Tuesday catch-up

I’m going to announce something new tomorrow on the personal front; stay tuned for details…

Until then, here’s what I missed while doing a lot of non-work-related stuff over the last couple of weeks.

Medrisk has launched telerehab, a new service designed to deliver therapy and related services direct to patients at their worksite or home.  I’m a big fan; used appropriately telerehab can help patients heal faster and ensure their home exercises are performed correctly and consistently. (MedRisk is a consulting client).

Medical leadership at Broadspire is changing hands. Dr Marcos Iglesias is taking over from the estimable Dr Jake Lazarovic; Dr Jake has been at Broadspire for as long as I can remember.  He’s always been a pleasure to speak with; humble, highly observant, innovative and focused on always doing the right thing.  Dr Jake has long been one of the good people in our industry.

Dr Iglesias is a friend as well; Marcos has deep experience in occupational medicine as both a provider and insurance company clinical leader.

The first segment of Coventry’s annual drug trend report is out; key takeaways are:

  • opioid utilization dropped 8.5% from 2015 – 2016
  • Average Morphine Equivalents per script decreased 5.6%
  • Total drug costs were down 5.8%

This is yet more evidence that PBMs and payers are doing really good work in cutting employers’ costs and patient risks.  Note to regulators – this is happening across the country; please don’t do things that will hamper PBMs’ efforts to ensure patients get the right drugs.

An excellent review of where the dollars flow in pharma from HealthAffairs; note this is for ALL pharma, not just workers comp or health insurance. (chart from HealthAffairs)

WCRI’s released a series of reports on worker outcomes, following on the heels of an assessment of workers’ comp income benefit adequacy.  WCRI has been focusing on outcomes and worker satisfaction for some time now; kudos to John Ruser and predecessor Rick Victor for this important work.

Finally, a really interesting piece from Harvard Business Review on how some very large employers are dumping health insurers and buying healthcare direct.  I will predict this is going to happen more frequently, and is a big risk for the big four healthplans.  

Concentra’s telemedicine move – part 2

Here’s the rest of my interview with Keith Newton, Concentra CEO.  Part 1 is here.

MCM – How has the market reacted to the launch of telemedicine?

Newton – Early adopters are coming on board; like other new services in work comp, everyone wants it then there’s a bit of a lag after initial launch [as the more cautious wait to see what happens]. Most of big players – TPAs and insurers – are [looking at or considering] coming on board. It is much easier to adopt [internet-based medical “visits”] if it is as familiar as possible to all users. Adoption will be faster if there’s less disruption to the normal medical process.

MCM – How will Concentra charge for this service?

Newton – There will be no change to reimbursement, it is based on normal fees for office visits. Payers will see savings in efficiency and time savings for employer. [There may be] Other savings from lower ancillary costs from lower utilization.

MCM – Talk about licensure and regulatory compliance. There’s a lot of movement towards telemedicine in many states, and it seems a lot of confusion about what is allowed, what entity regulates TM, fees, etc.

Newton – There have been some licensure and certification challenges, we have 5 coordinators doing intake for 4 full-time MDs dedicated to this to begin; 2 in CA, 1 in MD, 1 in NV. One example is we have a Maryland physician driving to one of our Washington DC centers to do their Telemedicine work from there…[we’ve done] lots of regulatory compliance work.

State regulations aren’t keeping up with changes in telemedicine. We evaluated this on a state by state basis, every legislative branch has something going on with telemedicine.

MCM – Is this partially a defensive strategy to protect Concentra’s occ medicine business?

Newton – We’ve got to protect our turf a little bit…there could be some cannibalization of own practice, but ultimately we know 1 of 8 workers will access a Concentra practice for injury care – and telemedicine will enable us to add more of those visits without bricks and mortars expansion and the expense of that.

Our goal by the end of the year is 320+ centers and 100 dedicated worksites.

What does this mean for you?

I expect telemedicine is going to be the next big thing – and unlike a lot of the other fads we’ve seen in comp, it will have a major disruptive effect.

 

 

 

Concentra’s major move into telemedicine

The largest occupational medicine company in the nation is jumping into telemedicine.

CEO Keith Newton and I spoke last week about Concentra’s rollout of its telemedicine program, following up on our in-depth discussion a month ago about the company’s plans and strategy.

The first patient interactions began a couple weeks ago with a limited rollout, and so far, patient reaction has been quite positive.  According to Newton, one of the first patients said “I love it so much I’m going to tell all my coworkers about it”.

Concentra is employing third-party technology vendor American Well’s web application to allow patients to “visit” Concentra’s physicians via the internet.

