Pre-Vacation catch up

Leaving tomorrow for eight days away, so today’s a quick catch-up.

First up, the news that there’s been a dramatic increase in investor interest in addiction rehab. The market for services will increase to $35 billion this year, up more than 50% over the last decade.

In a deal emblematic of the industry transition, Acadia will buy Bain Capital’s CRC Health for $1.2 billion; Bain purchased Acadia for $723 million eight years ago.

For those of us tracking the issue of addiction, the explosion in heroin use driven in large part by prescription drugs, and the damage caused to individuals, family, employers, and society, the hope is these entrepreneurs figure out a better/faster/more effective way to attack opioid addiction.  But, to paraphrase friend and colleague David Deitz, MD, those who expect to make huge profits from taking on this very difficult problem may be sorely disappointed.

Kudos to IAIABC for their effort to educate workers’ comp regulators; they will be launching a series of ten programs taught by subject matter experts to help regulators get up to speed on key issues related to work comp.

Data, research, and information

The latest research from California indicates the variation in surgery rates around the Golden State is rather dramatic.  For example, Orange County had twice as many lumbar fusions as San Mateo…and in hospital service regions, Coalinga’s rate among the <65 population was 3.5 times higher than Delano’s…

WCRI’s recently-released report examining Ambulatory Surgery Center costs and comparing same to hospitals should be required reading for managed care execs and regulators alike. Spoiler alert – ASC costs in many states are lower, due in large part to lower fee schedules

My vacation reading will include the just-released Dartmouth Atlas report on variations in treatment of prostate cancer.  (link opens pdf)  Why, you ask? Simple – there’s huge variation in treatment for prostate conditions, much of which is driven not by science or an active, involved patient – but rather by local practice patterns.  I began tracking this issue twenty years ago and hope the Atlas indicates things are getting better…

Now, back to finishing up work so I can relax unencumbered by the quest for filthy lucre!

Thanks for…

I wanted to do a post on all the things work-related I’m thankful for – but there aren’t enough pixels to include them all. So, here are the top few.

Most of the people in the work comp industry are committed to doing the right thing. Whether it’s getting injured workers the best care possible along with their indemnity checks, paying good docs fast and well, or helping employers lower their costs and increase productivity, the folks who do the work (mostly) do it well and diligently.

I’d like to single out a few organizations, jobs, and people:

  • Medical directors are a way under-appreciated force for good. Payers need to use them more effectively, elevate their importance and give them more responsibility.
  • The workers in the trenches – case managers, adjusters, bill processors. You are the “sharp point of the spear”, where all those brilliant ideas from home office end up in your work flow along with every other to-do.  How you manage we’ll never know.
  • Research organizations – specifically CWCI and WCRI, and the leaders thereof.  Rick Victor has remade WCRI into a more relevant, proactive, insight-delivering organization that uses social media quite effectively; his replacement at WCRI has enormous shoes to fill.  CWCI’s Alex Swedlow is brilliantly effective; a great speaker, Alex and his team are able to get more relevant research done faster than humanly possible, and present it in a way that demands attention.
  • Bob Wilson of  Bob’s coverage of Plotkin-Gate is one of the best examples of what social media can do and how effective it can be. We don’t agree on much anything politically, but we both agree Bob’s efforts have been a major force for good. Actually Bob probably thinks they’re even better than that…
  • The American Insurance Association, and especially Bruce Wood and Leigh Ann Pusey.  AIA’s leadership on critical issues, tireless advocacy, and commitment to doing the right thing for employers and injured workers has deeply impressed me. These are very good people.
  • The new crop of entrepreneurs and the companies they are running are shaking up the industry, finding under-served or poorly-served niches and fighting for business.  Whether run by newbies or veterans of other successful start-ups many of these new entrants are making a mark.
  • The work comp PBM industry.  Sure, I’m biased, as I run a trade group for PBMs – that also gives me a very good view into the business.  There’s no other segment of the industry that has been as effective in its core responsibility – delivering the right medical care at the best price to the most injured workers.  Across the industry customer service satisfaction is high, costs continue to decline, access continues to be a non-issue, and the quality of care improves with tighter controls on dangerous and inappropriate drugs.
  • Finally, the 5706 subscribers to  I deeply appreciate your readership, comments, views and contributions.  Even when I don’t agree.

Enjoy the holiday.  You’ve earned it!

Leaving Las Vegas

Quick takes from the blur that was NWCDC.

