My apologies for the previous attempt to post this…a picture in the post somehow blocked the view of the body of the post.

What’s the deal with long-term COVID?

Why are facility costs increasing and where?

How will labor market disruptions affect work comp?

These and other questions will be addressed in Boston March 16 and 17 at WCRI’s Issues and Research Conference. I caught up with WCRI CEO John Ruser and Communications Director Andrew Kenneally to get the scoop.

remember these days…?

[Register here…don’t put it off as this often sells out]


26 months into the COVID era we know a lot more about the short-term health impacts of COVID (and associated medical costs and duration) but we’re only starting to understand how COVID infections affect us – and may impact work comp – over the long term. Dr Ruser noted the:

“majority of COVID claims are short duration and most don’t have medical expense, things that are going to surprise us may well be long covid associated (issues)…(we are) doing studies on covid claims and persistence in terms of services provided that WC payers are covering”

Denise Algire, Dan Allen, and Craig Ross DO are the panelists for a discussion of the workplace “after” COVID; mandates, return to worksites, and medical care are all on the docket. [I’m not sure there will ever be an “after” COVID; more likely we’re entering a “COVID era.”]

Facility costs

WCRI’s members have identified facility costs (inpatient and outpatient hospital and ambulatory surgery facility) as a key concern; one of the biggest drivers is provider consolidation.  Dr Bogdan Savych and Dr Sebastian Negrusa will discuss their research into the effect of provider consolidation on workers’ comp medical payments; Dr Ruser:

WCRI’s stakeholders raised this as a top issue…there will be some eyebrows raised as there hasn’t been research on the impact of vertical and horizontal integration’s effect on workers comp. We will discuss the implications for costs from both vertical integration and the acquisition of Primary care practices by larger health systems.

More on this issue here here and here.


The estimable Dr Bob Hartwig will educate and engage as only he can. Somehow Dr Hartwig manages to make the densest of topics relevant and entertaining. With employment a key driver of all things workers’ comp;

“disruptions in labor markets are going to have lasting impacts on the way we work and on workers’ comp claims. Bob Hartwig is coming to talk about these disruptions and their implications for workers’ comp”

What does this mean for you?
All in all, a festival of facts, a cornucopia of content,  await us in Boston…along with a most-needed opportunity to see old friends and, dare I say…shake hands?


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.


(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.



Our healthcare system is breaking – part 2

Earlier this week I wrote the first in what is likely to be a wholly dispiriting series of posts documenting the decline of our healthcare system.

Make no mistake, in many areas it is coming apart at the seams. While the causes are many, there’s no question COVID has both sped up and steepened the fall.

Healthcare job vacancies are twice the historical high, with one out of every ten jobs unfilled. We are missing about 1.9 million nurses, doctors, technicians, administrators, lab techs, therapists, nutritionists, counselors, case managers, social service workers, aides, and support staff.

From the Bureau of Labor Statistics… note the graph includes both social workers (about 200k openings) and healthcare about 1.7 million.)

At the end October,

  • more than half of the healthcare job openings were for RNs
  • 15% were for LPNs
  • 7^ for nursing assistants
  • 17% for therapists.

Many of the healthcare workers that have been able to hang in there are exhausted, scared, emotionally scarred and beyond frustration.

Statistics don’t mean anything? OK, here’s what this feels like…

What does this mean for you?

You don’t know what you’ve got till it’s gone. 

Reminder to Trolls and Cowards

I highly value disagreement but only if it is courteous, fact-based and the other side isn’t hiding behind anonymity.

A reminder to all commenters; with rare exceptions – as in when I know who you are – anonymous comments are banned. You know who I am, it is only fair that I, and your fellow readers, know who you are. Indeed there are sometimes good reasons for anonymous comments, but never when you attack, insult, denigrate, and rant. So, Cowards are not welcome here.

Similarly, I’m done debating Trolls who engage in fact-free rants and/or cite completely not-credible “sources” (no, InfoWars is NOT a credible source). If you want to debate, avoid these common pitfalls.


