Wildly off-topic 2…

Again my fascination with the minutiae that brings defeat or victory causes me to diverge from managed care stuff to dive into what’s happening in Ukraine, why, and guess what the end result will be.

(Here’s my first post which dives into the why crappy vehicle maintenance and mud season are really helping Ukraine)

The damage Russia is doing to Ukraine and the Ukrainian people is immeasurable.  Yet it pales in comparison to what it is doing to itself, its future, its world standing, its economy . And it will get worse, because

Ukraine is still winning (or perhaps more accurately Russia is not, which is the same as Russia losing), and

The western world is unified as it has never been.

First, the no-fly zone. Unfortunately this is a no-go because:

  • Russian planes are not doing nearly as much damage as artillery and rockets – which CANNOT be stopped by a no-fly zone.
  • Implementing a no-fly zone would require NATO countries’ airplanes to:
    • bomb Russian ground radar and anti-aircraft assets – some of which are INSIDE RUSSIA
    • shoot down Russian air assets (planes and helicopters)
    • shoot ordnance (missiles, rockets, shells) that might cross the border into Russia)
  • Direct confrontation of Russian assets by NATO forces would support Putin’s claims that it’s Russia vs NATO and the west, thereby:
    • solidifying his position in Russia and
    • making the use of nuclear/biological/chemical more defensible  – at least in Putin’s mind and others in Russia.

Also, we (NATO, that is) are about to send some very capable ground-to-air missile systems to Ukraine, systems which Ukrainian soldiers are likely familiar with and will need little additional training on. Some of these systems have the ability to shoot down cruise missiles as well as planes and helicopters.

the contrail is from a Ukrainian rocket about to hit a Russian attack helicopter.

and here’s the helicopter as it hits the ground.

Second, “we should be doing more to help the Ukrainians” Well, like what?

Anti-tank rockets? Drones? Medical supplies? Anti-aircraft missiles?

check, check, check and check.

I’m also guessing our intelligence services are helping a LOT by sending data on Russian military movements to Ukrainian forces, data that those forces use to target precision munitions, identify potential threats, and better understand the tactical situation. Of course you’ll never hear about this.

[note more than two dozen (!) Republican Senators voted against legislation providing $13.6 billion in additional aid to Ukraine, then blasted the Biden Administration for “not doing more” to  help the Ukrainians.]

Okay, here’s what I’ve learned from untold hours of reading twitter feeds from some very well-informed and knowledgeable posters…


Russia is having logistical problems – for we civilians, that means their supply chain is in very bad shape. If we don’t get our drill bits, Etsy order, or several pair of shoes to try on, that’s a tragedy.

If an invading army runs out of artillery shells, food, medicine, rockets, medical supplies, and most importantly – fuel – it’s much worse. Hard to fight a war if your:

  • soldiers are hungry,
  • you can’t patch up your wounded, and
  • your tanks, trucks, command vehicles, and mobile artillery run out of fuel.

Which appears to be happening.

Couple issues here –

  1. the Russians can’t get the stuff they have on hand to the troops that need it because those Ukrainians who were supposed to welcome them with open arms didn’t get the memo. And,
  2. Putin and his generals evidently didn’t stock up on everything a modern army needs because they assumed (1.) above was reality.

There are reports that Putin has been asking China for food, artillery shells, medical kits, and probably everything else. (That’s why President Biden told Premier Xi Jinyang – in no uncertain words – to NOT send military goods to Russia)

Okay, back to 1…


Its mud season, and melt season, which means many roads are impassable which forces vehicles to go cross country – which means crossing streams/rivers. Armies have specialty vehicles intended to do this, but…

As we discussed a while back, vehicles require roads, which are narrow, can be mined, and offer lots of opportunities for the Ukrainians armed with man-portable rockets to blow them up.

The classic tactic is to destroy the front and rear vehicles, trapping the rest in the middle. Drivers then have a Hobbesian choice-  stay on the road and risk getting blown up by rockets or head off road where they risk getting blown up AND/OR stuck in the mud.

