Thursday catch-up

Hope you, your family and friends have a terrific Fourth of July; we will be celebrating at home in upstate New York and watching the American women take on Japan in the World Cup Final.

The brief update on what’s happened this week and last.

The economy

A sizable increase in employment in June – 223,000 new jobs were added.  About 1.2 million jobs have been created so far this year. (edit – quoted May’s figure in an earlier version; apologies for my confusion)

The unemployment rate dropped to 5.3% from May’s 5.5%, but the labor force participation rate also decreased, driven by lower participation among teens and younger men.

This morning’s employment report shows an economy that is adding jobs in construction, retail and business services.

While wages were essentially flat in June, over the last twelve months employers have been (slightly) increasing wages in an effort to land and keep good workers – work comp folks can expect more premium dollars, and likely more injuries as newly-employed workers tend to get hurt more often experienced employees.

Overall, the report is good news; more workers making more money means they spend more – a virtuous cycle.  BUT there are some economic headwinds. The strong US dollar is hurting exports which isn’t good for manufacturing.

The ACE – Chubb deal

Looks like “Hank Junior” is following in Hank Sr.’s footsteps; with the acquisition of perhaps the most respected brand in the P&C business, ACE becomes one of the largest insurers in the industry with a diverse portfolio of insurance lines, complementary distribution, and very strong management and culture in Chubb.

Notably, the new company will take the Chubb name.

There’s a LOT of press out there on this deal, most authored by folks with a lot more insight than I have.  My take is this is a smart deal for ACE; IF they don’t screw up Chubb and thereby damage a highly-regarded brand.  Evan Greenberg et al are too smart to do that; they didn’t pay a 30% premium for Chubb without clearly understanding why the company is worth it.

Healthcare reform

Lots of information out there re who’s newly insured, what they are paying, and related matters.

There are more uninsured men than women, and they have more problems accessing and paying for care.

There’s been a lot of talk about premium increases for next year – and that’s caused a lot of confusion. The latest data suggests that people with the most common plan – the lowest cost silver – won’t see those big price jumps. KFF reports a survey of the benchmark plans in 11 cities indicates an average premium increase of 4.4%.

The range is wide, from a 16.2% jump in Portland OR to a 10.1% decrease in neighboring Seattle (go figure).

BUT – there have been some big jumps in some markets, and pricing is all over the place.  Some plans have filed for increases north of 20%. Expect the marketplace to reward those plans that have held the line – and expect those plans to have narrow networks and hefty financial penalties for out of network care…

The reason there’s been so much talk about big price jumps is healthplans planning on raising premiums more than 10% have to report that to regulators early on; that generates a lot of buzz. Obviously, that buzz doesn’t take into consideration the plans that are NOT planning on big price jumps.

Much more on this in future posts.

There are a couple of really interesting work comp research reports that came out this week; I’ll be reading them on the plane back from Seattle today and report back to you, dear reader, next week.

Enjoy the weekend, and cheer for our women on Sunday!

Why is Genex buying more case management?

Yesterday Genex announced it acquired yet another case management firm; Integrated Care Management of Alpharetta GA and their 150 employees broaden Genex’ CM coverage in about 20 states.

This comes on the heels of the MHayes purchase. According to sources familiar with the deal, the Maryland-based firm reportedly commanded a pretty high multiple; congratulations to Melinda Hayes on that news.

While there were no details on price or cash/stock mix for the ICM transaction, the timing likely had everything to do with last week’s announcement that Genex increased their borrowing capability by almost $80 million.

The announcement, dated June 22, noted “Net proceeds from the offering will be used to fund acquisitions.”

ICM’s revenues will push Genex’ top line well above $400 million, and further consolidate its position as the dominant case management firm in work comp (with footholds in other insurance niches).

That said, the debt to earnings ratio will now exceed 7.5x, a level Moody’s considers “aggressive for the firm’s rating category…” The rating agency doesn’t seem too worried, as they expect the ratio to improve due to organic growth and higher EBITDA (earnings before interest, taxes, depreciation and amortization).

