The comp conference ended (for me) last Thursday; the passage of time allows for the individual impressions to meld into an overall picture of the current, and near-term future, of the comp managed care industry.
Here’s what it looks like.
The decade-and-a-half decline in frequency that has slashed the injury rate in half is causing real pain among occ health clinics. Sources indicate industry leader Concentra is seeing a decline in work comp patients, a trend that will likely be exacerbated by the steep drop in employment (when the number of people with jobs drops, so does the number of workers comp claims – for more on the impact of recession on workers comp click here). It is likely that other occ health companies such as US Healthworks are also experiencing declines in patient counts.
Together, Concentra and USHW together have almost 450 occ health clinics, and both have been adding clinics in 2008. It is too early to tell if the additions have been worth the added cost in cash or debt, but the current economic situation makes it unlikely they will be looking to expand aggressively over the near term. Unless they find clinics that are finding it difficult to make it on their own, in which case this may well be a good time to expand on the cheap.
The big game-changer will be health care reform. If, as I’ve predicted, Medicare increases reimbursement for E&M codes (cognitive services), then the clinic business could well get a major boost. Almost all WC fee schedules are based on Medicare, so any change in Medicare directly and immediately impacts comp reimbursement. Watch Capitol Hill carefully; if Congress passes legislation signed by future President Obama affecting Medicare reimbursement, clinic companies may be big winners.
Meanwhile, work comp managed care industry leader Coventry is continuing to hurt (due to non-workers comp issues), with rating agencies downgrading their outlook on the company. If anything, the workers comp business at Coventry is a plus, as the fee revenue helps to offset some of their problems in the health insurance, Part D, and Medicare Advantage sectors. Several people I spoke with at the conference confirmed Coventry is continuing to get price increases on their network and bill review products, although pricing for PBM First Script and other services (e.g. MSAs and case management) is soft.
The network business is under increasing pressure from regulators. In addition to the legal issues in Oregon and Louisiana, is is highly likely the ‘networks of networks’ will find their business model under attack as states adopt legislation/regulations forcing greater disclosure of rental network agreements, requiring positive agreement from providers (providers have to sign off on a document before they can be added to a network).
The future of networks that are mostly amalgamations of other network contracts is not promising. They will have to convince payers that their liability is under control and their value (to the payer) is greater than networks with direct provider contracts.
Good luck.
The PBM sector continues to grow, with the biggest player – Express Scripts – looking to add to the distance between itself and its rivals. Despite claims to the contrary, ESI is not winning business by using its group health contracts; a well-informed source adamantly refuted that assertion, stating that all workers comp scripts are processed under their workers comp agreements. Expect this sector to get even more competitive as ESI fights for business with newly-purchased PMSI (second largest PBM by volume), Progressive (excellent reputation for customer service), Cypress Care (aggressive, innovative marketing and strong clinical offering), ScripNet (expanding into the eastern US), and Aetna (cross-marketing to their large group health employer customers). MyMatrixx (focus on pain management) and Modern Medical (highly disciplined and responsive) are also in the mix.
Expect pharmacy to remain highly competitive, with vendors adding value through clinical services, first fill capture, and upgraded reporting and communications capabilities as companies seek to survive and prosper in what has become one of, if not the most, competitive segments of the work comp managed care industry.
I’d also say we need to pay attention to DC. If Congress calls for the Feds to negotiate drug prices, this will affect comp in one of two ways. Either comp payers will be able to piggyback on the Feds’ negotiated rates, in which case per-pill prices will come down, or (more likely) comp payers find their per-pill prices increase due to cost shifting.
Case management firms are facing the same issues confronting occ health clinics, with several folks at the major CM firms bemoaning the decline in volume. With volumes declining, and more big insurers and TPAs taking CM inhouse, expect continued pressure on pricing as Genex, Intracorp, Corvel, and Coventry struggle to ‘feed the monster in the basement‘.
What does this all mean?
External factors are the primary driver of workers comp. Medicare, the economy, and politics are all way more important than internal happenings in comp.
Look up and out if you want to know and understand.

