Employment’s effect on hypertension

Could hypertension be an occupational disease?

That’s the question addressed in an excellent article in HealthAffairs.

The short answer is there are many factors that contribute to or mitigate risk for hypertension, however the physical and psychological hazards associated with the worksite do correlate with hypertension risk.

Specifically, psychological demands such as how often one is required to work fast  and without errors are correlated with blood pressure while more freedom for workers to make independent decisions is associated with lower blood pressure.

The research looked at about 14,000 Alcoa blue-collar workers over a 16-year period and included surveys as well as medical billing data.  While other external factors are indeed important, the researchers concluded:

workplace environmental exposures may as a whole contribute substantially to hypertension among US blue-collar workers. We found evidence for this across multiple exposures in the categories of psychological hazards and the plant social environment.

Note that this study resulted from a partnership between a very large employer and researchers.  I’d hazard a guess that a study involving less paternalistic employers would show stronger correlations with greater impact.

What does this mean for you?

Employers have long known the worksite is a factor in employee health and productivity; this research clearly indicates hypertension could be characterized as an occupational disease specifically associated with employment.

Note – HealthAffairs has been doing really good work of late on workplace health and exposures.  Put their site on your reading list.

Work comp – the latest on back injury and treatment thereof

Back claims account for around a quarter of all workers’ comp claims.  They are also among the toughest to handle; what appears to be a simple strain at first report may end up a long-term, permanent disability claim.

Three recent studies on back pain, the treatment thereof, and how treatment varies from place to place are well worth your consideration.

Here’s the quick summary of each – followed by what it means for work comp patients, providers, and payers.

First up, a comprehensive study of management of nonspecific back pain treatment options will begin shortly, funded by the Patient-Centered Outcomes Research Institute (PCORI).

The Comparison of Surgical and Nonsurgical Options for Management of Chronic Nonspecific Low Back Pain will assess outcomes for patients receiving surgery (lumbar fusion) vs non-surgical treatment. This is a randomized control trial, so the results will be instructive indeed for work comp regulators, payers, and providers.

HOWEVER, a decade ago a very similar study was conducted which indicated similar outcomes for surgical and non-surgical patients – but this result was not deemed conclusive because lots of patients who were put in the “surgery” group chose not to have surgery and vice versa.

Implications for work comp – a valid study will greatly help regulators determine the approval process and standards for back surgery.

Whether or not you get back surgery appears to depend more on where you live than what your symptoms are.  That’s the conclusion from a recent Dartmouth analysis of Medicare data.  The other major takeaway –  – despite the lack of credible evidence that surgery produces better outcomes.

maps below are from Dartmouth Diffusion project.

Notice how surgery rates didn’t move much at all in New England, but dramatically increased in the southeast and Rocky Mountain regions.

If you want to know why, there’s this from the NYTimes article: “physician beliefs about the benefits of surgery were associated with surgical variations.”

Implications for work comp – Regulators, use NATIONAL guidelines, and don’t rely on local providers to drive your guideline selection.

Supporting this research is this – drugs don’t seem to help resolve back pain any quicker. A guideline was just released by the American College of Physicians advocating non-pharmaceutical approaches for treatment of back pain.

Implications for work comp – I’d be repeating myself…

Other Effects; an occasional look at how the new Administration’s affecting workers’ comp

It’s not just ACA; the new Administration’s changes to OSHA, the Department of Labor, immigration policy, trade, and myriad other programs and policies will significantly affect workers’ comp.

This is the first of an occasional look at these “Other Effects”.

Farm workers

California’s produce growers are concerned that most of their field workers will be deported, potentially leaving billions of dollars rotting in their fields.  While others argue that farmers should not be employing undocumented workers, the farmers, most of whom appear to have voted for Trump, disagree:

“If you only have legal labor, certain parts of this industry and this region will not exist,” said Harold McClarty, a fourth-generation farmer in Kingsburg whose operation grows, packs and ships peaches, plums and grapes throughout the country. “If we sent all these people back, it would be a total disaster.”

