Category: Manage Care – Group Health

Jan
29

Private health insurance has failed.

Posted by Joe Paduda on Wednesday, January 29th, 2020 | Comments

If you had “government” health insurance for the last decade, your costs would be 20 – 25% lower today.

That’s because private insurers have not controlled spending nearly as well as Medicare and Medicaid have.  This from KFN via Axios.

Doesn’t matter what your economic or political ideology is – that’s a fact.

You and your insurance company pay your doctors and hospital more than twice what Medicare does. Yes, the Feds can exert pricing power – but why can’t United Healthcare, or Aetna, or Blue Cross?

Those healthcare giants should be able to negotiate better deals with providers; they have massive buying power and millions of members to leverage. They should be able to use that power to give you lower insurance costs – but they can’t.

Those private insurers are (theoretically) more nimble, smarter, better run, and more efficient than the government. And they have hundreds of billions of healthcare dollars to leverage.

Yet they’ve failed to outperform a bunch of bureaucrats.

I won’t dive into the “whys” today, because that would take away from the over-arching truth – government has been much more effective than private insurers.

What does this mean for you?

Cutting your health insurance costs by a quarter = more dollars you could have spent on other stuff.

note – happy to hear other thoughts; please use citations to back up any assertions.

Jan
27

Quick hits – new services, good news, and why your health insurance costs are stupid expensive

Posted by Joe Paduda on Monday, January 27th, 2020 | Comments

What I missed when I was busy working last week…

Workers’ comp

HomeCareConnect launched a new service last week intended to smooth the transition for patients moving from acute care facilities to a skilled rehab facility.  HCC folks have credentialed and contracted some 15,000 providers; combining these providers with HCC’s in-house care coordination staff should help adjusters and case managers manage the complex needs of these patients.

The folks at the California State Comp Insurance Fund produced a pretty campy – and pretty useful – video training series about data security.  Not often a CEO allows her/himself to be the object lesson for training…

The fine folk at WCRI have a free webinar Thursday, Jan. 30, 2020, at 1:00 p.m. ET reviewing Pennsylvania’s workers’ comp system.  Register here…And do it now, as there’s a 500 viewer limit.

Friend and colleague Dwight Robertson MD penned an excellent piece on opioid management.  Dwight, who is the Medical Director for Employers’ Insurance, has found that three tactics can make a big difference; get on those opioid claims much sooner, have a direct conversation with the prescriber about the opioid plan, and focus on alternative approaches to pain management.

A quick read and quite topical.

Group health

Private insurers’ facility payments differ wildly; comparing them to Medicare indicates inpatient costs are roughly 2.4x Medicare, while outpatient is even higher at 2.9x.

The pic below is from an interactive tool that enables you to see what your state looks like. Spoiler alert – Orlando’s Florida Hospital gets more than 3x Medicare…

Here’s my Capt. Obvious moment – your healthcare insurer is paying more than twice what Medicare is – which means huge profits for your hospital.

And that’s why your insurance premiums, deductibles, and out of pocket costs are so high.

What does this mean for you?

Good stuff happening in workers’ comp, while hospitals are the biggest reason your health insurance premiums, deductibles and out of pocket payments are zooming

 

Jan
7

A wake-up call for the insurance industry

Posted by Joe Paduda on Tuesday, January 7th, 2020 | Comments

We are stuck in a self-destructive cycle, namely an industry-wide culture that rejects true innovation that leads to a huge talent deficit that prevents innovation.

With few exceptions, there is little in the way of innovation, effective marketing, risk-taking, creativity and substantive investment in systems and technology in the insurance industry. That will be the death of many insurers and healthplans.

As a result, we can’t get enough brilliant, impactful people to work in our business because our culture is anathema to most of them.

So, there’s no innovation.

The most important part of any organization is its people. Yet our industry’s talent deficit is as wide and deep as the Marianas Trench. Sure, there are some very smart folks doing great work – in healthplans, State Funds, private insurers, TPAs, and service companies.

They are the exception, not the rule.

Don’t agree?

How many of your brilliant college classmates chose a career in insurance? In your career, you were blown away by someone’s acumen, insight, brilliance, thinking how many times? How many execs in this business came out of top business or other schools?

Why is this?

I’d suggest it is the very nature of our industry; it isn’t dynamic, doesn’t reward innovation, hates self-reflection, abhors risk-taking, and doesn’t invest near enough in people or technology.

Proof statements, courtesy of The Economist 

  • No insurer ranks among the world’s top 1,000 public companies for R&D investment – yet dozens of insurers are in that top 1000.
  • On average insurers allocate 3.6% of revenue to IT —about half as much as banks.
  • In a study of 500 innovation topics across 250 firms, many insurers are working on the same narrow set of ideas.
  • Many property insurers, whose fortunes rely on forecasting climate-induced losses, are still learning how to use weather information.

