Mar
8

Your baby isn’t that pretty. Really.

OK, got my cranky pants on today, so here goes.  I get about a dozen press releases a day, most of which breathlessly tell me about something I NEED to know about – like right now!

This is your baby in a PR release.

And of course, I NEED to tell you, dear reader, all about the new product/executive hire/office location/logo/study that is so damn important it makes North Korea’s nuclear threat totally inconsequential.

Like these…

  • Formaspace just unveiled a new virtual furniture designing tool that is going to shake up the world of office furniture procurement
  • I’m writing to suggest a story idea for Managed Care Matters on the top three “fake it till you make it” hacks for entrepreneurial millennials.

  • Below is VisualVault’s latest press release sharing the exciting news of their new Director of Healthcare Solutions, Kathy Biggers.

And those are just from today. Many are so far out of my (and probably your) area of interest it’s hard to imagine how they found MCM. I wish I knew, then perhaps I could hide from them.

I get it – the executive at company X thinks their news is really, really important. Ground-breaking. Game-changing. A Black Swan, Unicorn, or some other super-cool mythical beast. What they don’t get is the more they send, the less anyone pays attention.

A few suggestions…

  • Press releases should be about important stuff. Think of it this way; if you got your announcement from some random organization, would you care? Really?
  • STOP with the hyperbole and adjectives. The more hysterical you are, the less anyone cares.
  • Target your stuff precisely. DO YOU CARE ABOUT OFFICE FURNITURE?
  • Be brief, to the point, use short sentences and bullet points.
  • Personalize the release – use the addressee’s name and tell her/him why s/he should care.

 

 

.

 


Mar
1

Who says gubmint can’t do anything right?

Not me.

One state fund has reduced the number of patients dependent on opioids by 60 percent over five years.

That’s 4,714 moms, dads, brothers, sisters, grandparents, sons, and daughters who can get back to living a real life, one free of opioid dependency.

BWC Ohio’s remarkable reduction in opioid usage was the result of a thoughtfully planned and well-executed approach to addressing the opioid scourge that has ravaged the state.

WIth leadership from the state’s Republican governor and a lot of work by the good folks at BWC, thousands of work comp patients have stopped taking opioids or greatly reduced their dosages. And BWC didn’t do this by cutting these patients off; the insurer paid for treatment, weaning, a wide array of programs and services to address chronic pain.

BWC’s pharmacy and therapeutics committee developed a comprehensive approach to opioids, one vetted by practicing physicians and embedded in the state’s Administrative Code. The approach requires prescribers follow a carefully crafted process, mandating compliance with the prescribing rules for all workers’ com patients.

Moreover, BWC did NOT start the opioid reduction effort until there were enough treatment facilities, programs, and trained providers to handle a big influx of patients.

I was peripherally involved in the early days of this; the State worked with a number of experts including Gary Franklin, MD, the Medical Director of the Washington State Fund (L&I). Dr Franklin was among the first to sound the warning about opioids, and as the leader of the State’s Agency Medical Directors, he was instrumental in developing and implementing the first comprehensive opioid guidelines. When Ohio started their planning process, Dr Franklin was heavily involved in helping the state develop it’s program.

Washington’s Guidelines were first implemented in 2007 – over a decade ago – and updated three years later. Dr Franklin et al were years ahead of most of us in identifying and developing comprehensive approaches to the opioid prescribing disaster.

Similar to Ohio, the impact on patients in Washington has been a major reduction in opioid prescribing and big drop in opioid-dependent patients. What’s not “reportable” is the thousands of families that haven’t been devastated and hundreds of lives ruined by opioids.

What does this mean for you?

Washington and Ohio have shown what government can do.

 


Feb
27

Work comp medical: cost vs “savings”

I still have a sports jacket I bought years ago because it was a great deal. It’s ugly and doesn’t fit right, but oh, what a deal. I keep it to remind myself that it’s not about the deal.

(I know, I can’t believe I spent money on this)

Most work comp buyers focus on the deal they get on medical expenses, paying little attention to the quality of care delivered, or what that care actually costs.

Reality is, most buyers measure their performance by how much they’ve “saved”, not how much they’ve spent – or what they got for their dollars.

Some, like Albertson’s, are focusing on what matters – quality. But most don’t, relying instead on “savings” reports that purport to show how many gazillions their vendors “saved” by not paying duplicate bills, slashing charges to fee schedule (!), applying state rules to bills, assessing relatedness and using clinical edits.

These buyers are saving themselves to death.

Instead of bill reductions, payers should be looking at medical cost per claim. Replace network penetration with physician performance evaluation, based on total outcomes. Stop looking at denied procedures and start identifying the providers who do a great job, send claimants to them, and leave them alone.

What is scary is that many in the industry think they are making progress. They are plodding deliberately along, reading bill review savings reports, studying, evaluating, debating, discussing, re-organizing, considering, meeting, presenting, recommending other ways to “save”.

They are mistaking activity for progress, when they should be focusing on what matters – measure and reward quality. 

