Friday catch-up

I can’t remember a busier and more portentous week in healthcare in the last thirty years.

Last few weeks, in fact.  A lot happened in the rest of the world while we (at least us wonks) were obsessing over the latest news from Capitol Hill. Here are some of the highlights

When hospitals are going thru inspections by their accrediting agency, fewer patients die. That’s the finding of a study published in JAMA.  (thanks Steve Feinberg MD!) While the percentage reduction was small, the impact was not – if the lower rate prevailed for an entire year across all hospitals, 3,500 fewer Medicare beneficiaries would die – and likely thousands more younger folk. Why?

I’d suggest the Hawthorne Effect is at play: A researcher hypothesized the decrease may be more diligence.

“when docs are being monitored, the focus and attention placed on clinical care goes up. I’d say it was figuring out the diagnosis and matching the treatment correctly, because you’ve been a little more thoughtful.”

Telemedicine prices are going up – from less than $35 per consult in 2009 to around $43 these days.  That’s one of the findings from a research report authored by IBISWorld’s Anna Son.  More details on this in a future post.

The American Chronic Pain Association has just published the updated 2017 ACPA Resource Guide to Chronic Pain Management: An Integrated Guide to Medical, Interventional, Behavioral, Pharmacologic and Rehabilitation Therapies. Another shout-out to Dr Feinberg, Lead Author.

A piece I missed a few weeks back had this striking datapoint – fully 10 percent of claims at the Hartford had at least one psychosocial issue – those claims accounted for 60 percent of claims costs – and claims processes aren’t set up to identify these early on. This from friend and colleague Tom Lynch:

“It takes way too long for adjusters, nurses, and case managers to come to the conclusion that something is going on there. It has been the last thing they look at, and by the time they see it, it’s an iceberg straight ahead and they are about to hit it.”

I’ve been talking about the huge problem of opioids combined with benzos aka sedative hypnotics for some time now.  Mitchell Pharmacy Solutions’ Mitch Freeman PharmD. sent me the latest FDA blackbox warning – and reminded me that this is a much bigger issue than that involving combinations of opioids and certain antidepressants.

Finally, good friend and colleague Sandy Blunt of Medata did his usual incredibly competent assessment of a report, and drew some startling – and terrifying – conclusions.

I am still stuck on the math from an article early this year (“A Charleston Gazette-Mail investigation found drug wholesalers shipped 780 million hydrocodone and oxycodone pills to West Virginia in six years, a period when 1,728 people statewide fatally overdosed.”). The math is staggering on averages. How can anyone with a straight face say they could only recommend a 0.001% suspicion rate to the DEA. 

If the WV state avg pop from Census data during this time was about 1.84m and 780m pills were consumed over six years then each and every man, woman, and child in WV statistically consumed 1.36 pills a week –every citizen, every week of the year, for six years without ceasing. If we consider that 20% of the population was under 18 and adjust our data to exclude this group, then each and every man and woman 18 and up in WV had 1.7 pills a week. 

Even more disturbing is that this was just (“JUST”) for hydrocodone and oxycodone pills and did not include drugs such as codeine, fentanyl, hydromorphone, meperidine, methadone, or morphine …

This from the Gazette-Mail article:

Between 2007 and 2012 — when McKesson, Cardinal Health and AmerisourceBergen collectively shipped 423 million pain pills to West Virginia, according to DEA data analyzed by the Gazette-Mail — the companies earned a combined $17 billion in net income.

Over the past four years, the CEOs of McKesson, Cardinal Health and AmerisourceBergen collectively received salaries and other compensation of more than $450 million.

In 2015, McKesson’s CEO collected compensation worth $89 million — more money than what 2,000 West Virginia families combined earned on average. [emphasis added]

McKesson Corp CEO John Hammergren tees off on the 17th hole during the first round of the Pebble Beach National Pro-Am golf tournament in Pebble Beach, California, February 12, 2015. REUTERS/Michael Fiala (UNITED STATES – Tags: BUSINESS SPORT GOLF)

Thank you, for-profit healthcare system!

Telemedicine – a primer

It’s among the hottest topics in work comp these days.