Here’s part one of our conversation.

MCM – What is Concentra’s approach to telemedicine today?

Newton – Our initial approach is to use telemedicine for [some] injury care and follow up rechecks with existing patients.  We have identified specific types of cases where [we will employ] telemedicine initially. Patients will be triaged 24/7 to an injury coordinator, then to an MD for secondary triage, then care [if appropriate via telemedicine]. We are also going to do PT and specialist care. There are a number of considerations including onsite staffing, load balancing, and reducing patient wait times. 20% or so of patients could be seen via telemedicine…California is our first state, we are initially doing visits from 7am – 11 pm; we’ll will add longer hours and multiple states over time.

MCM – Describe the technology you are using.

Newton -We met with 10-15 technology companies working in telemedicine to learn as much as possible. We are using American Well for the connection only, all back-end applications are internal Concentra applications so we access their technology…it is not an integration but using their tech for the “visit” and using Concentra’s Allscripts and Occusource internal applications for documentation [and other functions].

MCM – How are telemedicine interactions different from office visits?

Newton – You need the right intake coordinators and physicians. In a bricks and mortar setting [normal live office visit] there is lots of activity going on in the clinic. When you are on video it is just you and the patient, the doctors have to engage and show focus on the patient, connect with them one-on-one, maintain eye contact.That puts the patient at ease. This may make for better and stronger patient – physician relations and connections via telemedicine. It could also make in-person visits more productive and satisfying for patients and providers as they adopt that behavior for live encounters as well.

 

MCM – Tell me about the process Concentra used to prepare to see patients via telemedicine.

Newton – Internally we did about a hundred “mock visits” to make it as seamless as possible to make sure patient experience was made as successful as possible. [We] used internal staff as testers to provide feedback, improve the process and service. There will be continuing evolution; there are new tools arriving every day, some of which may be useful for incorporation into the telemedicine process. Things will look different in a few months – for now, we are looking to make it as simple as possible for any stakeholder – the payer employer or patient.

Tomorrow we’ll get into more details…

What does this mean for you?

Telemedicine is going to be highly disruptive to care delivery models, and has broad implications for all stakeholders. 

 

Acquisitions in Work Comp – what’s (not) happening today and why

After a seemingly-unending flood of deals that stretched for several years, mergers and acquisition activity in the work comp services sector slowed a lot last year.

There was a brief flurry of activity after the election, a flurry that – with some exceptions – seems to have come to an end.

What’s going on?

Several things.

First, the workers’ comp industry is mature; service sectors have consolidated and there just isn’t a lot of “organic” growth – growth driven by an expanding industry. Software, artificial intelligence, drones – these are rapidly growing industries, where investors see opportunities for investments to generate huge returns.

That’s not to say there aren’t work comp companies growing by taking share from competitors, acquiring other companies, and expanding their service lines. Genex is one example; the company is buying up competitors and diversifying within a fairly narrow service sector.

Second, there are far fewer companies to acquire.  One example is the PBM (pharmacy benefit management) industry has really consolidated of late, with Optum and Express Scripts now the dominant companies in what used to be a highly fragmented industry. 13 years ago when CompPharma started there were perhaps a dozen PBMs with appreciable market share. Today, there are less than half that number.

The same has happened in bill review, utilization review, specialty services, and every other sector.

External factors not directly related to workers’ comp are also at work; perhaps none more important than the mindset of powerful people.

While CEOs are enthusiastic about potential business growth, their Boards are much more cautious.  Overall, US M&A activity came to a screeching halt after the election, dropping 40% since the peak in 2013. This is significant because corporate boards are populated by investors, bankers, former CEOs, and other luminaries tasked with the long-term success of their company, not short term headline-grabbing deals.

There are a couple of recent transactions in our space that make a lot of sense – PBM Express Scripts’ purchase of myMatrixx is one example. MItchell has been buying up smaller PBMs and other companies as it continues to pursue a sale of the company.  And investors are continuing to look for potential acquisitions; I hear from private equity firms looking for the next breakout service provider pretty much every week.

Countering the caution are a couple drivers that may not be as apparent to the casual observer.

There is a shipload of private equity money looking for deals, and PE firms need to use that money to buy companies. European funds are at an eight-year high and we aren’t far behind on this side of the pond.

Interest rates are still low; while they’ve trended up of late, compared to historical averages money is still cheap.

What’s the net?

Expect smaller deals to keep happening, but there’s much less enthusiasm for the mega-deals in workers’ comp services.

A return to the dark ages?

No OSHA administrator.