A promising new tool for physical therapy

I’m approached by lots of companies looking for advice on how to get their products/services into the workers’ comp and/or group health space…most are:

  • not exactly ready for prime time &/or
  • don’t have enough solid research behind them &/or
  • have glaring deficiencies &/or
  • just don’t feel right.

But when Bill Zachry called me about Plethy, I paid attention (disclosure – Bill is a long-time friend and colleague, has huge experience in workers’ comp, and is one of the finest people I know).

While Plethy’s Recupe is technically in the digital musculoskeletal space, Recupe is unlike other approaches in that the technology is not the focus, rather a key component of a comprehensive approach that supports physical therapists’ work with patients. Yes there’s a smartphone-based app, yes there’s a sensor that is used to help the therapist monitor exercises and recovery, yes the data can be seamlessly shared with other members of the patient care team.

In my experience devices of this kind are either driven by technologists or clinicians – both have challenges. Technologist-driven approaches often have significant clinical gaps, while clinicians’ efforts are usually clunky and hard to use.

Plethy has involved orthos, DPTs, and other clinicians in the entire development process, which has been managed/done by highly experienced tech experts with deep background in tech product development.

Tech should NEVER displace the involvement of clinical experts. Rather tech should support those experts, provide actionable information and do so with minimal hassle factor.

So far, Recupe checks those boxes.

What does this mean for you?

We are getting there…

note – I am an advisor to Plethy.


Facts vs beliefs

The medical community is wrestling with ethical issues arising from vaccines.

Simply put, should unvaccinated people infected with COVID be treated differently than the vaccinated?

This isn’t just an academic exercise; here in the Upper Valley of New Hampshire and Vermont, emergency rooms, critical care units, ICUs and Pediatric ICUs are stuffed full of COVID patients, almost all of whom are unvaccinated.

The Governor has issued an Executive Order intended to give hospitals more flexibility in setting up overflow units. At least two NH hospitals have postponed or halted elective surgeries as a result of the latest COVID surge.

Michigan may be in even worse shape.

The implications are real and potentially tragic.  Parents, friends, children or neighbors in car accidents, struck by heart attacks or strokes, suffering from kidney failure or pancreatitis or appendicitis or anaphylactic shock may find their local hospital doesn’t have an open bed and/or is operating short-staffed.

The latter is worsening by the day, as nurses, support staff, physicians and other clinicians are exhausted, frustrated, angry and despondent over long hours and the need to treat unvaccinated COVID patients. That and a relatively tiny number of healthcare providers have also bought into the lies perpetrated by antivaxxers, exacerbating the staffing shortage as they lose their jobs.

The exception to this discussion is for populations that have been mistreated, lied to, abused and misled by eugenicists masquerading as researchers.

The arguments for NOT treating those adults who are unvaccinated by choice (rather than due to a medical exemption) go like this…

  • the “slippery slope” argument – once we do this, then we’ll
    • refuse to treat obese people for heart disease, kidney disorders, diabetes, hypertension etc; smokers for heart disease, cancer or COPD; drinkers for liver disease – as if individual decisions with repercussions limited to that individual are the same as antivaxxers’ potential to spread infections, contribute to variant development and possibly kill family members, kids, health care workers and co-workers in the process.
      • as long as we’re talking about obesity…it isn’t
        • communicable,
        • preventable by vaccination, or
        • filling ICUs to over-capacity.
  • the false equivalency argument
    • refusing to treat the “unvaxxed by choice”? than you shouldn’t provide care to women who have unplanned pregnancies – as if a one-time event is equivalent to a person’s brazen willingness to potentially infect dozens of us.
  • the “you are violating my freedoms” argument
    • if we can ban smoking in schools, restaurants, offices, airports and public transportation, we can certainly require immunization and penalize those without valid exemptions (if you think you should be “free” to smoke in a school or medical facility, that’s a whole different issue)
      • Oh, and pets are required to be immunized against dangerous diseases, as are kids.

Which leads us to the facts vs beliefs issue.