While I and a few thousand other industry folks have been conferring in Las Vegas, the world (most inconveniently I would add) has been marching forward without us. In Florida, it looks their progress is headed right for the edge of a metaphorical cliff.
Florida’s workers comp regulatory bosses yesterday approved a change in the way workers comp payers will reimburse outpatient facility bills. According to WorkCompCentral, Florida regulators will:
“begin drafting a rule to base outpatient fees paid to hospitals on the Medicare Outpatient Prospective Payment System. But the fees would be adjusted using Florida-specific multipliers based on the usual-and-customary charges now employed to establish outpatient fees…Under the new system, the Medicare-based fees would be adjusted by a new factor created by a hospital’s usual and customary charges, by 174% for outpatient surgeries and 395% for other outpatient services.”
Okay, here’s why this is a bad idea.
First, Medicare fees are for treatment of elderly folks. Not working age, employed people. As a corollary, providers treating Medicare patients are not concerned with functionality or return to work. CMS has repeatedly stated their reimbursement methodology is specific to their population, and discouraged use of that methodology by other payers.
Second, The reimbursement scheme pays hospitals 74% more than Medicare for surgeries and four times Medicare for other outpatient services. This is insane. Workers comp is already the most profitable line of business for Florida hospitals, and this methodology makes it even more lucrative. It is indeed unfortunate that the Sunshine State has the second highest percentage of working folks without health insurance, but why make workers comp payers cover their medical bills? No, there’s not a direct link, and no, this wasn’t expressly addressed (as far as I know as I wasn’t at the hearing) but from here it sure looks like workers comp payers are being asked to help facilities cover the underpayments from Medicaid and provide funds to help treat the uninsured.
Oh, and these costs will now be the highest in the country.
Third, basing reimbursement on charges is just nutty. Providers increase charges around 14% every year This methodology now locks in a 14% trend rate for outpatient hospital services in Florida. Take it to the bank (if yours is still in business) – the slope of the inflation line is about to steepen dramatically.
Fourth, according to sources present at the hearing, there are serious problems with the methodology and data used to support the three member panel’s decision. Florida State University health economics guru Gary Fortier submitted a brief that stated that the methodology being used by the Department was “fundamentally flawed,, and in my opinion the study and methodology used cannot be relied upon….to make policy.” Fortier also warned that once this payment system, which encourages greatly increased utilization of hospital services to treat WC patients, is put in place it will be hard to change even if payments become more tight-fisted in the future.
Mike Malloy, former managed care analytics expert at E&Y, gave details about how easy it will be for hospitals to game their charges and drive up employers’ costs under the proposed system.
And FairPay Solutions (HSA consulting client) presented industry statistics illustrating how paying hospitals 333% more to treat WC patients than they are paid by FL group health plans creates such significant financial incentives that it will inevitably lead to greatly increased treatment of work comp patients by hospitals and cost Florida employers several hundreds of million of dollars more.
As I’ve noted here and here and here this is going to end up costing the comp industry in Florida a lot more than many think.
What does this mean for you?
the end of the happy times in the Sunshine State.

My quest for an actual provider-centric network is not complete. But there are a couple of companies that look to be off to a good start.
By way of background, most networks tout their huge directories of lots of providers, their discounts, and not much else. They sell their network by electronically matching their provider database against the prospect’s 1099 data (historical payments to providers). The better the match, the better their chances of landing the deal. At one level this makes perfect sense.
I’d suggest that this methodology is fatally flawed; the payer is asking the wrong question. By identifying networks that have as many docs as possible that already treat the payer’s claimants, the payer is asking for nothing other than a cheaper per-unit price. Yes, they will get a lower price per service from the docs they like, but they will also keep in the network docs they do not like at all – the ones who don’t return adjusters’ calls, don’t understand workers comp, do lots of unnecessary PT in their offices, and dispense drugs at outrageous markups.
Harbor Health takes a different approach – they have developed a process and analytical capability that enables HH and their clients to analyze sort thru their gigabytes of data to identify the providers that meet their definition of ‘good’. The analysis includes claims data as well as patient satisfaction and claims satisfaction information and billing/admin data to identify physicians who meet (customizable) criteria. HH is also building networks. To date, most of their customers have been large self insured employers (SoCal Edison was one of the first, and Sears is their latest).
After spending a half hour discussing Harbor Health’s process, methodology, ranking system, and approach, I’m impressed.
FairPay Solutions (current HSA consulting client) has built a physician-only network in Florida that is currently being evaluated by several large payers and soon to be implemented in Florida by one. FairPay also has access to a wealth of data, and has mined that data using sophisticated criteria as well as local knowledge in their development effort. The folks FPS brought in to develop the network came out of the old Choice Medical Management, acknowledged as the premier network company in the Sunshine State.
FairPay is, quite intelligently, building a physician-only network. There are any number of companies that do an excellent job of managing physical medicine, drugs, DME/HHC, imaging, and hospital costs. What FPS is focused on is the physician who controls how these other services are utilized.

