to Sen Sanders’ call for free public insurance for all.
This could have some major downstream effects; by removing we older and more expensive people from the privately-insured pool, insurance costs for younger folks would decrease. This “public” option would also inject competition into areas where there isn’t any due; rural markets in particular could benefit.
Address drug prices
Clinton has several ideas including eliminating the tax deductibility of marketing expenses, setting limits on consumers’ out of pocket costs for prescription drugs, and allowing Medicare to negotiate directly with drug companies.
Most striking is the mostly-unformed concept of forcing drug developers to spend a set amount on R&D, with any additional revenues handed back to the Feds for government research on new therapies. This is intended to address the industry’s argument that research costs demand high prices (an oft-criticized and rather doubtful argument).
Sounds good, but I doubt – very much – if it could be implemented without causing a lot of problems as drug companies quickly figure out ways to game the system.
At some point it may make sense to review Trump’s, but at this point the GOP nominee has yet to come forth with any coherent health reform plan other than “repeal Obamacare” and sell insurance across state lines.
Summer’s arrived in upstate New York – and boy do we appreciate it. While I was watching all the trees turn green, I missed reporting on a bunch of stuff last week.
So better late than never, here it is.
P&C industry outlook
Let’s start with the macro stuff. A couple weeks back, Fitch published a piece wherein they opined the P&C industry is in for a tough time this year. After several years of stellar performance, Fitch expects prices to decrease as competitors battle for market share. Here’s how they put it:
Renewal rates are flat or declining for most commercial market segments following a hardened market from 2011-2014. The price competition comes from underwriting success and market capacity expansion from earnings accumulation. As price competition intensifies however, this will likely be a drag on premium growth, according to Fitch. Commercial lines written premium volume grew by only 1.8 percent in 2015.
For work comp, Fitch identified prescription drug costs and continued low interest rates as problematic; the first increases costs while the second reduces investment income.
Opioids
The number of opioid scripts in the US actually declined last year. And that was the third year in a row. That’s the best news we’ve heard in quite a while. Since 2012 – the peak year for opioid script volume – the number of scripts has dropped by 12% – 18% (depending on the data source).
In case you’re interested, prescription opioids accounted for about $10 billion in total spend in 2015. Workers comp accounted for around 14% of that, a rather striking figure when you consider total work comp medical spend accounts for 1.4% of overall US medical spend.
Yup, work comp uses about ten times more opioids than other payers.
And how the bad news; the drop in scripts hasn’t been accompanied by a decrease in the death count, which stands at 28,000 for 2014.
California Workers’ Comp
Well, at least it hasn’t gotten any worse. That’s my take on the just-released CWCI study on the UR/IMR process for Q1 2016.
My take – the IMR process is preventing people who don’t need opioids from getting scripts for opioids. That’s a very, very good thing. Yet the same docs keep prescribing this crap to patients knowing full well these requests will be rejected.
I’m very much looking forward to hearing all those “injured worker advocates” heaping praise upon the system for protecting their clients’ health and wellbeing, and that of their kids as well.
I’ll personally nominate each of them for a Comp Laude Award.
“The economy seems to pulse — surges a little bit, pauses, surges a little bit, pauses,” said Kevin Logan, chief U.S. economist at HSBC. “And in the end it’s nothing.”
That’s the money quote from a very readable piece in today’s Washington Post, one that seems at odds with the doom and gloom emanating from some politicians and pundits.
Before my inbox overflows with tales of woe, I fully understand there are places where the recovery is halting at best. And there are still too many who have decided to exit the workforce – although the number isn’t nearly as high as many think.
And, the percentage of the population that is without health insurance continues to decline – down to 11.0% in Q1, 2016. Deductibles are increasing for many – as they have for the last two decades – but it’s still far better to be insured than not.
Wage growth has increased, the unemployment rate is half what it was at the peak of the recession (and likely headed lower), manufacturing is growing, consumer spending is high, and most stock market indices remain relatively high. Consumer confidence is in a six-month slump, but one wonders if that’s partially driven by the incessant drumbeat of negativity from Trump et al.
All that said, it’s abundantly clear the employment world is going to change dramatically over the next decade, and it is possible if not likely some of the unease is due to fears that automation and offshoring will continue to eliminate stable, good-paying jobs.
I bring this to your attention, dear reader, to add a bit of perspective and data to the discussion.
Enjoy the first weekend in June
HWR veteran – and Blab host David Harlow – is hosting this fortnight’s edition of Health Wonk Review – if you like clean, fresh graphics and some surprise sounds, click on over!
The rest of the world is beginning to catch up to the progress workers’ comp has made fighting the opioid scourge. Kudos to PBMs, payers, regulators, researchers and some physicians for recognizing the incredibly negative effects of opioids years ago, and taking action to mitigate some of these effects.
That is NOT to say we’re anywhere close to getting this solved – far from it.
But we have seen some evidence of decreases in the number of new claims getting opioids in some areas and an overall decline in opioid scripts and morphine equivalents (MEDs). We’ll have more information in a couple of months when CompPharma (a consortium of work comp pharmacy benefit managers) releases its 13th Annual Survey of Prescription Drug Management in Workers’ Compensation. (note I’m president of the organization and am conducting the research, past reports are available free for download here.)
A few factoids to give some perspective:
From CWCI’s most recent research:
What we have NOT seen is any significant progress dealing with the knottiest and most important problem – long term opioid users.
I can’t count the number of erstwhile start-ups, business ventures, and eager entrepreneurs I’ve spoken with who contend they’ve figured it out.
By definition, anyone who claims to have a universal solution most certainly doesn’t understand the problem. Unlike reducing initial and secondary scripts, addressing patients who’ve been taking opioids for months is very much an
That’s not to say there isn’t opportunity – there most certainly is.
What does this mean for you?
We’re at the end of the beginning of the work to address opioids. This will take focus, years, diligence, and unrelenting focus.