MedRisk’s Restore presentation was sitting-room-only; the company’s new venture is a comprehensive approach to managing delayed RTW – Restore targets all factors including psychosocial issues and involves comprehensive physical therapy, opioid-withdrawal management, and delayed recovery treatment.  (yes, MedRisk is a client)

Heard former Coventry CEO David Young is back in the game as CFO of a new venture with an old name – Occusystem.  No details available yet…

Speaking of Coventry, stopped into their booth yesterday to say hello.  Learned that their perspective on the move of AIG’s bill review business – and pending move of Liberty’s – is (surprise!) different from mine.  They noted that Coventry had informed both parties a couple years back that they would no longer be in the BR application business, therefore they took issue with my statement that they’d “lost” the business. I suggested that if the business was no longer their’s, then they had indeed “lost” it. Rather than argue semantics, I’ll report.  You decide.

Spoke with several investment types about Coventry’s possible re-emergence on the auction table.  As I’ve said ad nauseum, it’s value is the network, which is declining in effectiveness/size/discounts; the re-contracting effort is going to take a long time, and there’s not much else of value. (no, Coventry is not a client)

HealtheSystems has added Johns Eastern as a PBM client- word is things are going well.

Had a great time jousting with Bob Wilson, Becki Shafer, and David DePaolo at the bloggers’ roundtable.  Was hoping for a bit more “Jane you ignorant slut” and a bit less “I agree with…”

Caught up with Foresight Medical – they’ve engineered a pretty interesting surgical implant solution that is gaining traction.  Working with Broadspire and Medata, so they’ve already gone thru the virtual endoscopy.  (no they are not a client)

Ascential Care is growing fast.  Adding clients and getting more business from old ones, thanks to a focus on quality that’s like no other CM firm I’ve ever seen. The case management company also has one of the best websites in the business – and those people are actual AC folks. (no, they’re not a client either)

Finally, had a great session with three private equity executives.  Can’t thank Camilo Horvilleur, Jeff McKibben, and Hunter Philbrick enough – as the brains and dollars behind deals involving PMSI, MSC, OneCall, Align, Sedgwick, Mitchell, and many other work comp companies, this was a rare opportunity to hear about the process, understand what investors look for, get their views on leadership, management, and execution, and find out where they think the market is going.

Hope the conference was blindingly successful for you. Unless you were that ass in the elevator.  

Size isn’t all that.

The work comp services market is bifurcating. The big are getting (much) bigger, the $100-$250 million companies morphing into giants as they merge together or are acquired by private equity backed firms.

Meanwhile a whole host of new entrants are appearing – more on that in a minute.

Much of this has been rather mysterious to most. A good bit of light will be shed on the big-getting-bigger phenomenon today in a session at the NWCDC. I’ll be moderating a panel of three eminent investment executives tasked with explaining the whys and hows and whats; it kicks off at 10:45. Don’t be late as this is going to be very popular.

One of the key topics will be the factors that make some of the newly-constructed companies succeed while others don’t. There are a couple firms that provide real-world examples…

Back to the little gals and guys. I lead with gals because women seem to be inordinately represented among the CEO ranks of these emerging companies.

Whether its transportation or home health/DME or SIU, the exhibit floor and attendee ranks are brimming with hyper-motivated, very focused, totally committed small companies looking to take advantage of distracted, stodgy, slowly moving megacorps seemingly more focused on managing perceptions than service.

Many will succeed.

The long-rumored York acquisition will not close during the show, but it will close. Final details are being wrapped up and regulatory approvals obtained. Knowing the parties and principals involved, it’s very likely they will not make the same mistakes  noted above.

Comp conference day 1

The first day is more ease-into-it than jump-in-with-both-feet. For we East Coasters that’s a good thing as we can’t keep up with the late night events after waking at 3:30…

One noteworthy item and a couple observations from Tuesday.

The Coventry bill review RFI is out and rumor has it – it is Bill Review only. As in no other services needed. And lots and lots and lots of requirements. And the info required in a response is voluminous.

There is a rather limited pool of potential respondents; as in fewer than five. The business potential, while large, is shrinking. With the loss of AIG and pending loss of Liberty any successful bidder is going to have to staunch the bleeding.

Or more accurately, hope Coventry does.


As noted last year, what happens in Vegas gets posted to youtube. On an elevator departing a social event last night several men were commenting loudly and often in vulgar terms on the physical attributes of a woman. Who was also on the elevator.

I’m looking forward to meeting these boys on the exhibit floor. And their boss. I hope she’s a woman.


No one cares about your product or service. They care about their needs, which you don’t and can’t know unless you ask questions, shut up and listen.

Much more going on, but alas I heard “this is off the record” all too often yesterday.





And the first real news in Vegas is…

While no one from Medata will comment, word is the company has just implemented their bill review platform for AIG.

This has been very long in the making; we first heard rumors about the deal a couple years back.  It was all over the room at last night’s Medata event; evidently AIG went live within the last week or so.

There are at least two significant implications.

First, bill review application firm Medata is a force to be reckoned with.  Long a relatively small player, this relationship clearly moves them into the top tier with Xerox and Mitchell. No disrespect to Tristar, PMA, Amerisafe, and Medata’s other customers, but adding the 5 million plus bills flowing thru AIG is a whole different ballgame.