I’m puzzled by the “organic growth” expectation.  Case management, especially field case management, is declining for two reasons; work comp claim frequency continues to drop 2 – 4% a year, a decline that is structural, long-term, and seemingly-inevitable. And payers’ use of field case management continues to decline, with most preferring telephonic and using field only for a relatively-narrowly-defined group of claims. While Genex does a LOT of telephonic CM, TCM is fairly easy to internalize (altho some states regulatory requirements make it feasible only for payers with significant volume).

Moreover, payers continue to seek ways to capture more and more services internally; they don’t like to vend claims services they can do themselves, thereby adding revenue, increasing efficiency, and better integrating process. Think York’s acquisition of Wellcomp, Sedgwick’s ongoing efforts to acquire a wide variety of claim service vendors, GB and MedInsight, the Hartford handling MSAs with internal staff.

Methinks there is one primary reason for the growth-by-acquisition strategy – case managers may well be expected to drive business to One Call Care Management.

And one secondary – organic growth (despite Moody’s optimism) just isn’t happening.

Genex is owned by Apax, the private equity firm that also owns One Call Care Management.  One Call provides imaging, physical therapy, DME/home health, transportation/translation, dental and other services to the work comp industry, a portfolio of services that accounts for about a quarter of total workers comp medical spend.  Genex’ 1800 +/- case managers would be a great mechanism to recommend/refer/direct business to OCCM whenever and wherever possible.

From an ownership perspective, this makes perfect sense.  At some point Apax will sell these assets, and combining them – the service provider and the referral driver – into one entity makes the whole greater than the sum of the parts.

Of course, this assumes Genex et al provide exemplary customer service, meet the needs of current customers, resolve any issues quickly and to the satisfaction of clients…

A cautionary note for ICM employees; study any new paperwork very carefully, and look closely at any non-compete agreements.  You want to be sure you know what you are signing. 

What does this mean for you?

Who controls your referrals?

Work comp drug trends; Coventry’s report

Coventry’s work comp PBM – First Script – released their drug trend review last week; they’ve taken a bit of a different tack than other PBMs, choosing to report broadly across all scripts while differentiating between “managed” (in-network retail/mail and contracted physician and clinic dispensed) and unmanaged scripts.  Note that Coventry reports on compounds separately.

The report is replete with infographics used to highlight cost trends, workflows and decision processes, charts and graphs which make it quite readable; specific data points and issues are easily located and understood.  Overall, the report is well laid-out and professionally done; as with other recent efforts (including CompPharma’s most recent PBM in WC Survey) drug trend reports have benefited greatly from the expertise of graphic designers.

Physician- and clinic-dispensed medications accounted for 5.1% of spend; retail/mail for about 69% of spend. Opioid dollars totaled about a third of total managed drug dollars.

Key cost drivers include an AWP increase of almost 10% across all drugs. That price increase was somewhat offset by a 5 percent decrease in utilization (7.4% for narcotics) which resulted in an overall cost-per-claim increase of 7.3%.

A key finding is a major increase in generic utilization and spending (mirrored by CompPharma’s soon-to-be-released 2015 report).  Generic spend was up a whopping 19.3% while single source brand spend dropped by 9%; generic forms of Cymbalta and Lidoderm helped drive generic utilization up over 5 percent.

Coventry reported a 4.1% decrease in short-acting (SA) narcotic script volume; long-acting dropped by 3.2%. Vicodin, the #1 prescribed drug, saw utilization drop almost 8%. Unfortunately higher AWP pricing for several common SA narcotics more than offset that decrease in units, driving overall SA narcotic spend up 8 points.

There are helpful statistics on utilization by drug class by age of claim; changes in specific drug spend and utilization year over year, details on what drugs saw the biggest changes in volume and price, charts illustrating various correlations between claim age and pharmacy, and details on compound utilization.

Notably, Terocin(c), a compound, accounts for more unmanaged spend than any other drug; the growth in all topical medications is quite remarkable. In total, compounds accounted for 7.7% of managed spend and 28.1% of unmanaged spend.

Coventry’s report is data-rich, and this is particularly illuminating in their in-depth analysis of compounds.  Trends in utilization and spend by state, claimant usage, and in-network v out-of-network are analyzed in depth.

What does this mean for you?

Compounds are growing rapidly, efforts to control narcotic utilization are bearing fruit, and generic price inflation remains problematic.

King v Burwell – implications for workers’ comp


The Supreme Court decision against the plaintiffs in King v Burwell marks the end of the significant legal challenges to the PPACA.