Telemedicine will be one of – if not the – most disruptive force in workers’ compensation medical care. Companies such as CHC Telehealth, Go2Care, and AmericanWell are moving rapidly, adopting different business models in an effort to gain first mover advantage.

Looking for a broader perspective, I recently had the chance to interview Jonathan Linkous, CEO of the American Telemedicine Association. Here’s what he had to say…

MCM – What service types/specialties are embracing telemedicine most rapidly?  Why those?

JL – It covers the gamut from primary care to urgent care, but there are some popular specialties – mental health, behavioral health, neurology – stroke care, ICU/CCU. Dermatology is one of the earlier adopters and radiology via remote reading of images has become a standard in the industry

The greatest increase in the number of services has been via consultations with online providers, Intensive Care monitoring either continuously or in evening hours (30% of ICU beds are hooked up to remote monitoring) and remote monitoring of chronic care.

Slower adopters include surgery, although that is changing with some robotics and oversight/proctoring from specialists from a distance

[Telemedicine is now being used for] Initial or follow-up visits with providers. Online consults are growing quite significantly with 1.2 million services delivered to 750,000 members in 2016. Possible stroke victims are being assessed by neurologists remotely today.

In terms of the largest number of people served, the top specialty is radiology where 7 – 10 million pictures are read remotely followed by cardiology with remote monitoring.

MCM – Which payer types are currently involved in telemedicine?

JL – The fastest adoption is by employers and private payers, then Medicaid, then Medicare. [Reimbursement is a driver, as value-based organizations aren’t concerned with billing per service but rather with delivering optimal outcome they see telemedicine as a way to deliver care faster to key patient populations]. The easiest way for providers using telemedicine to get reimbursed is by value-based care and not FFS; it is harder to get it paid for by FFS as need to justify the usage.

MCM – What states or regions appear to be early adopters?  Why those?

JL – Telemedicine started out in rural healthcare [and was] funded by the federal government; today it is urban as that’s where people are. California, AZ, MD have all been early adopters and enablers; in general states are more supportive than Medicare. The VA has been very supportive, as have other governmental payer programs [excluding Medicare].

MCM – What obstacles exist and how are they being addressed?

JL – Resistance by provider community and HC in general as this is typically a slow adopting industry; that’s dissipating of late. Providers need CMS to move more quickly with this for Medicare. Some state medical boards have been slow in developing practice guidelines. There are licensure issues, and crossing state lines is a complex issue; we need to get that addressed. Regulatory complexity is a burden. The ATA is working on pathways for communities and state medical boards which will get resolved before licensure.

Ancillary professions eg psych, nursing, and physical therapy, are moving faster to resolve licensure issues than medical societies. PT groups are working on interstate compacts now to enable state-to-state reciprocity. [This is likely due in large part to the nature of ancillary practice, as these providers] practice under guidance of a physician. Of course, it is easier to do telemedicine within a state but payment is another issue due to FFS and other requirements. Telemedicine is [as much about] expanding relationships with patients and not just reducing office visits. Telemedicine providers can document findings and notes in a chart and have a record of that as opposed to some of the issues inherent in an office visit such as a “white coat” issue. Parkinsons groups have embraced TM as its hard to get out and see a doc. Specialists are far away and telemedicine can improve access, so patient groups are advocating for TM.

MCM – What is an example of a successful workflow – patient identification, enrollment, delivery, reporting/documentation, billing ?

JL – Key to success is integration. [Originally telemedicine was televideo, now on a desktop or laptop or even phone. He has seen conferences where docs show up and see patients during a meeting.] There has also been an improvement in workflow as electronic records integration is key. This hasn’t been a requirement but can be a huge help if you have robust EMR system that is portable and interoperable – we are a ways from that.

MCM – Does telemedicine support vertically-integrated health systems or is it more an independent practice driver?

JL – Both. Mayo uses e-Consult where for some patients considering a procedure or with a diagnosis, Mayo sends their records go to another Mayo provider perhaps in a different state to do second opinion remotely. Local hospitals can tie into Mayo to differentiate, to take advantage of Mayo providers’ expertise and brand strength. Private practices can use this to expand their practice if they have strong capabilities via patient portal with video consults etc. Some alliances are forming among independent practices in cities to enable providers in different groups to work together.

MCM – What is happening with reimbursement and what does the future hold?

