NoDak state fund – be VERY careful what you ask for…

WSI, the North Dakota state work comp fund, is suing AON for an alleged failure to deliver a new claims system.

AON’s response included the statement “We look forward to telling our side of the story in court.”  This may seem innocuous at first read, but it isn’t; far from it.  WSI’s leaders are heading down what will likely be a very dangerous path.

The legal process will undoubtedly include substantial discovery efforts on the part of AON, efforts that will show WSI’s current senior management (with a couple exceptions) is in way over its head.  System change requests, poor oversight, and a lack of specificity on the part of management will be highlighted, publicized, and poured over.  Attempts will be made to place the blame squarely on the shoulders of former boss Sandy Blunt, but those attempts will show the process – which had just begun when Blunt was ousted – was moving along on schedule and on budget until he was terminated in a horrendous miscarriage of justice.

The suit will be very important to AON, as it will be highly visible to their customers, prospects, and competitors.  A loss, or even slightly unfavorable ruling, would damage the giant broker, while a well-documented win will show they did everything they could to deliver.

For AON, this isn’t be about the state fund in a tiny state, but about their reputation and brand.

Whether WSI’s decision to sue AON is due to a mis-guided attempt to save face, naiveté or political pressure is irrelevant; the outcome of the suit will further damage WSI.

I’m of two decidedly different minds on this.

I’ve come to know well and deeply respect Sandy Blunt, a true gentleman, workers’ comp expert and ultimate professional.  What current WSI CEO Bryan Klipfel and his cronies did to Sandy is a travesty, a character assassination that should make everyone’s blood boil.  For Klipfel and his buddies to be exposed for the incompetent fools that they are is, in some small way, payback for their sins.

Rest assured, AON’s discovery will make that all too obvious.

But.  That payback comes at a high cost.

WSI is responsible for workplace safety and claims for the vast majority of the state’s workers, and the agency’s continued downward spiral is a gross disservice to those workers, their employers, and North Dakota’s taxpayers, not to mention those WSI staffers who are really trying to do the right thing.

What does this mean for you?

Nothing good for NoDak’s employers and the many good folks at WSI.  And a well-deserved public humiliation for Klipfel and those who put him in the job.

(note – Klipfel was a state trooper who investigated Blunt, then got the job as WSI Executive Director)

The work comp service market’s response to consolidation

With OneCall getting ever larger, KKR buying TPAs and tech companies, EXAM Works’ consolidation of the IME business all but complete, and the private equity world’s seemingly insatiable appetite for work comp services assets, the continued consolidation of the work comp services business seems to be inevitable.

Perhaps.  But there’s another side to this big-getting-bigger story; there is a new crop of innovators beginning to emerge, one led by “cast off” execs from the “consolidated”, former business owners whose non-competes have expired, and newbies with great energy and a desire to do it better.

Ascential Care Partners is a relatively new regional company in the not-glamorous case management business.  Founder Cindy Whitehouse is one of the most delightful people I’ve met in the business; her passion, dedication, and desire to deliver the best possible service is beyond impressive.

curavita focuses on providing DME and related services for complex and cat cases; those really difficult, knotty situations where integrating all aspects of care is absolutely critical as is communicating with adjusters, family, and caregivers. Strong in technology and reporting, curavita was founded by long-time industry entrepreneurs (and good friends) Hank and Lisa Datelle and Mike Marsau. (I have a tiny stake in the company).

HomeCareConnect has a slightly different business model; they are a supplier of broad DME, soft goods, and home health care services – and only those services – and have a strong clinical orientation. 

LifeTEAM Health is also narrowly focused; They do “disability prevention” based on identifying and addressing psychosocial risk factors  - perhaps THE key factor in long-term, seemingly-intractable disability.  With providers around the country, they can and do bring a much-needed service to an industry that has yet to fully appreciate the importance of psychosocial issues.

What’s the common thread here?  It’s hard to discern, but there is one.

Case management is old as the hills; integrated complex case services with real-time reporting is cutting-edige ; DME/HHC with a clinical orientation is a different take on a common issue; psychological services are woefully underused in work comp.

But all are narrowly-focused companies working on knotty problems using unique (if not immediately apparent) approaches.

What does this mean for you?

Innovators take advantage of niches and their mega-competitors’ focus on “other” issues to solve tough problems.  You may well find they can help with yours.

 

 

Drugs and work comp – top issues are…

Opioids, ACOEM’s new guidelines, compounds, and, alas, physician dispensing.

