The anti-vaccination idiocy

Penn and Teller profanely destroy the anti-vaccination case in a 90 second video well worth watching.

Unfortunately, many of the so-called anti-vaxxers won’t watch it, or understand it, or believe it.  No, they are willing to put their own kids – and everyone’s kids – at risk because of a completely wrong, now-retracted article in the Lancet purported to show a link between vaccinations and autism.

When, of course, there is NO SUCH LINK. As this group of parents with kids afflicted with autism eloquently shows…

And there’s any number of lunatics claiming vaccinations cause all type of horribles, e.g. whack-job, cartoon character Michelle Bachman’s assertion that the HPV vaccination can cause mental retardation

From the other side of the political spectrum, there are anti-vaxxer liberals who don’t get refuse to understand/outright deny the science – nice to know we all have morons in our midst…

Fortunately, people in third world countries are a lot smarter than these cretins -

We take vaccines so for granted in the United States,” Melinda Gates told HuffPost Live in January…

“They will walk 10 kilometers in the heat with their child and line up to get a vaccine because they have seen death. We’ve forgotten what measles deaths look like. We’ve forgotten … the scourges they used to be. But in Africa, the women know death in their children and they want their children to survive.”

The anti-vaxxers claim it is their right to jeopardize their kids – and yours. Fine.  While one could make a compelling case that their stupidity is grounds for a charge of child abuse, there’s a much bigger public health issue here, one that is all too obvious now that these idiots have allowed their kids into public spaces where they’ve infected others.

That case is simply this – if you choose to do, or not do, something that creates a significant public health risk, then you get to pay for the consequences.

Monetarily, criminally, civilly.

DWI, knowingly infecting partners with STDs, failing to keep firearms locked up, texting and driving, all are akin to the anti-vaccine movement.  And all come with legal consequences.

What does this mean for you?

Be careful, stupidity didn’t die out with the Middle Ages.

2015 health care predictions

I’ve decided to split my predictions into work comp stuff (where I do most of my work) and health care stuff not directly related to work comp.  Here’s my health care predictions…

1.  Health care cost inflation will remain low.  After five years of growth at or below 4 percent, health care costs remain relatively stable at 17.4 percent of GDP.  It is possible that health care costs for 2014 will come in below that benchmark due to increasing productivity and stable health care costs.  In the interest of setting a metric, I’ll predict costs remain at 17.4% of GDP…

2.  ACA will be less of a story.  The healthcare.gov website appears to be working well – at least on the front (enrollment/consumer) end.  Work on the back end (communications with internal governmental programs and agencies, financial links, and ties to health plans) continues but seems to be proceeding apace.  We’ll base evaluation on the volume of news stories this year vs 2014.

3.  Employer take-up of health insurance will remain stable; if it drops it won’t do so by more than a percentage point. Despite the hysteria from ACA opponents claiming employers would drop insurance en masse, it hasn’t happened.  And it won’t.

4.  Expect 11 million plus enrolled via the Exchanges this year (federal and state).  Initial enrollment in late 2013 was strong in key states, and the outreach efforts are paying off.

5.  More ACOs will close down or suspend operations, while others will grow and expand. Net is we will see more lives covered via ACO-type models.  For those of us old enough to remember the halcyon days of HMOs this is hardly surprising. The number of HMOs reached 640+ in the late eighties before market forces led to consolidation via merger/acquisition, failure of some, and expansion of the successful ones into new markets.  This is how it works – a decreasing number of ACOs is not an indication that the model doesn’t work.

6.  More hospitals will close as the reduction in Medicare and private pay reimbursement hits those unable to adapt.  While there will be pain in affected local communities, this is inevitable as a sixth of our economy goes thru restructuring.  It happened in the oil industry in Pennsylvania in the 1940s, shipbuilding in the 1960s, textiles, clothing, clothing, furniture, automobiles…

7.  More doctors will work for very large multi-specialty groups and health systems.  Currently about three-fifths of physicians are employed; expect that to bump up by a couple percent.