Las Vegas is a weird setting for a workers comp conference. The hyperactive, eternally lit, wildly exciting town that is ‘Vegas’ makes for a bizarre counterpoint to the world of risk management – a business that works very hard to be steady, buttoned-down, predictable, and is certainly not glamorous.
Then again, the boom-and-bust that plays out every minute on the felt of the craps tables and poker games is workers comp in miniature.
Right now the sense seems to be the comp industry is starting to recover from the years-long soft market. Vendors throughout the hall are seeing employers and insurers focusing more tightly on cost drivers, on risk management and loss prevention. Risk managers are looking for new answers, different ways to attack the problem of rising medical costs that has been the one constant in this highly cyclical industry. The vendors’ perspective is borne out in conversations with managed care execs, who are getting much more attention from large employers interested in ‘real managed care’, who want to delve into the details, the workflows, outcomes, and results. No longer satisfied with ‘yeah, we’ve got that managed care stuff’, employers are (finally) getting serious.
About time.
For too long employers have been satisfied with ‘me, too’, cookie-cutter approaches to managed care. Most every large payer uses the same network, the same case management and UR schemes, pretty generic bill review and some amalgamation of specialty managed care vendors. They’ve been talking about outcomes oriented networks for years, and far too complacent when vendors have consistently failed to deliver on their promises to actually build them.
Yet employers haven’t been completely complacent. While the market’s been soft, employers have beat the bejesus out of their TPAs and carriers, demanding more and more coverage and service at ever-lower costs.
Now it’s coming back to them. Medical costs are rising, the power is shifting to the other side of the table, and there are few new and promising answers.
The good news – there are a few answers. I’ll talk about them later today.

The annual gathering of the tribes is happening, in Las Vegas this year, as the National Workers Comp and Disability Conference opens this evening.
Here’s what I’ll be looking for.
1. any palpable evidence of outcomes-based physician networks – or any networks that do not have large, yellow-pages-sized directories of physicians who are selected based on their ability to fog a mirror and give a discount below fee schedule or U&C. Coventry talked about such a network at their annual client meeting in Naples, but it has yet to make an appearance.
2. the next big thing – a few years ago it was emergency preparedness and recovery, then pharmacy management, then imaging and workflow, then brand spanking new networks. What will it be this year? outsourced claims? medical tourism for orthopedic surgery?
3. which company will get the award for most blatantly misogynistic marketing? Will it be cheerleaders, women in skintight superhero costumes, or shoeshine ladies? Don’t these vendors know that many risk managers are female? that more than a few companies are woman-owned and/or run?
4. will the private equity companies once again be wandering the halls, buttonholing entrepreneurs and grilling booth staff on performance, competitors, and new customers and products?
5. will we hear the same old stuff about return to work, teaming case managers with adjusters, safety and loss prevention or will there be something new and fresh?
Any bets?

Once again the fall is here, which means it is time for the Workers Compensation Research Institute’s annual meeting (today and tomorrow in Boston) and the National Workers Comp and Disability meeting (next week in Las Vegas).
Today’s kickoff began with a review of how the system has evolved since the WCRI’s inception in 1983. Peter Barth PhD began with the historical perspective.
A presentation on worker outcomes and variation in medical treatment patterns by Dr Sharon Belton indicated there were significant variations in the treatment patterns for back injuries across states. Dr Belton suggested that the design of the work comp system may be what is affecting both treatment patterns and outcomes. That sparked a question from your author regarding the potential impact of external factors unrelated to workers comp, such as practice pattern variation that have been documented in the Dartmouth Atlas. With workers comp accounting for less than 2% of national medical costs in a system dominated by Medicare, Medicaid, and private payers, the other, larger payers are likely to have more impact on treatment patterns than work comp.
Responding to my question and a similar one from Peter Rousmaniere, Dr Rick Victor, Executive Director of WCRI, said the Institute has looked into this. Although they are not ready to publish the results, Dr Victor said words to the effect that, when looking at state level data, there is almost no correlation between practice pattern variation as documented in the Dartmouth Atlas and workers comp back surgery rates. The (possible) implication is that reimbursement and other workers comp system idiosyncrasies are causing physicians to vary their treatment patterns.
My sense Is the degree of interstate variation is a result of the aggregate of local medical treatment patterns. What I’d really like to know is does the back surgery rate for workers comp mirror that reported in the Dartmouth Atlas. One example of this variation is this: The back surgery rate in Miami is less than one-fifth the rate in southwest Florida.
Historically there is solid evidence illustrating the impact of compensation and reimbursement on practice patterns; the treatment of insured v uninsured patients at hospitals is but one example. The real question is this: “is the variation among/between states as important or significant as the intrastate variation?”