Tough to recruit talent to an industry that – for Pete’s sake, invests half what banks do in IT…

  • Or for a property insurer that hasn’t figured out weather is kinda important?
  • Where all your competitors define “innovation” as doing the same stuff you do?
  • That probably spends more on janitorial services than R&D? (Ok, that may be a bit of an exaggeration.)

Many of the big primary insurers in today’s market will be overtaken by the Apples, Amazons, Googles, Beazleys, Trupos, and Slices tomorrow. The names you know are brilliant innovators and have billions upon billions of cash to invest. The names you don’t know have figured out and are diving into markets that the traditional, stodgy, glacially-fast insurers can’t even conceive of – reputational risk, very short-term insurance for specific items, disability coverage for gig workers, and a host of other opportunities.

Oh, and they are doing it without all the paperwork, hassle and nonsense that keeps insurance admin expenses at 20% of premiums while frustrating the bejezus out of potential customers. (having just spent hours on the phone fixing a problem with flood insurance, count me as one)

And no, with rare exceptions health insurers aren’t any better. With structural inflation that guarantees annual growth of 5-8% and an employer customer that has to provide workers with health insurance, plus governmental contracts that pay on a percentage of paid medical, and record profits across the entire industry, there’s every reason to NOT control costs.

Those record profits may well continue till a Cat 5 storm hits the Jersey shore and/or a deep recession hits and/or investment portfolios are crunched by macro factors.

In the meantime, Jeff Bezos will be looking for places to plow some of his hundreds of billions.

Tomorrow – what to do about this.

What does this mean for you?

Critical self-reflection is really hard, and really necessary. This industry is ripe for disruption and it will happen. The question is, what will you – and your company – do?

 

 

Aug
26

Monday update – healthcare costs, guidelines, what docs want, and market consolidation

Posted by Joe Paduda on Monday, August 26th, 2019 | Comments

Here’s what happened last week…

People who enroll in exchange programs in red states pay 3.2 percent more for their health insurance than folks in purple or blue states.  Research indicates it is because fewer folks in red states sign up for coverage – and these are likely the healthier people.

Families pay about a third of their healthcare costs, with employers picking up most of the rest.

In part that may be because healthcare now costs more than a new car…Yet one more straw on that poor camel’s back…

Yet another indicator that the healthcare market continues to rapidly consolidate came last week with news that Tufts and Harvard Pilgrim look to be merging.

A you-should-definitely-read-this piece from Harvard Business Review reminds us that variations in data should be considered thru the lens of statistics, not emotion or intuition. An excerpt:

Sorting out variation provides needed context, points to opportunity, and helps managers maintain their cool when something goes wrong. Managers should learn how to measure variation, understand what it tells them about their business, decompose it, and, when necessary, reduce it.

WCRI’s Vennela Thumula PharmD will be discussing Interstate variations in opioid dispensing in a webinar on September 12.  Dr Thumula is one of the nation’s leading experts on workers’ comp opioids and well worth your listen. Register here.

Great piece from HealthAffairs on evidence-based treatment guidelines.  There’s a lot of nonsense and BS out there – especially in workers’ comp guidelines – and this article provides a solid foundation to understand what’s real and what isn’t. Here’s the central message…

There are two core issues that lead to a host of problems. First, there is a lack of centralized authority to coordinate, vet, approve, and catalog guidelines. Second, there is an absence of a universal methodology to create guidelines—every professional organization promulgating guidelines today generally decides freely which, if any, framework they will use to construct guidelines.

Finally, if you want to understand how to incentivize physicians – and improve your ability to work with them, read this.

take time to develop relationships with physicians. I need to develop trust. I need to convey the why. And then, once we do that, you can begin to move into the how and the what. And then physicians are ready to look at the dashboards to help you move them forward.

 

Jan
31

Media coverage of Amazon/Berkshire/JPMorgan misses the point.

Posted by Joe Paduda on Wednesday, January 31st, 2018 | Comments

The coverage of the JPMorgan/Amazon/Berkshire Hathaway healthcare initiative has been universal, breathless, and mostly superficial.

Scoffers, “experts” are gleefully predicting this attempt to do something really different will fail miserably, victim of ignorance and hubris. While there are no guarantees, these naysayers ignore:

  • the three CEOS and their staff are brilliant, powerful, have almost unlimited resources, and are very, very cognizant of the difficulties they face. These are as far from idealistic newbies as one could get.
  • the “competition” is pretty lousy, hasn’t delivered, and their incentives are NOT aligned with employers’. If the big healthplan companies could have figured this out on their own, you wouldn’t be reading this.  It’s not like A/B/J are taking on Apple, Salesforce, or the old GE.
  • the financial incentives are overwhelming; healthcare costs are over $24,000 per family and heading inexorably higher. Unless these companies reduce and reverse this trend, they’ll have a lot less cash for future investments.