Which seems to be happening.

2. Those fancy hypersonic rockets Putin is using? he doesn’t have that many. And they cost about $100 million EACH. Using them now – against a nation that should have surrendered weeks ago, may be an indicator of desperation.

He’s actually been forced to use anti-ship rockets against land-based targets. Which implies he’s running out of regular rockets. And artillery shells. and lots of other stuff.

Here’s the worst part – Russian casualties – killed, wounded, missing, taken prisoner – are staggeringly high. 

Typically, for every killed-in-action (KIA) there are three wounded (WIA). If this holds here, we’re talking over 50,000 additional casualties.

This is stunning.

By way of comparison, in 9 years in Afghanistan – a brutal war indeed – the Soviets lost 9500 KIA.

So in less than a month the Russians may have almost twice as many KIA than in 9 years in Afghanistan.

“Worst” because many of those soldiers were conscripts with little education, poorly fed and trained, unaware of where they were going and why, but told they would be welcomed with open arms.

Where do we go from here?

  1. Will Putin use WMD (weapons of mass destruction)?
    I don’t know – and no one else does either. But I’d say it is likely he does something horrific, because he’s Putin and will likely be shot if Russia fails in Ukraine.
    Chemical is the likeliest as he will try to blame it on Ukrainians blowing up an ammonia or chlorine storage facility.
    Due to massive corruption in Russia it is highly unlikely Russian troops have protective gear. That implies Putin will use chemicals on civilians and do so far from his own troops. Then again, he does not care if his guys get slaughtered and could blame that on Ukraine.
  2. Stalemate
    Russia is making some progress in the south, and appears to be stalled in the north and west – if not losing ground.
    It is nearing bankruptcy, has lost massive amounts of equipment, and cannot get critical components to replace that equipment and has suffered more than 50,000 casualties.
    Ukraine’s morale is high, its civil and professional forces are performing incredibly well, supplies are coming and its people are unified yet it has a much smaller air force, is fighting an enemy that does not care who or what it kills.

Where does this end up?

No one knows.

What does this mean?

Support Ukraine. 

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. They are doing great work in Ukraine.

Screenshot your contribution and put it in comments. I’ll post it – and my ever-lasting thanks.


Wildly off topic…why Ukraine is winning

As the son of two parents in the CIA who grew up on military bases all over the world, I’ve had a special fascination with the minutiae…the (seemingly) minor and (seemingly) random things that cascade into defeat or victory.

After hours in the TwitterSphere, here’s my totally amateur take on why the Russians are losing despite an overwhelming advantage in military technology and hardware and personnel and the West’s absolutely correct decision to NOT intervene militarily.

stick with me here…the journey is worth it.

You’ve seen lots of photos and video of that gigantic convoy sitting on the road north of Kyiv…one that will ensure the total destruction of the capital and pretty much everyone in it.

Except that column hasn’t moved in three days. Two reasons…tires and rasputitsa.


If you don’t keep tires inflated, move vehicles around, and minimize exposure to sunlight, they rot.

If tires fail, what was a HUGE asset – mobility, and a logistics train (supplies of fuel, food, water, ammunition, medical supplies, spare parts) – becomes a HUGE liability…modern armies consume gigantic quantities of everything, and when that runs out, they stop moving, shooting, and surviving.

A military tire expert(!) posted this…

If that column had been able to move quickly, Kyiv and Ukraine would be flying the Russian flag…sure the Ukrainians have done everything humanly possible to slow/stop it, but AK-47s and molotov cocktails are no match for masses of T-90s.

Okay, but it’s just tires, you say?


Rasputitsa is the Russian word for mud, which in the steppe country is bottomless. The incredibly fertile and deep soils of eastern Ukraines turn to mud when the spring thaw hits.  Reports indicate Putin bowed to China’s demand that Russia not invade Ukraine until after the Olympics…after the weather had turned just a bit warmer.

The Ukrainian defense, coupled with lousy Russian vehicle maintenance, likely caused breakdowns at the head of the column. So, the Russians had to get off the road to make any progress.