So, you may want to ask yourself, would you buy medical care for your family the way you buy it for your employees or insureds?

What does this mean for you?

If you do want to dig into medical, here are a few ideas.

 


Feb
23

Are you being gamed?

I’ve had a number of conversations of late with self-insured employers about their workers’ comp “savings” reports; one thing that keeps coming up is how- and why – vendors ‘game’ the numbers.

(this post is a follow up to a post I did seven years ago…)

Perhaps the greatest variation is in bill review “savings” – and the fees attached to those “savings”.

Bill review savings are reported as a percentage below the applicable fee schedule or, in states without fee schedules, usual and customary rates or billed charges (depending on the vendor and state). Savings are also attributed to application of state rules, for example a denial of an assistant surgeon’s fee or physical therapy 59 modifier. These savings don’t generate additional fees for the vendor as they arise from mere application of state regs and fees.

One would think this is an objective result, and therefore there should be little variation among and between vendors, and in an ideal world, one would be right.

However, there is almost always a bit of judgment involved in determining what the ‘right’ fee schedule amount is and what state rules apply. The complexities are many, and the justifications, while often thin, are given to payers unequipped to refute the vendor’s statements.

Then there is the gamesmanship where savings that should be attributed to fee schedule or application of state rules are put in a different bucket, a bucket that just happens to generate additional fees for the vendor.

Let’s look at the ‘why’ vendor BR savings vary.

Simply put, follow the money.

Most bill review services these days are priced on a flat charge per line or per bill; Most BR vendors also charge for additional ‘value-added’ services on a percentage of savings basis – typically 25% of savings delivered on top of fee schedule/UCR cuts. That’s where the…variation usually lies.

The financial motivation is obvious; the vendor gets the same fee for processing a bill whether they deliver $1 or $1000 in BR savings, but their compensation for ‘value-added’ services is based on the savings that are delivered – the higher the ‘savings’, the greater the fees for the vendor.

Therein lies one explanation – perhaps the most significant one – for the wide variation in BR savings percentages. In my consulting practice I’ve had access to reports from several of the larger BR vendors, and the variation can be as much as 300 percent from vendor to vendor. Yes, you read that right – one vendor’s bill review “savings” in a state can be three times higher than another’s.

Almost always the vendor with the lower FS savings delivers great results from ‘nurse review’, ‘complex bill review’, ‘coding edits’, ‘unbundling and upcoding review’, or whatever they call it – suffice it to say that the savings delivered from these ‘extra, value-added’ services – when added to the ‘standard’ bill review reductions – are usually only a bit higher than other vendors who don’t have all those extra, value-added add-ons.

That’s not to say that some savings can – and should – be derived from careful and professional review of bills – coding and clinical reviews are often helpful.

How can you protect yourself?

  1. Ask competing vendors to reprice a set of bills and provide savings numbers in aggregate and for each bill. Compare reductions from application of FS and state rules from the vendors, and on individual bills.
  2. Where there’s wide variation, ask the vendors for an explanation, and don’t accept mumbo jumbo BS.
  3. Make very sure your vendor knows you are holding them to the same standard they used in repricing your sample bill.
  4. Ask your colleagues if you can see their savings reports, and compare the savings allocations to your reports.
  5. Ask your broker, consultant, or adviser for their views, and get them to share de-identified client savings reports with you.

What does this mean for you?

The bad actors are known to many – make very sure you know who they are.


Feb
21

Single Payer is Inevitable.

It’s going to happen. The US healthcare system will collapse.

It’s hard to say what’s the worst thing about American healthcare; the outrageous cost, the crappy outcomes, the endless paperwork hassles, the ridiculous rules, the dead and damaged patients, the huge financial burden for taxpayers and families.

American healthcare sucks.

For people, that is. For insurers, pharma, device companies, it’s never been better. 

People are dying younger every year. Infant mortality rates are worse than any other developed country. Costs are going up. More and more people are uninsured. Rural hospitals are closing. Employer premiums are unaffordable.

All while pharma, device companies, and for-profit healthcare companies are making billions and the tax cuts are increasing families’ costs and generating huge profits for health insurers.

 

Funny thing is, the last best hope for our Frankenstein-like healthcare system was the ACA. Based on a Heritage Foundation/Republican plan, the ACA relies on a hybrid private/public system, using Medicare and Medicaid regulation to drive innovation and improve care.

That’s being gutted by the current controllers of Congress and the White House, who have no plans to fix anything.

This will continue until it no longer can. No one knows when voters will rebel, but they will.

And when they do, we’ll have single payer.


Feb
20

Hey Washington, where’s the health care fix?

It’s a hell of a lot easier to blow something up than to build a replacement.

Especially when you don’t care about a replacement.

Fact is, we – you, me, taxpayers, governments – cannot afford our current health care “system.”  And it is getting more expensive every day.

Congress and the President are continuing their efforts to weaken and hobble the ACA, and they are generally succeeding. Without enforcement of the individual mandate, fewer young folks are getting insurance, increasing premium for us oldsters. The number of Americans without health insurance is up, health care costs are rising, and future Medicare costs are escalating.

