Insight, analysis & opinion from Joe Paduda

Feb
1

Consequences.

Since the Supreme Court overturned the right to abortion, almost 60,000 women had rape-caused pregnancies – and live in states where they cannot get an abortion.

From the American Medical Association’s research:

In the 14 states that implemented total abortion bans following the Dobbs decision, we estimated that 519 981 completed rapes were associated with 64 565 pregnancies during the 4 to 18 months that bans were in effect (Table 2). Of these, an estimated 5586 rape-related pregnancies (9%) occurred in states with rape exceptions, and 58 979 (91%) in states with no exception, with 26 313 (45%) in Texas.

Notably, even in states that allegedly allow exceptions for rape or incest – e.g. Idaho – the AMA found NO abortions have occurred.

So…consequences.

60,000 girls, teens, and women who were raped will have live or dead babies.

The psychological damage will be devastating for them, their loved ones, and their babies.

Make no mistake, the burden will fall on the least fortunate of us...almost everyone subscribed to MCM has healthcare; you and your daughters/wives can travel to states that allow abortion.

The vast majority of victims live in states that have crappy Medicaid coverage, so many/most won’t have coverage for/access to pre-natal care, ob/gyn services, labor and delivery, and infant/pediatric health.

Not to mention mental health.

The shameless hypocrisy of the “protect life” crowd in these states is overwhelming... forcing rape victims to have babies and not providing the women or the babies with healthcare is just…unthinkable.

The cost – in terms of destroyed lives and unfunded/uncovered healthcare expenses – is immeasurable.

What does this mean for you?

WWJD?

 

 

 


Jan
30

NCCI’s executive survey…what medical inflation??

A couple weeks back NCCI released information about its annual survey of work comp execs.  About 100 participated in the survey; some of the results were a bit surprising.

Execs were asked about their “concerns” re workers’ comp…frankly I found some of their concerns (financial health? rate adequacy? medical inflation?) puzzling at best.

Here’s a couple questions from my discussion with Damian England, Executive Director, Affiliate Services and Raji Chadarevian, Executive Director-Actuarial Research – and thanks tons to NCCI’s Cristine Pike for making this happen.

Where did the responses rank concerns?

Damian England, Executive Director, Affiliate Services – “While some carriers mentioned multiple concerns, roughly 40% of the responses were related to the financial health of the system and rate adequacy. About a quarter reflected the changing workforce, followed by medical inflation and the economy. Climate change and artificial intelligence were cited as emerging concerns.”

MCM – Rate adequacy concerns?

Damian England, Executive Director, Affiliate Services – Rate adequacy concerns are more of a global fear of the future and the unknown, amid a long-term trend of steady declines in loss costs/rates.  Although the industry in aggregate has seen nearly 10 consecutive years of underwriting profitability, not every carrier has same results or books of business; rather, individual carrier performance varies in many ways from the aggregate.  We also hear about changing underwriting cycles and whether we have the data necessary to recognize a turn in trends, as there is a recognition that recent trends will not last forever.

MCM – Why are they worried about medical costs – which are a non issue?

Raji Chadarevian, Executive Director-Actuarial Research (and all around good guy). – Medical cost drivers are not well understood; some are just looking at the overall medical price index, but medical cost drivers go beyond that. Changing medical practices, new medications, new ways to administer treatments and other transformations need to be considered. It is starting to resonate that some are understanding it is more complex…but there is a misconception in the industry that we look at health insurance rates and think that is representative of medical inflation – those rates [health insurance premiums] are going up but that is not medical inflation.

Also, WC is a long tail business, so a small change in the inflation rate one year can mean a lot in terms of overall cost of claims – that is where some of the concern emanates from – what does it mean for a 20-30 year claim?  Furthermore, for LT claims it isn’t general medical inflation largely driven by physician and facility prices, rather, for claims that are beyond the critical treatment period, medical costs have more to do with the price of Rx, home health care, medical equipment. Prices for HHC and DME have gone up significantly in recent years.

Ok, couple things here.  And please, this is not meant to argue with Raji or Damien, rather to point out that work comp execs need to study up on medical issues and worry about REAL issues, not NON-issues.