Tires that work really well on roads have to be de-pressurized to get through mud, and when you lower the pressure, sidewalls flex, crack, and fail, and gazillion-rouble mobile air-defense vehicles, troop carriers, and fuel trucks get stuck.

Which allows very mobile, incredibly brave, and highly motivated Ukrainians to either fix and then use them to fight Russians or destroy them.

So, the rest of the convoy is stuck on the roads, where it runs out of fuel, food, water, and esprit de corps.


Well…Russia’s still got a huge and deadly air force…right?

Good question.

If the Russians didn’t take care of tires, what else did they ignore? Modern military equipment is incredibly maintenance-intensive. US fighter jets need more than 30 hours of maintenance per flight hour. 

The Russian air force has 4 times more planes than the Ukrainians, yet hasn’t achieved air dominance over Ukraine – a situation that has puzzled every “expert” pundit.

While I haven’t seen any current insights into Russian air force maintenance practices, there have been a LOT of problems of late, problems due to crappy maintenance, inexperienced crews, and a lack of training.

Net is, there’s a lot more to fighting and winning than lots of troops and fancy equipment.

Back story

There’s a LOT more to this, as in why the Russian military is so poorly maintained, trained and led (hint – Putin’s buddies are oligarchs that get huge contracts to provide tires to the military, contracts they fill by using cheap, crappy Chinese knock-offs so they can spend the rest on superyachts and apartments in London).

What does this mean?

Support Ukraine. 

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.

Screenshot your contribution and put it in comments. I’ll post it – and my ever-lasting thanks.


The Ukrainian War’s impact

Equity markets are getting hammered, the bond market is up substantially, and energy prices and assets are zooming.

Those are the immediate effects of Russia’s invasion of Ukraine.

What will happen now is anyone’s guess, but here’s how I see it.

  • Putin is all in.  Attacks are hitting cities hundreds of miles from the Donbass and eastern Ukraine, signifying Putin’s intent to take over the entire country.
  • The western countries – Europe and North America, as well as some Asian nations will rally around severe penalties for Russia – blocking access to the SWIFT system, banning trade in Russian debt and equities, and instituting a broad ban on exports to Russia.
  • This isn’t going to end anytime soon.
  • Ukraine will be very hard-pressed to hold off Russian forces; the Ukrainian military is much smaller, has fewer armored vehicles and airplanes, and isn’t positioned well to fend off attacks from the north and southwest.
  • China is a bit of a wild card; it
    • consumes a lot of Russian foodstuffs, gas and oil,
    • sees Russian aggression as a not-very-big-deal,
    • likes the strategic problems the invasion creates for the West (China could move aggressively on Taiwan), but
    • knows Russia’s financial situation is going to deteriorate quickly,
    • has tens of billions invested in Russia, and
    • understands that Putin is playing with a fairly weak hand.

So, I’d expect:

On the scarier side, expect Russia to launch cyber attacks in retaliation for Western sanctions, attacks that will very likely target financial institutions, infrastructure and commercial entities.

What does this mean for you?

Uncertainty breeds stasis…until we see where this is headed, expect interest rates to rise which will increase the cost of debt and reduce private equity investment.



Science denial – or perhaps a total absence of common sense – is nothing new – if anything it has gotten more pervasive of late.

Here are a few examples of willful ignorance guaranteed to make you smack your head (I hope…)

This from Scott Galloway…


Here’s the map they use…

Belief in Evolution

Belief in creationism

This is NOT a Right vs left, Liberal or Conservative issue.

an almost-comprehensive view of the many, many examples of nonsense…

What does this mean for you?


Friday update

Apologies for lack of posts this week; this was the annual father-son hunting trip, and work is strictly banned.

Here’s what happened this week…

News hit the wire that Enlyte (aka Mitchell Genex Coventry) is for sale. Owner Stone Point Capital (deep experience in workers’ comp) is reportedly “exploring a sale” of the company which is generating about $450 million in earnings (I’d be a bit careful about that figure as sellers almost always include stuff in “earnings” that doesn’t usually “count” as such.)