Many are also talking about “initiatives” that are little more than tweaks around the edges; things like:

  • publishing prices and outcomes for specific providers aka “transparency”
    My view – research clearly demonstrates consumers don’t pay attention to this information, so there’s no point
  • using technology to monitor health conditions and prompt treatment/compliance
    My view – lots of other companies are already doing this, and this is by no means transformational
  • use buying power to negotiate prices
    My view – it’s about a lot more than price, it’s about value.

Here’s a few things A/B/J may end up doing.

  1. Own their own healthcare delivery assets.
    My view – Insourcing primary care, tying it all together with technology, and owning a centralized best-of-breed tertiary care delivery center would allow for vastly better care, lower patient hassle, and cost control.
  2. Buy healthcare on the basis of employee productivity
    My view – Healthcare is perhaps the only purchase organizations make where there is no consideration of value – of what they get for their dollars. To the Bezos’, Dimons, and Buffets of the world, this is nonsensical at best. They will push for value-based care, defined as employee productivity.
  3. Build their own generic drug manufacturer
    My view – No-brainer.
  4. Allow employees to go to any primary care provider they want, but require them to go to Centers of Excellence for treatment of conditions that are high cost with high outcome variability.
    My view – No brainer.

I’d also expect many more large employers will join the coalition, for the simple reason that they have no other choice.

What does this mean for you?

Do not discount this.

 

Jan
2

We haven’t seen anything yet.

Posted by Joe Paduda on Tuesday, January 2nd, 2018 | Comments

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.

Jul
28

What will Aetna do with Coventry Workers’ Comp?

Posted by Joe Paduda on Friday, July 28th, 2017 | Comments

That’s a question that’s been around for years, but one that’s being asked more and more these days.

One clue could be – but probably isn’t – Aetna CEO Mark Bertolini’s evolving view of the purpose of health insurance and healthplans.

Bertolini’s personal brushes with mortality (a horrific skiing accident and his son’s cancer diagnosis) have fundamentally changed how he sees the role of health insurance. Unlike other insurance executives, he is pushing Aetna to deliver health defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,”

That’s what we do in workers’ comp, admittedly not all that well some times, but that’s our goal – prevent accidents and illnesses, get people healthy and functional if they do get hurt, and keep them that way.

I agree with Bertolini’s perspective.

That being the case, CWCS seems like a valuable asset indeed with exactly the right people, technology, business models, and intellectual property Bertolini needs to transform Aetna.

The question is, does Bertolini understand what he has, or will Aetna continue to treat CWCS as a purely financial asset?…a tiny part of a huge healthcare company valued not for its potential impact on the company as a whole, but for the dollars it delivers to the bottom line.

Rumors persist that CWCS is on the block, rumors without solid evidence behind them. As the work comp services industry continues to consolidate, CWCS’ name will continue to come up in conversations whenever investors are contemplating the next big deal. While it is indeed possible Aetna will entertain offers for CWCS, the division’s value (as a financial asset) has likely decreased over the past few years.  CWCS’ core asset, it’s provider network, is not the dominant force it once was, the bill review business has dropped off, and under-investment throughout the division has hampered innovation.

What does this mean for you?

Sometimes exactly what you need is right in front of you.

Jan
11

Monday catch up

Posted by Joe Paduda on Monday, January 11th, 2016 | Comments

Too much work and travel last week – actually missed posting three days in a row – my apologies!

Here’s what happened.

In the never-ending saga of California work comp, a recent appeals court ruling found a UR doctor potentially liable for problems associated with terminating a patient’s prescription drugs.  The case, King v CompPartners, appears to revolve around the court’s assertion that the UR physician had a patient-doctor relationship with the patient, and thus had a “duty of care”.

If King v CompPartners stands, there could be major implications for California work comp, including significant changes to the entire UR process and landscape. (CompPartners is a subsidiary of MCMC, an HSA consulting client)

Mitchell Pharmacy Solutions acquired PBM Jordan Reses. Mitchell also announced they will re-brand the company’s PBM services as ScriptAdviser. Jordan Reses’ work comp PBM serves a diverse group of employers including school districts, managed care firms, the State of Kansas; it also provides services for the auto PIP program in NJ for Liberty Mutual and other auto insurers. (Mitchell is a member of CompPharma, a PBM consortium; I am president of CompPharma)

After a multi-year hiatus, friend and colleague Bob Wilson finally posted a top ten predictions for work comp .  Despite his antediluvian political views, Bob is the most entertaining of the work comp bloggers – myself included.