8.  Care extenders will get more care authority.  This is going to be contentious, at times nasty, politically charged. It is also inevitable.  PTs can do a lot of things orthopods currently do; nurse practitioners are already delivering a lot of primary care, and nurse midwives are increasing their scope of practice in many areas.

9.  Specialty drugs will continue their meteoric rise in cost and prevalence.  I know, an easy one, but absolutely worthy of note as they will become an even larger portion of medical spend, forcing payers and policymakers to make some very hard decisions about coverage.

10.  Ebola will disappear from American mass media.  If it’s not here, we don’t care, and it won’t be here. Yet another example of the American public and American media’s obsession with really bad things only when they directly affect us.

 

Med mal’s not a factor in health care costs – more evidence

More research indicates tight restrictions protecting physicians and facilities from malpractice suits doesn’t reduce health care costs.

Three states, Georgia, South Carolina, and Texas, essentially prohibit suits unless the physician intentionally orders care that s/he knows will hurt the patient.  A pretty very high standard, and one that would – one would think – allow docs to practice care with no concern about “defensive medicine.”

That may indeed be the case, however it is also the case that there’s no evidence that this high standard reduces cost.  The research, which focused on Emergency Department utilization and costs, found tight limits on suits didn’t reduce the “cost or volume of ED care.”

Moreover, “Legal risk does not motivate physicians as much as some previously thought.” [emphasis added]

This will not still the wagging tongues in the talking heads – nothing will.  But they’ll have less to wag about.

What does this mean for you?

Question those assumptions…

Good news is bad news – Medical cost inflation’s continued decline

Perhaps the biggest news to hit this summer is the decline in medical inflation.

Make no mistake, this is very, very important.

Important – as in huge decreases in the federal deficit.

Important – as in low-single-digit health premium increases.

Important – as in placing huge pressure on health care systems, hospitals, and other providers – because low premiums for employers equals less income for providers.

Here’s what the data shows.

Today, CBO projects the 2019 Medicare spend will be $95 billion less than it projected four years ago.  That’s equivalent to a fifth of the military budget.  Or the entire budget for welfare, Amtrak, and unemployment.

Over a decade, the reduction is about $700 billion.  According to a piece in the NYTimes (link above);

much of the recent reductions come from changes in behavior among doctors, nurses, hospitals and patients. Medicare beneficiaries are using fewer high-cost health care services than in the past — taking fewer brand-name drugs, for example, or spending less time in the hospital. The C.B.O.’s economists call these changes “technical changes,” and they dominate the downward revisions since 2010…[CBO analysts say] the economy is playing a negligible role in what’s happening in Medicare, meaning that they’re more confident that the practice of medicine really is changing. (emphasis added)

That’s all good, right?  The fiscal cliff is farther away, and not nearly so steep and scary as it was even a couple years ago.

Not so fast. One person’s savings is another one’s income.  In this case, that “other one” is the healthy care delivery system – doctors, pharmaceutical companies, hospitals, device companies, health systems.

Those stakeholders are adapting as fast as they can, and making great strides.  But a big part of that adaptation is revenue maximization – making darn sure they are getting as many dollars from every patient as possible.

What does this mean for you?

Pretty obvious, methinks…

Delivery systems and workers’ comp

There’s been quite a bit of focus on alternate health care delivery methods of late, with medical homes and Accountable Care Organizations prominently noted as ways care will be improved and costs reduced.  One source indicates there are 270 ACOs currently operating with an estimated 20 million members.

While the early evidence is somewhat mixed, in general the news is positive; a Pennsylvania ACO raised quality, and decreased infections and readmission rates, leading to a year over year decrease in medical costs.  Generally, ACOs involve facilities and providers agreeing to focus on specific quality measures and reward performance instead of paying on a fee for service basis.  In PA:

Half of hospitals and physicians’ potential earnings are based on their performance improvement in hospital-acquired infections, patient experience, readmissions, surgical care, and treatment for heart attacks, heart failure and pneumonia. The other half of the earnings are based on the providers’ ability to manage costs across inpatient care, outpatient care, ancillary care, home health services and prescription drugs.

