How much are we spending on orthopedic implants?

According to market research firm Supplier Relations LLC, the total US surgical appliance and device industry’s revenue for the year 2007 was “approximately $30.4 billion USD, with an estimated gross profit of 46.15%”.
Note that this total includes more than just implantable devices – sutures, surgical dressings, and prosthetics and other stuff are also counted towards the totals. Without buying the report for $600, you won’t know exactly how much is spent on which categories. But research indicates the orthopedic and surgical device share of the total has been quite significant – well above 50%.
The growth of the implant market has been marred by allegations of illegal kickbacks, sleazy business deals between manufacturers and physicians, and hugely inflated prices to payers.
That hasn’t slowed the market.
Another report (more specific to orthopedics) predicts total implant demand will rise “9.8 percent annually to $23 billion in 2012. The four major product segments — reconstructive joint replacements, spinal implants, orthobiologics and trauma implants — will all provide strong growth opportunities.”
But the big growth will come from spine. According to an excerpt from the report,
“Spinal implants will show strong growth due to advances in product technologies and related surgical techniques, coupled with an increasing prevalence of chronic back conditions. Fixation devices and artificial discs used in spinal fusion and motion preservation surgeries, especially procedures for the repair of vertebrae and replacement of degenerative discs, will account for the largest share of the market and best growth opportunities.”[emphasis added]
What does this mean for you?
Higher costs with uncertain results.


ASCs — good, bad, or just ugly?

A recent court ruling in New Jersey could shut down Ambulatory Surgical Centers across the state.
The judge determined that physician-owned ASCs (almost all ASCs are at least partly owned by physicians) violate a state law banning physician self-referral. Not surprisingly, the 200 ASCs in the Garden State (there are about 5000 nationwide) are pulling out the stops to overturn a ruling that, if it stands, would effectively shut down most ASCs in NJ.

Continue reading ASCs — good, bad, or just ugly?


Medicare sneezes

The adage goes something like – when the US sneezes, the world catches a cold, signifying just how much influence this country has on the rest of the world.
That’s analogous to Medicare’s impact on the health care sector. And Medicare is about to change the way it pays hospitals, a change that will have a dramatic effect on every private payer from HMO to individual carrier to workers comp insurer to self-insured employer.

Continue reading Medicare sneezes


You need a P&T Committee

Pharmacy and Therapeutics committees have been around for ages in the provider community – they are the “link between medicine and pharmacy”. In the managed care world, P&T committees take on a somewhat different role, establishing formularies, reviewing medical device reimbursement (at some health plans), contributing to coverage determinations and benefit design.
Mostly, they provide the health plan or insurer with an expert opinion on most things pharmacy-related. Without a P&T Committee, these decisions often are left to a medical director, or worse, claims adjuster (in the P&C world), individuals who are not equiped to make educated decisions about pharmaceuticals.

Continue reading You need a P&T Committee


Developments in the WC PBM world

Cypress Care, one of the leading Workers Comp Pharmacy Benefit Management firms, has just announced the company has received a “strategic investment” from Dallas-based Brazos Private Equity Partners. The company has also added David George (former President of AdvancePCS) to the management staff; George will be taking over the CEO spot from co-founder Hank Datelle and has also made an investment in Cypress Care.
The press release contains the typical comments about all parties’ delight at the deal and enthusiasm for the future. As one who has been directly involved, I can attest that in this case, the PR has it right. David George is a highly experienced and very well respected managed care pro with stints at United Healthcare and on the Board of Concentra, Inc. Bart Hester, a former colleague of George’s at AdvancePCS will be joining Cypress as EVP Account Management and Strategy; the rest of the Cypress senior management team including co-founder Lisa Datelle and President Marc Datelle are all staying with the company.
Note – Cypress Care is a Health Strategy Associates consulting client an dsponsors our annual Survey of Prescription Drug Management in Workers Compensation.