Implication – if deportations begin, farmers will have to scramble to find legal residents to replace the 70% of current workers who are undocumented.  Labor costs will go up, and so will workers’ comp premiums.  Expect claims to rise as well, as the field work is very strenuous physical labor which most new workers will be unaccustomed to.

Of course, it’s illegal for those farmers to employ undocumented workers in the first place, so their lobbying efforts – intended to convince the President to not do what he said he would do – amount to asking the Administration to not enforce laws currently on the books requiring farmers to comply with the E-Verify program.

What does this mean for you?

The President is doing what he said he would, surprising some of his supporters and delighting others.

Drones cutting occupational accidents

One of the most dangerous jobs in America is power line maintenance.

Over 330 people were killed last year due to falls and electrocution while working on power lines, thousands more were injured. Now one energy company is employing sophisticated drones to monitor power lines, allowing workers to trade the sometimes-scary task of climbing way up a swaying tower in possibly lousy weather to check out a junction for a ground-based drone control and monitoring job.

According to an AES exec; 

“We find that using drones, we can reduce the number of hazardous hours that it takes to do certain types of maintenance. And we can also enhance the efficiency of the business.”

And AES is not just focused on aerial drones to reduce occupational risks.  It recently announced a program seeking unmanned methods of evaluating energy production and transmission equipment.  The risk here is intense heat; when something goes awry it often takes considerable time for the site to cool down enough for a human to enter and figure out what’s happened.  AES is looking for ways to use “unmanned technology” to get in quickly, assess the problem, and fix it.

measure is the company working with AES; they’re deep into multiple ways to use drones in heavy industry. For example…

  • shipboard workers using drones to check on container stability, possible fuel leaks, wiring and hoses
  • firefighters using drones heat-mapping capabilities to identify hotspots, vulnerable areas, trapped people
  • tower workers using drones to keep nesting birds at bay

What does this mean for you?

Fewer accidents, lower risks for workers, reduced worker’s comp premiums. 

And this is just the start.

Four questions for WCRI’s Dr John Ruser

I (virtually) sat down with WCRI CEO John Ruser PhD last week to catch up on his first year at the Institute and get a preview of next month’s WCRI Conference. (Registration is here)

MCM – Talk about the last year and WCRI’s accomplishments.

Dr Ruser – We are working to maintain and build on the momentum Rick [Victor, former CEO] created – a rigorous approach to our research agenda, addressing a series of issues in workers’ compensation. One we are focused on is the worker outcome surveys. This can add considerable value to the industry; it addresses access to care, satisfaction with care, Return to Work, Return to Functionality, and earning history post-injury.

We are excited about what’s coming up. We want to provide information in a more readily accessible fashion. We will be launching a new website; the current one is functional but it’s time to refresh. We will go live soon with a site that is visually appealing; the new website allows us to experiment with a blog and video and provides more readily accessible content that is easier to search.

MCM – Can you expand on that [making information more accessible]?

Dr Ruser – Our work is very scholarly; it is hard to digest sometimes, so we are focusing on producing new products to reach a broader set of stakeholders that aren’t researchers. These will be written in layman’s terms that are more approachable.

MCM – The annual conference is set – what are you most looking forward to?

Dr Ruser – The theme is Persistent Challenges and New Opportunities: Using Research to Accelerate the Dialogue. There have been lots of challenges and questioning of workers’ comp over the last few years. Is workers’ comp fulfilling its obligation to injured workers? We will address some of those issues, as well as discuss what the election means for healthcare in general, labor regulations and workers’ comp. We’ve invited veteran politicians and other experts to talk about what they see down the road.

We’ve been talking about opioids for years. Are we making progress, defined as reducing new pts and reducing duration? Our people have looked at this and we see lots of variation across states, but in many states there have been fairly dramatic declines in opioid dispensing (pharmacy and physician) even back in 2014.

