WCRI #4 – Provider consolidation’s impact on workers’ comp

Is Not Good.

that’s the primary takeaway from Bogdan Savych PhD’s presentation at WCRI’s annual conference– and a lot of other work I’ve done on the topic.

Consolidation eliminates competition – although I’d posit there’s little true competition in health care services. [I’ve written a LOT about  consolidation and the impact thereof]

There’s solid evidence that consolidation actually leads to increased prices and some research indicating it leads to decreased quality.

So how has healthcare evolved – well, primary care docs shifted from mostly solo practice to employment by health systems or group practices. Note this data is from 2018; consolidation has accelerated since then.

Of course, like everything else in healthcare, it’s local…orthopedic practices in Wisconsin are much more likely to be owned by health systems than those in Delaware.

Dr Savych’s research hit on a critical issue – exactly how many workers’ comp patients do primary care docs see? – the answer is most see almost none – with just one out of every ten physicians seeing more than 10 WC patients per year. Of course orthos see more – but still not many; only about a third see more than 10 claimants per year.

There are a whole host of issues with this which we’ll get into in a future post. For now, the net is researchers have to identify the specific physician responsible for the care of and outcomes for specific patients – which is fiendishly difficult especially when that physician moves from a group practice to employment by a health system. Provider identification is the main challenge – but by no means the only one.

Case mix adjusting – the art of comparing patients with similar diagnoses (often primary, secondary, and tertiary) over time – is as or almost as hard to get consistently right.

All that said, Dr Savych noted that cost increases are due more to a shift in the volume and type of procedures than higher prices for individual services.

The initial takeaway (there’s a LOT more research and analysis to do) is vertical integration (physician practices absorbed but health systems) leads to docs providing more expensive services.

What does this mean for you?

Consolidation raises work comp medical costs.

The best way to think about this is on a state-specific basis; understand where there’s more consolidation and watch the type of services delivered to your patients like a hawk.


I told you so.

I cannot stand that statement…yet it is spot on. I’ve been posting on this for some time, often feeling like Cassandra.

Healthcare staffing shortages are fast approaching crisis levels, with major implications for each of us.

From ModernHealthcare:

As of last month, 27% reported critical shortages to the Health and Human Services Department…During crisis levels in the early phases of the pandemic, mortality rates spiked as hospitals rationed care. One-quarter of COVID-19 deaths between March and August 2020 were attributable to overstretched hospitals, according to the National Institutes of Health. Patients with the most serious non-coronavirus illnesses suffered under the same conditions. [emphasis added]

HHS recommended that providers use the Sequential Organ Failure Assessments score, which evaluates organ function to determine patients’ likelihood of mortality if they were to receive treatments or beds. Those most likely to die go untreated and often are diverted to palliative care.

Terminal burnout is the main driver. Nurses and hospital staff have been dealing with entitled, arrogant, mean-spirited patients many of whom are unvaccinated for more than two years.

One of the drivers is the archaic, hidebound, and wildly incompetent way we license nurses. Full disclosure – a future family member and nursing school graduate has been waiting three months for their nursing license paperwork to come through.

This at a time when nursing shortages are forcing hospitals to close entire departments and shutter entire floors.

It doesn’t have to be this way; the licensing compact adopted by 35 states and Guam allows some nurses licensed in one state to practice in others – with limitations.  Revamping the criteria and removing limitations would speed up the licensing process immeasurably.

But the licensing debacle is an effect, not a cause. The real cause is the unvaccinated who get COVID and spread and their enablers.

What does this mean for you?

Some people’s “freedoms” are killing others. 


Stuff you should know

When Physician Management Companies took over anesthesia practices, the units (amount of services) and prices went up dramatically (when compared to other practices).

As in 16.5% and 18.7% respectively.

No surprise, prices went up even more – as in 26% – if the PMCs were owned by private equity companies.

The fine folks at WorkCompCentral published the news that OptumRx settled with the Commonwealth of Massachusetts over the Commonwealth’s claim that OptumRx failed to follow workers’ compensation prescription drug pricing procedures. OptumRx agreed to pay the state $5.8 million. The settlement is here.

I’m trying to get more detail on this as the Commonwealth’s press release is a bit confusing.  You’ll know if/when we get more details.

Finally, the conspiracy theory that somehow COVID came from a lab has been put to rest – at least for those of us who believe in science. Somehow I doubt the tin foil hat crowd will accept the news that the virus originated in the Wuhan market.

