Jan
24

Telemedicine – Coventry’s approach

A few weeks ago I had the opportunity to virtually sit down with Coventry’s product development folks to hear what they’ve been doing with tele-. 

I checked in again this week, and here’s what they’ve been up to. Quick take – tele-triage is gaining traction, while patients are slower to agree to do virtual office visits.

Coventry, a provider of services ranging from networks to pharmacy benefit management, case management to durable medical equipment, is well into Phase One, of their telemedicine offering which is tied into Coventry’s Nurse Triage program, NT24.

Working with technology vendor KuraMD  Coventry’s nurse triage staff connects with the patient, evaluates the injury or illness, and, based on their findings, recommends an appropriate level of care whether it be self-care, a “live” visit with a clinician, or a telemedicine visit (urgent and emergent cases are identified at call onset). Diagnosis and other factors drive the recommendation.

While the program has been in place for the better part of a year, Coventry has found many customers have yet to embrace the telemedicine office visit. Customers have “a tough time thinking of this as an office visit.” Telemedicine providers provide initial visits where they can send patients to physical locations for physical therapy or for imaging studies. While TM follow-up visits are offered, to date most employers want patients to visit a provider for those follow-up visits.

The program is live with two TPAs; a total of 10 employers have been implemented to date nationally with 4 in single states. Employers are quite diverse, including labor, retail, temp staffing, and construction.

For those patients able and willing to use telemedicine for a virtual initial visit, Coventry uses providers contracted with KuraMD. Care coordinators initiate the tele-visit, ensuring the patient has the right technology, walking the patient through the set-up and sign-on process, then passing the patient to the clinician for the visit.

Concentra will also be working with Coventry in the future

Phase Two involves broadening the number of clinicians that can provide telemedicine and also offering telemedicine visits without the nurse triage component. As one of, if not the largest workers’ comp PPOs, Coventry is working to get information to the company’s contracted network physicians to educate them about the service and requirements, discuss compensation, and provide training. The credentialing process and standards are identical to the company’s “regular” network but there are more questions regarding state licensing to ensure compliance with state regulations.

Down the road, Coventry is looking to incorporate tele- into case management. Ideally, case managers would connect with the patient, provider, and/or employer via video conference and enter information in real-time into the company’s proprietary CM IT system. There’s much work to be done connecting with claims systems to identify the types of and format of information needed by adjusters, build data feeds, and separate out key bits of data that need an adjuster’s attention.

What does this mean for you?

Expect tele-visits to gain traction as patients use similar services for family members and their own care. Telemedicine is moving quickly in group health, and this will accelerate adoption in comp.

 


Jan
22

Tele-everything

In the 30+ years I’ve been around the workers’ comp industry, there hasn’t been anything truly disruptive, until now.

Telemedicine, telerehab, teletriage are just three of the ways technology will enable remote delivery of services to injured workers and other key participants in the injury recovery process.

The implications are broad and deep, as are the challenges.

The implications are robust; Faster access to care. Quicker determination of compensability, causation, and relatedness.  Deeper understanding of psycho-social factors. Stronger rapport with employer and patient. Instant access to information for adjusters and case managers. Better tracking of patient compliance with physical therapy and home exercise.

The challenges are many: Do patients and providers have the necessary technology. Are connections secure. Do laws and rules allow for/support/enable tele-everything. How and who will get paid how much for what. What jobs are at stake. How will service providers adapt to tele-everything, and can they.

And this isn’t touching the implications implicit in the adoption and use of Artificial Intelligence, which will revolutionize most of what is done in our industry.

We’ll focus on tele-everything this week, with interviews with several of the early adopters.

 

 


Jan
19

What’s going on with health coverage for poor kids?

The current clustermess in DC around keeping the government funded is just bizarre.

What’s most bizarre is politicians are holding poor kids hostage, which is the only way to describe what is happening.

Republicans are refusing to consider legislation – requested by the President – to address DACA as part of the budget resolution. This is a core requirement for many Democrats, as is long-term funding for CHIP.

Background – CHIP has long been a bi-partisan program, championed by Sen Orrin Hatch R UT among other staunch conservatives. It provides insurance for poor kids and pregnant women, and has been funded for decades with nary a blip. Till now.  CHIP has been unfunded since October; most states are about to run out of residual funds, which would throw about 8 million poor kids and pregnant women off the program – and leave them with no insurance. 