Here’s a quick guide to the top issues and sources for additional info.

Opioids continue to plague the industry; while many PBMs and payers are having some success in reducing the use of opioids in new claims, there’s still a huge group of legacy claimants that have been on far too many pills for far too long.  Sandy Blunt and I conducted a survey on the opioid issue last fall (thanks to CID for sponsoring and the 400 participants for their insights) – The Survey of Opioid Management in Workers’ Comp can be downloaded here.

Last reminder – make sure you are going to Operation UNITE’s Prescription Rx Summit in Atlanta April 22 – 24.  The Summit is focused on all aspects of the prescription drug abuse problem.

Perhaps the best new tool in our armamentarium comes from ACOEM – their opioid guidelines were released last month and are available to subscribers here.  (you can also get a 14-day trial subscription).  A trio of highlights that challenge conventional wisdom merit attention:

  • No comparative trial shows that an opioid is superior to another medication (out of 28 trials.)
  • No evidence shows the long-term efficacy of opioids – the longest placebo controlled trial lasted only 4 months
  • 80-94% of opioid trials have industry conflicts (funding and/or conflicts of interest in the trials).

I’ll be posting an in-depth review of these guidelines later this week.  For now, my non-clinicians take is these are the best opioid guidelines out there; very well researched, highly credible, and desperately needed.

Express Scripts published a report on their work comp results; you can get a summary here. (hat tip to WorkCompWire)

CompPharma, the consortium of work comp pharmacy benefit managers (of which I am president), released a research paper on compounding medications in work comp; you can get a copy here (no cost, and no registration required)

I don’t see medical marijuana as a big issue; If anything it will be of occasional interest.  That said, in our upcoming Survey of Prescription Drug Management in Work Comp, we will be asking payers what their view of the issue is, and will report back on the results. Participants (previous reports can be found here).

Finally, we’d love to have you participate in the Prescription Drug Management in Work Comp survey; participants receive a MUCH more detailed copy of the report than regular people which includes a wealth of data points and statistics.  e-mail me at infoAT healthstrategyassocDOTcom (replace the caps with symbols first!) and we’ll sign you up (all responses are confidential and no company-specific data is shared).

 

Work comp’s new Coventry?

The work comp services market is consolidating - at a very rapid rate.  At this pace, pretty soon there will be relatively few entities providing a broad range of claims-related services.

And that scares insurers and employers.  A lot.

Work comp execs like to have control over their vendors; whenever possible they seek to have two (or more) vendors providing the same service, to “keep them on their toes.” Most execs (and desk-level folks too) want to dictate terms to their vendors, or if not “dictate” than at least “determine”.  That’s for two reasons; a) they’ve always been this way and aren’t likely to change; and b) a few years back Coventry work comp got very powerful and turned the tables on buyers.

A bit of history is helpful here.

Coventry Work Comp was built by combining the “old” OUCH network with Healthcare Compare, followed by an acquisition of Concentra’s WC services division, which had acquired NHR, which had acquired MetraComp, plus the acquisition of a few other bits and pieces.  Along the way, the company became the dominant work comp PPO.  A few years ago, it was the “must have” network for workers’ comp payers as it was the largest, had the best discounts, and had the most coverage in the most states. While other vendors may have had better networks in one or a couple of states, Coventry’s was the best (defined as largest number of providers and deepest discounts) and broadest.

Coventry’s management (since departed) used this market leader position very effectively.  They forced (yes, that’s the right term) payers to use their network – and other services – by raising their fees for payers who carved out specific states where another network was stronger.  In addition, they discounted other services (notably PBM) if the payer bought their network and bill review services.

This put payers in a tough position.  Try as they might to seek out the best-in-class network, PBM, or bill review offerings, insurers would have to pay a LOT more for Coventry’s network if they didn’t buy everything.

For Coventry’s erstwhile competitors, the playing field was anything but level.  If they built a great network in a state or two, one that far exceeded the depth, effectiveness, and discounts of Coventry, they’d often find the big buyers would tell them they’d won their business, only to learn a bit later that the deal had been undone and Coventry was going to keep it, having told the buyer that their fees were going to go up – often way up – if the state/s were awarded to the competitor.

Things got even more one-sided after Coventry bought Concentra’s work comp services business.

Coventry actually raised their prices, telling customers that the larger network delivered more value, and therefore a higher price was warranted.  Never mind that the larger network would deliver more revenue just by virtue of including more providers; Coventry management very successfully leveraged their all-but-monopolistic status to increase prices and beat out competitors.