Second, AIG moved from Coventry.  This is a major loss for Aetna/Coventry’s bill review business; with Liberty Mutual likely switching over to Xerox the writing is on the wall.

Expect Coventry to either make a major investment in bill review (highly unlikely) or outsource the application to a third party (highly likely).

Asbestos pokes its long nose out from under the workers comp tent

Judgments in two recent court cases held that long-tail asbestos claims are not subject to the comp bar.

A very good friend who spends most of his time dealing with asbestos claims for a very large carrier shared this with me in a recent email.  Here’s how he put it:

If this contagion were to spread (and that depends very much on the precise wording of the comp statutes in each state), a lot of employers who might have believed that they were protected by the comp bar will find themselves defendants in lawsuits brought by former employees, which raises lots of questions about the applicability of their GL or EL coverage, assuming they had it and can identify the insurers.  [emphasis added]

The two cases are Tooey v AK Steel Corp et al., 81 A.3d 851 (Pa. 2013) in Pennsylvania and  Folta v. Ferro Engineering, 2014 Ill. App. LEXIS 444 in Illinois.

In Tooey, the PA Supreme Court ruled that the exclusivity provisions of the Pennsylvania Workers’ Compensation Act did not bar former employees alleging asbestos exposure from bringing lawsuits against their former employers when the asbestos related disease didn’t appear until after the time limit for filing for statutory work comp benefits had ended – which is 300 weeks in PA.

In Folta, an Illinois appeals court used the Tooey citation in revisiting an asbestos injury suit filed by an alleged victim who wasn’t diagnosed with an asbestos-related disease until 41 years after leaving his employment.

There’s a lot of legal detail involved including determining which statute takes precedence, however the likelihood that the Courts’ rationales are not likely to be limited to asbestos claims may well be the most significant.

What does this mean for you?

This strikes me as one of those things that could either be very, very meaningful.  What think you?

Friday catch-up

Lots happening in the workers’ comp world these days – here’s what caught my attention this week.

WCRI released its CompScope report, which is actually 15 separate reports covering 16 states.  I’ll be reviewing it in detail next week; for those who can’t wait you can find the summary of the news on Illinois here.  WCRI will be releasing other highlights over the next couple of weeks.

The good news in IL is the change to the fee schedule has had the desired effect; costs are about 20% lower.  That’s the good news; but all is not rosy.

  • PT continues to be problematic; utilization in IL is much higher than average among CompScope states at 25 visits per LT claim.  Only PA, with 27, is higher…
  • Surgery costs per claim were also highest among the study states.

More work to do in the Land of Lincoln.

Several states are looking hard at implementing formularies; Arkansas is considering adopting ODG’s, scheduling a public hearing on that proposed change for later this fall.

There is considerable interest in Washington’s formulary.  CWCI’s analysis of the ODG and WA formularies and implications of implementing them in the Golden State has generated quite a bit of interest; with projected annual savings ranging from $124 million to $420 million that’s not surprising.

Notably, Ohio’s formulary – which is truly closed, has resulted in almost no “non-formulary’ drugs dispensed to claimants.  While it is not as well known as TX and WA, the OH formulary, adoption process, and results show just how effective a well-managed formulary and drug management program can be.

WCRI’s hosting a webinar on the potential impact of adoption of the ODG formulary in other states.  Led by Dr. Vennela Thumula, the one-hour  webinar is on Thursday, Nov. 20, 2014 at 2 p.m. ET (1 p.m. CT, 12 noon MT, and 11 a.m. PT).

For those interested in the future of the workers’ comp world – which should include anyone working in the work comp industry, a lengthy piece on the future of international labor markets by The Economist is worthy of your attention.  Very well-written (as is typical for the Economist), they key points (quoting the article) are: [emphasis added]

  • the rise of machine intelligence means more workers will see their jobs threatened. The effects will be felt further up the skill ladder, as auditors, radiologists and researchers of all sorts begin competing with machines. Technology will enable some doctors or professors to be much more productive, leaving others redundant.
  • wealth creation in the digital era has so far generated little employment. Entrepreneurs can turn their ideas into firms with huge valuations and hardly any staff.
  • these shifts are now evident in emerging economies. Foxconn, long the symbol of China’s manufacturing economy, at one point employed 1.5m workers to assemble electronics for Western markets. Now, as the costs of labour rise and those of automated manufacturing fall, Foxconn is swapping workers for robots

Time to get to work – the annual Health Strategy Associates Halloween party is tonight!


Friday catch-up

Here’s a quick tour of what else happened this week…

First, let’s just relax about Ebola.  Yes, a physician in NYC – who treated patients in Africa – has come down with the disease.  Yes, he traveled on the subway and went bowling before he was diagnosed.  No, this doesn’t mean there’s a nascent epidemic, the City needs to go into lockdown, and residents should panic.