This makes no sense.  If the Childrens’ Health Insurance Program is re-authorized for a decade, it SAVES $6 billion.  There is NO fiscal reason to NOT re-authorize CHIP, just a political one. The GOP is using the re-authorization in an attempt to force Democrats to support a budget proposal that is anathema to many Democrats – and more than a few Republicans as well.

It appears likely that we’ll be forced into a government shutdown over this, which will end up costing taxpayers a LOT more money than if the party in power had just passed a budget months ago as it was supposed to.  In case you aren’t as nerdy as your author, there have been four separate continuing resolutions to keep the government funding since Trump was inaugurated – and there are NO plans by the Senate Appropriations Committee to discuss a budget for this year – or next for that matter.

Moreover, the Committee, which is dominated by Republicans hasn’t even bothered to hold a vote on a budget over the last year.

If this stuff makes you nuts, well, it should.

What does this mean for you?

Be very thankful you aren’t a poor kid.  And really mad about what this idiots are doing to poor kids. 


Jan
16

WCRI is just around the corner

Had a chance to sit down with WCRI CEO John Ruser a couple weeks ago and get his take on the Institute’s Annual Meeting, scheduled for March 22-23.

For those who have yet to attend WCRI, get yourself there this year…and unlike other conferences, attendance is limited.

I’d strongly encourage you to register now if you haven’t already…

MCM – What’s going to be different about this year’s conference?

JR – We are going to start with a focus on the future – Dr. Erica L. Groshen, former Commissioner of Labor Statistics and head of the U.S. Bureau of Labor Statistics will open with a discussion of the changing workforce and technology’s influence from the perspective of a labor economist, more about what is going to happen.  The theme throughout the conference is we will revisit that.  The Sedgwick Institute’s Dr. Rick Victor (former WCRI CEO) will speak to the challenges facing work comp system including the changes in the workforce, We will close with a panel discussion to hear from different perspectives on this theme.

MCM – Why this focus?

JR – There’s been an acceleration in the rate of change in the workforce, we thought it was time to bring that topic into the conference and bring it to bear on workers’ compensation in particular, it’s time to start considering this in our conference. I anticipate there will be discussion of potential impact of these changes on claim frequency and claim severity.

MCM – Any teasers you can provide on what those trends might look like?

JR – In general, what’s going on in the economy in the labor market is the substitution of capital for labor; capital we used to think of as heavy machines, now it’s software and computers are driving the trend where high risk jobs will go away because of substitution of capital for labor.

Since I’m an optimist and this has been happening for 150 years or so, I believe new jobs will spring up, the question is what does that mean for workers’ comp. Along with that is the change in the employment relationship typified in part by Uber, but its gong to be amore general aspect of the labor market where workers won’t necessarily be attached to employers in the way they were before. That certainly creates challenges for workers’ compensation.

MCM – The implication is that insuring occupationally related injuries and illnesses is going to fundamentally change, is that fair?

JR – It certainly will change.  We’ve seen a quarter-century of declines in OSHA reportables and claiming rates, there is a notion the workforce is changing so there aren’t as many claims as there were in the past.

MCM – There is some indication that wages are heading up in some states, but given the substitution of capital for labor, that means folks in low wage jobs are not going to see increases in pay. For that and other reasons is it likely we will see medical expenses continue to increase as a percentage of claims?

JR – This is the area that Dr Groshen is going to get into…There are other factors as well, new technology that will help workers recover faster or even survive accidents that they wouldn’t have before. With that comes higher medical costs. Advanced prosthetics allow injured workers to function better, and while costs will go down over time, for now those devices are quite expensive.

MCM – Is there going to be discussion about Artificial Intelligence and the role that is going to play?

JR – Yes, that is likely to come up. There are lots of other topics, for example are we ready for value-based care? We are doing work interviewing stakeholders to determine if we are ready for that, and that will be a discussion topic at the conference. We have a session on opioids and the impact of opioids on return to work. The National Safety Council and a large employer will talk about the issue of opioids in the workplace.

Fee schedules, prices, and access to care is always a topic of interest. We will be looking at this, in particular comparing group health to workers’ compensation in several areas including delays in accessing primary care and other types of treatment.

The agenda is here.

2019’s conference will be in Phoenix…


Jan
10

Why your “predictive analytics” program isn’t working

I’m hearing more complaints and concerns about the lack of results from projects involving “big data”, analytics, predictive modeling and the like. These have me scratching my head, as effective use of data is critical to any enterprise these days.

I think I’ve figured out why some of these projects haven’t turned out the way sponsors want.