“Beliefs” – that you are a better driver than anyone else so should be allowed to drive at twice the speed limit through a school area and your child doesn’t need to be in a child safety seat and you don’t need to wear a seatbelt and you can hold your liquor so driving buzzed isn’t a problem for you; that you know more than 99% of the experts so you won’t get vaccinated, that children don’t die of COVID are NOT facts.

And when those beliefs are demonstrably false – as the anti-vaxxers’ arguments clearly are – the moral dilemma becomes more complicated.

“Freedom” isn’t free – if you want to be free to be unvaccinated, then you – no one else but you – have decided to accept the consequences of that decision.

Actually, that’s not right – because your decision is directly affecting your neighbors, family members, and co-workers. It is directly affecting my family members who work in healthcare, people you will infect, and lives you will disrupt.

In fact, freedom from disease, from economic disruption, from grief when loved ones die – comes at a cost – and that cost – however slight – is all of us getting vaccinated.

What does this mean for you?

Spare us the false equivalencies, the slippery slopes, the my freedoms nonsense, get the damn vaccination and wear a damn mask.

And when you get COVID, stay home and don’t interfere with our freedom to be free of COVID.

A more comprehensive discussion of the arguments against vaccination is here.



for hospitals, Cost ≠ Quality

Some hospitals are efficient – defined as delivering excellent care at relatively low cost, while others are quite inefficient – high cost, not great care.

Then there are the high cost and unknown quality of care facilities – but the net is this – cost ≠ quality, and quality does not cost more.

The Lown Institute has done some great research on this, and identified the nation’s 10 most efficient hospitals – the criterion being how much Medicare was charged compared to how many patients died 30 and 90 days from admission. OK, that isn’t by any stretch a comprehensive definition, but the results were revealing.

Costs ranged from $9,000 to $27,000 per patient…and if all hospitals operated as efficiently as the top 10, we taxpayers would save $8 billion each year.

Of course private payers are charged more, and pay more than Medicare. Nonetheless, efficient hospitals are going to be efficient for all payers.

Here’s the top ten.

  1. Pinnacle Hospital (Crown Point, Ind.)
  2. Saint Mary’s Regional Medical Center (Reno, Nev.)
  3. MercyOne Dubuque Medical Center (Dubuque, Iowa)
  4. Encino Hospital Medical Center (Encino, Calif.)
  5. Park Ridge Health (Hendersonville, N.C.)
  6. Oroville Hospital (Oroville, Calif.)
  7. Saint Michael’s Medical Center (Newark, N.J.)
  8. UnityPoint Health-Meriter (Madison, Wis.)
  9. East Liverpool City Hospital (East Liverpool, Ohio)
  10. Maple Grove Hospital (Maple Grove, Minn.)

Curious about another hospital?  Click here to find out how it ranked.

What does this mean for you?

Knowledge is power – but only if you use it.


Hypocrisy and Hippocrates

A physician posting on MedPage blamed many of the problems in healthcare on private equity…and for-profit insurers.

That takes some…[insert anatomical reference here]. While his assault on Private Equity does have some merit, I can’t let his assertion that the profiteers are insurance companies stand.  What makes me nuts is Liu’s mindless and demonstrably false assertion, coupled with his complete inability to see that he is part of US healthcare’s cost problem.

Dr Mitchel Liu stated “For-profit insurance companies have long been regarded as the ultimate offenders in medical profiteering.”
Wow. Coming from a physician, who make more than docs in any other country, that is ballsy indeed.
Reality is physician compensation is a key driver of healthcare costs, and one of the reasons our healthcare costs are so much more expensive than other countries’. For-profit healthplans do make billions…but their margins are tiny compared to healthcare providers.
Liu also says:
“It’s time for medicine, including individuals and professional societies, to restore the integrity of the physician-patient relationship by taking a strong stand against all forms of corporate greed.”
Well, docs are often partners in Ambulatory Surgical Centers and hospital outpatient surgery centers.  Many docs belong to big multi-specialty groups that are quite profitable.  And, docs make a lot of money.
What does this mean for you, Dr Liu?
How about taking a stand against physician greed, Dr Liu?


that giant sucking sound…

Is coming from hospital trauma centers vacuuming thousands out of your wallet.