There aren’t too many potential buyers for a deal this big as we’re talking a “multi-billion dollar” deal.

HomeCareConnect was bought by Paradigm – more on this later, but my initial take is this is a smart move by the big cat case management company as it brings a well-regarded DME and home health provider into the fold, allowing Paradigm to capture all that revenue and margin on their financials.


The fine folk at WCRI have just released a very helpful report on the use and reimbursement of telemedicine in work comp.  The report is free to members; non-members get their copy for a nominal fee.

From WCRI; the report addresses:

evaluation and management and physical medicine services. It investigates the patterns of telemedicine utilization among these services in workers’ compensation during the early months of the pandemic (primarily March–June 2020) across 28 states. It also examines the actual prices paid for the most frequent services delivered via telemedicine versus in person across the study states.

NCCI researchers collaborating with various other agencies published a summary report on the impact of COVID on workers comp. Download a copy at the link…

Key takeaways include:

  • Covid claims are cheap – as in a LOT less costly than non-COVID claims
  • There’s a “new” claim category – “Indemnity only” that accounted for a plurality of claims.

Interestingly,  more and more insurers have stopped waiving member payments for COVID treatment.

Oh, and costs varied a LOT across states – $49k for non-complex hospitalizations in Maryland vs $129k in New Jersey. That’s likely largely due to Maryland’s very smart hospital charge regulation policies.

from FairHealth

The median length of complex hospitalization declined from a peak of 13 days in April 2020 to 7 days in July of this year…which is likely a big contributor to lower treatment costs.

What does this mean for you?

The investment community’s fascination with workers’ comp will be put to the test.

If you get COVID, you’re gonna pay a lot for your care – if you go into the hospital. 


I’m thankful for

The many, many good friends I’ve made over 30+ years in this business…people I would not have met if I hadn’t somehow stumbled into and stayed/got stuck here.

The passion many have to do the right thing and the privilege it has been and is to work with companies and organizations with that central objective.

Readers who challenge, confront, correct, applaud, cheer, and debate and have been doing so for 17 (!) years.

The mistakes I’ve made over the last few decades, for what they have taught me about hubris, assumptions, lack of diligence, and the power of experience.

My family – Deb, the most positive, joyful person on the planet who’s somehow tolerated me for 34 years; Erin who’s become an amazing mom, fierce advocate for her patients, and incredibly strong person; Molly whose intensity in competition is matched only by her love for and dedication to family; and Cal who has persevered in the face of overwhelming difficulties, always pushing through and never giving in.

A lot about our world is less than great these days, so it’s more important than ever to keep the good front and center.

Be well.




Infrastructure = jobs = premiums and claims

Three days ago President Biden signed the Infrastructure Investment and Jobs Act, a notable accomplishment coming after bipartisan support in Congress.  Pretty remarkable that this happened at all; past Administrations  – both Democratic and Republican that enjoyed majorities in Congress were unable to pass this desperately needed legislation.

There’s lots of good news in the Act; including: (source Business Facilities)

  • US$47 billion in climate resilience measures to protect buildings from the storms and fires that result from climate change
  • $65 billion to repair and protect the electric grid, build new transmission lines for renewable power and develop nuclear energy and “green hydrogen” and carbon capture technologies
  • $39 billion to continue and expand current public transit programs, including help that allows cities and states to buy zero- or low-emission buses
  • $66 billion to fix Amtrak and build out its service along the Northwest Corridor, in addition to building tens of millions for high-speed rail and other commuter rail
  • $7.5 billion to build electric vehicle charging stations;
  • $25 billion to repair airports to reduce congestion and emissions, encouraging the use of low-carbon flight technology

States are already targeting the funds for much-needed projects; North Carolina is getting $1.5 billion for bridge repairs,  broadband expansion, and transportation upgrades – and more dollars for other projects.

Wyoming’s roads, dams, water systems and bridges will get $2.5 billion in repairs and upgrades.