According to several colleagues who worked with Coventry at the time (remember this was a few years ago), Coventry knew they had the leverage, weren’t afraid to use it, and was only too happy to let their customers know it.  Even more troubling, customer service and responsiveness got steadily worse.  Managed care execs used words like “arrogant”, “uncooperative”, and “dictatorial” when describing their interactions; many were very surprised, if not shocked, by the tone and tenor of discussions and negotiations.

Fast forward to today.

Coventry’s power has diminished markedly, the ancillary services are likely to be sold off soon, bill review is losing customers, and insurers and TPAs are only too happy to turn the tables as Coventry’s leverage has greatly diminished.  

Which brings us to the current state of the market; it is highly likely a very few vendors will hold leverage akin to that enjoyed by Coventry back in the late 2000′s.  Managed care execs at insurers, TPAs, and large employers are apprehensive/concerned that this may well mark a return to the “bad old days.”

Many of the private equity folks who are doing the consolidating don’t fully grasp this issue.  They say that their efforts will lead to lower costs, better service, improved outcomes, and are somewhat bewildered by payers’ concerns.  Make no mistake; that concern is real, it is pervasive, and it will definitely affect payers’ decisions about which vendors to use for what services.

What does this mean for you?

Insurers, TPAs, and large employers have been there, done that, and aren’t going back.

 

Friday catch up and idle speculation

Lots of big info out this week, and a few tidbits about pending deals in the workers’ comp services space too.  Here are the highlights…(for the latest on deals in the work comp space, scroll down)

There’s a lot of confusion about the Obamacare signups; I’ll cover this in detail next week, but here are the facts as of today…

  • more than 7.1 million signed up via the federal and state exchanges (we won’t know the total for a week or so as some state exchanges haven’t posted final March numbers)
  • a lot more – i’d guess a million to two million – bought insurance via the private exchanges
  • about 20 percent won’t pay the premium and there’s some duplication between all the exchanges and other enrollment methods for reasons we’ll discuss next week
  • more than 5 million MORE Americans have insurance today than at the end of 2013.

The net – Obamacare has increased coverage substantially; the uninsurance rate has dropped by 2.7 points.

Meanwhile, Fitch reports the P&C industry is doing just grand, thank you.  Profits are up, loss ratios declined, underwriting margins are improving, and revenue is too.  Thank the continued hard market and expanding economy.

Work comp is doing better as well, altho there’s still a negative underwriting margin.  It remains to be seen if pricing discipline holds, or if some big carriers cross the stupid line.

The “doc fix” is in; Congress passed and the President signed a bill that will increase Medicare reimbursement for physicians by 0.5% for the next 12 months. The bill also:

  • delays implementation of ICD-10 for a year till October 2015 – for an excellent discussion of how this will affect workers’ comp, read Sandy Blunt’s piece at workers compensation.com
  • and does some other stuff which you probably don’t care about and I won’t bore you with.

Work comp services Coventry is trying to sell their marginally-profitable work comp service business lines - we’re talking CM, UM, MSA, peer review, and likely pharmacy. They will NOT be selling the jewels – bill review and the network, because a) they make huge profits; b) bill review really isn’t sellable as the application is quite dated and would require the buyer to transition to a different platform likely resulting in customer defections; and c) they can’t sell the network.

Coincidentally, another large case management firm is also for sale; word is Apax/OneCallCareManagement is currently the leading contender; most likely they will add the asset to their ever-growing list of companies.

And I’d be remiss if I didn’t speculate that Apax is looking hard at the Coventry assets as well. OCCM CEO Joe Delaney has certainly proved himself a competent manager, but methinks the thought of adding these two to the portfolio would give even the best of execs pause…

Enjoy the weekend, watch some baseball, get out in the gardens, and ride your bike.

Sorry about that…

well, not really.

I’m referring to yesterday’s annual April Fool’s Day post, in which I “reported” Obamacare would include a single-payer federal workers’ comp system for small employers.  While some chalk it up to my sophomoric attempt at humor, (and they would be right), there’s another, more important takeaway, one that is particularly relevant in the work comp industry.

There’s a lot of mis-information out there, much in the form of reports, statistics, metrics, findings, research, and it often goes unchallenged.  Here are a couple examples.