An excellent article on the effective use of analytics identifies 6 keys to ensuring success hit my inbox a bit ago and I’ve read it seveal times, passed it on to respected colleagues, and gotten their feedback.

Targets and accountability. The Central Analytics Business Unit (ABU) was set up as a centralized profit center with ambitious targets and with direct reporting to the chief operations officer;

Support from the top. Obvious, critical, and bearing repeating.

Incentive scheme alignment. The returns generated by ABU’s analytics projects accrue to the departments, who do not contribute to the cost of the ABU. And the ABU team is paid using variable compensation, based on projects that have been fully implemented and based on their ROI.

Rigorous assessment of results. The contribution of analytics is always measured and in some cases is reviewed by the accounting department.

Communicating with strategic goals in mind.  The ABU emphasized communication

The right people. Recruited employees had:
(1) significant quantitative strength;
(2) negotiating skills and diplomacy;
(3) the ability to communicate with the business lines; and
(4) entrepreneurial instincts. Recruiting this high-demand skill set was not easy.

Most of the initial ABU recruits were external hires, and several of them had little knowledge of the banking industry.

BUT…information without action is nothing but a waste of time and money.

This from a physician executive colleague:

One of the things they don’t discuss that I see as an issue throughout the insurance industry (commercial as well as WC) is that analytics often produce counter-intuitive results, and/or suggest conclusions that are at odds with what passes for traditional wisdom.  

An example – I had 3 years of analytics (pretty good ones, too) that demonstrated a 5 or 6:1 ROI from the medical directors’ department (and that included all costs, fully loaded salaries, etc).  No one would believe it, and they dismantled the whole operation.  So, what I’d add to the HBR piece is that the CEO championing (which is one of their 6) has to include championing of business plans based on the analytics, no matter how uncomfortable that makes some people.  

Think analysis of the true costs of network discount strategies is going to be well received anywhere?

 

 

 


Jan
9

There’s no such thing as “sales”

The word connotes getting someone to buy your stuff, solution, or expertise – but the direction is all wrong. After making many mistakes in the sales process, I’m finally beginning to learn what works and what doesn’t; here’s a few takeaways that may be helpful to you.

This doesn’t work…

Salesman offers

Don’t think of it as selling to someone, rather it is get people to buy from you. A seemingly small semantic change makes all the difference, because the focus shifts from you to them.

People buy because they want or need the service or product.  Sure, a few may buy just because they want you to go away and leave them alone, but they won’t buy again and probably won’t like what you sold them.

They buy because you have something that solves their problem, obvious or not. That problem may be they can’t achieve their objectives using current provider networks, they need to expand into other regions but don’t have the infrastructure, their addressable market is shrinking and they need to find another source of revenue.

How many times have you actually figured out exactly what the buyer’s problem is? Not their employer’s problem, but the buyer’s? Because it’s not unusual to find out what works for the buyer is different from what you think is the best solution for their employer. 

When you approach selling from the buyer’s perspective, it forces a completely different focus. Here’s what I see as keys:

  • Ask questions.  Ask more questions. Then ask even more questions.
  • Until you are ready to close the deal, Do NOT talk about what your company does for more than 15 seconds. No one cares about your history, awards, building, number of employees, or mission.
  • People buy, companies don’t. Figure out what’s important to the buyer(s), and why. Don’t get caught up in the “but this is the best solution to your problem” trap; if the buyer believed that they would be writing the check.
  • Powerpoint (and other types of) presentations are too often a crutch, take way too much time to prepare, and are rarely helpful. Avoid them until you can present a buyer-specific solution.
  • Do not present your solution UNTIL the buyer has helped you design a solution that s/he believes is the best answer.

There’s a lot more to this, but I’ll leave you with this: when the buyer is talking you should be listening really hard, and when you are talking, you should be asking questions.

Be this guy…

 


Jan
8

Monday catch-up

Lots has been happening, here are a few items that caught my attention.

WCRI’s been diving deep into hospital reimbursement. This is an issue I’ve been tracking closely – and I’d suggest you should too. I see hospital/facility costs and utilization as a major cost driver; hear from Carol Telles in a webinar Thursday January 18 at 1 eastern.

As we’ve noted here previously, work comp payers would do well to pay close attention to facility reimbursement and utilization; expect work comp, auto, and other P&C lines to become even more attractive to hospitals seeking revenues and margins.

Healthcare spending inflation actually slowed significantly last yearAn analysis by Kaiser Health News indicates trend in 2016 was 4.3 percent, higher than the overall 2.8 percent inflation rate, but a 1.5 point drop from 2015’s rate.  Notably, drug cost inflation was just above 1 percent (although that’s a lot higher than the double-digit drop we’ve seen in workers’ comp).