Final enrollment figures for the public Exchanges are out – Timothy Jost of Health Affairs reports a total of 11.3 million enrollees, 3 million of which were new for 2016.  While 35% are under the age of 35, we do NOT know what percentage of this group were dependents.  That’s critical, as enrollment among young heads-of-household is key to determine the extent of adverse selectio n.

Tom Barrett of BBG posted on a echocardiogram test a client company paid for; same test, prescribing doc, insurer – two different test providers – 525% difference in cost.

Happy Monday!

Dec
4

Provider reimbursement changes – painful and necessary

Posted by Joe Paduda on Friday, December 4th, 2015 | Comments

Full or partial capitation, with or without risk withholds.  Per-episode payments or cost caps.  Fee-for-service with or without pay-for-performance.  Ambulatory care episodic payments.  Discount below billed charges.  Packaged prices. Value-based reimbursement.

The list of reimbursement types and variations is long and growing.  As providers and payers struggle to find the right mix of risk and reward, they are tinkering with long-established reimbursement methodologies (think capitation) and coming up with entirely new concepts (value-based pricing).

If there’s a universal, it is fee-for-service is falling out of favor, at least for the big payers – governmental and private.  It encourages overuse and over-treatment.  But it does have benefits.  FFS motivates providers to maximize their productivity, a goal that every health care provider organization is striving for.

Each variation has its plusses and minuses, but there are several common threads.

First, the providers affected need to buy in.  If they think they are being gamed, or worse, screwed, they will instantly figure out how to return the favor.  There’s a lot of skepticism among providers about these new arrangements, much of it well-founded.  Problems with capitation and risk withholds almost killed the entire managed care movement back in the nineties and providers remember those days all too well.

Which leads directly to the next have-to.

Transparency is key.  Price setting, risk-reward formulae, the bases on which capitation is calculated all have to be clear and readily understood.  That way when questions arise, all involved have “equal access” to the methodology and discussions can focus on material issues.

Third, it’s about outcomes and results, not volumes and procedures.  We are seeing a wrenching shift away from paying providers to do stuff to patients, and towards paying providers to maintain and improve health status.  This is going to be ugly, difficult, and painful for all involved.  There will be winners and losers, and some folks are going to be hurt.

What health care is going thru is not far from that experienced by manufacturing and heavy industry over the last forty years.

And, like manufacturing and heavy industry, the US health care “system” has to change if it is to survive.  We cannot continue with fee for service, rewarding providers for doing more and more expensive stuff to fewer and fewer insureds.  And allowing insurers and health plans to make money by covering only those people unlikely to have a claim.

If health care could be offshored, it would be.  As it (mostly) can’t be, we have to fix it right here.

That doesn’t mean it’s going to be any less wrenching.

What does this mean for you?

Huge changes are required.  Avoiding them is not an option.

Jul
24

Consolidation in the real world – implications for workers’ comp

Posted by Joe Paduda on Friday, July 24th, 2015 | Comments

There’s been a lot of mergers and acquisitions in the work comp arena, and certainly more to come.

But the activity in our little corner is minor indeed compared to what’s happening in the “real world” – group health, Medicaid, and Medicare. Make no mistake, these transactions will affect work comp.

You’ve probably heard of some of the activity among payers;

When these deals are completed, there will be three giant health insurers; United, Anthem, and Aetna.  All will have major operations in the Health Exchanges, Medicaid, Medicare, and employer-sponsored health insurance. Anthem, which owns many Blues plans, will have more local dominance in specific markets while Aetna and UHG are bigger players in the employer marketplace.

What you may not be tracking is the provider consolidation – which is equally frantic.  Just a few examples from the last few months:

The ongoing seesaw of market power is playing out nationally and locally – but the local scene is much more relevant for workers comp payers.  Local health systems negotiate with these big payers, with both sides coming to the table from positions of strength.  If Aetna wants coverage in southeastern PA, UPenn-Lancaster must be in their network.  For UHC to compete for employer and/or exchange business in New Jersey, they’ve got to have access to facilities and docs controlled by the two entities listed above.

The bruising battle over access, rates, and exclusivity is what’s driving the move to narrow networks. Health plans have to deliver more patients to specific health systems or those systems will not negotiate on price.

The best way to ensure increased patient volume is to make a deal exclusive – and we will see more and more narrowing of networks as competition heats up among the big three health insurers.

What does this mean for workers comp?

Work comp is incidental to Medicaid/Medicare/group/Exchange business. Health systems are going to get squeezed in these deals. Health plan execs will look to several reimbursement sources to make up margins; out-of-network care being most important but workers comp will be considered quite attractive as well. Comp is quite profitable, particularly as it drives orthopedic and ancillary revenue, services which have traditionally high margins for hospitals.

The other consideration is the care that is delivered via a health system or facility is billed under a hospital fee schedule. And, there can be a facility charge in addition to the physician fee. 

The net is work comp will be seen as a great source of very profitable patients.