Sales – the least “professional” business role?

BY that I do NOT mean sales people are NOT professional – rather the role is not really considered so by many.  Just think of the titles sales people go by: Marketing representative. Account executive.  Business development manager.

Ever notice how people who are supposed to be selling stuff aren’t labeled as sales people?  Yet “nothing happens until a sale is made” and no company exists without customers.

There are far more “chief marketing officers” than “chief sales officers”, and – with some notable exceptions – the prestige is in the marketing title.

It isn’t just the titles on business cards, although that’s a symptom of the larger problem. It’s the lack of training provided by many companies, the failure to adequately vet and hire due to a lack of understanding of what works and what doesn’t in “sales”. You can see the impact of this in the relatively high turnover among sales departments.

All of the really good sales people I know are true professionals.  They do their homework, are persistent, listen a lot, ask a lot of questions, prepare carefully and thoroughly, and don’t waste time on likely-futile lunches and golf games. There’s a mistaken impression among many that this is “natural”, that these women and men just “get sales.”

Not true.  In fact, these “pros” are likely the ones fortunate enough to start their careers at companies that invested in sales training; had mentors who helped them grow and mature, worked for managers that supported them and helped them learn from their mistakes. These managers understand the sales process, and how it works both internally and externally. Did they learn this in business school? Highly unlikely.

Sales’ task is to find out what customers’ pain points were and figure out if and how their company’s offerings will alleviate that pain.  It is NOT convincing a prospect to use your stuff, but rather to know prospects so well that you can identify the ones most likely to buy your stuff.  There’s a VERY big difference.

In the work comp world, we all know sales people who are constantly on the move. Many are pure relationships sales people; they sell to their friends, and when they run out of friends to sell their current stuff to, they move on.  In contrast there are a relative few who are true professionals, able to mix the relationship with the consultative, skilled at leveraging their personal reputation to gain entre to a prospect where they work very hard to determine if there’s a fit.

As I look at the work comp services industry, not much has changed over the last couple of decades.  At many companies there’s a lack of appreciation for and of sales. That’s not to say senior management doesn’t want great sales people, they just don’t understand what makes one a great sales person, and what management needs to do to help sales continue to deliver.  There’s usually a distinct lack of training as well, little effective mentoring, and lots of internal conflict between operations and sales – a clear indication that not enough has been done to ensure sales and operations work together effectively.

What does this mean for you?

With the ever-changing landscape in work comp – mergers, acquisitions, vertical consolidation and internalization of services by many TPAs, retirement of many senior execs in “buying” roles, the growing role of the Procurement departments at carriers such as the Hartford and Liberty Mutual, it is becoming increasingly clear that work comp service entities will have to invest in their sales departments and staff if they are to succeed.



Monday catch-up

Happy Monday! here’s a few items you may have missed.

King v CompPartners – the California case may have implications for UR, IMR, and the “exclusive remedy” foundation of worker’s comp.

Here’s a very brief summary (see url above for more detail).

  • The underlying issue – did CompPartners’ UR reviewer do the right thing? is not in question.  The treating doc’s request was appropriately rejected as it was inconsistent with California’s evidence-based treatment guidelines.
  • However, the patient allegedly suffered seizures due to sudden cessation of the medication, and contended that the UR physician had a “duty of care” to inform the patient of that risk and recommend a weaning process.
  • The plaintiff took the case outside the work comp judicial process to civil court, where he lost.  It then went to Appellate Court, where the ruling raised this “question”: could Utilization Review be considered medical treatment, and the reviewer a treating provider?
  • This is contrary to all work comp precedent; the case is now before the State Supreme Court, which has stayed the Appellate Court’s ruling pending a decision.

Implications – talking to those who know better than I, the Supreme Court will likely reject the Appellate Court’s validation of civil court as an appropriate venue for the case, thereby reaffirming the “exclusive remedy” inherent in workers’ comp.

One issue that strikes me about this case; as the medication in question was prescribed by a physician for a condition deemed not covered by workers’ comp, why did the patient not a) pay for the medication himself or more likely b) get his health insurer to cover the script?

This would have allowed the patient to continue taking the drug and avoid the health issues experienced by the patient allegedly due to suddenly stopping the medication.

If you are in ChicagoLand and/or looking into value-based networks, read this. Really interesting piece on how a big provider system thinks about narrow networks, contracting, and what it wants to get paid for high-end services.  And will “eat” on commodities, such as MRIs for $100.