JL – The market sees value. At the federal level it is just a matter of time. [I see a] 5 year timeframe where we are past tipping point to value based care, lots of healthcare systems are looking at these care systems and when the value-based:FFS balance shifts to 50:50 it will flip their business plans which will drive more TM. DoD, Prisons, IHS, others are embracing this – Medicare is last of holdouts.

Anyone interested in diving deep into telehealth can attend the association’s conference…

It’s about healthcare costs, NOT insurance premiums

What’s missing from the debate about AHCA and ACA is any discussion about what’s making premiums so damn expensive.  We are arguing over what we pay, not what we’re paying for.

That makes zero sense.

AHCA makes older folks pay more, and lets younger people pay less for health insurance. But it’s a zero-sum game; all of us are going to pay, we’re just arguing over who pays how much.

That’s not to say ACA was much better at “bending the cost curve”. Most real efforts (excepting Medicare physician reimbursement changes) were taken off the table during the negotiation process, so we were left with ACOs, medical homes, outcomes research, and “death panels” instead of:

  • federal drug price negotiation,
  • re-importation of meds from Canada,
  • requirements that new procedures demonstrate higher efficacy and lower cost,
  • stringent controls on medical devices, and
  • publication of prices and outcomes by provider.

ACA was – and is – an attempt to get insurers to compete for customers by lowering the cost of care. Some – Centene, Molina, Fidelis, and a few others – are succeeding, but the big commercial plans are mostly failing, resorting to hoary old “cost containment” techniques such as higher deductibles and copays instead of real innovation and effective branding and marketing.

This is especially striking as healthcare outcomes in the US are pretty awful, and research clearly proves spending more on physician care does NOT produce better outcomes. In fact, all credible research indicates the US lags well behind other developed countries in terms of health outcomes.

Link between health spending and life expectancy_ US is an outlier – Our World In Data

We pay more – a lot more – for health care than other countries.

So, here’s the solution – but one our politicians won’t pursue because they can’t afford to piss off the healthcare lobbying industry.

Cut what we pay for medical care, drugs, facilities and other services, and reduce the volume of services we pay for.

What does this mean for you?

Medical care drives premiums, and if we don’t deal with medical care, we’ll never control what you and I pay for insurance and taxes.



Are you the frog in the pot?

At some point the frog figures out the water is getting too hot – but by then the heat has sapped so much of its strength that it can’t escape. It’s morbidly funny – except if you’re the frog.

Our economy is changing so rapidly, many businesses, “thought leaders”, regulators, legislators, and other actors are going to be shocked when they find their long-held beliefs – and the businesses based on them – are no longer valid.

More succinctly, ignorance kills, and there’s a LOT of ignorance out there.

How much of your business relies on blue-collar employment? If you are a work comp insurer, case management company, adjusting firm, or loss prevention entity, likely a lot.

If you are a worker in that business, times are changing rapidly indeed.

If you had a job laying communications cables, wireless technology killed it. If you bolted pipes together in an oilfield, a machine can do it faster better cheaper – and with no injury risk. If you inspected pipes to look for possible weak spots, a robot can do that way more effectively and efficiently than you can. If you analyzed data in the field to figure out precisely where to drill to find possible natural gas reserves, a computer is about to replace you.

Oil rigs are increasingly automated. Even if we continue on this disastrous push to increase use of carbon-based energy, it isn’t going to do much to help blue-collar workers. Rigs that used to need 20 workers now do just fine with 5. One Texas oil producer added over 200 new wells – without hiring a single additional worker.

Coal production is falling because natural gas is much cheaper and easier to use – but coal mining jobs are disappearing largely because of automation.  Studies indicate 40% – 80% of mining jobs are at risk due to automation.

I’ve posted before about the coming demise of the long-haul trucker, one of the few blue-collar jobs that still provides something close to middle-class pay and benefits.

And don’t think those workers are going to jump industries and become construction workers.  Even if Congress and the President are able to pass a huge infrastructure bill, there will be fewer jobs than you might expect.  Even construction is being automated…

Think these guys and gals are likely to get hurt?

What does this mean for you?

How far out is your business forecast, exit plan, or “equity event”?


WCRI – What’s happening with medical?