“Research” published by benefits giant AFLAC claims companies that set up voluntary disability programs saw reductions in work comp claims.  Except the “research” is not credible, isn’t reproducible, is based on nothing more than opinion, and therefore is just marketing BS. (hat tip to Mark Larsen of WorkCompCentral for the info)

The key here is don’t believe “research” unless it is credible, which means there was a solid methodology (asking people their opinion then drawing a statistical conclusion from those opinions is NOT a solid methodology).

Vendor claims that they can “save” X% more than your current vendor on pharmacy/medical bills/provider costs/whatever are often – but not always – pure speculation.  Fact is, unless the vendor making the claim really, really understands what your current program/vendor is doing, how they are doing it, the methodology they are using to calculate results, and reviews the bill/provider/script data, their claims are suspect at best.

That’s not to say that some programs don’t deliver measurably better performance, but unless the vendor pitching you can provide a detailed analysis of why and how they can do better, they’re just blowing smoke.  How can you figure this out?  Simple – ask lots of questions – starting with how, when, who, how much, where.  Dig deep and do not be satisfied with generic marketing-speak answers.

You will find some vendors are only too happy to get into the details, while others get really uncomfortable.  And that tells you a lot about their REAL ability to deliver.

Finally, the April Fool’s post caught more than a few readers, so if you were one, you’re in pretty good company (there were several clients and a few regulators – all shall remain nameless – who fell for it).

What does this mean for you?

Don’t be an April – or any other month – fool.

 

Obamacare exchanges to be used for work comp enrollment

Turns out one reason the small employer mandate has been delayed is the Feds are incorporating a national “single payer” work comp program that is not quite ready for prime time.

The POWER (Protecting Our Workers and Ensuring Reemployment) program, which will be administered by the Office of Workers’ Compensation Programs, had been back-burnered while the tech folks worked on the other parts of the site, added capacity, and straightened out the back-end issues related to enrollment, payment, and citizen verification. POWER was not part of the original healthcare reform bill; it was initiated as part of a Presidential directive shortly after PPACA was passed and signed in to law.

Now that the health exchange “glitches” are mostly fixed, the expectation is the workers’ comp program will be moving very quickly. It should be much less complicated, as there will be a single payer (the Feds’ OWCP), a single payment system, and universal benefits and coverage specs.  Detailed in the POWER initiative, the program will measure employers’ performance across eight metrics, with those employers failing to demonstrate improvement targeted for additional Federal oversight.

DOL is targeting June 1 as the implementation date; small employers (26-99 employees) will be required to sign up for POWER as their current workers’ comp policies expire.  (The POWER press release says this should make for an “orderly and straightforward transition”; safe to say that’s highly doubtful).  Evidently employers WILL be allowed to “opt out” of POWER; this requires completion of an application of exemption, documentation of three years’ ex mods below 1.00, and a commitment from their current carrier to maintain current premiums; it has to be renewed every year.  While not too onerous, the paperwork and reporting burden may well give employers pause.

According to an OWCP press release, the POWER program is intended to “reduce the administrative burden on small employers while ensuring rapid, professional, and fair adjudication of claims for injured workers.”  Although this will “negatively impact” some insurance companies, the (anticipated) reduced expense for employers coupled with the additional oversight by OWCP staff will help “improve the competitiveness of America’s small business.”  POWER will use the OSHA reporting system to cross-index claims reporting to ensure all claims are captured; evidently there’s sensitivity/concern that some employers will avoid reporting claims to reduce the risk of the dreaded “additional Federal oversight.”

The details – The federal fee schedule will likely be used for medical treatment, and indemnity benefits will be almost certainly be pegged to the existing DOL standards.  OSHA will have to revamp their reporting process, with much more emphasis on timeliness and additional data points captured; expect the Exchange website to be used for claims reporting.

What does this mean for you?

We can only hope it doesn’t take months to figure it out.

Compounding drugs – myth v reality

There’s a lot of nonsense circulating about the wonders of compounded medications, almost all of it promulgated by companies and people in the compounding industry.

What’s notable about all of their claims is the complete lack of scientific research supporting their claims that more people need compounds, that compounds work, are safe, and deliver better results than non-compounded medications.

Turns out the reason these advocates don’t cite research is – the research doesn’t support the use of compounds for more than a very few patients.

That’s the key takeaway from CompPharma’s just-released research paper; Compounding is Confounding Worker’s Compensation.  You can download it here.