Here’s a shocker – media is all over reports on how chocolate helps athletes – even if the underlying study is pretty much nonsense. A much more important study that determined a very common spinal procedure is fraught with danger and likely counter-productive – was all but ignored.

From HealthNewsReview:

“Provocative discography” is a diagnostic procedure that’s used up to 70,000 times a year in the United States at great cost to the health care system. It’s commonly performed on patients with so-called “degenerative disc disease” who are considering spinal fusion surgery — a $40 billion per year industry”

If you have to rely on MCM to hear about critically-important research, there’s something really wrong with the mass media.

Looking forward to NCCI next week; will be on a panel moderated by Peter Burton with Mark Walls and Bob Wilson discussing regulatory issues.

Hope to see you there.

Spring in Health Wonk Land

Thanks to Peggy Salvatore of Health System Ed for hosting this week’s Health Wonk Review – great graphics coupled with quick synopses make for a readable and entertaining edition indeed.

One don’t-miss is Dr Bradley Flansbaum’s piece on his history with the pharma industry. Pretty compelling stuff and especially enlightening for those of us without direct experience similar to Dr F’s.

Health insurance, DOS, and Apple

Between a seeming inability to design a benefits plan that fits on one sheet of paper, a refusal to actually explain those benefits in terms normal humans can grasp, network arrangements that only a provider relations expert can understand, and a “explanations of benefits” that are dense and stuffed with jargon, health plans are way out of touch with consumers.
It doesn’t have to be this way.

If there’s one service that should be simple, easy to understand, and approachable for everyone it is health care.  What do I pay, where can I go, who do I have to call.

Health plans could learn a lot from the computer industry.  We old folks remember when only pocket-protector-people used computers; remember those big rooms with rows of metal boxes fronted by blinking lights and whirring tape drives? Those blue boxes were connected to green screens in the sea of cubicles outside the “computer room”, screens with horrible resolution requiring users to know what each of the dozen(s) of Function keys did and why.

The geniuses at Microsoft made computing much more user-friendly with Windows – and the PC industry exploded.

Then Apple got serious, designing their hardware and software around the non-nerdy user.  Macs were simple enough for schoolkids to use, and eventually even their parents got comfortable with Macs and PCs.

Now it’s smartphones, Siri, and google maps.  We don’t have to know anything about programming, or APIs, or backslash v frontslash.  The technology does it for us.  And “it” is pretty much everything.  We know the weather in Philly, score of the hoops game, whereabouts of our kids, monthly sales figures, meeting schedule for next week, and anything and everything else – instantly and in a format we grasp intuitively.

Which leads us back to health care.  Insurers and health plans need to take a lesson from Apple and Google; people want good health care that’s easy to access and fits their unique needs. They do NOT want to wade thru fine print stuffed with SAT-test words and jargon that’s murky at best. Blaming the consumer for misunderstanding a benefit plan is just nuts; write the plan so it’s understandable for everyone.

Give them the tools they need to use your health plan, tools that adapt to the consumer and their situation.  Tools that are intuitive, accurate, and user-friendly.

It’s long past time to scrap the “green screen” approach to health benefits.

What does this mean for you?

Some health plan(s) will figure this out.  And they will do very, very well.

Making work comp services more “efficient”

That is the reason there’s been so much investor interest in workers’ comp – we are the epitome of the “yellow sticky” business…


Workarounds abound, driven by individual adjuster’s requests, insurer system limitations, ever-changing state requirements, unrealistic-but-nonetheless-mandatory employer demands, and system “upgrades” that eliminate prior changes built specifically to accommodate a specific customer.

A couple examples…

Some state regulations require insurers to allow physician dispensing of drugs only within seven days of the date of injury. This requires the payer, Pharmacy Benefit Manager, bill review processor, and adjuster to have a “counter” to make sure they aren’t approving/allowing/paying for doc dispensed drugs they shouldn’t be. Data feeds have to be designed and built and tested, new fields added, new alerts coded, and staff trained and monitored and QA processes developed.

Or, more likely, put a yellow sticky with “do not pay Doc Disp Rx w/i  DoI” on that computer.

A large employer’s risk manager does NOT want Dr Awful to perform any Independent Medical Examinations (IMEs).  The employer TPA has to ensure its adjusters never use Dr Awful.  The adjuster that usually handles that employer’s claims is out on maternity leave, and somehow their replacement is supposed to KNOW this, perhaps by puzzling thru the SLAs (Service Level Agreements), reading the special handling instructions, or asking their manager.