It also makes it much more difficult for a future President to undo key parts of ACA, as the Court opined that the mandate, penalty, subsidies, and other key components are set in statute and therefore cannot be modified or eliminated by administrative or executive action (I’m no attorney, so may have the wording wrong; clarifications welcomed).

Yes, there will be continued attempts by opponents to attack this or that part of PPACA. And the GOP may well pass repeal legislation if the party wins the necessary seats and the White House next year.  But I don’t think they will.

17 percent of our nation’s economy is in the health care sector, a sector that has, for the better part of a decade, totally focused on operating under PPACA.  If PPACA is overturned, the stuff will hit the fan, and the overturners will be blamed.  Politicians don’t like blame, and while the hard core right may rail, their Representatives and Senators will keep focused on the swing voters who decide elections.

Okay, so much for my amateur political punditry.

What does this mean for workers’ compensation?

Not much.  In fact, I can’t discern any meaningful impact other than “business as usual.”

That doesn’t mean ACA hasn’t impacted work comp, however so far the data is rather inconclusive.  I’ll post on that early next week – spoiler alert – the evidence to date indicates there has NOT been a problem for claimant access to care.

Supreme Court upholds ACA

In a ruling that just came down, the Supreme Court ruled in favor of the Obama Administration and against the plaintiffs in King v Burwell.

The Court ruled 6-3, with Thomas, Scalia, and Alito dissenting.

The opinion was written by Chief Justice John Roberts, who also authored the opinion in the previous case concerning the individual mandate. His strongly worded opinion included this: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them…[the decision will] avoid the type of calamitous result that Congress plainly meant to avoid.”

The King v Burwell case was based on six words in PPACA, namely “an Exchange established by the State”, with the plaintiffs contending “the federal government isn’t allowed to provide subsidies to the residents of states that refused to establish health insurance exchanges under the law.” (quote from HuffPo).

There are 37 states where the federal exchange is operational; losing the subsidies would have increased members’ costs by an average of 417% in the ten states that would have been most affected.

Opponents of ACA said these words meant subsidies were illegal and must end, while proponents averred that this was just a small misstatement in the original language.

While this may appear as a defeat for GOP opponents, it may well be a decision that GOP politicians are privately relieved to see.  If the Court had ruled in favor of the plaintiffs, the subsidies in the majority of states would be thrown out – or at least would be ended unless a legislative fix was authored either on a Federal or state level.  If these efforts had not borne fruit, and there’s a lot of doubt they would have, GOP politicians running for office would have faced many voters angry that their subsidies were gone, along with their health insurance.

As most of the would-have-been-affected states are GOP strongholds, this would have been bad news indeed in a Presidential election year.

What does this mean for you?

Not much – unless you work for a health plan…

Of course, this guy is pretty happy…

ACA continues, and while we may see some additional legal challenges, they will be minor at best, and nowhere near the significance of this decision. 

If you work for a health plan, there’s a huge sigh of relief.  The opposite decision would have murdered health plan stocks, thrown markets into chaos, and led to an administrative cluster-mess.

Oh, and if you own health care stocks, it’s a pretty great day, with three big health care provider stocks up close to double digits.



Liberty Mutual is NOT exiting workers’ comp

The headline of an article at WorkCompCentral this morning is “Liberty Mutual to Exit Workers’ Compensation.”  That headline is misleading.


WCC revised the headline; it now reads “Liberty Mutual backing away from workers compensation”

While there’s no question the formerly-largest-writer-of-workers’ comp insurance has dramatically cut back, lopping off about a third of its WC premium, it remains the fourth-largest writer, continuing to seek new business in some markets and hold on to existing accounts in many.

Yes, it sold Summit; and its WC business in Argentina; and paid Berkshire to take over several billion dollars in WC legacy claims. Yes the executive ranks are no longer the exclusive domain of former Liberty WC claims handlers and sales folks – far from it.  Yes, personal lines is the future of the company.

None of those changes, dramatic as they are, nor all of those changes together, mean Liberty’s dumping WC entirely.

But what if mother Liberty does bid farewell to work comp?

The WCC article contained a passage that – in my view – is inaccurate at best.