Perhaps the most insightful presentation of the entire WCRI conference was this morning’s session, where Dr Kathryn Mueller of the University of Colorado gave a detailed summary of the current, rather pathetic (my word not her’s) state of the medical care delivery system, population health, and the health care financing system. Dr Mueller’s central contention (and one with which I wholeheartedly agree) is that health reform is coming, and with it will come fundamental changes in the way health care is delivered, the virtual ‘location’ delivering that care, and the evaluation of care.
And this is going to dramatically affect workers comp.
Dr Mueller noted that today health care is delivered episode by episode; diagnosis, care plan, treatment, assessment, and repeat steps 2-4 until the situation is resolved (again, my summary of episodic care, not her’s). Her view is that this episodic model of care will change to one based on functional outcome management – care focused on returning the patient to functionality, and maintaining that functionality.
This will be in large part driven by the growing influence of chronic care and need to develop a better care model to address chronic care, one that will heavily emphasize patient education and monitoring. It will also require a different ‘location’ of care – more on that in a minute.
Where the mainstream, i.e. non-workers compensation health care delivery system has not been focused on function or outcomes, these issues have been central to workers comp. Dr Mueller observed that physicians are not trained to deal with functional recovery, and don’t take this rather significant issue into consideration when treating patients.
As my kids would say, ‘True that’.
She also believes, with reason, that most high cost claims are not medically catastrophic, but rather are chronic, high cost cases due to the management of the case. (see Bernacki JOEM 2007 July).
Think about this. While there are undoubtedly really horrible injuries – significant third degree burns over a large part of the body, crushing injuries, multiple trauma, some of the more potent blood-borne disorders caused by needle sticks – most of the high cost claims are not ‘high cost’ due to the medical condition itself, but because we in the workers comp industry just don’t manage medical well.
Dr Mueller sees the medical home model as a big part of the solution in workers compensation, as the medical home will be the dominant model for delivery of care throughout the health system in years to come. Studies indicate the home decreases medical errors and improves the quality of care delivered. Notably, the medical home model is NOT a primary-care gatekeeper model – but rather a model wherein the physician is tasked with and responsible for coordinating care and educating the patient.
One other takeaway from Dr Mueller’s talk. She noted that “provider networks are not necessarily medical homes”; to date, provider networks have been based on changing/reducing fees, and have not been based on “quality”.
Amen.

Dave North, CEO of Sedgwick CMS was one of the morning panelists. He began with a rather strong statement about workers comp, a statement that was also an indictment of the industry’s complete inability to manage medical – the fact that medical costs have increased 892% over the last 25 years.
North’s presentation reviewed the history of medical management, evolution of managed care, and changes in regulations that have occurred over the last 25 years and then made a few suggestion about hat the comp industry should focus on over the next ten years. North said that despite changes in society, business, and medical care, the types of injuries we see today are similar to the injuries we say 25 years ago.
He made two particularly trenchant observations. First, the unintended consequences of regulations. Specifically, North noted that when the CA pharmacy fee schedule was changed several years ago, it had the unintended consequence of increasing costs – specifically, the repackaging of drugs and dispensing by physicians and clinics at much higher rates due to a loophole in the regulations.
Second, North stated (this is close but probably not word for word) “Discounted networks have underperformed and will someday be regarded as first generation, primitive efforts to address costs.”
Agreed. The question is, when will the industry stop decrying the problem, studying potential solutions and implementing tiny pilots and launch ‘second generation’, outcomes based networks?

Yesterday I opined that health care costs are on the way back up, driven by a worsening economy. Premiums will also rise due to cost-shifting by providers seeking compensation for underpayments by Medicaid and Medicare and no payments from the uninsured.
Those providers will also cost-shift to workers comp payers, driving up medical expenses, claims costs, and premiums. Physician income has been stagnant or declining for years, and many docs are struggling to keep the doors open. Here’s what comp payers can expect.
As a provider’s patient mix (Medicare, Medicaid, commercial, work comp) changes, their income is affected. The price per service is relatively fixed – either by Medicare’s RBRVS, the Medicaid fee schedule, their commercial contracts, or the workers comp fee schedule (most states have a physician fee schedule) or their comp PPO contracted rate. A provider seeking to increase his/her income has to either see more patients (pretty tough to do when many are already working sixty hours per week) or figure out how to do more services for the patients they see.
Increasing utilization is the key driver behind rising Medicare costs, with physician service volume up 11.3% in 2006.
Workers comp is particularly vulnerable to increasing utilization, as managed care models actually incentivize networks to drive up utilization by paying networks based on discounts per service delivered. The more services performed, the greater the “savings,” and the more revenue and profit for the network. Everyone benefits from this arrangement; that is, everyone except the payer.
There’s already evidence that comp medical costs are on the upswing in California, and my prediction is that true to legend, California’s experience foreshadows what we’ll see in the rest of the country.
What does this mean for you?
Expect medical to become an even larger part of the claims dollar, expect to pay your PPO network more for the ‘savings’ they deliver, and expect your combined ratio to deteriorate.