Arizona’s rapidly expanding population desperately needs new infrastructure – and big improvements to utilities especially water as well as ports of entry along the border. 

The federal Transportation Department “plans to open competition for the first round of port infrastructure grants funded by the bill within 90 days, as part of a broader effort to ease supply chain bottlenecks slowing down the delivery of goods.”

That will impact Long Beach, Savannah, Houston, Los Angeles, Miami, Mobile, Seattle, Norfolk and other critical ports.

The question is – how fast will these dollars translate into employment? I’d say next summer we will see a noticeable impact as plans that are already under development get funding commitments.

The Federal Highway Administration projects each billion dollars in highway funding supports 13,000 jobs.

S&P estimated a:

 $2.1 trillion boost of public infrastructure spending over a 10-year period, to the levels (relative to GDP) of the mid-20th century, could add as much as $5.7 trillion to the U.S. over the next decade, creating 2.3 million jobs by 2024 as the work is being completed.

The Act is about $1.7 trillion in spending, so we’re looking at about 1.9 million jobs. 

Of course, that is an estimate – it could be higher or lower. However, there’s no question workers’ comp will see:

  • higher premiums;
  • more claims; and
  • higher severity.

What does this mean for you?

Prepare for some much-needed growth. 


Opioids, tapering, and risks – what you need to know

WorkCompCentral’s Mark Powell penned an excellent piece on just-released research on tapering long-term opioid patients.

One finding demands our attention; researchers found a statistically significant increase in overdoses and mental health crises in the 12 months after tapering was concluded. On average, these adverse events (science talk for bad stuff) happened 6 months after tapering concluded.

From the JAMA article:

In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering. These findings suggest that adverse events associated with tapering may be relatively common and support HHS recommendations for more gradual dose reductions when feasible and careful monitoring for withdrawal, substance use, and psychological distress. (emphasis added)

The study included 114,000 patients who had been on stable, higher doses (50+ morphine equivalents) of opioids over an 11-year period. It came on the heels of two chronic pain studies published earlier this year; one addressed opioid treatment for chronic pain and the other was a meta-analysis of 190 studies focused on non-opioid treatment. I wrote about both here.

Tapering is an opioid management approach involving a steady decrease in opioid dosage over a prescribed time. The decreases in dosage and how fast patients were tapered varied significantly among the patient population; patients who were on higher doses before tapering were at increased risk for adverse events.

There were some limitations in the study including; the population was Medicare Advantage and commercially insured; individual patient tapering may have varied after the initial decrease; and the data didn’t indicate if the prescriber or patient initiated the tapering.

A thoughtful and detailed discussion of tapering is here…in part the paper states:

The authors emphasize that any medical action taken should involve as much patient buy-in as possible and should not be driven by rigid opioid dose cutoff s and misinterpreted guidelines. The authors of this paper also support sustaining patients on their existing medication at its existing level if patients are continuing to benefit from use, are not experiencing significant side effects, and express the desire to remain on their current medication as opposed to pursuing a taper. In such cases, the risks of a taper would outweigh the potential benefits.

Regardless, this is a wake-up call to the industry. Yes, workers’ comp – once the addiction creation industry – has made great progress in reducing inappropriate opioid usage and some progress in helping long-term opioid patients reduce or eliminate opioids.

That said, there are a variety of opioid management approaches, and we should be considering – and open to – any and all.  Medication-assisted therapy involving methadone or buprenorphine, physical therapy, acupuncture, yoga, and talk therapy are among the approaches that have shown promise.

I’ll end quoting myself from a post back in 2019;

we need to make very sure we are doing the right thing for patients. In some instances this will involve telling patients what they don’t want to hear; we need to be prepared to do that and help them thru the process, while understanding that process is very difficult.


Why are you using that metric?

I’ve had several conversations with claims and managed care folks over the last few months about measuring performance, outcome metrics vs process metrics, and the challenges of data collection, aggregation and analysis.

Two takeaways.

