May
24

Happy Memorial Day Weekend!

Hope yours is filled with family and friends…and time to reflect on those who gave their lives for us.

Thanks to them, we have much to be thankful for.

Starting with…despite what many think we’re NOT in a recession…

From the Guardian’s survey…

The vast majority of respondents, 72%, indicated they think inflation is increasing. In reality, the rate of inflation has fallen sharply from its post-Covid peak of 9.1% and has been fluctuating between 3% and 4% a year.

In April, the inflation rate went down from 3.5% to 3.4% – far from inflation’s 40-year peak of 9.1% in June 2022 – triggering a stock market rally that pushed the Dow Jones index to a record high.

And job creation has been pretty darn great.

Government works!

Remember the botched start-up of the ACA aka “ObamaCare” way back in 2014?

Well, like many new and really big change, its gotten a whole lot better. Almost 2/3rds of Americans view the ACA favorably.

For some, “Obamacare saved my life”…

Support for recovering addicts…

This is really good news…The Feds and California are partnering on a program that pays addicts continuing to remain sober.  The program – “contingency management” –

is the gold standard for stimulant use disorder because you can win things for good behavior. But not a lot of places are providing it yet,” said PK Fonsworth, a psychiatric emergency room doctor and addiction psychiatrist in Los Angeles. (cite WaPo)

Research shows promise for contingency management. For instance, study participants achieve significant periods of sobriety, agree to long-term addiction treatment and even reduce risky sexual behavior.

The Biden administration is pushing more states to consider the approach, calling it a “proven treatment” that “remains underutilized.”

Kudos to CMS (Medicare and Medicaid) and the Golden State for the collaboration.


May
13

Research indicates state abortion bans will deprive residents of healthcare. Newly minted MDs are avoiding states with restrictive abortion policies, as are physicians seeking advanced training in OB/GYN and primary care.

AAMC-sponsored research found there are fewer applications for residency and more advanced training in states with abortion limits. These are the physicians who deliver a lot of care to folks in the hospital and outpatient facilities.

Implications – untrained physicians and reduced access to healthcare.

From FierceHealthcare:

physicians without adequate abortion training may not be able to manage miscarriages, ectopic pregnancies, or potential complications such as infection or hemorrhaging that could stem from pregnancy loss…

“The geographic misalignment between where the needs are and where people are choosing to go is really problematic,” she said. “We don’t need people further concentrating in urban areas where there’s already good access.”

What does this mean for you?

Poor people will suffer, not-poor people will be able to access care.

Remind me…is this how a great country treats its least fortunate?


May
10

Lots of really good stuff to end your week…

the Economy…

remains quite good with 175,000 new jobs last month. This was not as many in previous months…

BUT it looks increasingly like (From NYT) “the exuberance of the last two years might be settling into a more sustainable rhythm”.

Stock markets jumped (the Dow is up 723 (!!!) points this week), interest rates declined modestly,

Seniors’ lower drug costs…

Insulin prices are capped at $35 per month, a major reduction from an average of $300…even better, next year President Biden’s Inflation Reduction Act will limit seniors’ out-of-pocket costs for all prescription medications $2,000 per year.

There’s activity in Congress and by the Biden Administration that would limit everyone’s cost – young, old, and in-between – for insulin to no more than $35 a month…here’s hoping the pols get this done.

This means...With diabetes affecting more Americans, improving access to insulin means healthier families and employees, which leads to lower healthcare costs.

More good news…the Medicare Hospital Trust Fund’s financial solvency was extended to 2036, a five year extension. Not to worry, there’s no doubt this will be extended again.

This means…better finances for hospitals and seniors.

Lots more jobs in Wisconsin and…No more noncompetes!

In the “government CAN actually make life better” category,  we have…lots of great jobs coming to Wisconsin…AND a ban on non-competes.

Microsoft is building a giant AI Center near Racine, Wisconsin. The city was hit hard by the collapse of the Foxconn deal which promised gazillions of dollars and jobs…but never happened. Supported by the Investing in America project, this brings new investment why private companies in Wisconsin to $5 billion – and counting.