Rollback of regulations on exposure limits for beryllium and silica.

Eliminating the Chemical Safety Board.

These are just three examples of the Trump Administration’s apparent move to de-emphasize worker safety, and appear to be a harbinger of things to come. There’s no question the current regime is focused on business’ interests; what’s troubling is there appears to be no recognition that worker safety IS good business.

As a frequent and scathing critic of some of ProPublica’s past mis-reporting on workers’ comp, I do have to acknowledge they have done good work reporting on individual companies abusing workers, particularly undocumented immigrants. However, the ProPublicas of the world have been mostly silent on these alarming changes at the Federal level. These self-appointed watchdogs made hay two years ago using distortions and anecdote to pillory an entire industry; I would suggest that their reporting expertise would be well-employed if it focused on the potential long-term impact of the Trump Administration’s rollback in worker safety.

As a side note, WCRI’s just-published report on wage replacement for long term injured workers in Michigan brings some much-needed perspective to this key issue. If the feds are going to roll back safety enforcement, the burden is going to fall on individual states. That will require resources that many state legislators will be loathe to find in these days of tax revolts.

What does this mean for you?

Don’t buy cheap chicken.

The real fraud in workers’ comp

Is not the occasional worker cashing checks s/he shouldn’t, or bowling while fully disabled, or double dipping.  No, it’s:

  • employers going without insurance coverage so workers and taxpayers foot the bill,
  • providers scamming the system to make millions, and
  • a relative few applicant attorneys and their schemes to defraud employers and taxpayers.

Today’s WorkCompCentral has a terrific piece by Greg Jones highlighting this last scam. Jones has dug deep into “capping”, a California scheme to recruit allegedly injured workers for attorneys and their physician “partners”.  These fraudsters may have single-handedly generated hundreds of repetitive trauma cases in the LA County area…CWCI’s done masterful reporting on this issue, finding “a strong association between attorney involvement and regional variation in the Los Angeles Basin and the high cost of CT claims.”

Then there’s the incredibly creative providers that make millions from:

  • dispensing drugs to patients;
  • doing drug “tests” using their inhouse machines;
  • unholy alliances with compounding “pharmacies” or
  • compounding drugs in their own offices.

A new scam was also reported in this am’s WCC; a Florida doc (why is it always Florida and LA County?!) allegedly used telemedicine “visits” to prescribe compounds to work comp claimants.

These bad actors suck money out of taxpayers and employers and do NOTHING to help work comp patients.

Blood boiling yet? Well, it’s about to vaporize.

Bad as that is, the real fraud is employer misclassification and related schemes.

A seminal study indicates ten to twenty percent of employers misclassify workers as independent contractors.

As the gig economy expands, this is going to get worse – much worse. From the Economic Policy Institute:

  • Atlanta stagehands for concerts produced by Live Nation, a company listed on the New York Stock Exchange that has held shows for such artists as Maroon 5 and Billy Joel, have been misclassified as ICs by a staffing provider (Vail 2015; DePillis 2015).
  • An estimated one-third of construction workers in Southern states such as North Carolina and Texas have been misclassified (Ordonez and Locke 2014a). [emphasis added]
  • And roughly 20,000 employees of CrowdFlower Inc., a San Francisco–based startup that breaks down digital jobs such as data entry, are misclassified, alleges a case now moving through the courts (Weber and Silverman 2015)

This is particularly problematic in construction, but it isn’t limited to southern states. Payroll fraud cases have been reported in Massachusetts, Washington, and many other states.

Yet you wouldn’t know from the press – and press releases from insurers – that payroll fraud and other schemes are the real problem dwarfing the individual worker fraud problem.

That’s just too bad disappointing awful.

I’d encourage real journalists to concentrate a lot more on the real problem – employer fraud – and avoid the clickbait nickel-and-dime “fraud” allegedly perpetrated by individuals.

What does this mean for you?

Work comp insurers, the ones that are really screwing you are employers. Get with it.

 

The ignorance of arrogance

“If we didn’t come up with the idea, it isn’t worth considering.”

“That can’t be a good idea, we didn’t think of it.”

“Why would we listen to anyone from outside our company; we’re the biggest/best/most experienced/industry leader.”

Those are just three of the statements I’ve heard from large work comp insurers over the last two decades – all  from insurers who’ve fallen far from their glory days of market dominance. They may seem ignorant, or dumb, or even kind of funny – but they were real.

Sitting comfortably in leather chairs behind their nice desks, the men who made these statements were completely secure in their belief that their company, their way of doing things, their mindset and culture were completely infallible.