We will also be focusing on alternatives to opioids, a variety of solutions to control pain aside from opioids – excited about this – research on marijuana and pain and biochemistry of that. Apart from sharing our latest opioid research, we will have a panel that talks about about a variety of different approaches, including mindfulness, and we have some policymakers will discuss medical marijuana and complexities involved [in dealing with marijuana].

There is a session on grand bargain and we are really excited about it.  Among the speakers are Dr. David Michaels now at GWU, who was behind record keeping changes and is the former head of OSHA is there, Northeastern’s Prof. Emily Spieler, Dr. David Deitz, and former AIA Workers’ Compensation executive Bruce Wood.

MCM – What’s been the biggest surprise in your first year?

Ruser – [The] amount of support and respect that WCRI gets from the industry and our broad base of stakeholders, the recognition of the value and independence of our work, [we are] filling a void, [stakeholders have been] very supportive in general. Some disagree, but when they do they are respectful due to WCRI’s reputation.

Michelle Buckman – one of work comp’s good people

Ok, I’m biased. But there’s no question Michelle Buckman is one of the really good – and very talented – people in the industry.

Not only is Michelle a fellow Syracuse University grad, she’s also COO at MedRisk, a long-time HSA consulting client.

Michelle started out in MedRisk’s marketing department before she moved into operations. That’s where she made her mark – and continues to do so. A little history is needed here.

Responding to customer concerns, MedRisk decided to internalize ALL customer-facing functions just after Michele joined the company. While Michelle, a graduate of Syracuse’ famed Newhouse School of Public Communications, didn’t have much in the way of formal business training, she most certainly understood interpersonal relations and communications. She put that expertise to good use, building a department with 165 highly trained and very motivated college graduates focused solely on helping each and every patient, provider, employer, adjuster, and case manager they work with. (Lots more detail on this here.)

Michelle worked very closely with IT under Vic Pytleski to develop applications, programs, and technology that would enable quick access to lots of information – and a way to report and monitor activity critical to continually improving results.

Regrettable Turnover (losing people you’d like to keep) among MedRisk’s Customer Advocates is 9 percent annually.

9 percent.

After the Customer Advocacy Program went into effect, duration of PT care decreased 15 percent.

Michelle and her colleagues have built a department staffed with highly trained, well paid, happy employees doing a really good job and materially improving results.

And all these folks are located here – in Pennsylvania, to be precise. Instead of “keeping expenses low” by outsourcing or offshoring jobs, Michelle et al viewed this from the customer’s perspective.  By approaching it from that angle, they were able to focus on what’s most important to any company – serving each and every customer as well as you possibly can.

The focus is NOT on “how can we squeeze another nickel out of operations?” but rather “what can we do better to make our customers’ lives easier and our patients healthier?”

That focus was the easy part. The hard part is to operationalize it, to make it real, to keep that tight focus, to recruit, train, incentivize, motivate, measure, and manage the people who make it work. It’s easy for consultants (and I am one) to talk about what organizations need to do.

It’s a whole different thing to actually do it – and not only keep it going year after year, but to continue improving.

What does this mean for you?

What’s really needed is not a degree or experience or training, it is a deep understanding of what’s important, and the passion and dedication and persistence to deliver.

Justice gets closer for John Plotkin

Former CEO John Plotkin should not have been fired by SAIF, Oregon’s state workers’ comp fund.  That’s the ruling by a Marion County Oregon Judge, and led to SAIF’s Board of Directors offering Plotkin $1.7 million as a settlement.

It isn’t clear if Plotkin has agreed to the settlement offer; published reports do not confirm his assent.

Judge Claudia Burton’s ruling requires SAIF to give Plotkin his job back – but SAIF already has a CEO, and the Board appears extremely reluctant to return Plotkin to the corner office.

SAIF’s summary firing of Plotkin was not only illegal, it was grossly unfair to Plotkin, SAIF employees, SAIF policyholders, and the taxpayers of Oregon.  The evidence clearly shows – and the Judge agreed – that his firing was motivated by SAIF’s internal politics, the ambitions of Board members, and not by anything Plotkin did or didn’t do.