The Federal Trade Commission effectively banned non-competes...thereby freeing you up to…actually control where you want to work.

Non-competes are contractual controls that effectively prohibit employees from working at specific jobs, customers, or companies for a defined period in exchange for a/some defined “benefit(s).”

This is a MAJOR bonus for anyone working today as it allows you – not some corporate entity – to control your life. And, the rule is quite broad, clearly empowering workers.

This from Harvard Business Review…

“Worker” is defined not just as an employee but also includes independent contractors, externs, interns, volunteers, apprentices, or a sole proprietor who provides a service. The rule also broadly defines noncompete clauses not only as terms or conditions of employment that explicitly prohibit a worker from competing with a former employer, but also to mean any other clauses that “penalize a worker for” or “function to prevent a worker from” competing. With this definition, the FTC also prohibits clauses that operate as de facto noncompetes, including overly broad NDAs, nonsolicitation clauses, and TRAPs — training repayment agreement provisions. [Emphasis added]

Have a most excellent weekend!


Apr
30

Walmart is shutting down its healthcare centers…which means…what?

Three things.

First, healthcare is a very complicated and complex business, nothing like Walmart’s core business 

Walmart’s culture, ethos, business practices, priorities, and people built a multi-gazillion dollar consumer business by TBH, beating the crap out of vendors to deliver really low prices.

That is diabolically different from building a service-oriented, one-at-a-time, people-based interaction around a very complex need – healthcare.

So, yeah, healthcare is about as different from Walmart’s core culture as you cold possible get. 

Walmart’s failure comes after Haven Healthcare, the joint venture of giants Amazon, Berkshire Hathaway and JP Morgan went belly-up early in 2021.

Haven CEO Atul Gawande MD lacked the intimate, deep knowledge of healthcare infrastructure, reimbursement, regulations and management required to be successful. A brilliant writer, insightful analyst, and highly visible public figure, Gawande didn’t have the management chops. He also didn’t give up his other jobs and had no experience as CEO of a start-up.

Many who think they know healthcare – don’t.

Then there’s commitment. Gawande was committed to Haven – and frankly the three founding companies were as well – like the chicken is committed to breakfast.

If you want to take on something as daunting as reforming healthcare, you’d best be committed to the task like the the pig is committed to breakfast.

Second, reimbursement.

Despite a partnership with giant UnitedHealthcare, Walmart Health was unable to attract enough customers paying enough for care at its 51 centers. This MAY have been due – at least in part – to the venture’s focus on Medicare Advantage members…

This from UHG’s announcement back in 2021:

(the partnership will launch in) 2023 with 15 Walmart Health locations in Florida and Georgia and expand into new geographies over time, ultimately serving hundreds of thousands of Medicare beneficiaries in value-based arrangements through multiple Medicare Advantage [MA] plans. [italics added]

MA has been having a rough time of late which may have factored into a non-produdctive partnership…As the payor, UHG would want WH to agree to low reimbursement rates…as the provider, WH wanted high reimbursement…

Third, providers.

Primary care providers are expensive, rare, and thus have a lot of bargaining power. Oh, and you can’t have a business without them.

Which – to return to the lede, runs directly counter to Walmart’s…everything.

What does this mean for you?

Fixing healthcare requires understanding healthcare.

 

 


Apr
26

There’s a LOT of good news today

The House finally approved a massive aid bill for Ukraine – and the aid is already flowing – hallelujah.

Several encouraging takeaways…

  • It was bipartisan, with strong support from both parties (who’da thought??)
  • It passed despite strong opposition from the Republican Presidential candidate
  • It includes long-range missiles that Ukraine can use to demolish Russian air defenses, oil infrastructure, shipping, bridges and railroads

Long range ATACMS

Here’s why this is so incredibly important…

Health insurance coverage

is benefiting more Americans than ever, thanks to expansion of the Affordable Care Act. Another major driver is the increase in insurance subsidies for lower-income folks.

This means more moms and dads, kids, and families have access to health care.

The addition of dental care is the cherry on top; new regs allow states to add that coverage.

Work comp

WCRI’s just released in-depth analyses in its CompScope series…this year they’ve added details on COVID’s impact in 17 states.