There are problems inherent in the model; patient satisfaction is a tough metric to achieve when ER patients only want narcotics for their pain, while readmission rates are going to be higher when patients refuse to be responsible for post-discharge care. Our daughter works in an inner-city ER and this is all too common; patients KNOW these are key criteria and tell care givers they will downscore them if they don’t get their meds.

Nonetheless, it’s a far better financial model than fee for service as it doesn’t incent more care and higher intensity care.

Notably, it’s hard to find any evidence of ACOs in work comp.  I’d be most grateful if readers could point me to any reports or information related to alternative delivery systems in WC; while there are some bundled payment models, and a couple episode-of-care pilots I’m aware of, there’s just not much going on as far as I can see.

Just leave a comment here – and thanks!

The revenge of the nerds

It’s about understanding medical care, cost drivers, and components thereof.

Several years ago (ok, more like ten) I was in a client CEO’s office discussing medical care cost drivers, competitors, and possible differentiation strategies.  He stepped out for a few minutes to take a call, and, finding myself with nothing to do, I pulled out the latest Health Affairs to catch up on the latest and greatest in health policy research.

Upon this august gentleman’s return to his office, he asked me if I actually read Health Affair. When I said I did, he said something to the effect of “no one reads that, they just carry it around to look smart.”

And therein lies the problem.

And no, it’s not that I don’t need all the help I can get to look smart.

It is a lack of attention to the underlying drivers, influencers, issues.  It is a failure to think about how Medicare’s physician reimbursement affects commercial rates, how Medicaid enrollment drives provider behavior, how Part D enrollment influences drug pricing, how the lack of coverage among certain populations increases facility costs to commercially-insureds, how low adoption of evidence-based medicine makes for poor outcomes, how productivity is affected by insurance coverage status, how payment reform will affect workers’ compensation medical expense ratios.

There’s also a predilection on the part of some to ignore, or more commonly discount, information that runs counter to their worldview.  I see this all the time with workers’ comp execs when discussing Obamacare; they allow their political blinders to affect their business decisions.

There is so much happening in health care delivery and financing and reimbursement and evaluation and coverage that no one can possibly keep up.

What does this mean for you?

The ones who take the time to read and listen objectively, to think about import and impact are going to be more prepared, more aware, and better equipped than those that, for ideological or other reasons, have tunnel vision.

And thus more successful.

 

Friday catch-up

It’s been a very busy week.

Today Mitchell announced they’re going to buy specialty bill review firm FairPay Solutions.  Makes sense for Mitchell, as FPS’ technology and expertise is unmatched in the business, and will add a lot of value to Mitchell’s WC and auto BR solutions. Looks like current FPS CEO Chad Birckelbaw is only sticking around for a few months.  That’s a BIG loss for Mitchell; Chad is not only one of the best people in the work comp services business, he’s also the guy who automated what had been a mostly-manual process and kept FPS moving forward in what has become a very competitive business.

Notably, Mitchell’s announcement said FPS will continue to support other bill review entities.  That’s not going to last.  I very much doubt the other BR companies are going to keep working with FPS; there’s just too much inherent conflict and the other firms are likely very concerned about KKR’s future plans for Mitchell.

There are a couple other transactions in process now which should close shortly.  Looks like the trend is positive for strategic buyers – other companies with related businesses as they are winning most of these bidding wars.

WCRI has just released their annual CompScope Medical Benchmarks reports; the latest info on what’s happening in 14 states; haven’t had time to dig into them but hey, that’s what weekends are for!

The Benchmarks will be discussed at length at WCRI’s annual meeting – if you haven’t signed up yet, best get on it as they do max out.  March 12-13 in Boston…details are here.