Hospitals are losing work comp share. You would think that’s good news as non-hospital care is much cheaper.  But that may well be wrong. 

The hospital info was the headline from Carol Telles’ kickoff presentation Friday morning at WCRI’s Annual Conference. Workers’ comp patients are using less inpatient hospital care AND care is moving from hospital facilities to ambulatory surgery centers.

This isn’t specific to work comp.  Care has been moving from inpatient to outpatient to non-hospital facilities for decades.  Way back in the eighties – when I started my career in what was then known as “cost containment” – the big effort was to reduce hospital length of stay and admission rates. Over the last thirty (gulp!) years we’ve seen massive shifts in the location of care, as procedures that once HAD to be done on an inpatient basis – think back surgery – moved to outpatient facilities.

The result – outpatient/ambulatory facility use for all payers grew dramatically over the last 30 years, while inpatient admissions actually decreased over that period. This despite the aging and fattening of America.

For work comp patients, this trend persisted across all states – but this did NOT result in lower cost. In fact while the decrease in inpatient admissions was in the low single digits, costs per admit increased on average 24%. This makes sense. As providers and payers have moved patients to outpatient locations, only the sickest and most risky patients have required inpatient treatment. Unlike ambulatory surgery centers, hospitals have a broad array of emergency and life support resources needed.

Not surprisingly, hospitals are pretty unhappy about this. They are losing healthy, easy, well-insured patients to doctor-owned facilities, but get to keep treating the risky, low-health-status Medicaid and uninsured patients. Over the years, hospitals’ patient population has gotten more expensive to care for and less likely to have good outcomes.

What this means for workers’ comp

To fight back, hospitals are getting much better at revenue maximization.

In English, that means they get as much revenue from vulnerable payers as possible to offset lower reimbursement for unprofitable patients. And you, work comp payer, are about as vulnerable as it gets.

While fee schedules in some states (Maryland for example) generally protect work comp payers, most states’ fee schedules ensure work comp is very lucrative indeed for hospitals.

And no, your PPO isn’t helping.

Work comp PPO discounts may look ok, but the actual cost of treatment has been ballooning in many states. Payers THINK they are doing fine when they see the “savings” below fee schedule, but many aren’t focused on the real problem – how much they are paying.

What can you do about this?

Direct care to providers that deliver the best value, defined as cost divided by quality.



Opioid use in work comp has dropped – and cannabis does reduce chronic pain

Several states have seen precipitous decreases in the amount of opioids dispensed per claim.  KY, NY, MD, and MI all saw reductions in excess of 35%.

In every one of the states WCRI studed, at least 30% of patients with opioid scripts also had a script for a central nervous system depressant.  That’s just remarkable; the risk of adverse consequences goes up dramatically when patients take both drugs.  The good news is the percentage of workers who were prescribed this combination declined in most states – but the average decrease was a few percent.  While there can and may well be good reasons for docs to prescribe these drugs for individual patients, the research indicates there are significant risks.

Some have said medical marijuana should be considered an alternative to opioids.  If that’s a valid claim, that’s wonderful news indeed – and not just for growers, marketers, and pizza purveyors.

Dean Hashimoto MD reviewed the National Academies of Science’ report on all literature and evidence concerning the medical use of marijuana. Summary is here.

There’s conclusive support for cannabis’ ability to reduce chronic pain in adults, BUT at great risk of motor vehicle accidents and the development of schizophrenia and other psychoses.  This is a big deal, as most patients using medical marijuana cite chronic pain as the reason for consumption. There’s a lot of evidence that medical marijuana is effective – evidence derived from well-controlled clinical trials.  But little is known about efficacy, dosage, frequency, administration routes, or side effects.

There was moderate support for better sleep outcomes but at the price of impairment of learning and memory and increased dependence on other substances eg tobacco and alcohol.

Interestingly, there isn’t enough data or research to associate non-medical cannabis use with occ injuries or accidents.

There’s more good news.

Two solid studies documented significant decreases in opioid overdose mortality rates and opioid addiction in states that allowed medical marijuana.

What does this mean for comp?

Well, 22 million Americans used cannabis in the last month. So it’s real, and it’s common. There’s no legal way to use the banking system to pay for medical marijuana, and there’s no guidance on dosage or other prescribing standards.