Trauma centers are supposed to handle the worst trauma cases – those from major car accidents, gunshots, airplane crashes, building collapses – you get the picture. Smelling gold, some hospital systems – including HCA – figured out that “activating” trauma centers lets them charge fees up to$50,000 per patient – even if that “trauma center” never actually treats the patient.

The fact that HCA has opened trauma centers in 90 of its 179 hospitals – many in close proximity to other trauma centers – indicates it is not a pubic health need as that “need” is already being met.

Shockingly, Florida is once again the poster child for what look to be abusive billing practices.  From Kaiser Health News:

In Florida alone, where the number of trauma centers has exploded, hospitals charged such fees more than 13,000 times in 2019 even though the patient went home the same day,

Florida trauma activation cases without an admission rose from 22% in 2012 to 27% last year, according to the data. At one Florida facility, Broward Health Medical Center, there were 1,285 trauma activation cases in 2019 with no admission — almost equal to the number that led to admissions. [emphasis added]

Work comp and auto alert…

Peter Johnson penned a deep dive into the explosive growth of trauma centers in the latest edition of Health Plan Weekly [subscription required]. In his article, Peter reported the number of Level I and II trauma centers almost doubled from 2008 to 2020, going from 305 to 567.

From his piece (Peter was quoting me):

It is abundantly clear this [the growth in the number of trauma centers] is not due to a years- or even months-long dramatic increase in apartment building fires, accidents, gun fights, or multi-car crashes.

Trauma used to be defined as high-acuity, emergent cases involving severe injury. Not any more at some of these facilities. Reports abound of patients with minor injuries requiring stitches, cold compresses, and even just a baby bottle and a nap billed for trauma activation.

What does this mean for you?

Any facility bill with a trauma center charge must be subjected to very careful and thorough review. Especially in states that allow higher payments for so-called “outliers”.

Auto insurers – pay attention!!


The hospital war is ramping up.

The Biden administration is clamping down on hospital mergers and ramping up enforcement of surprise billing laws. 

Meanwhile, most hospitals are pretty much ignoring the requirement that they post prices. and are going to the mattresses to fight over mergers. (going to the mattresses is what Mafioso did back in the day during major turf battles)

I’ve written extensively about the impact of mergers on cost – it goes up, a lot – and quality – no evidence that it improves. But this isn’t just about hospitals, it is about the entire healthcare system and where it is headed.

Hospitals accounted for $1.2 TRILLION in spending back in 2018

Price is the reason healthcare is so damn expensive here compared to other developed countries; and price is driven more and more by hospitals. Pricing power is how hospitals and health systems generate ever margins, pricing power is what they get when hospitals merge and reduce competition in markets.

This from Cooper and Gaynor:

A number of studies have examined individual hospital mergers and found price increases of greater than 20% (e.g., Town and Vistnes 2001, Krishnan 2001, Vita and Sacher 2001, Gaynor and Vogt 2003, Capps et al. 2003, Capps and Dranove 2004, Dafny 2009, Thompson 2011, Tenn 2011, Gowrisankaran et al. 2015).

The FTC has conducted a series of merger retrospectives. These analyses have found price increases of 20% to 50% (Haas-Wilson and Garmon 2011, Tenn 2011, Thompson 2011).

There has also been work analyzing “cross-market mergers” of hospitals that are not geographically proximate competitors (Dafny, Ho, and Lee 2019, Lewis and Pflum 2017). These studies have observed cross-market merger effects that raised prices between 10% and 17%.

That’s how Tenet reported record profits last quarter, it’s why Michigan’s two largest systems are merging.

The merger thing has gone on so long that 4 out of 5 hospital market areas are “highly consolidated” – meaning the locally-dominant health systems have pricing power, and can use that to dictate prices to payers of all kinds. Mergers peaked several years ago – not because they are losing popularity, but rather because there just aren’t that many merger targets any more.

Because hospitals thrive on profitable services, we’re seeing cutbacks in less-profitable lines, cutbacks that are limiting the availability of services especially in rural and under-served areas. 

What does this mean for you?

We have got to get control of the hospital beast before it eats us alive.