Part 2 of The NCCI State o’ the Line; aka the Dennis Mealy farewell tour.

There was a good bit of discussion re frequency in his SoL report, with Mealy noting there was a sharp decline in relatively low-cost claims early in 2008/9, but little change in the number of high cost claims. This is consistent with other research indicating employees are reluctant to file claims in a recession for fear of losing their jobs; however those with major injuries really have to file.

Indemnity severity (cost for wage replacement) was up just a point over 2011; not surprising given the continued tough employment situation – wages weren’t up, so wage replacement costs weren’t either.

Medical severity was up 3 percent, overall “not bad” according to Mr Mealy.  Recall workers’ comp is just 2 percent of total national health spend, thus we are more affected by external factors than in control of our own destiny.  There are structural changes working their way thru the medical community, driven in large part by efforts to prepare for PPACA implementation in 2014 that are likely having a significant impact.

Somewhat surprisingly, the medical CPI is actually running a full point higher than lost time medical severity – only the second time in memory this has happened.

There was a bit of discussion about the impact of health reform on workers’ comp; I remain convinced the overall impact will be quite positive; I was puzzled by some comments that ACA might increase cost shifting.  As ACA will ensure somewhere around 20 – 30 million more Americans have health insurance, there’s no question there will be LESS need for providers to cost shift post-ACA than there is today.  

Those uninsured are getting free care today, and that care will be reimbursed tomorrow. Even if that reimbursement is at Medicaid levels, that’s a heckuva lot better than zero reimbursement.

That said, I’d also note access to key specialties – think orthopedics – is going to be very tight this time next year as pent-up demand meets insurance coverage.

With a day and a drive to reflect on the WCRI conference, there’s much to be taken away.

Attendance was high.  Over the last decade, WCRI has become a must-attend for many payers and regulators, and as a result the number of service entities at the conference has grown steadily.  That’s good; all stakeholders need to hear what’s happening, share ideas, and debate solutions.

WCRI’s growing use and acceptance of social media is impressive.  Andrew Kenneally was tweeting away through every session, and there were several other media folks there live blogging (including your trusty author).  They’ve gone out of their way to make our work easier, and the benefits for WCRI can be measured in the media mentions – which were likely in the gazillions.

From a content perspective, it was (with one exception) perhaps the best I’ve attended.  WCRI’s done an admirable job “freshening” their data: a past criticism was that the research was based on data that was quite dated, and therefore was not actionable.  The research we heard about this week reflected information from November 2011 – quite an improvement.

The discussion of guidelines was (generally) quite good – a solid explanation and background, a necessary albeit discouraging discussion of challenges getting docs to comply with guidelines, and a good synopsis of some key results in the non-WC world. There was also a review of some WC-specific results (I would have liked more results, but that’s a quibble). Prof. Wickizer’s summary was excellent, altho some of the citations were dated.

Some came away from that talk lamenting that they hadn’t heard much they hadn’t heard before.  I hadn’t either, but in fairness those I spoke with have very long and deep experience in this area; several could have given the talk themselves.  For many attendees, it was “new news”.

The focus on opioids on day two was absolutely on point.  I have the uneasy feeling most payers, actuaries, and rating agencies have yet to consider the financial impact of long-term opioid usage – and when they do it’s going to be really ugly.

OperationUNITE’s Karen Kelly gave a presentation on the human impact of opioid abuse that was terrifying.  In some counties in Kentucky, over half the kids are in households with NO PARENTS.  In one small elementary school, over ten percent of the kids had lost parents to opioid abuse. And there’s no question we in the workers’ comp world are contributing to this problem.

A colleague texted me during that session that IAIABC’s Executive Committee would do well to meet with Ms Kelly; they may well decide to reverse their decision and promulgate model language for opioids…

The following sessions detailed the cost, prevalence, and trends of opioid usage in WC.  Data on opioid usage was revealing, current, and actionable.

That was followed by two presentations by vendors – Paradigm (cat claims management) and Ameritox (urine drug testing).  Both were well-done, professional, and polished.  And totally inappropriate for WCRI.  The speakers discussed their company’s programs, provided details on their results, and shared their research, essentially marketing their services to the 350 attendees.  More to the point, their presence on the podium amounted to a subtle, if unintended, endorsement by WCRI. It would have been acceptable if their clients had presented; Paradigm has a long and successful relationship with the Travelers and Ameritox has many payer customers who have used their services for years.

Lest you, dear reader, think this is sour grapes, it is not.  As I’ve disclosed umpteen times, a competitor in the UDT space, Millennium Labs, is a consulting client.  If Millennium had asked me for my views on presenting at WCRI, I would have strongly discouraged their participation.  There are plenty of other venues where it is quite appropriate; the National WC and Disability conference, WCI, and RIMS are the top three.

WCRI is different.  And should remain so.

It has long been known that medical care delivery can vary dramatically from state to state, and even within a state.  Jack Wennberg and his colleagues at Dartmouth have reported deep and long on the issue, with the initial revelation – and it was that – coming forty years ago.  The latest work can be found at the Dartmouth Atlas of healthcare – and it is well worth visiting.

So, here’s the deal – medicine is as much art as science, driven by local knowledge and personal beliefs as much as by best practices and evidence-based clinical guidelines.  While we like to THINK it’s about science, it often isn’t.

WCRI’s Dr Rebecca Yang delivered the initial presentation at WCRI’s annual meeting focused on interstate variation in medical care.  Their analysis looked at surgery, MRIs, pain management injections, and physical medicine; a few highlights (for those not able or willing to make it to Boston this year) include:

• Surgical rates varied from about 18 percent in Massachusetts to 38 percent in Indiana.
• MRIs of the lumbar region had an even larger range, from 18% in MA to 50% (FIFTY PERCENT!) in Florida; Florida’s rate was 20% (8 points) above the next highest state.