And there’s conflict between state regulations, case law, and federal law.

We live in interesting times indeed.


Calling out Coburn at WCRI

Some WCRI attendees thought my public criticism of former Republican Sen. Tom Coburn (OK) was inappropriate (many did not).

Here’s why I called him out.

First, in talking about disability, Coburn asserted that SSDI – Social Security Disability Income – participation has exploded due to Democratic policies and politics. He said 25 million Americans are now covered by SSDI.  That is flat-out wrong.

I questioned him publicly about his figure, asking where he got it.  He immediately backtracked, saying it may be 22 or 25 million.  I responded that, according to a quick google search, the actual number was less than 15 million.

Coburn had blamed the opposition party for a huge growth in SSDI that NEVER HAPPENED.  He either made up the number of SSDI beneficiaries, was misled, or lied.

The real number, according to expert Yonatan Benshalom of Mathematica, is 9.8 million. Yonatan’s source is here. [Thanks Yonatan]

Why this matters

If Coburn’s false claim was allowed to stand, many in the audience may have left WCRI believing it.  As policymakers, regulators, and thought leaders in workers comp, they would then have perpetuated the myth.  That would lead to wrong decisions, lousy policy, and “solutions” for problems that don’t exist. For example, lawmakers may have sought legislation requiring an MSA-type allocation to indemnify SSDI for occupational disability from work comp insurers.

A more complex issue involves Coburn’s false assertion that the ACA was rammed thru “without any Republican input.” I noted that:

  • The ACA’s core design came from the conservative Heritage Foundation
  • The Gang of Six – half Dems, half Reps, met multiple times while ACA was being written – the Republicans were Enzi, Snowe, and Grassley, all of whom dropped out of the Gang under pressure from Republican Minority Leader McConnell.
  • As a results of those meetings and other dialogue, multiple components of ACA were added or changed in an effort to garner Republican support including:
    • removal of any public option
    • addition of the Cadillac Tax
    • reduction of the penalty for uninsurance
    • removal of funding requirement for abortion services
    • allowance for “religious” health insurance

Responding to my statements, Coburn said since he “was there”, he knew more about this than I did.  He said was part of the Gang of Six – which he wasn’t.  He WAS involved in a previous version of the “Gang” that dealt with tax reform –– but he was not involved in the Gang’s healthcare discussions. [I was peripherally involved via discussions with Congressional staffers and a meeting with Sen Ron Wyden (D OR) about reform]

There are many sources that refute Coburn’s false statements; here’s one.

For those interested in the real story, an excerpt:

[Senate Finance Committee] Chairman Max Baucus (D MT), in the spring of 2009, signaled his desire to find a bipartisan compromise, working especially closely with Grassley, his dear friend and Republican counterpart, who had been deeply involved in crafting the Republican alternative to Clintoncare. Baucus and Grassley convened an informal group of three Democrats and three Republicans on the committee, which became known as the “Gang of Six.” They covered the parties’ ideological bases; the other GOPers were conservative Mike Enzi of Wyoming and moderate Olympia Snowe of Maine, and the Democrats were liberal Jeff Bingaman of New Mexico and moderate Kent Conrad of North Dakota.

Baucus very deliberately started the talks with a template that was the core of the 1993-4 Republican [health reform] plan, built around an individual mandate and exchanges with private insurers—much to the chagrin of many Democrats and liberals who wanted, if not a single-payer system, at least one with a public insurance option. Through the summer, the Gang of Six engaged in detailed discussions and negotiations to turn a template into a plan. But as the summer wore along, it became clear that something had changed; both Grassley and Enzi began to signal that participation in the talks—and their demands for changes in the evolving plan—would not translate into a bipartisan agreement.What became clear before September, when the talks fell apart, is that Senate Republican Leader Mitch McConnell had warned both Grassley and Enzi that their futures in the Senate would be much dimmer if they moved toward a deal with the Democrats that would produce legislation to be signed by Barack Obama. They both listened to their leader. An early embrace by both of the framework turned to shrill anti-reform rhetoric by Grassley—talking, for example, about death panels that would kill grandma—and statements by Enzi that he was not going to sign on to a deal.