Too often the discussion has been too focused on process, too down-in-the-weeds, too concerned about how and what to measure. While process and detail are important, they are secondary to the “why” question.

The most important question is “Why?”

Why are you doing this? Why are you using that metric? Why do you think that is the right metric?

Sometimes I’m a (very) slow learner, but I’ve finally figured out that it is far better to ask those questions than to tell the person what they should be doing. Telling someone something eliminates the chance for them to think through what they have done, why they’ve done that, and if it that was the best thing they could have done.

It forces them to take a step back and question themselves, their assumptions, their pre-conceived notions.

It’s easier – and more ego-gratifying – to tell someone what they should do. I’ve found that this can shift the discussion into a far less productive direction, one where the client may well disagree, to defend what they are currently doing. After all,  to hear someone say what you have been doing for X years is “wrong” will make anyone bristle a bit.

Second, metrics are almost never directly aligned with the organization’s overall goals.

For example, the goal of medical management is to improve the combined ratio.  Has anyone in your organization verbalized that…ever?

If they have, then you:

  • wouldn’t give a rat’s rear end about “savings” or “discounts”;
  • would focus on overall spend;
  • would evaluate providers not on how much of a “discount” they give but on what their services cost and how that compares to other providers;
  • would evaluate networks not on how big their directory is and how deep their discounts are, but on the quality of their providers and the cost of their services.

And that’s just the beginning.

Once you establish the “why” the “what” is pretty straightforward – with one big caveat – every time you settle on what you will measure, go back and see if it aligns with your “why”.

Don’t be surprised if it takes a bit to re-orient thinking. Be patient – with yourself and others. It took me 30+ years, so hopefully you’re a much faster learner.

What does this mean for you?

Asking the right questions requires one to invest time and thought. If you don’t have time to do it right on the front end, you’ll never have time to fix it.


Health Strategy Associates has been purchased.

When you get an offer you can’t refuse…you don’t.

A couple months ago I was approached by an investment firm looking to build a niche practice focused on non-group health medical management. Long story short, for some undoubtedly very good reasons they decided HSA was the right fit.

I never thought a highly specialized, boutique consultancy with one “employee” would have any value beyond what we bring to clients, but clearly I didn’t think hard enough.  Sure, the footprint is solid. Yes, we can bring some very skilled, smart, and experienced experts to any engagement. And we certainly have a brand. Most of the time that’s a good thing, but sometimes it most definitely isn’t.

This isn’t a firm you’ve likely heard of; it’s not even domiciled here. For that reason, we’ll keep the HSA name.  Expect there to be additional resources and expertise, a broader array of skills and knowledge “on offer.” [I have to get used to the non-American English terms, so that’s a start]. There may be a bit less snarkiness from your faithful author too – but that’s attributable more to age sanding off some of the rougher edges than any edict from on high.

Speaking of which, we talked long and deep about whether and how we could work together, and ended up deciding we could. Despite my pathologic aversion to others attempting to tell me what to do, that shouldn’t be [pause for deep breath] an issue. There’s mutual respect and an understanding that when friction does arise we’ll work through it.

Couple of items of note.

First, expect an announcement from our new owners in the coming days.  We agreed that it would be best if we kept the initial focus on HSA and how this [doesn’t] affect clients.  Shortly we will do a more formal mutual release.

Second, yes there will be changes – good ones. HSA will remain focused on niche areas and serve the same client base (payers, service providers, and related businesses). I will continue to speak out on issues, commend those I respect and admire and condemn misguided and wrong actions and results.

Expect more use of technology to aid communications with blog subscribers, more polished presentations and reports, and expand into other channels.

I’d suspect we’ll get into other communications channels – perhaps podcasting, maybe even some video stuff. There are any number of things I’ve wanted to do but just don’t have the bandwidth or expertise or diligence to actually get done.

Finally, I cannot thank clients, supporters, and detractors enough. Over the last 25 years you have helped build HSA, made it better, and made me better. Critics have challenged me and in many cases made me re-think long-held beliefs.

What does this mean for you?

Expect the unexpected.