Where COVID originated 

From Michael Worobey, a co-author on both studies and an evolutionary biologist at the University of Arizona via Medscape “When you look at all the evidence together, it’s an extraordinarily clear picture that the pandemic started at the Wuhan market…”

More details on the two studies:

In one study, researchers used spatial analysis to show that the earliest COVID-19 cases, which were diagnosed in December 2019, were linked to the market. Researchers also found that environmental samples that tested positive for the SARS-CoV-2 virus were associated with animal vendors.

In another study, researchers found that two major viral lineages of the coronavirus resulted from at least two events when the virus spread from animals into humans. The first transmission most likely happened in late November or early December 2019, they wrote, and the other likely happened a few weeks later.

There’s an excellent synopsis of the research and methodologies here. If you want to weigh in, please review the article at the link first.

What does this mean for you?

For-profit healthcare can be very problematic, and science always wins.

We are all shocked and heartsick over Putin’s War on Ukraine – if you want to help Ukraine and Ukrainians, please consider a contribution to Care. Care is a very reputable and highly effective NGO with a rich history of successfully mitigating disasters and helping people.


COVID update

yes, things are getting better – but that’s not universal, as some states/regions are still dealing with the Omicron tsunami.

First, idiot alert…

An Oklahoma hospital was forced to lock down its ICU due to what can only be described as rampant idiocy.  From Medpage Today:

In a recent press release, [a] church group [that has been protesting outside the facility and making threats against its staff online], known as Ekklesia Oklahoma, called Mercy Hospital an “evil Marxist controlled death camp.” [emphasis added]

Court documents stated that the founder of the group called one of the hospital’s doctors a “murderer,” noting that members even posted the doctor’s home address online, according to KFOR.

It’s not just Oklahoma…in Boston, a neo-Nazi group protesting outside the hospital called Brigham and Women’s Hospital “anti-white.” The stupidity of the protestors is stunning, as is their twisting of facts.

As I’v noted multiple times, we have family members in emergency medicine/critical care.  These types of attacks happen every day, everywhere. Patients yell, scream, hit, spit on staff. Some patients’ family members call and make demands, cursing at staff who refuse to dispense ivermectin. They abuse them mercilessly.

And nurses and staff are supposed to stand there and take it.

Would you tolerate that in your job?

What does this mean for you?

These idiots and their enablers are destroying our healthcare system. Call them out. 


COVID infections are associated with much higher use of medications to address behavioral health conditions. That’s from a study published in the British Medical Journal. The study was conducted by the Veteran’s Administration and analyzed data on over 150,000 patients with a previous acute COVID diagnosis.

From the BMJ:

people with covid-19 show an increased risk of incident mental health disorders, including anxiety disorders, depressive disorders, stress and adjustment disorders, opioid use disorder, other (non-opioid) substance use disorders, neurocognitive decline, and sleep disorders. The risks were evident even among those who were not admitted to hospital during the acute phase of covid-19—this group represents most people with covid-19 [emphasis added]

Vaccinations are good

A UK meta-analysis focused on long-COVID found that individuals previously infected with COVID benefited from vaccinations, and those with COVID that got a vaccination did better than those without a vaccination.

  • Six of the 8 studies assessing the effectiveness of vaccination before COVID-19 infection suggested that vaccinated cases (1 or 2 doses) were less likely to develop symptoms of long COVID following infection, in the short term (4 weeks after infection), medium term (12 to 20 weeks after infection) and long term (6 months after infection).
      • Six of the 8 studies assessing the effectiveness of vaccination before COVID-19 infection suggested that vaccinated cases (1 or 2 doses) were less likely to develop symptoms of long COVID following infection, in the short term (4 weeks after infection), medium term (12 to 20 weeks after infection) and long term (6 months after infection).

      Finally, more support for the benefit of vaccinations for those previously infected with COVID.  

      A study published in the new England Journal of Medicine found that:

      Among patients who had recovered from Covid-19, the receipt of at least one dose of the BNT162b2 vaccine was associated with a significantly lower risk of recurrent infection.

      So, yeah, just because you had COVID doesn’t mean you don’t need the jab.

      What does this mean for you?

      Get vaccinated. 


Quick hits…

I’ve done a few podcasts recently, and find them to be a lot of fun. Yvonne and Rafael hosted me in a kick off the second season of their Deconstructing Comp pod…we dove into opioids, humility, making things real, testifying before Congress, physician dispensing, blogging and grandkids.

CWCI’s annual meeting is DIFFERENT this year.

The fine folks at CWCI recognize that many members and other usual attendees are still under travel restrictions and may have personal and/or public health concerns. To accommodate as many people as possible, this year there will be both live (3/8) and virtual (3/10) conferences.  Register for both the live and virtual meetings here:; the virtual meeting will combine recordings of the live sessions with a live Q&A.