Workers comp’s top problem drug

Actiq, the lollypop pain killer, is rapidly becoming the biggest problem drug in workers comp. FDA approved only for treating cancer pain, the potent narcotic is now on most payers’ top 5 drug list (ranked by dollars spent).
There are likely several factors that have enabled a drug clearly not approved for musculo-skeletal conditions to achieve this high “honor”.

Continue reading Workers comp’s top problem drug


Concentra’s investor briefing

Concentra Inc.’s presentation at the Bank of America Investor Conference earlier this month focused on their continued growth, focus on workers comp, and impact of the acquisitions of Beech Street and Occupational Health and Rehab.
Here are some of the highligts from the presentation and comments on same.
Revenues for 2005 are projected to be $1.1 billion, with EBITDA of $156 million and operating cash flow of $101 million. Revenues are growing organically about 5% per year, while operating cash flow is down from $114 million in 2003 to $98 in 2004 to $101 in 2005.
Workers comp is by far their largest market, driving 70% of revenues. The Beech deal will certainly help diversify Concentra’s revenue base, as Beech is a strong mid-tier group health PPO. Beech’s provider contracts will also be compared to the Concentra contracts to identify the ones with the best rates. This, coupled with the greater buying power brought by Beech, may help Concentra drive better deals with some providers.
Of Concentra’s three distinct business units, by far the highest margin business is network services, with a margin of 31%, followed by the clinic business’ 14% margin. The care management sector, which is primarily field and telephonic case management, was hurt by declining revenues and price compression and returned 6%.
Of note, the clinics saw same store revenues up 6.6% on a 5% increase in visits. This at a time when the WC injury rate has been declining by about 4%.
Thomas made the point several times that after the completion of the OH+R deal, Concentra’s clinics will see one of of every ten workers’ comp injuries for initial care. While that sounds impressive, and is impressive, it is important to note that the clinics only see the routine injuries, and most of the dollars that are spent on WC medical go to the more complex cases that are treated by specialists.
The Beech Street and OH+R acquisitions were expensive at $210 million +. The Beech deal adds significantly to Concentra’s group health product offering. while OH+R will add 26 clinics after 8 existing clinics are closed.
Both Thomas and Kiraly repeated their assertion that Concentra is the industry leader in the WC managed care business, and is a full service integrated services provider. From a sheer numbers perspective, they are correct. However, other entities are leaders in segments of the WC business. For example, Coventry’s First Health is by far the leader in the WC PPO sector. MedRisk is the industry leader in management of physical medicine; and PMSI in pharmacy management.
Thomas noted that because Concentra manages all aspects of the claim, it therefore impacts more claims dollars than other competitors. Not exactly. Intracorp has case management, networks, bill review, peer review, and access to specialty managed care. So do Genex and CorVel. Concentra’s out of network bill negotiation entity (Concentra Payment Services) may well be the industry leader in non-network bill processing, but a host of competitors are now in this space.
While Concentra is not a public company, rumors have been rampant for years of their desire to become one. That, coupled with the large amount of debt outstanding, is evidently the reason for their continued participation in these road shows.


Auto insurance and the uninsured

In 2003 Colorado changed its auto insurance law from one in “which all drivers were required to have coverage for treatment of any injuries resulting from auto accidents to a system in which just the driver at fault pays.” The result has been a decline in the percentage of auto injury victims with insurance, leading to reduced revenues for hospitals and an increase in uncompensated care.
Health care providers in Colorado are up in arms about the impact the change away from the no-fault coverage has had on their financial wellbeing, claiming an $80 million hit from the new law. Interestingly, according to Insurance Journal, insurance spokespeople seem to acknowledge the transference of expense from the insurance companies and their policyholders to the hospitals. Carole Walker, executive director of the Rocky Mountain Insurance Information Association, stated:
“We don’t believe people should be required to have medical coverage as part of their auto insurance just because some people don’t have health insurance