On the I-Can’t-Wait-Till-We-Drive-A-Stake-In-Their-Black-Hearts front, Pennsylvania, Arizona, Hawai’i and Maryland are doing their best to control physician dispensing in work comp.   Alas, bought-and-paid-for legislators are much more interested in taking cash from dispensers than saving taxpayer dollars and employer jobs; in a hearing in the PA legislature, Representative Donna Oberlander asked Labor and Industry Secretary Julia Hearthway how much money the Workers Compensation Program would save if the General Assembly ended physician dispensing.   

The response – $18-$26 million.  

 

 

The GOP’s Alternative to Obamacare

Three republican senators have proposed a bill – the Patient CARE Act – to replace PPACA aka Obamacare.

Kudos to Senators Burr Coburn and Hatch for their efforts – and for staying away from the useless ideas of selling insurance across state lines, high-risk pools which are never adequately funded, and that favorite non-solution, tort reform.

In a nutshell, the GOP bill does away with most PPACA regulations including the mandate, reduces the tax break on employer-sponsored insurance, does away with Medicaid expansion, and gives low income folks tax credits to buy insurance.  There’s not a lot of detail, and it’s clear this is a work in progress.  I would note the GOP’s claim that their bill expands coverage without increasing taxes is sophistry;  according to many in their party, eliminating a tax break IS raising taxes.

There is no mechanism or approach or tools that would reduce health care costs, no assurance that those with pre-existing conditions will get coverage (unless they constantly maintain insurance, something that many folks don’t do), no control over benefit design (which is skillfully employed by insurers to discourage the unhealthy from signing up)

While a home-team analysis indicates the GOP bill will reduce uninsurance by about the same amount as Obamacare, the analysis isn’t credible.  For one thing, the “coverage” provided under the GOP bill would be a LOT thinner than that provided under Obamacare – they’d have to be, as the maximum credit for young singles would be $1,560, hardly enough to pay for anything but the skimpiest of catastrophic coverage.  This may be “insurance” but it certainly isn’t “coverage” .  In addition, doing away with the Medicaid expansion would dump millions of just-covered folks back on the safety net, aka emergency rooms, charity care, and community health centers that have been hammered by budget cutbacks.

 

Finally, the provider, payer, information technology, supplier and health system communities have all been working feverishly to prepare for and implement Obamacare.  This train left the station four years ago, and Burr, Coburn, and Hatch are just now showing up trackside with a revised itinerary.

Moreover, the passengers on this train – the middle class, health care providers, and older folks – are going to be adamantly opposed to the GOP plan as it:

  • raises taxes on the middle class;
  • undoes Medicaid expansion thereby harming health care providers; and
  • increases insurance costs for older people.

Politically brilliant it’s not.

As Jonathon Cohn notes; “It would have been a lot more productive if these three senators, or any other Republicans, had been similarly constructive back in 2009…”

He also thinks it is better late than never – I disagree.

Obamacare is the law of the land.  It is not going to be repealed.  The triad would have better spent their time working on something more productive; say immigration reform or revamping the tax code.  Alas, this is an election year, and the GOP bill is a political ploy.

But it’s not a very smart one.

What does this mean for you?

Not much.

 

 

Opioid guidelines are about to get a whole lot better

In about ten days, providers and payers struggling with opioids will get a big hand up.

ACOEM will be releasing their just-completed Opioid Guidelines; they are comprehensive, extremely well-researched and well-documented, and desperately needed.

I learned about the guidelines from a presentation delivered by Kurt Hegmann MD MPH, Professor at the University of Utah and Chair of the Occ Med Division at the University of Utah’s Compensable Disabilty Forum.  In his spare time, Kurt is also responsible for ACOEM’s guidelines as the Editor-in-Chief, a role he’s filled for eight years.

Affable and engaging, Dr Hegmann walked the audience through the development process (quite rigorous, involving 26 professionals with NO conflicts of interest using the Institute of Medicine methodology), the research and (960) references behind the guidelines and the ranking/categorization of individual guidelines.