There’s a lot on the agenda related to legislative targets including access to care/MPNs, presumptions, med/legal & QMEs as well as the usual claims monitoring report (COVID/Non-COVID claim dynamics, utilization, pharmacy).

Michael Marks, a most insightful attorney will tie together the theme (“Are We There Yet”) with a comparison of the original grand bargain to our current state.

Not to be outdone, NCCI’s out with their latest economic briefing; highlights include:

  • Unemployment rates at or below 4% in December and January indicate that the US economy is nearing full employment.
  • Job losses are now concentrated in just two major sectors: Leisure and Hospitality, and Education and Health Services. (With family members in healthcare, I know first hand why so many are quitting)
  • January’s employment numbers showed no effects of the Omicron surge…deferred jobs hit in February is unlikely.

The Conference Board forecast that the US economy will grow by 2.6 percent (year-over-year) in 2022. I’m no economist (yippee!) but I’m betting we’ll see significantly higher growth – which will positively effect employment, wages, and thus workers’ comp and group health premium growth.

What does this mean for you?

Things are getting better. 


Hospital CEO pay ≠ Outcomes

An excellent piece by Merrill Goozner highlighted – among other things – the disconnect between not-for-profit hospital CEO pay and their hospital’s ability to control costs. 

Merrill cited the Lown Institute’s analysis of hospital performance, DEI results, outcomes, cost and pay equity

Since 1996, hospital costs have risen about 2 1/2 times faster than overall inflation…


Quoting Merrill..

You’d think the boards of trustees at the nation’s non-profit hospitals, which account for 80% of all staffed beds in this country, would be up in arms over top management’s inability to keep prices and thereby patient costs under control. At the least, they might want to incentivize their chief executive officers and other C-suite staff to take cost control seriously.


up to 40% of a CEO’s bonus depended on measures that directly affect hospital finances.

Not for profit hospitals are a BIG part our healthcare problem; most don’t care about rising healthcare costs, and they don’t tightly link CEO compensation to clinical outcomes.

Now I know why I had to pay $355 for ear wax removal.

What does this mean for you?

Hospital leaders’ and their boards’ priorities are not ours. 

Subscribe to Merrill’s posts here.


Our healthcare system is breaking, part 4

This is the fourth attempt to warn you about the impending disaster facing all of us. 

Our incredibly dysfunctional healthcare system is collapsing, falling apart as thousands of highly-experienced and very well-trained critical staff leave care provider roles.

Two national nursing experts:

  • nurses who are inexperienced are replacing those who retired or were enticed by financial incentives to become travel nurses.
  • So many older nurses have quit, and younger nurses are at the bedside.

Hospitals are turning to traveling staff, costing facilities 4 to 5 times more than full-time workers. In response, and in a classic “treat the symptom while ignoring the problem” move some well-intentioned but pretty clueless elected officials are trying to pass a bill that would restrict traveling staff agencies’ pricing.

That is both pointless and pathetic. It reflects those officials’ paying attention to healthcare executives while ignoring what’s happening to care workers on front lines.

Instead our Representatives should be:

  • confronting those who are lying about COVID and vaccines,
  • using every tool and lever they have to support health care workers,
  • implementing financial penalties for illegitimate vaccine refusers in the form of higher premiums, copays, and deductibles.

It’s even worse at long-term care and rehab facilities…and it has undoubtedly gotten worse since those data were collected back in June 2021. And it’s happening in Florida, California, and Indiana – and in your state too.

Here’s why. And no, it’s not vaccine mandates.

From a great piece in The Baltimore Sun:

The great “financialization” of the health care industry has finally trickled down. Capitalism and the unfettered and unfiltered drive for the dollar has degraded the nursing profession in many regards. The historic exploitation of nurses to increase productivity and reduce costs, worsened by the pandemic, has led to a historic nursing shortage being faced today. [emphasis added]

This is the macro, structural driver – the unbound drive for profits..

COVID – and more specifically disinformation and vaccine resistance – has greatly accelerated and deepened the crisis. 

The multiple waves of COVID and the relentless flood of disinformation and lies have crushed the life out of nurses and healthcare workers, each successive wave burying healthcare workers ever deeper until many can see no escape.  Nurses are at much higher risk for suicide than most other workers.

Experienced, trained, passionate and skilled nurses and healthcare workers are leaving patient care.

What does this mean for you?

Sooner or later you will bring a family member to a hospital.

The staff will be less experienced, less skilled, less knowledgeable and less able to provide care.

Lies and disinformation have consequences.



COVID, Science, and “Natural” Immunity

There’s a good deal of confusion out there about “natural” immunity and COVID.