  1. Rate adequacy is NOT AN ISSUE. Over the last decade rates have been too high – evidenced by continuing rates drops in almost all states over that period, accompanied by huge profits AND $14 billion in “excess” reserves.
  2. Medical inflation is NOT AN ISSUE. Over the last few years there have been no reports of significant increases in medical trend. None. Zippo, Zilch.
  3. Drug costs have been dropping for years – for lost time claims as well as med onlies.
  4. Claims with ultimate costs >$1 million account for – at most – 15% of total WC costs  – and a huge chunk of that is not medical, but indemnity expense. So, while I get some execs may be concerned about future costs, this feels more like catastrophizing than rational business thinking.
  5. Climate change – hard to believe that this was not one of the top concerns, but completely consistent with the industry’s ignorance of the issue. Talk to insurers, employers, and TPAs in Louisiana and California and they’ll regale you with the horrific and extremely expensive impacts of human-caused climate change.

What does this mean for you?

Execs are working about non-issues and willfully ignoring those that will have real and sustained impact on the industry.

 


Jan
25

Dumbest law of the month…#2

Okay, this isn’t a law, rather a school board ruling.

But it is so amazingly, blindingly, completely stupid that it beggars belief.

Last June the duly-elected Escambia County School Board  banned 8 dictionaries and encyclopedias because they…wait for it…contain depictions or descriptions of sexual conduct.

Who knows if these vile, disgusting, immoral books contained anything problematic…but under Florida’s “Don’t Say Gay” law, one parent – yup, just one – can force a school to pull a book from its shelves and conduct a lengthy review to ascertain if it is – according to some made-up criteria – inappropriate for that school.

So, let’s see…what could qualify?

  • A parent kissing their spouse?
  • Reproduction by an earthworm?
  • A trout laying eggs?
  • A medical textbook describing intercourse?

Those are all “sexual conduct…

That’s not the worst of it. Under Florida’s law, ANY parent could force a school too pull ANY book – which could include…the Biblewhich does reference various activities that could be construed as “sexual conduct”.

What does this mean for you?

Don’t let your kids go to Escambia County schools.

 

 


Jan
22

What should happen in workers’ comp – but probably won’t

I’ve finally figured out that what I think should happen often doesn’t.

So, here’s my take on the 5 things that SHOULD happen in worker’s comp this year but likely won’t.

  1. We won’t hear more caterwauling about “rising medical costs”.
    Ha. The latest NCCI research indicates execs still don’t understand what’s really happening with medical costs – despite NCCI’s diligent efforts to educate same.
  2. Work comp execs will embrace innovation.
    I wrote about this three years ago here. Basically,

    1. execs got to be execs by avoiding anything remotely risky.
    2. The industry is making billions in profits so why try anything new.
    3. Frequency and premium rates are declining, so why try something for a declining business?
    4. And worker’s comp is mandatory in 48 states, so they’ll have to buy it from someone.
  3. Buyers will stop asking about/measuring/caring about medical “savings”.
    I’ve written about this a gazillion times…here’s one example. The net – it’s really easy to show a reduction below list price – we Americans have been trained to do just that.
    Even when it makes zero sense…follow the link to get why there’s a horrendously ugly sport jacket here…

    Oh, And, this industry is pretty lazy.
  4. The industry will wake up to human-caused global warming. 
    Ha. Nice to see that some pundits have finally raised this as an issue – but jeez people it’s 2024, and we’ve KNOWN we are boiling the planet for decades. Nope, there will be minor moves, with little public discussion among or by work comp execs.
    Why?
    Great question.
  5. The industry will seriously embrace behavioral health, take major steps to understand this as a disability driver, and seek out meaningful solutions.
    Sure, some have – and kudos to them for doing so – And kudos to good friend, colleague, and mentor Bill Zachry, David Vittoria of Carisk, Dr Les Kertay, and others who have been leading the charge.
    But let’s get real folks…disability is as much- if not more – mental/emotional/
    psychological as physical, yet far too many payers don’t want to accept that blindingly obvious truth, scared of “owning the psych”.”
    You already own it.

    (Carisk is an HSA client)

 


Jan
19

Good news Friday…

The best possible news hit the wires yesterday – there won’t be a government shutdown next week.