How wrong they were. As easy as it is for us to see that now is how impossible it was for them to see reality then. 

The next five years are going to bring profound changes to workers’ compensation, changes which – by definition – will make many of today’s business practices obsolete. It isn’t hyperbole to say that unless you completely revamp the processes, systems, technology applications, and metrics you use today, you’re toast tomorrow.

We are seeing that with Liberty’s progressive de-emphasis of workers’ comp. With the increasing outsourcing of claims functions to TPAs. With the rapid growth of what were relatively small players just a few years ago.

And that’s just the beginning.

All these changes have been driven by lower work comp claims frequency – that’s not new news to anyone. But hidden behind this is another major driver – the continued inability of major insurers to understand the business they are in.

Work comp insurers are in the business of managing medical and disability. While many think that’s what they are doing, they aren’t. Their claims management approach, predicated on the disproven model of huge provider networks delivering discounted care and the medical model of disability, overseen by overworked and under-resourced claims adjusters reporting to executives steeped in claims who don’t understand medical issues at all, only seems to work as long as premiums stay high and frequency continues to decline.

Wrenching changes are coming to employment, job availability, workplace demographics, trade and safety nets, changes that the industry is completely unprepared for.

Not to worry; the powers-that-be will schedule meetings, draft memos, write white papers, and do re-org planning, most of which will be completely ineffective, except insofar as it makes the execs feel like they are doing something. They’ll get rid of managed care departments, expertise, programs because “those programs haven’t worked.”

Of course they haven’t, because they were either the wrong programs to start with (percentage of savings network models) or the execs didn’t force adoption of intelligent medical management on a recalcitrant claims culture.

I see this happening all around the industry, and it’s like watching Antarctica melt. By the time these worthies figure out it’s real, they’ll be floating towards the tropics on a rapidly-melting iceberg.

With no landfall in sight.

 

Sheral Kellar is right about formularies.

Formularies that always allow opioids make no sense. That should be obvious to anyone, and it is to Ms Kellar.

(I’m basing this on an article in today’s WorkCompCentral, which stated:

“A pharmacy formulary is a tool that can be used to address the opioid issue. But it is not the only tool. In fact, Dr. Marcus Dillender, a Ph.D. from W.E. Upjohn Institute for Employment Research, suggests that careful management by insurers and administrators can achieve the same result,”

Sheral Kellar, Esq. is the Director of Louisiana’s Office of Workers’ Compensation Administration; deeply experienced, thoughtful and competent. I met Ms Kellar at CompPharma’s annual meeting last fall when she and several other state regulators spoke about formularies and managing drug usage.

Ms Kellar’s state has the second highest rate of opioid usage among workers comp patients, so she is keenly aware of the issue. She also knows a formulary is NOT a panacea, rather just one tool in the armamentarium.

  • Prescription drug monitoring programs that require and facilitate pharmacist and physician participation,
  • Strong and well-designed utilization review programs,
  • Flexibility for PBMs and payers to customize medication therapy to ensure patients get ready access to appropriate drugs and reduce risks from inappropriate medications,
  • Carefully-planned implementation,
  • Drug testing, opioid agreements, and addiction/dependency treatment

are all key to the solution.

I hesitate to pick on one issue as THE problem – however any formulary that always allows hydrocodone is not what Louisiana’s workers need. According to WCRI

  • A higher proportion of injured workers prescribed pain medications in Louisiana (85 percent) received opioids.
  • Among study states, LA had the second highest rate of patients taking two or more opioids
  • LA had the highest morphine equivalents per claim. – 3540 MEDs, more than double the average.

When you have docs using opioids as first-line pain meds – which clearly is the case in Louisiana, and they prescribe more than twice as much as the average state (which is already too high), and they prescribe more than one opioid most of the time, a formulary that automatically allows docs to prescribe hydrocodone – the most commonly used opioid in LA – is not part of the solution.

What does this mean for you?

Yes, solutions require a multi-pronged approach, but those “prongs” should “first do no harm.”

 

 

Friday catch-up

It’s been a bit busy this week; helping my sister take care of our mom in Maine.  Mom is 96 and ready to move on. She’s had an amazing life; grew up during the Great Depression, master’s degree at 21, ran the FBI’s fingerprint lab during WWII and worked for the CIA overseas in the fifties. Tiny, tough, and very, very smart.

Here’s what’s been happening this week…

Thoughtful post from Richard Krasner on medical cost drivers in workers’ comp. Richard’s dug into the recent NCCI analysis of medical cost categories; his take is inpatient hospital costs are a primary driver.