Here are the facts.

first, there’s no such thing as “artificial” immunity. ALL immunity is natural…whether one is infected by COVID or gets a vaccination, the body has a natural response.

Virologist Stuart Neil: 

all a vaccine does is prime the immune system with a dead pathogen, a protein (or part of a protein from it), or a related but harmless pathogen so that the body can respond so much more quickly when the actual pathogen is actually encountered…

second, if you want to protect against a COVID infection, would you rather:

a) get a vaccine that is FDA approved, has been proven safe and effective, or:

b) get infected with COVID.

Sure, there can be side effects from COVID vaccines (a family member had a pretty nasty albeit brief headache and chill episode after his/her second Moderna  jab, but I had no side effects from any of my three Pfizer shots). Balance that against the potentially much worse illness – or death – from a real COVID infection, and the choice is pretty obvious.

third, multiple recent studies prove that previous COVID infections are NOT as effective at preventing future COVID infections as are vaccines. Summary findings from two:

This study “found that the chances of these adults testing positive for COVID-19 were 5.49 times higher in unvaccinated people who had COVID-19 in the past than they were for those who had been vaccinated for COVID and had not had an infection before.”

And this one “indicates that if you had COVID-19 before and are not vaccinated, your risk of getting re-infected is more than two times higher than for those who got vaccinated after having COVID-19.”

Finally, if you were unlucky enough to have contracted COVID AND smart enough to get fully vaccinated, you’re even less likely to get COVID again.

Sure, there’s a LOT of misinformation out there, including this total distortion/misstatement/nonsense (just one – it was conducted BEFORE “most persons had received additional or booster COVID-19 vaccine doses to protect against waning immunity. (Actual study is here.)

But hey, if you want to fight science, go right ahead. Just remember what happened to Wile E Coyote when he denied gravity’s existence…

Oh, and if you do fall off the cliff, don’t get upset if healthcare workers are less than sympathetic.

What does this mean for you?

Get vaccinated. Wear a mask.

and a hat tip to Bill F for alerting me to the issue!


COVID update

Two years (almost) to the day and we’re still talking about &^%$(*# COVID…

OK, here’s the latest.


73 million confirmed cases in the U.S.

876 thousand COVID-related deaths.

that’s 12 deaths per thousand cases.

that, dear reader, is a very high case mortality rate.

Here’s a comparison of death rates (NOT case mortality rates) for flu vs COVID.

Long-term impact

A study published in JAMA of one-year outcomes for patients who survived ICU treatment in Holland found:

  • 74.3% reported physical symptoms,
  • 26.2% reported mental symptoms, and
  • 16.2% reported cognitive symptoms.

More specifically, patients self-reported issues with fatigue, mental symptoms, depression, PTSD, anxiety, and indications of cognitive failure.

NCCI’s webinar on COVID’s impact on work comp is up for viewing here.  Highly recommended.

Vaccination data

Excellent ongoing reporting from the Kaiser Family Foundation; latest data is here.

Overall 73% of us are vaccinated

Couple head-slapping statistics…

Republicans used to be the rational party, or at least the party of rationality. That’s a stunning disparity.

Here’s why the unvaxxed are unvaxxed…

What does this mean for you?

Get vaccinated and boosted, and wear a mask. COVID doesn’t care about your political affiliations.



(Most) private insurers aren’t controlling costs

The prices private insurers have paid to hospitals and physicians have increased much faster than prices paid by Medicare and Medicaid.

And it’s not because providers are cost-shifting.

Those are the main takeaways from a just-released CBO report; here’s what CBO said (emphasis added):

  • commercial insurers pay much higher prices for hospitals’ and physicians’ services than Medicare FFS does.
  • In addition, the prices that commercial insurers pay hospitals are much higher than hospitals’ costs.
  • Paying higher prices to providers can have several effects.
    • First, it can increase insurers’ spending on claims, which may lead to higher premiums, greater cost-sharing requirements for patients...
    • Second, it can increase the federal government’s subsidies for health care .
    • And third, it can slow the growth of wages.
  • The share of providers’ patients who are covered by Medicare and Medicaid is not related to higher prices paid by commercial insurers. That finding suggests that providers do not raise the prices they negotiate with commercial insurers to offset lower prices paid by government programs (a concept known as cost shifting).

Ok, that said, these are findings based on national data…things are different market to market.

I’d note that price increases in workers’ comp correlates with states’ Medicaid expansion. That is, price inflation is generally much higher in states that did NOT expand medicaid.

More on that here.

What does that mean for you?

Private insurers aren’t doing their job very well.