Or, more likely, just put a yellow sticky with “DO NOT USE DR AWFUL FOR COMPANY X’S IMEs” on that computer

Pretty soon you get a cube that looks like our photo above.

Our industry is seen – rightly so – as horribly inefficient, ripe for automation, desperate for change. It is also inherently un-automatable, for several reasons.

First, it’s a state-driven system.  And when you’ve seen one state, you’ve seen one state.  Fee schedules, billing rules, employee direction to preferred providers, clinical guidelines, utilization review, state forms, dispute resolution processes, documentation requirements, all vary from state to state, and are constantly changing.  It’s just very, very hard to stay on top of these changes, figure out how to implement them, and also educate adjusters, clinical staff, bill processors, employers, lawyers and patients.

Second, payers chronically under-invest in technology, so even if the vendors have this whiz-bang terrific artificially intelligent tech platform, chances are pretty good they are trying connect with a payer just a generation away from the green screen era…if they ever left it.

Third, TPAs and service vendors have gotten very good at figuring out how to jury-rig their platforms and workflows to accommodate demanding customers.  It’s a hyper-competitive business; it’s either accommodate or lose the business.  Often it comes down to Martha or Mike in operations knowing that Fred the adjuster wants his reports on pink paper on Tuesdays and purple on Wednesdays.  And if that’s what Fred wants, that’s what you need to give him to earn – and keep – his business.

What does this mean for you?

Smart people who really understand the business can find lots of ways to do things more efficiently, increasing performance while stripping out cost and eliminating errors. However, if one doesn’t really understand the business, making things more efficient may well disrupt and break processes put in place because customers want and need them to work that way.

Highlighting the lowlifes – Real investigative journalism looks into workers comp


Investigative journalists are catching on to the widespread, rampant abuse of work comp by unscrupulous “doctors” and scam artists who’ve figured out it’s easy to make bank by cheating employers and taxpayers out of their workers’ comp dollars; and a whole lot less risky than taking on Medicare or Medicaid.

Christina Jewett’s series in Reveal highlights the lowlifes in California who’ve made millions filing fraudulent claims for non-existent medical conditions attributed to both real and imaginary patients. Comparing work comp fraud to Medicare, Jewett cites the relative ease and low risk inherent in cheating workers comp compared to the higher risk, harsh penalties, and Federal investigative muscle confronting would-be Medicare fraudsters.

The list of scams won’t surprise anyone who’s been in workers’ comp; fake diagnoses used to justify procedures that never happened; non-existent medical providers billing for services never delivered to claimants; claimants subjected to surgeries for conditions they never had.

Nauseating indeed, if for no other reason than we’ve seen it all before so many times.

Another “area of opportunity” for profiteers looking to shake the work comp money tree is the air ambulance industry. A recent Nightline story shines a very bright light into the very cloudy world of “life flights;” families bankrupted, insurers bilked, and employers stuck with bills for “life-saving” flights for patients whose lives were not in imminent danger.  Last summer, James Laughlin reported there were over five hundred fee disputes between comp payers and air ambulance companies in just one state – Texas.

I applaud Nightline, Jewett and the Center for Investigative Reporting for their diligence.  It’s remarkable how real journalists can help focus public attention on what’s really wrong with workers’ comp.

Michael Grabell and Howard Berkes could learn a lot from Nightline and Ms Jewett.

Opt out – the final word from the experts

Wrapping up WCRI’s opt out marathon, a four-person roundtable dove into the issue with AIA’s Bruce Wood leading off.  Bruce began with something I kept thinking during the earlier talk: what problem is opt out solving?

Work comp rates are down, no systems are in crisis, benefits are decent and in many states improving, and medical costs are, with a couple notable exceptions, not increasing too much.

Yes, there are problems in many states, some much worse than others – opioids, crappy docs, too much litigation, some outright lousy incentives that motivate bad behavior, and some bad employers, but overall, we’re doing ok.

Bruce went thru a litany of reasons opt out isn’t viable or appropriate; as one of the nation’s most knowledgeable experts on all states’ systems, he knows of what he speaks. One key point is that opt out is a federally regulated plan, therefore states can’t require financial stability or standards or minimums or audits.  Thus, even if states pass laws requiring financial standards, guarantee funds, etc, these laws will not apply to opt out.