No, the case against Plotkin was fabricated, comprised of misquotes, misattributions, and outright lies on the part of his antagonists. The Board’s conduct was appalling at best.

I won’t restate the many issues with the Board, the history of this disgusting affair, or the damage this has done to employee morale at SAIF; Bob Wilson has masterfully documented this case. I encourage you to read his view on SAIF’s offer.

What does this mean for you?

Justice can be done, but Plotkin’s case demonstrates it can require a lot of money, an ocean of resolve and patience, and a lot of vocal support from other stakeholders.



Monday catch-up – management moves in work comp services

Just when you think things are calming down in the work comp world, you get a week like last week.

Leading off, management changes.

First, sources indicated occupational clinic company US Healthworks laid off a sixth of its management staff, most in headquarters state California. This comes just six months after the company announced a major expansion in the Southeast with the acquisition of Lakeside Occupational Medicine Clinics.

The Lakeside deal followed a series of clinic acquisitions in other states over the last few years.

Acquired by healthcare giant Dignity Health for $455 million in 2012,word from these sources is USHW has not produced the desired financial results of late.

Couple major management changes in the work comp Pharmacy Benefit Management business.

OptumRx CEO Emry Sisson will be departing effective March 1, 2017.  Emry took the role after the Helios/Catamaran/Optum entities were combined; prior to that he shared the CEO slot at Progressive Medical and third-party biller Third Party Solutions with Tommy Young (Tommy left after the Optum acquisition).

Optum parent United Healthcare will be looking inside and out for a replacement. Knowledgeable sources within Optum indicate this was solely Emry’s decision and in no way driven by United or Optum.

Mitchell Pharmacy Solutions’ Brian Anderson will also be moving on; I’ve known Brian for over a decade and he is one of the most forward-thinking, innovative people in the industry.  He helped start the third-party billing business, so I do hold that against him :). Haven’t heard of a replacement yet and will let you know when I do.

Coventry Work Comp Services business is said to be coming back on the market.  Word is the “book” will be not be released until parent Aetna’s acquisition of Humana is resolved.

That may well take a while…

Evidently this was the subject of much speculation at the JPMorgan Healthcare conference last week.  Key to any transaction will be the status of Coventry’s provider network contract.  Industry followers will recall Aetna’s first attempt to sell the business ended rather abruptly when potential buyers’ bids were much lower than expected due to concern about Coventry provider network contracts.

Word is the vast majority of those contracts – and especially those with providers who have a lot of Coventry business – have been transferred to “Coventry paper”. This should make the company much more attractive.

Conflicting reports on whether Aetna will bundle all component parts or pursue a different path.

Finally, registration for NCCI’s Annual Issues Symposium is open, and AMCOMP’s annual meeting is set for mid-March in Las Vegas.  Agenda is here.

ACA Deathwatch – The Impact on Workers’ Comp

With Republicans getting closer to repealing ACA, it’s time to consider how this would impact workers’ compensation.

I’ve discussed the possible impact of ACA here; net is the big increase in the insured/employed population may be at least partially responsible for the flat-to-declining work comp medical costs we’ve seen over the last two years.

There’s also this.  A colleague alerted me to a 2014 RAND study that assessed the potential impact of ACA on liability insurance, including workers’ comp in 2016.

RAND’s main takeaway:

“the ACA is expected to reduce auto and workers’ compensation insurer costs and increase medical professional liability insurer costs by a few percentage points as of 2016.”

The report is fairly complex (a summary is here); here’s what it had to say in bullet points.

  1. RAND estimated work comp costs would be $930 million lower due to ACA.
  2. This reduction is driven by lower fees and other insurance coverage for workers.

“Lower fees” derive from lower fee schedules (we’ve seen this in imaging in CA and FL and facility and surgery in other states) and lower prices due to providers less concerned about indigent care and associated bad debt.