There is worry that Liberty Mutual’s dropping out of workers’ compensation could lead to higher costs for employers and result in companies making cutbacks to injury benefits or challenge claims submitted by workers, Ishida Sengupta, director of workers’ compensation at the National Academy of Social Insurance, told the Globe.

“I certainly think it doesn’t bode well,” Sengupta said.

That is totally nonsensical – companies CANNOT make “cutbacks to injury benefits.”  This is workers’ comp, and benefits are statutorily determined.

In addition, there’s no logical reason the fourth largest WC insurer’s decision to exit work comp would lead to higher cost to employers or encourage those employers to challenge claims.  I’m really surprised that someone from NASI (an organization in which I am a member) said that – if they did.

BTW I asked Liberty’s press people to comment early this am; they haven’t done so as of 4 pm.



My favorite day of the year

This year Father’s Day and the Summer Solstice fall on the same day – making for a very long day here in upstate NY with lots of daylight so I can loll around while being waited on (well, maybe not that last part).

While I was busy inundating your inbox with posts on the profitability – or lack thereof – of workers’ comp, a bunch of other stuff happened.

Another shot in the subrogation/third party liability battle was fired by Kentucky’s Medicaid program.  According to WorkCompCentral’s Ben Miller, hundreds of letters have been sent to work comp insurers in an attempt to ascertain if specific individuals’ medical care is due to a work comp injury.  The rationale is clear; Medicaid doesn’t want to pay for medical care it doesn’t have to.  As a taxpayer I completely support this.  Where it could get really sticky involves settled claims; if the work comp insurer/employer has settled the claim, my assumption (always dangerous) is the settlement requires the claimant to use those funds to pay for injury-related medical care.

What if the claimant doesn’t have any of the settlement dollars left?  If the claimant doesn’t pay, is the work comp insurer/employer liable? Who’s going to be stuck with the bill; the claimant?  the provider? Medicaid? another insurer?

Oh boy.

A terrific article in Harvard Business Review on what private equity investors do when they buy companies notes three distinct types of “engineering”; financial, governance, and operational.  Lots of insight, data, and examples make this a must read for anyone considering a transaction, or trying to understand how PE firms work.

Activity in the oil patch is slowing down, but claims counts are not going up.  Reuters quotes a Travelers insurance exec who’s a bit surprised about this; I have a call into Travelers to see if we can get more insight into the issue, and will share whatever I learn.

The new, updated Washington Guidelines for Prescribing Opioids for Pain are out; a product of the Agency Medical Directors (AMD), the new guidelines address opioid usage for many different conditions, cover special population issues, and update and expand a variety of treatment- and risk-assessment-related topics.  With five years’ experience under its belt, the AMD have learned a lot, lessons that other jurisdictions would be well-served to consider.

Finally, for many families in Charleston – and elsewhere – this Father’s Day is anything but joyful.  If I may be so bold, I’d suggest we strive to be part of the solution.

Workers’ comp profitability, Part 3

We’ve seen that work comp’s “profitability” isn’t very good, whether measured (inappropriately) as operating gain or (appropriately) as return on net worth/return on equity (ROE).

Today we’ll dig deeper into the data; below is a chart provided courtesy of CWCI, it is NAIC’s 2004-2013 Profitability Report, comparing average rates of return on net worth among California and US WC, property & casualty (P&C) insurers and all industries.

2004 2005 2006 2007 2008 2009  2010 2011 2012 2013 04-13Avg
Calif WC 12.6% 14.2% 16.4% 12.1% 7.0% 4.6% 5.2% 7.4% 3.9% 3.0% 8.6%
Calif All Lines 14.8% 14.5% 17.1% 11.9% 6.0% 9.4% 9.7% 8.4% 7.4% 7.6% 10.7%
US WC 10.1% 9.6% 10.0% 9.0% 5.1% 4.2% 3.9% 6.2% 5.9% 7.2% 7.1%
US All Lines 10.0% 5.3% 14.4% 12.5% 2.4% 6.3% 8.0% 4.9% 5.8% 9.0% 7.9%
NAIC P&C 8.0% 8.3% 12.2% 9.7% 2.2% 5.7% 6.0% 3.4% 5.2% 8.0% 6.9%
Fortune All Ind 13.9% 14.9% 15.4% 15.2% 13.1% 10.5% 12.7% 14.3% 13.4% 16.6% 14.0%

First up, look at the last row, Fortune’s All Industry average is higher than the US WC results every year for the last decade.