Here are a couple of takeaways.

  • Of the 220 pages, the vast majority are tables of evidence – some practitioners may peruse them, but most will focus on the couple dozen pages specific to individual treatments
  • The guidelines address acute and chronic treatment, with chronic defined as > 3 months
  • The detail, specificity, and depth of research and their application to guidelines are impressive indeed.  What these guidelines add to our understanding of what works, why, and what doesn’t is impressive by itself; how they blow apart pre-conceived notions of “appropriate” care and challenge long-held conventional wisdom was – at least for me – rather jarring.

    For example;

  • Other guidelines say it is Ok to be on safety sensitive jobs and take opioids – that is NOT supported by the research
  • The researchers found NO link between opioids and improved function – studies that show there is a link almost always use self-reported data.
  • No trials indicate opioids are superior for acute pain than NSAIDs.
  • The MAXIMUM dosage recommended is 50 MEDs (morphine equivalent dosage), significantly lower than most guidelines which use 100-120.  The reason is the research – there is a much lower risk at this level, with the data indicating a sharply higher risk profile for higher dosage.
  • Drug testing is recommended with a baseline and random tests 2-4x a year; the higher the dosage – more screening
  • Pain rating scales are all but useless as data points as lots of patients indicate their pain is a 10 and yet are working full time.  This is not possible, and indicates the uselessness of subjective ratings/scores/data.

Are they perfect?  No.  But that’s due to the lack of research on specific issues, and not to the diligence and perseverance of the developers.  If the research is solid, it is in the guidelines.

What does this mean for you?

A lot of confidence in the guidelines, and hope that we can begin to gain control of the epidemic of opioid overprescribing.

The health insurance world in 2014 – lots of uncertainty but no death spiral

Uncertainty.

That’s the best way to describe health insurance execs’ views on their business these days.  The massively-screwed-up-but-steadily-improving rollout of the federal exchange is the biggest reason for that uncertainty, but there’d be huge uncertainty even if things had gone flawlessly.

Health care providers are consolidating rapidly, increasing their negotiating leverage.  More and more physicians are working for health systems.  Some employers are dropping coverage, while others are moving to narrow-network based plans. All this against a backdrop of an aging population, increasing income inequality, major growth in Medicaid enrollment, reduced Medicare reimbursement for facilities and a possible “fix” to the fatally-flawed physician reimbursement system/mechanism.

And, the metrics they use to measure performance are in flux as well; the old measurements were fine when insurers could underwrite, adjust benefit designs, change deductibles and copays, and negotiate with providers from a position of strength.

Add to that the uncertainty over who is going to enroll via the exchanges – will there be enough “young immortals” to balance the older, sicker folks who sign up?  More importantly, how will that play out for individual health plans; Plan A isn’t concerned about the overall picture, but is very, very concerned about the demographics of their member group.

It’s no wonder senior management – and other stakeholders – are “uncertain” about the short-term, much less the longer-term.

Amongst all this confusion, there’s one thing that is clear – there isn’t going to be an “Obamacare death spiral”, at least not for three years.  The scaremongering about death spirals and adverse selection that might result from too many old folks and not enough young folks signing up is mis-informed.

There is a financial back-stop in the form of reinsurance that protects insurers from high cost claims for the next three years.  Bob Laszewski has an excellent description of the program and implications thereof here.  Funded by a tax on each insured, the program provides coverage for insurers “selling coverage on the state and federal health insurance exchanges as well as in the small group (less than 50 workers) market…”

By then, things will have settled down, insurers will have figured out what works, what doesn’t, and what they need to do to operate profitably.  Some will drop out of the exchange(s), while others will expand their service offerings and coverage areas.

What does this mean for you?

Lots of uncertainty means lots of opportunity for those aware, nimble, and stalwart enough to take advantage.  Not that there are many in this business that fit that description!