Work comp rates for employers continue to dropIVANS reported a drop of 0.9% for the first quarter of this year. (Hat tip to R&I for the news)

California is slamming work comp fraudsters, (sub req) with the latest conviction resulting in a 54+ year prison sentence for a scheming fraudster. The Golden State’s been ramping up its prosecution of these dirtbags...here’s hoping these massive penalties discourage others from stealing from employers and taxpayers. Kudos to WorkCompCentral for a comprehensive update on recent convictions.

What does this mean for you?

A safer America comes from a diminished Russia.

More insured Americans = healthier families.

More crooks in jail = hopefully less future fraud.


Apr
9

Consolidation among health systems and hospitals continues apace, and with it comes higher costs, more utilization, and longer disability durations.  Get the details from WCRI’s much-watch webinar on the impact of vertical provider integration on prices, medical utilization and outcomes.

It’s on Thursday May 2 at 2 pm eastern.

You can access the written report (free for members) here.

Another major factor that will greatly affect a state’s health, outcomes and costs is Medicaid expansion. A thorough yet simple discussion of implications of one state’s refusal to expand Medicaid is here.

The benefits of Medicaid expansion are broad, deep, and impactful.

Among the findings

  • A 2020 national study found that expansion was associated with a significant 3.6% decrease in all-cause mortality,
  • Two studies found significant declines in maternal mortality
  • expansion is associated with improvements in access to care and outcomes related to substance use disorder (SUD) as well as other mental health care.
  • hospitals in non-metropolitan areas and small hospitals experienced improved profit margins
  • Analyses find effects of expansion on numerous economic outcomes, including state budget savings, revenue gains, and overall economic growth
  • rural hospitals experienced particularly substantial improvements in financial performance following expansion

KFF on Texas’ uninsured population [note Texas is just one of 10 states yet to expand Medicaid]…

(a) significant proportion of adults in the coverage gap are employed unless they are elderly or disabled. The most common jobs among adults in the coverage gap are construction laborer, cashier, cook, waiter, house cleaner, retail salesperson, and janitor. These workers usually do not have access to employer-based health insurance and cannot afford plans on the federal insurance exchange. [emphasis added]

Crossover

Most of the non-expansion states:

  • have major problems with rural hospital cutbacks and closures
  • have significantly worse health outcomes
  • have healthcare access challenges

What does this mean for you?

Pay attention to the real drivers of healthcare outcomes and costs – they have more impact on duration and ultimate costs than anything else.

 


Mar
28

Two big things

Aren’t getting near enough coverage from industry media.

We’re talking about the battle over prior authorizations (PA) and the Change Healthcare cyber attack.

Both have major implications for healthcare and workers’ comp; I’ll very briefly summarize both here and we’ll dive in next week.

Prior Auth.

PAs are used by healthcare payers to evaluate medical procedures, drugs, facility services and treatments before approving them. There’s been a major effort by the AMA and others to restrict the use of PAs, claiming PAs are all about increasing insurer profits, harming patients, delaying care, and leading to the end of civilization.

Well, maybe not the last, but pretty close.

PAs were instituted decades ago because some treatments/services/procedures/ hospital stays appeared to be unnecessary.

Several states appear ready to restrict the use of PAs or otherwise limit their use, add requirements and tighter time limits. 

Needless to say, there’s a lot of claims and counter-claims out there, some pretty strident with language intended to inflame.

Net – keep a close eye on this…it’s an election year and pols may well lean into the PA fight…likely on the side of physicians.

Change cyber attack.

I posted on this a few days ago…Change, which is part of UnitedHealthcare’s Optum subsidiary, suffered a major cyberattack a few weeks ago, one that has crippled a huge chunk of payer-provider electronic communications.

From WebMD

Change Healthcare, part of Optum and owned by UnitedHealth Group, processes about half of medical claims in the U.S. for about 900,000 doctors, 118,000 dentists, 33,000 pharmacies, 5,500 hospitals, and 600 laboratories…

Much of the system is (reportedly) back up and running, but the fallout  – severe cash crunches for small practices, delays in PA transmissions, confusion on what’s covered and what isn’t – continues to make life miserable for office staffs, providers, insurers and banking entities. 