Ebola is hard to catch – a symptomatic victim has to share bodily fluids with another person for the virus to be transmitted.

You don’t get it from a bowling ball or subway seat.

Oh, and the two nurses in Dallas are recovering nicely; one is virus-free and the other improving steadily.

And, of the eight people treated for Ebola in this country, one – Mr Duncan – died, six recovered (or are recovering) and one (Dr Spencer) is in treatment now.

Last word – the nasty, over-the-top criticism of the CDC from critics as diverse as Mitch McConnell and Bill Maher is completely off base.  Dinging the CDC because a hospital in Dallas didn’t immediately understand a potential Ebola patient had presented and wasn’t thoroughly prepared for that (remote) possibility is just ludicrous; as is the vitriol directed at the hospital.

okay, back to the real world. or what passes for it in the US health care non-system.

First up, a piece in JAMA finds patient care delivered by hospital-physician organizations costs more than physician organizations.

After adjusting for patient severity and other factors over the period, local hospital-owned physician organizations incurred expenditures per patient 10.3 percent higher than did physician-owned organizations, according to the study. Organizations owned by multi-hospital systems incurred expenditures 19.8 percent higher than physician-owned organizations. 

Let’s not read too much into this – JAMA is a doc-run publication, but it does have the ring of truth to it; billing practices change when hospitals/health care systems own doc practices, and they don’t get cheaper.  Abstract is here.

Coincidentally, Fitch recently published a study indicating for-profit hospitals are doing quite well, thank you! Seems “the financial headwind of caring for uninsured patients has lessened, evidenced by markedly lower adjusted bad debt expense for large hospital companies.” This is ‘more true’ in Medicaid-expansion states, but is also happening in non-expansion states.

Less need to cost shift to work comp…

A few years back we were hearing how ACA would cause large employers’ health care costs to explode, leading them to drop coverage.  Hasn’t happened.

From Bloomberg; “Employers and their workers have benefited in the form of lower premium increases for their insurance plans. Other than a spike in 2011, after the law required plans to cover children until age 26 and eliminated cost limits on care, premium increases have averaged less than 5 percent a year since 2010, according to Kaiser. ”

Notably, a big part of this is due to employers raising insureds’ copays, deductibles, and cost-sharing.  That was going on before ACA, but now it’s capped.

Sources indicate Aetna is proceeding with efforts to recontract the Coventry Work Comp network onto Coventry “paper”.  However, those efforts seem to be rather lackadaisical; negotiators aren’t pushing hard for discounts, seemingly more interested in “dots than discounts.”  That is, there’s much more focus on getting contracts signed then on the discount itself.

No details on how successful those efforts are; will keep you posted as we hear.

Time to get to work – enjoy the weekend – away from work!

Physician dispensing in work comp; two victories!

I know, you are as tired of reading about physician dispensing in work comp as I am writing about it.  At last, there’s some very good news.

Quick refresher – docs dispensing drugs adds about a billion dollars in excess drug costs – plus increases disability duration by 10 percent, medical costs, and total claims costs.  Dispensing docs also prescribe more opioids to more claimants.

Benefits?  None, except huge profits to dispensing docs, dispensing companies, and their owners – we’re talking about you, ABRY. (investment firm that owns dispensing “technology” firm Automated Healthcare Solutions)

First up, a court case in Louisiana found in favor of the employer, as the 3rd Circuit upheld a workers’ compensation judge’s determination that a claimant would not be reimbursed for drugs dispensed by a third party pharmacy, in this case Injured Workers’ Pharmacy, when the employer had provided access to other pharmacies and otherwise complied with regulations. According to Troy Prevot, Executive Director of LCTA Workers’ Comp -  “The result of this decision will allow us to continue to use retail pharmacies to control pharmacy cost by negotiating lower pricing thru PBMs” instead of paying much higher prices for doctor dispensed or third-party mail order drugs.  

I’d add that LCTA’s victory will enable all other employers in Louisiana to ensure the clinical management of pharmacy is handled correctly by one entity.

Big news from Pennsylvania too – a bill (HB 1846) limiting physician dispensing duration and cost, and specifically targeting opioid dispensing, will become law (there’s some technical stuff going on, but it will happen). Among other things, the law will:

There has been much heavy lifting here – kudos to AIA, the Insurance Federation of Pennsylvania (the leader of the effort) PCI, the PA Chamber and CompPharma’s member PBMs (full disclosure I am president of CompPharma; the PBMs did the work).

This follows the good results in North Carolina – but all is not rosy, as Maryland and Hawaii employers and taxpayers are still stuck paying far too much for drugs and the crappy outcomes they deliver.

What does this mean for you?

Better outcomes for claimants, lower costs for employers and taxpayers!