Next up Elizabeth Bailey of Waffle House gave her views; the covered-smothered-chunked-and-served company is a non-subscriber in TX and insured thru the work comp system in OK. For those unfamiliar with WH, they sell waffles and related foodstuffs in sort of a mini-diner setting.  WH opted out in TX because the system was broken back in 2002; Bailey indicated that the lack of settlement ability and lifetime medical benefits coupled with the strength of providers made the TX WC system untenable.

That’s worked out pretty well – according to Bailey their plan features solid benefits, the ability to direct to specific medical providers, a strong focus on workplace safety have delivered much lower costs due to a dramatically lower injury rate, almost no indemnity expenses, and an overall decrease of almost 90% in costs.

My based-on-almost-no-real-knowledge-of-WH’s-program view is these folks are doing things the right way, which benefits their workers greatly – far fewer have injuries, which is the core goal of any occupational program.  And they get back to work quickly, so they don’t get stuck in a disability mindset.

Attorney Alan Pierce then weighed in; his slides were very detailed (much better for future reading than trying to follow live).  Perhaps his key point was the contention work comp is a right, not a benefit; a right owned by the employer.

Aside – Pierce’s pontification was more than a bit annoying; his attempt to denigrate the sessions and attendees by asserting that there were few/no injured workers in the audience, and therefore he, as an “injured worker advocate” was somehow uniquely qualified and special.  A physician friend and colleague noted afterwards that this was offensive indeed as there were several treating docs in attendance, all of whom likely had just as much experience “advocating” for injured workers.

Pierce made a case that opt out results in a dramatically greater cost shifting.  While I don’t agree with all the examples of potential issues, he made a reasonable case that opt out may well increase cost shifting of both medical and wage replacement expense away from the employer.

The session wrapped up with a representative from the Oklahoma Insurance Dept, James Mills.  He provided a concise overview of the program, which is regulated much more tightly than Texas’.

The key takeaway is one offered by…once again…David Deitz MD.  There just isn’t enough data, or, arguably, any data that would allow anyone to make a reasonable assessment of opt out and/or a comparison with workers’ comp.

Until and unless there is, it is difficult if not impossible to evaluate opt out.

Bill Minick – In defense of Opt Out

At the WCRI Conference, PartnerSource’s Bill Minick began his talk stating that one shouldn’t just read the language of ERISA opt-out plans but rather understand what actually happens in the real world.  I’m a bit skeptical of this, as whenever something goes wrong, it comes down to the contractual/legal language. I’ve been involved in a few contractual disputes and in every instance the interpretation of the legal agreement was the deciding factor.

Minick noted that the insurance policies issued to cover excess losses under opt-out usually contain language that provides comprehensive coverage, in direct disagreement with the limitations cited by PCI’s Trey Gillespie.  Ed. note – As these are excess loss policies they specifically address claims above a certain dollar limit, and may not cover any claims not deemed “eligible” by the employer due to their ERISA plan.

Key to the argument in favor of opt out is litigation rates and risk thereof.  

While the employer liability risk inherent in opting out of workers’ comp is certainly high, there is less litigation in opt out than in comp in Texas.  Minick asserted that litigation in TX is quite low relative to workers comp, while the risk of litigation and the potential high costs are real. Evidently there have been over 90 awards and settlements in Texas >$1 million.

He also suggested that modifying and altering current ERISA contracts to address some of the shortcomings pointed out by others can and should occur to address issues including reporting timeframes, medical benefits and coverage.

The data cited by Minick certainly supports his assertion that employers’ financial results are better under opt out than in the work comp system. However given that employers can reject claims much more readily in an opt out environment than under work comp, I’m not sure lower LT claims rates, faster RTW, or lower costs cited by Minick are comparable as the “covered incidents” may be significantly different.

Jeff Eddinger of NCCI noted that less than 1/10th of one percent employers in OK have opted out.  Gillespie opined that the legal uncertainty surrounding OK opt out has prevented the vast majority – including the largest employers who originally promoted opt-out – from electing opt out.

There was a series of other questions from several audience members, with the general sense one of skepticism towards opt out.  That’s not surprising as this is, after all, the Workers’ Compensation Research Institute annual meeting.

The final word on opt-out is coming up next…

More from WCRI – What happened after “reform” to states’ work comp systems?

Rather than inundate your in-box with multiple posts last week, I decided to delay posting on some of the research for a few days.  Today, WCRI’s analysis of work comp reform’s impact.