That makes sense for several reasons.

  • health systems are rapidly consolidating the healthcare provider industry, so more providers bill using facility codes every month.
  • health systems know work comp is a very profitable line; at a time when governmental payers are reducing reimbursement, their financial analysts are digging under every bed to find dollars.
  • health systems are very good at reimbursement – they’ve got more people, more systems, more resources and use them very effectively.

Which makes WCRI’s upcoming webinar on provider choice all the more important.

Following their study on the issue, the fine folk from Cambridge Mass. will walk us through what actually happens when employers or employees control the choice of provider. There’s a good bit of nuance here; it isn’t black and white.

HealthNewsReview has a great piece on a very questionable “research study” published by Proove Biosciences. Proove has been hyper-aggressively pursuing workers’ comp business; I’ll let HNR give you their view of Proove’s press release about a “study”:

[the] release summarizes a study showing that the company’s algorithm, which combines genetic markers with lifestyle and behavior variables, accurately distinguishes between healthy patients with no history of opioid abuse and patients receiving opioid addiction treatment. The study, however, may be comparing people with opioid use disorder with the wrong control group, given that a more useful distinction would be between those who have become addicted and those who have used opioids in similar circumstances without becoming addicted. In addition, the news release fails to provide information about the study’s funding source, nor does it note that four of the study’s six authors work for Proove. [emphasis added]

HNR goes on to state: this tool and others like it have been criticized for both reliability and questionable marketing practices.

Intriguing data on Medicaid patient access and satisfaction, from Axios

While you are spending time with friends and family this weekend, enjoying the extra day off and remembering those who made this possible, you may want to consider how fortunate we are.

Tom Lynch penned a piece in WorkersCompInsider about a Massachusetts worker who broke his leg in a construction accident. The guy fell off a ladder, but his employer didn’t carry work comp insurance. Did the boss get in trouble? No – but he did turn the worker into Immigration and Customs Enforcement, who threw him in jail. The victim in this has a wife and three young kids and, as you can imagine, is terrified.

So are his kids.

Have a great weekend.

Compounds in workers’ comp

CompPharma’s second research paper on compounds in workers’ comp was published last week. Authored by pharmacists and government affairs professionals from member PBMs, this paper builds on the ground-breaking research published in our first paper. (I’m president and co-founder of CompPharma)

The first research paper provided a solid foundation to provide stakeholders with a deep understanding of the history, practice, limitations, and issues associated with compounds.

This paper takes a deep dive into patient safety, efficacy, and cost.

It also includes a review of many legal issues surrounding compounds in workers comp and details regulatory and legal cases involving allegedly inappropriate activity by compounders and prescribers.

A few key quotes:

CompPharma supports the use of compounding when prescribed by a licensed practitioner with knowledge of evidence-based medicine supporting the use of a compound for a single patient with special needs that prevent the use of a drug approved by the Food and Drug Administration (FDA). [emphasis added]

the use of topical compounded products is not recommended as first-line treatment for workers’ compensation patients [emphasis added]

CompPharma’s 2014 compound research paper stated, “Pharmacies have received FDA warnings regarding topical lidocaine in concentrations greater than 5% and other topical anesthetics.” Some compounding pharmacists responding to the 2014 paper characterized this statement as a misrepresentation. The authors stand by the statement…

…a chief criticism is that by acting as intermediaries, PBMs profit from the use of compounds and other over-priced medications. In reality, the clinical management programs employed by these companies actually decrease PBMs’ top-line revenue [emphasis added]

The first paper upset a few compounding advocates. Their complaints mostly arose because we didn’t address compounding outside of work comp. Frankly, the paper’s focus was, and the latest paper’s focus still is, purposely limited to workers’ comp. Others are welcome to address non-work comp issues, that’s not what we do.

You can download the paper here – there’s no charge and no registration required.

CompPharma is proud to have been the leading force educating the work comp world about compound drugs; thanks to member PBMs for supporting our work, and a special thank you to

  • Phil Walls, RPh, myMatrixx
  • Deborah Conlon, RPh,  BS Pharm, PharmD, OptumRx
  • Brigette Nelson, MS, PharmD, BCNP, Express Scripts
  • Kevin Tribout, OptumRx
  • Nikki Wilson, PharmD/MBA, Coventry

and Contributing Editor Robert E. Bonner, MD, MPH, Principal, Bonner Consulting Group, LLC.

What does this mean for you?

Compounds can be useful and appropriate for patients with unique and unusual needs. This report provides objective, thoroughly-researched information essential to understanding this issue.