The false narrative that Democrats rammed thru ACA without any Republican involvement has become accepted fact by many who haven’t read anything but headlines. Coburn’s false statements perpetuated that nonsense, and he deserved to be called out publicly for them.

There’s a bigger problem here – ideological blinders worn by some make it seemingly impossible for those individuals to accept facts. Fact-free discussions, or, even worse, decisions based on beliefs that are the opposite of reality lead to bad public policy.

What does this mean for you?

The people who attend WCRI are enormously influential in our little industry.   They will determine the future of workers’ comp, how employees are treated and who will pay for that treatment.

They deserve to hear the truth.

PS – to the several anonymous commenters – as I’ve stated here numerous times, I don’t publish anonymous comments from cowards afraid to identify themselves.

WCRI – Attorney involvement; data says…

A really interesting (nerd alert!) presentation from the ever-informative Dr Rebecca Yang dug into factors associated with attorney involvement in work comp claims.

Dr Yang contrasted states with very low vs very high attorney involvement.

NJ and IL both had attorneys involved in almost half of LT claims with defense attorney payments over $500. However costs were relatively low considering the high involvement rate…

Multiple factors are involved in determining a permanent partial award in IL, and before 2011 there were no published standards for determining awards. That lack of standardization and potential for additional payments for PPD vs TTD benefits in IL may well have motivated patients to seek attorney assistance.

NJ also had higher attorney involvement.  To get a permanency rating, patients have to attend two hearings, and there are often dueling medical experts disputing each others’ findings. For experienced attorneys, these hearings can go quickly as benefits are resolved by negotiation and agreement.  Thus, there is more attorney involvement, but lower per-claim costs for attorneys.

In contrast, Texas and Wisconsin had the lowest incidence of attorney involvement, at 14% and 13% respectively.

In TX, maximum attorney fees were set by regulation and just increased in January of this year.  WI’s standards, fee structures, and processes are efficient an relatively easy to navigate for the layperson.


Work comp service companies – Don’t do this.

Call centers often use average call time (ACT, also known as Average Handling Time or AHT)) as a metric to measure customer service “efficiency”.

That is a really dumb idea. 

Especially in workers’ comp.  In fact, one could make a compelling argument that the lower the ACT, the worse the outcome – defined as customer loyalty and likelihood the customer will “buy” again.

In the real world outside of work comp, there are lots of ways customers can get answers to questions about products and services; YouTube, reddit, websites, and even Yelp are just a couple. In that “real world”, customers who call service centers have a specific question, which MAY lend itself to a pretty quick answer.  But it’s just as likely the customer has a complex question which does NOT lend itself to a quick answer…This from the article linked above:

AHT might have been a fine way to gauge performance on simple issues like address changes, balance inquiries, or delivery tracking, when throughput was the name of the game, it’s a terrible way to assess performance on complex issues that by definition take more time to handle. [emphasis added]

While YouTube et al do provide customers with helpful info, those “alternative customer service resources” don’t really exist in work comp.  The business just doesn’t lend itself to automation, because:

  • issues are often jurisdictionally-related and those regulations often change with minimal notice.  Moreover, many states are pretty small in terms of work comp claim totals, so it’s hard to justify allocating big business analyst/programming resources to automating answers about new state claim reporting requirements in Montana (no offense to my many esteemed colleagues in Big Sky Country)
  • answers may have significant downstream legal implications so nuance and opinions can matter a lot
  • patients rarely know much at all about workers’ comp and want to talk with someone who does.  The interaction is really more about listening and empathy than just providing correct answers.
  • Calming down an angry, confused, or upset customer takes time

More importantly, treating call center workers as machines who must produce X widgets (defined as handled calls) per hour isn’t likely to make those workers love their jobs, care about their customers, or want to stay at your company.

In fact, they’ll “perform” to expectations, working hard to get off the line as quickly as possible, regardless of whether the customer’s happy or not.

So, you’ll get what you want – “efficiency”.  And your customers will go elsewhere.

What does this mean for you?

Do you like it when a “customer service” rep hurries you off the line, can’t seem to understand or care about your problem, or even if they do, turfs you off to someone else or, heaven forbid, the company’s website?


HealthWonkReview takes on Alternative Facts!

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!