Net – expect the Feds to dive deep into this, assess impacts, require much studier cyber protections and regulatory controls/monitoring of healthcare’s electronic information exchanges.

note – Change was an HSA consulting client prior to it’s acquisition by Optum.

 


Mar
27

They lied to you.

A really scary study was just published…one that shows just how deadly healthcare misinformation is.

Not “can be”, but is.

Remember those politicians promoting hydroxychloroquine as a cure for COVID – AFTER studies showed it had little to no benefit – and was dangerous?

Well, they have blood on their hands.

A very well done meta-analysis (rigorous review of all available research studies)  estimated there were 16,990 hydroxychloroquine related deaths in hospitalized patients in six countries.

One of the studies, known as the RECOVERY trial, showed a significant increase in cardiac mortality among patients receiving hydroxychloroquine (HCQ). 

The study published in PubMed this February is here.

Two things.

First, anyone willfully lying – or passing along someone else’s lies – to people terrified of a deadly disease has much to apologize for. Would these people tell friends and family to eat rat poison?

Drive drunk?

Inject fentanyl?

Of course not – yet by pushing HCQ misinformation out to friends and family, they did much the same thing.

Second, in a case before the Supreme Court, some politicians are trying to argue that spreading misinformation – like “hydroxychloroquine cures COVID” is “protected free speech.”

What utter BS. Again, is it okay to tell kids – “hey, vaping is good for you!”… or “Sure, unprotected sex is fine!” or “No car seat needed – just carry your baby sister in your lap!”

Tobacco companies and the opioid business are just two examples of industries forced to pay billions for publishing lies.

 

As noted in yesterday’s post, thousands of us are dying from preventable causes…that’s really, really bad…what’s much worse is politicians legitimizing deadly disinformation. 

What does this mean for you?

Spreading deadly misinformation is NOT “free speech”. It is a cynical and disgusting abuse of power.

 

 

 


Mar
13

Hackers disable nation’s largest healthcare data interchange

A major cyber attack has crippled the nation’s largest healthcare authorization and payment system, leading to weeks of missed payments.

From WaPo:

The hackers stole data about patients, encrypted company files and demanded money to unlock them. Change Healthcare subsequently shut down most of its network as it tried to recover.

The system owned by Change Healthcare, a subsidiary of United Healthcare, has been down since February 21; reports indicate BlackCat, a shadowy hacking group is responsible. BlackCat and/or a closely related entity reportedly received what appears to be a ransom payment of $22 million

UHC reported Change’s pharmacy processing functionality had been restored last week, and its

electronic payment platform would be reestablished beginning March 15, and that it expected to start testing and establishing claims network connectivity on March 18, with service restored through the week.

Don’t expect a full recovery then; that’s the date UHC will start testing a rebuilt system.

Change’s electronic communications, billing and payment system handles everything from utilization review to bill submission to validation to payment and reconciliation for hospitals, health systems, provider groups, clinics, specialty providers, pharmacies and Pharmacy Benefit Managers.

According to Change, the system handles about 15 billion transactions a year, or about half of all medical claims.

What does this mean for you?

P&C insurance execs and Boards should re-think  their chronic under-investment in all things IT.

note: HSA consulted for Change prior to its acquisition by UHG in 2022.


Mar
6

To know why some think the US healthcare system is going to get better and cheaper – and why I strongly disagree, read on.

David Cutler PhD led off the WCRI’s confab with a discussion of the future of healthcare. It was GREAT that a conference has finally tried to educate work comp people about healthcare – after all that is the biggest driver of workers’ comp.  Sorely needed.

But…(more on that in a minute)

Dr Cutler noted that US healthcare is about as unstable as it has been for some time. And there is much more uncertainty to come.

He then asked the audience to vote on whether healthcare will get better and cheaper, stay the same, or collapse.

I voted collapse.

He also differentiated between “Trend” and “Wiggle”, noting it is important to consider what is actually a trend vs what is more likely slight ups and downs – need to differentiate between one-time factors and overall structural issues with long-lasting implications.