Key point – this slowdown in the rate of growth occurred after ACA implementation.  Not surprising that costs went up; we insured millions more people, most of which had pent-up demand for services they couldn’t get or couldn’t afford.

While costs continue to grow, life expectancy declines. We have the most expensive healthcare in the world – by far – yet our life expectancy has dropped two years in a row. As a result, we rank 26th out of 37 developed countries for life expectancy.

Here’s why – we’re paying hundreds of billions for low-value care…

An excellent piece on how to make analytics actually work from Harvard Business Review.  Key points:

  • attach an ROI to the analytics unit itself
  • hire experts from OUTSIDE your industry…

Enjoy your week.


Jan
3

The greatest health “system” in the world

Is responsible for a two-year decline in life expectancy.

Make no mistake, the profit motive embedded in the US healthcare system is directly responsible for an unprecedented drop in life expectancy; opioid manufacturers’ and distributors’ focus on profits coupled with lax governmental oversight led to the opioid disaster.

So, 42,000 of your kids, neighbors, friends, relatives, co-workers died from opioids last year.

But fear not, the addiction treatment industry is riding to the rescue.  Funded by your insurance premiums and tax dollars, a plethora of “treatment” centers are popping up.  While some are excellent, many are nothing more than “treatment mills”, operations set up to suck as many dollars as possible from patients, taxpayers and insurers. Once the dollars run out, the patients are kicked to the curb.

Here’s one example…

The schemes are many, with treatment mills paying body brokers to recruit addicts, false addresses to ensure insurance coverage, fake credentials for “clinicians” and huge bills for non-existent services.

The next time some uninformed individual starts babbling about the exceptionalism of the American healthcare “system”, stick this under his/her nose – we’re exceptional at creating addicts, killing people, lowering life expectancy, crushing souls, while making huge profits for investors legitimate and not.

What’s the solution? 

We pay more for healthcare than anyone else in the world, dollars that are diverted from education, job creation, infrastructure. Many of these dollars are well spent, but the opioid treadmill is just one example of waste and fraud.

A good start would be to much more aggressively prosecute the opioid shills and their buddies in the “treatment” business.  Long and hard jail time for the executives and investors would help prevent the next disaster, but the $209 million in lobbying dollars spent last year by the pharma and device industry makes that unlikely at best.

You get the government you deserve, and you deserve to get it good and hard. HL Mencken.

 

 


Jan
2

We haven’t seen anything yet.

Healthcare is changing really quickly and quite dramatically. Stuff we never would have thought of is happening every day.

  • A huge PBM is buying one of the largest health insurers in the world.
  • Provider consolidation is rapidly accelerating.
  • Many insurers are vertically integrating; they own thousands of providers, care-delivery locations, and are racing to build even more infrastructure.
  • Private insurers are pushing hard and fast into the Medicaid and Medicare markets.
  • Pharma is making gazillions in profits and driving medical costs higher: many employers are beginning to rebel.
  • The world is finally taking opioids seriously, while many fraudulent and sleazy people and companies are looking to profit from the crisis.
  • Medicare and Medicaid are facing major changes; the Trump Tax Bill is just the beginning of efforts to cut benefits and reimbursement.

The healthcare infrastructure of 2021 will look a lot different than it does today.

A couple things to think about.

  1.  While scale is critically important, the bigger the organization, the harder it is to anticipate and adapt to change. Huge health insurers and healthcare delivery systems must force their people to take risks and innovate – but most of these institutions are led by executives with little tolerance for failure. 
  2. The fee-for-service system is deeply entrenched in our entire industry. Provider practice patterns, sales rep incentive programs, provider marketing strategies, employer healthplan purchasing priorities, hospital financial systems, billing and reimbursement infrastructure, insurer business models all are fundamentally based on fee-for-service. Improving outcomes and reducing costs cannot happen without disrupting the very roots of our healthcare “system”.
  3. Our healthcare system is vastly inefficient – and that is precisely why tens of millions of Americans live off that system. Disrupting that system will cost hundreds of thousands of jobs.

What does this mean for you?

The winners will be those that understand where things are going.

There are two basic strategic options: those with a long-term view must become part of the disruption or short-termers will have to carve out a niche that’s sustainable over the near term.

This is the third option, which most will inadvertently pursue.  Business-as-usual folks will wake up one morning and find out they’re toast.