I had to listen very quickly and type even faster while listening to WCRI’s Carol Telles discussion of the impact of reform efforts in four states…as a result I probably missed most of the really good stuff.

When IL changed their Fee Schedule in 2011, medical payments per claim dropped about 19% while overall prices paid for non-hospital services dropped 27%. What’s with the discrepancy?  Did utilization or intensity of services increase to partially offset the intended 30% decrease in the fee schedule?  I might’ve missed the answer…

North Carolina also tried to reduce facility costs by changing the fee schedule from one based on charges to one based on Medicare for hospitals and Ambulatory Surgical Centers – there is a progressive decrease for services each year from 2015 to 2017, resulting in inpatient at 160% of Medicare and outpatient and ASC at 200%, with no separate billing or mar-ups for surgical implants.

In our favorite state – California – the implementation of SB 863 led to slight but significant decreases in medical payments per claim after many years of continual steady inflation. This was driven by reduction of reimbursement for ASCs from 120% of medicare to 80% effective 1/1/13, the elimination of additional reimbursement for surgical implants, and as of 1/1/14, a gradual transition to a Medicare-based FS for non-hospital providers.

Not surprisingly, ASC payments per claim decreased dramatically, dropping 24% in 2013/2014.  Imaging was also hit hard with a 23% drop, while physical medicine payments increased 28%.  This isn’t surprising as it is consistent with CMS’ desire to increase reimbursement for cognitive services.

Interestingly, the shift to the Medicare RBRVS system  resulted in a change in billing practices; the “rise in billing more complex office visits…stopped…after RBRVS transition.”

Last up was Louisiana.  State-set medical treatment guidelines were introduced five years ago, and there have been slightly fewer visits per claim after that intro.  The biggest drop was in pain management injections followed by a 5.7% drop in physical medicine (PT, OT, chiro).

The net – reform can effectively reduce cost if effectively targeted and well-designed.

Gov. Baker gets it right on opioids, we got it wrong on crack

On opioids, Massachusetts Governor Charlie Baker (R) has been in the forefront, working with the Democratic-led legislature on intelligent, comprehensive legislation designed to save lives, assign accountability, and reduce costs. The passage and adoption of HB4056 shows what can be done – and what should be done – by every state.

Yet there’s something unsettling about this – for me and for many others.  More on that in a minute.

Friend and colleague David Deitz MD, also a member of the Mass Healthcare Services Board, was involved in this process; here’s his take:

Gov. Baker and his administration have shown real leadership in addressing this issue, and it’s important to note that other groups within the Commonwealth, notably the Department of Industrial Accidents and the Massachusetts Medical Society, have also acted in concert to address problematic opioid prescribing.  The MA Healthcare Services Boards’ guidelines have been updated to reflect the new legislation so there are no inconsistencies.  Much work remains to be done, but this is a good step forward that puts important protections in place for injured workers, in particular.”

Key components of the bill include:

  • a seven-day limit on first-time opioid prescriptions,
  • new efforts to evaluate patients within 24 hours after an overdose,
  • addiction screening for middle and high school students.
  • requires doctors to check a state Prescription Monitoring Program each time they prescribe an addictive opioid to prevent someone from getting prescriptions from multiple doctors;
  • incorporates education about opioid addiction into high school sports training; and
  • establishes a drug stewardship program to dispose of unneeded drugs.

The other 49 states would do well to consider similar legislation.

What bothers me about my/our focus on opioids is that the victims of opioids are generally white, with many middle-class.  Did we – me, you, the powers-that-be, legislators, governors – handle this differently than the crack or “pre-opioid” heroin crisis?

Yes.  And that’s just wrong.

Back when crack and heroin were predominantly a poor and minority issue, it was a crime problem.  Policing, criminal prosecutions and jail time were the approach.  Just contrast the sentencing guidelines passed by Congress and signed into law in the eighties with the legislation pending before Congress today. Crack sentences were 100 times longer than those for powder cocaine.  Today, the bills are all about naloxone, buprenorphine, and addiction treatment, brought to our attention by weeping elected officials.  Back then, it was quite a bit different.

Now that it’s affecting a wealthier and whiter population, the solution is education, prevention, compassion, a disease model of addiction.  Abusers are victims, not criminals.

What does this mean for you?

There are lessons to be learned here, some of them uncomfortable indeed.