Cutler attributes consolidation among small providers to the drop off in patient service demand; that is, demand for providers’ services declined and therefore the smaller providers needed to merge or be acquired. I’d note that Cutler did not mention other factors driving consolidation, namely:

  • Interoperability (CMS IT requirements that can be a big lift)
  • small office staffing woes,
  • office operational expense increases, and
  • PE buyouts that make owners wealthy overnight.

Why Cutler is positive about the future of the US healthcare system

  • Delivery of medical care (number of services rendered) fell off during covid and really hasn’t fully recovered, which implies there are fewer unnecessary procedures/visits/treatments these days. (assumes the decline was mostly in unneeded services)
  • Elective stuff didn’t come back – such as hip replacements, shoulder surgery, etc.
  • Staff shortages are less of an issue of late

Dr Cutler also noted that in his view, medical staff burnout and labor force withdrawal from healthcare delivery roles will be temporary…Employment is coming back.

Very briefly, Dr Cutler’s thinking is that hospitals have too many beds; a lot of care has moved to outpatient facilities and ambulatory surgical centers (ASCs)…as a result hospitals will close floors, other hospitals will close, and the need for nurses in hospitals will thus decline.

Notably, Dr Cutler provided data from CMS to build a case that healthcare itself is better controlled – Medicare growth has been relatively flat over the last few years, and some analysts believe this has reduced total spend by several trillion dollars.

Finally, Dr Cutler also discussed value-based care and the move to bundled care, I suppose as evidence that healthcare is getting more efficient.

So here’s the “But…” in which I respectfully disagreed – and and still do disagree – with Cutler’s optimistic outlook.

Cutler – Shift of care away from and hospital closures will reduce costs and staffing needs

MCM – I don’t have the data, and I’m sure Dr Cutler does, but there’s both anecdotal “evidence” (family members have left patient care for other jobs in healthcare) and actual research that clinical staff shortages are NOT moderating.

Here’s rather compelling evidence that the shortage is NOT going away.

According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country through 2030. In this state-by-state analysis, the authors forecast a significant RN shortage in 30 states with the most intense shortage in the Western region of the U.S.

Perhaps Dr Cutler is talking over the very long term – and perhaps the Journal’s authors are not accounting for the shift in care to outpatient facilities.

Perhaps. On the other hand, change is very, very slow in healthcare.

Also, hospitals are major assets, assets which are providing a ton of revenue to the health system or hospital’s owners. Sure, many owners might like to walk away…but they can’t – not without huge pressure from unions, workers, communities and politicians. So, they’ll do anything they can to keep the patients coming, to keep the hospital open – if they don’t they will go belly up – oh and some of the hospital’s execs will not have jobs.

Cutler – Value-based care is saving money…

MCM – There is very little evidence that VBC actually saves money, and a lot of evidence that it doesn’t. In fact, a CBO study indicates that overall, well-funded, well-designed and well-run VBC initiatives actually resulted in higher costs. I’d note that some disagree with CBO’s results. – however those disagreements generally focus around better outcomes, health indicators and the like – NOT on cost reductions.

Cutler – Medicare spending is below predictions thus healthcare is less costly

MCM – But other payer spend has not.

Yes, Medicare’s costs have been below predictions…but that’s NOT the case for individual insurance, group health and Medicaid spend – which has has increased.

To be fair, Cutler agreed with my comment (which I made after his talk), but noted Medicaid spend per enrollee has declined.

He is correct…however in my view but likely because the expansion of Medicaid involved more healthier people being signed up before and during the COVID emergency.  And, their costs prior to enrollment were likely uncompensated care…so my take is overall medical costs weren’t reduced, just shifted to a different payer.

At least for the next few years – and likely longer – the “shiftee”, dear reader, is often workers’ comp.

Finally, good friend and colleague Gary Anderberg PhD of Gallagher Bassett commented that all of us are getting older and sicker and how does that factor into predictions re cost. Cutler indicated he sees it as a mixed picture as cognitive and CV health are improving while others – obesity-related such as diabetes in particular – are declining.

What does this mean for you?

I still vote collapse.