Over the last decade, WC’s returns have been just half the All Industry average.

Next, kindly allow me to direct your attention to the bolded red numbers – California WC insurers’ return on net worth for 2013 and the national average for the same year.  Fellow WC geeks will recall 2013 was identified by ProPubica/NPR as WC insurers’ “most profitable year in over a decade, bringing in a hefty 18 percent return.”

Oh were it only so.

(We dissected PP/NPR’s interpretation of profitability yesterday)

PP/NPR’s series of “reports” on workers’ comp allege that this “hefty” return is due in large part to reductions in benefits for workers pushed by employers and insurers and “reforms” that have taken away workers’ ability to choose their doctors – among other changes.  The reporters specifically cited big problems in California, where insurers’ doctors “deny” care without seeing the patient, where benefits have been slashed and workers made to suffer due to ill-conceived “reforms”.

This is a classic example of writers looking for “facts” that support their pre-conceived bias.  NAIC’s data shows just how wrong reporters Grabell and Berkes are; if the “reforms” in California were so one-sided, so employee-unfriendly, designed to benefit insurers at the expense of injured workers, those reforms have clearly NOT delivered the intended financial results.

By way of reference, historically the target ROE for US companies is in the 12-15 percent range, making the US WC insurance industry’s 7.1% return over the last decade look shabby indeed.

Remind me again why anyone would want to be a workers comp insurer???



Workers’ comp profitability, Part 2

So, Liberty Mutual is de-emphasizing workers comp, a move that is increasing profits. But ProPublica/NPR reported “in 2013, insurers had their most profitable year in over a decade, bringing in a hefty 18 percent return.”

Just how “profitable” is workers’ comp?  Why is Liberty ratcheting things down while the industry is enjoying its “most profitable year in a decade?”

That’s a difficult question to answer for a number of reasons, but the long and the short of it is; comp is not very profitable.

First, the slide that PP/NPR used to make their 18 percent claim.

Courtesy NCCI

Courtesy NCCI

Let’s parse this out, shall we?

First, there are no perfect measures for calculating WC profitability.

Second, the operating gain is not the same as “profitability”.

Operating gain as a measure has several limitations, not least of which is annual operating gain figures jump around quite a bit for reasons completely unrelated to core financial returns. For example, 2013’s “gain” was significantly increased by one very large carrier’s internal financial transfer, a transfer that, in and of itself, was responsible for several percentage points.

Using a multi-year operating gain (OG) ratio is more meaningful than using a single year as it reduces the effect of one-time financial events.  The average NCCI OG ratio from 1990 to 2013 was 5.8%, with a maximum of 19.9% in 1995 and minimum of -10.0% in 2001. The most recent 5 and 10 year averages were 4.8% and 7.4% respectively.

A couple other factoids – The NCCI OG ratio only includes private carrier results, a subset of the total industry. State funds (which tend to be MUCH less profitable) are excluded from the calculations.  In addition, the NCCI OG ratio is pre-tax. 

Finally,  investment income (one key component of operating gain) can’t be allocated to one specific line of coverage (except if the carrier is a mono-line WC insurer).  Reserves and other funds are put into a single “bucket” and invested by the insurer in a variety of instruments.  Then, when funds are needed to pay claims, they are withdrawn.

So, what metric should be used?

The estimable Bob Hartwig PhD of III, in a piece questioning PP/NPR’s claim of profitability, suggested return on net worth;

According to the National Association of Insurance Commissioners, workers comp return on net worth was just 7.2 percent that year [2013], less than half the figure cited in the article. The average return over the decade from 2004 through 2013 was just 7.1 percent. The returns over that 10-year span ranged from 3.9 percent in 2010 to 10.1 percent in 2004

(PP/NPR’s response is here)

There’s more on the return on net worth discussion at III, in addition to a chart depicting financial returns for other industries. (the metric is also known as return on equity [ROE]).

By way of comparison, you can find representative industry ROE figures from Yahoo.

What’s the net?

Relative to other industries workers’ comp is not terribly financially rewarding.  Many industries deliver much better returns.