The misguided and ill-intentioned “work for Medicaid” effort is going to create a whole new governmental bureaucracy, raise costs, and have zero positive impact. Medicaid changes are going to lead to hospital closures, especially in rural areas and inner cities. 

Health care costs were $3.5 trillion last year – and they’ll top $4 billion in two years. That’s a meaningless figure – until you realize our national and your personal budget is going to get whacked.

But it’s worse than that. The bi-partisan budget deal and tax cuts will exacerbate our already-huge national debt, screwing our kids and grandkids. The biggest driver? Health care.

And Congress’ and the President’s solution is nowhere to be seen.

Where’s the “replacement” the GOP has been talking about? Where’s the “market-based solution” to our health care crisis? Where’s the plan to lower drug costs?

Have you seen anything from Congress or the President that gives you any hope they have any plan?

These politicians aren’t interested in governing, don’t care about your costs or your kids’ debt, and hope you don’t pay attention. They have no political courage, no interest in doing anything that might cost them the next election.

What does this mean for you?

Nothing good.

 

 

 

 


Feb
16

Friday catch-up

Buried under two projects this week – here’s what crossed my desk while I was trying to do actual work…

First, after the horrific tragedy in Parkland, I recalled this data point – the US has a significantly higher child mortality rate than other developed countries.  Gun violence is a major driver. A child age 15 to 19 in the U.S. is 82 times more likely to die from gun violence than such a child in the other countries.

More than 1500 of our kids die from gun violence every year.

The next time someone blathers on about “American Exceptionalism”, show them this graph.

Big spenders – 

We’ve long known that a few people account for a lot of health care spending. New news indicates this is more true now than ever; 5% of patients accounted for 53% of spending in 2015. What isn’t as well known is there’s a LOT of turnover in that 5%; fully two-thirds of the people in the group this year weren’t big spenders last year.

Consistently High Turnover in the Group of Top Health Care Spenders  Implications abound:

  • high risk pools can’t cover these folks if they can’t predict who they are
  • insurance is needed to protect us from the risk we need high cost services

Drug costs

From Adam Fein, news that the rest of the world is following in the work comp world’s footsteps at least when it comes to moderating drug cost inflation. There’s a lot of great information in Adam’s post, much of which refutes generally accepted wisdom or common knowledge.  One item of note – utilization – the volume of pills – was almost flat last year across all payers.  

Webinar on IME Reports  

Independent medical evaluations (IMEs) are a critical component of workers’ compensation and other disability benefit systems. Unfortunately, IME reports often lack quality, customer satisfaction of the various stakeholders is not measured, and TQM is rarely, if ever, applied to medicolegal and IME work.

On Wednesday, February 21 at 3 pm ET, Noon PT, Christopher R. Brigham, MD , a world-class expert on independent medical evaluations (IMEs), will host a unique, no cost webinar on “IME Reports: Assuring Excellence! ” 

You can register at this link https://zoom.us/webinar/register/WN_PsLc3YHXTRWBU6aq2W9Wsg

Have a safe weekend, and please demand your elected officials stop ignoring the causes of gun violence 


Feb
15

The Olympic Edition!

Of Health Wonk Review is up – thanks to Steve Anderson of healthinsurance.org…

Stronger, higher, faster, brilliant-er – all for your reading pleasure.  And really cool pictures too.


Feb
15

Stone Point buys Genex – again

Case management/bill review/UR/IME company Genex has been re-purchased by Stone Point Capital; Stone Point sold the business to Apax in 2014. Takeaways are:

  • Stone Point really understands workers comp and the WC services business. The company is currently pursuing insurer AmTrust and own or have owned a number of companies involved in workers’ comp including:
    • Cunningham Lindsey
    • Oasis Outsourcing
    • StoneRiver
    • Sedgwick
  • Apax’ divestiture is likely NOT a signal the firm is going to break up or sell off OneCall Care Management. OCCM is deep into a systems conversion intended to tie the disparate businesses it owns together and the company just moved most of it’s home office people into a single location. Perhaps most importantly, OCCM’s debt is still trading well below par, an indication the investment is under water.
  • CEO Peter Madeja and the core of the senior management team will stay on. Peter is one of the finest people I know, universally liked and respected in the work comp community, and he and his team have performed well, keeping Genex growing in a declining market.
  • My guess is Genex will likely keep acquiring related businesses. These could include firms in the IME and MSA space as well as the occasional case management company. Mature markets require participants to grow via acquisition, a strategy Madeja et al have mastered.
  • I’d also expect some much bigger acquisitions. I don’t think Stone Point bought Genex to get into the case management and bill review business; these folks have bigger plans.

A couple of side notes...

Stone Point’s initial investment in Genex back in 2007 was reportedly about $56 million. 

One report indicated a source said that this time around, Genex sold for three times the original equity investment (note Apax paid for Genex with a combination of debt and equity). Without any detail or ability to dig into that, I have no idea if that is accurate or even likely.