“Other insurance coverage” refers to group health or Medicaid coverage for non-occ conditions, as well as substituting for workers’ comp in some instances.

If ACA is repealed without a simultaneous and credible replacement, we may well see a rise in the number of workers without health insurance. The key issue to track is a cutoff of funding for Medicaid expansion – ACA added about 13 million more employed people to the insured rolls; if they lose coverage they’ll need a different payer to cover their injuries. Bad news for workers’ comp.

There are other issues, but Medicaid is the big one.

What does this mean for you?

Be careful what you wish for.  And be even more careful of hasty and simple solutions to very complex problems.

Friday catch-up

2017 is starting off to be the most interesting/bizarre/entertaining/terrifying year in memory.

As one who tracks the goings-on internationally and in DC with some diligence, it’s been impossible to keep up with the craziness. Here’s my attempt to summarize the week that was.

The one thing you missed – and why you shouldn’t have

Trying out a new mini-post on the most important thing may have missed this week. Today’s it’s UnitedHealthcare’s acquisition of a big outpatient surgical clinic company.

This is important because the giant ($175 billion) healthcare company is investing more in care delivery – likely to better control its “cost of goods sold”.  As vertically integrated healthcare systems (think Kaiser, UPMC) get better at insurance, insurers have to get better at care delivery.

ACA Deathwatch

The reports of ACA’s death appear to have been greatly exaggerated. 

Yes, the Senate passed a bill that is the first step in a repeal process.  But it is ONLY a first step. Without diving too deep into the nerdy details, the bill just instructs Senate Committees to begin drafting a repeal bill and lays out general principles.  But there’s no consensus on when the repeal would take effect, what a replacement would look like, or even how it would be funded.

Things are going to get pretty complicated, especially in the Senate. There’s a lot of concern among Republicans in key leadership positions that quick movement on a bill would lead to a considerable backlash – and major political damage.

For freemarketers and Libertarians, there’s this:

“We did have the government out of the individual market up until 2014 [when most of the ACA provisions went into effect], and we know exactly what happened: There were millions of people who couldn’t get coverage,” Field said.

The ACA created a market that did not exist before — one that insures sick people. Field says it’s a market failure that the industry on its own will not cover the highest-risk customers. “If you want to cover everyone, the government has to do something.”

Town said pushing the government out of the equation will leave many citizens without access to health care.

“If you want to live in that world, so be it,” he said. “But I think we as a society have made the joint decision that having a vast part of a population uninsured and having limited access to health care is not a route that we want to go. Getting rid of the ACA is not going to get rid of the government’s role in health care.” [emphasis added]

Here’s a good summary of some of the issues the Republicans face – and why they are treading carefully…key quote:

The real reason health care premiums and deductibles are so high is that medical care is very expensive in the United Statesfar more costly than it is anywhere else in the world. The United States pays very high prices to doctors and hospitals and drug and device makers, and Americans use a lot of that expensive medical care. [emphasis added]

And here’s why keeping only the popular parts of ACA won’t work.  Alas.

Work comp

The M&A activity level has dropped off considerably – if not precipitously. The WLDI sale – a relatively small transaction – is one of the very few recent deals. Don’t expect activity to ramp up as the industry is:

  • pretty consolidated already, so there are fewer companies available to buy;
  • work comp is a declining industry with negative growth – not very attractive to investors;
  • prices were really high for a long time, and company owners still expect to get paid a lot. Sellers still expect to get those high prices, but…
  • buyers are much more cautious due in large part to the “OneCall Effect” (financial returns haven’t met expectations).

Don’t miss the Rx Drug Abuse Summit – April 17-20 in Atlanta.  It’s the most comprehensive and focused event on the biggest issue in workers’ comp.

Nothing is more important to work comp than the overall economy.  Read this – when you have time – for a solid grounding on what to watch for in 2017.  Spoiler alert – economic growth, which has trended up significantly over 2016, is likely to moderate over the next two years. And watch out for inflation.


Finally, for management wonks, here’s a great piece on execution from Harvard Business Review.