Here are a few of the findings:

  • Compounds have not been proven to be more effective than commercially available, manufactured drugs that have been approved by the U.S. Food and Drug Administration (FDA) in similar classes. In fact, efficacy data in general are non-existent for the types of compounds seen in workers’ compensation claims.
  • Using compounds poses risks to patients
  • Compounds are often not medically necessary
  • Compounds are expensive

Despite reports of outrageous cost inflation, dozens of deaths due to faulty processes and poor quality control, and little progress in improving oversight, compounding continues to plague work comp.

What does this mean for you?

Time to develop and implement a policy for approving and reimbursing for compounds – one based on science, and not marketing nonsense.

Note – I am president of CompPharma, altho I had little to do with the actual research paper; credit for that goes to the pharmacists and government affairs people from CompPharma’s member PBMs.  They did a terrific job.

Another bomb drops on physician dispensers

Allstate Insurance filed suit against physician dispensing “technology” firms Infinite Strategic Innovations Inc (ISI) and Doctors Medical LLC earlier this week.  This is the second in what may be an-ongoing series of legal actions by the giant insurer, and comes on the heels of a settlement in their earlier suit against dispensing “technology company” Automated Healthcare Solutions.  

While the AHCS suit has been dismissed, I think we can assume Allstate made out quite well in the “dismissal”; Allstate doesn’t move unless they are very confident, and they come with overwhelming force.  Even the most arrogant, litigious, and downright nasty opponents are going to quail in the face of an Allstate lawsuit. While no one’s talking,   it is logical that Allstate would not have allowed the suit to be withdrawn unless they were pretty darn happy with the resolution.

My guess is Doctors Medical’s owner, Tom Mollick, is having a very bad week. And things are not going to get any better for Mollick et al.

From reading the complaint, Allstate is claiming ISI and DM received payments totaling $93,265 for PIP claims in Michigan, and has billed Allstate another $443,751 for other claims.  Allstate wants (most of) their money back, doesn’t want to have to pay most of the pending claims, and wants ISI and DM to agree to stop billing the insurer.

The key parts of the suit include:

  • request for declaration judgment
  • a statement that ISI and DM have no standing to bill as they are not medical providers
  • request for restitution for claims adjusting, administrative, and legal costs
  • assertion that ISI and DM operated “under the umbrella” of Rx Development Associates, Inc.  

There’s a lot more to this, but the net is this.  This is the second in what may well be a series of suits against physician dispensing companies; my guess is Allstate won big in their initial suit against AHCS, and is pursuing Mollick now, and will go after other dispensing companies as well.

As the AHCS suit was withdrawn, we don’t know what the resolution was – and never will.  And more’s the pity, because Allstate may well have solved its problem, but did nothing to address the problem for the rest of the industry.  That’s understandable as it isn’t their lawyers’ job to fix other insurers’ problems.

Nonetheless, it would be…helpful if the result of these legal actions was public knowledge – it would give pause to the other dispensers and their cronies, alert other insurers to the issue, and, over the long term, reduce Michigan auto insurance costs.

What does this mean for you?

Check your payment records, figure out how much you’re paying dispensers and their enablers, and do something about it.

 

Reality vs magical thinking

Too many workers’ comp execs are allowing their political viewpoints to cloud their business thinking. They can’t abide the notion of PPACA/Obamacare, and along with the majority party in the House of Repesentatives, want it repealed or blown up or completely emasculated.

This is magical thinking.

And magical thinking will not help those execs, or their companies, prepare for or deal with the implications of Obamacare.

Look, as an proud socially-liberal Democrat (as if that’s any new news to you, dear reader), I had to suffer thru 8 long, painful, miserable, agonizing, soul-destroying years of George Bush.  For those of you on the other side of the political spectrum, I feel your pain.  Really.  Even if the current resident of 1600 Pennsylvania Ave is pretty far from a liberal (sorry, had to slip that in!).

That said, it’s time to accept reality.

PPACA/Obamacare is the law of the land, it is not going to be repealed, substantially delayed, or emasculated. It is here, and it is going to stay.

Despise it you might (as I despise Medicare Part D and the Medicare Modernization Act of 2003, and the Iraq war) but accept it you must.  If you spend your work time focused on what you don’t like about health reform, you’re not spending your time thinking about reform’s implications for workers’ comp – how you can mitigate any problems, leverage any advantages, and monitor and measure ways reform affects your business.

What does this mean for you?

Those who do focus on the business implications are going to be better prepared, and therefore more likely to be successful, than those who dwell on uncontrollables.