The House – in a bipartisan vote – passed a continuing resolution (aka CR) to keep current funding levels in place till early March, giving the House and Senate time to negotiate on 12 individual spending bills.

The really good news is this passage:

  • was bipartisan, with 207 Democrats and 107 Republicans joining together to pass the CR
  • did not result in a move to oust current House Speaker Mike Johnson (R LA) (a similar bill cost then-speaker Kevin McCarthy R CA the Speakership)

While it is way too early to celebrate a new era of bipartisanship and congratulate the radicals on both ends of the spectrum for their maturity, and

…it is mind-blowing that we now celebrate a near-government shutdown as “good” news, 

Given recent history this does count as good news.

What does this mean for you?

That said, we cannot continue governing like this.  Thoughtful, principled compromise must return to Washington.


Jan
18

Hospitals are…

a) in desperate financial shape, on the verge of bankruptcy…

b) doing quite well thank you, enjoying very healthy profits…

c) both.

The answer is…C.

For-profits – HCA, Tenet et al are doing great, while (most/many) not-for-profits are really struggling, with some on the verge of/going into bankruptcy.

Why?

Very briefly, for-profits (there’s lots of nuance here, but generally);

  • don’t take Medicaid patients,
  • have very strong orthopedic and cardiac surgery practices which are very profitable;
  • do their best to avoid/transfer/not care for the uninsured.

Not-for-profits…

  • include inner-city and rural facilities that must take Medicaid and
  • serve as primary care providers for the indigent and uninsured and
  • deliver lots of babies and provide general med/surgical services which are marginally profitable

What does this mean for you?

Hospitals of all types are looking to maximize revenue, especially from very profitable payer types.

Is that you?

 

 


Jan
15

What’s REALLY going on with inflation?

A couple subscribers have been pushing back on my take on inflation; essentially their position is that “real people” (as opposed to “fake people”?) are suffering from pocketbook issues, issues that I do not understand.

Well…lets – very briefly – dig into “pocketbook” issues.

First, here’s the latest Consumer Price Index figures from last month courtesy of the US Labor Department…this looks at price changes from December 2022.

But that’s just one year…looking further back, food prices have indeed increased a lot  – almost 20%. – since 2019.

Some food producers claim inflation is the driver, forcing them to increase prices to keep up with inflation,

But there’s solid evidence many food companies are just jacking up your prices to jack up their profits.

This from NYT

  • PepsiCoprices for its drinks and chips were up 17 percent in the latest quarter … its third-quarter profit grew more than 20 percent.
  • Coca-Cola reported profit up 14 percent from a year earlier, thanks in large part to price increases.
  • Chipotle Mexican Grill’s prices are now nearly 15 percent higher than a year earlier, reported $257.1 million in profit… up nearly 26 percent…

From BonAppetit

From TIME:

  • Conagra Brands—one of the largest consumer packaged goods companies in the U.S.—announced that it had posted a nearly 60% year-over-year profit increase between December 2022 and February 2023. The Chicago-based company, which makes a long list of grocery staples including Chef Boyardee, Hunt’s, Slim Jim, Reddi-wip, and Marie Callender’s frozen meals, reported a net income of $342 million, up from $219 million in the same quarter a year prior.
  • Tyson Foods, the largest meat company in the U.S., more than doubled its profits between the first quarters of 2021 and 2022.
  • remember the huge price jump for eggs? According to TIME, “Cal-Maine Foods, the largest egg producer in the U.S., reported that its revenue doubled and profit surged 718% [in Q1 2023] because of higher egg prices.”

What does this mean for you?

If you’re going to point fingers, make sure you know who to point at.

 


Jan
12

Good news Friday!!

With all the craziness in the world, its easy to miss some of the good things that are happening…stuff that makes life just a little better.

The gubmint is actually making progress…on those incredibly annoying junk fees.

Overdraft and other banking fees

The Consumer Financial Protection Bureau is finalizing regs that will protect us from bank overcharge fees.  In 2022 banks took $7.7 billion from customers.

A big percentage of those hit with overdraft fees are poorer folks – the ones who get hit with a $35 charge for buying a few groceries. The new regs will really help  those folks.

Retirement junk fees

There are potential conflicts of interest for retirement plan advisers, conflicts that might encourage advisers to recommend an investment that isn’t in your best interest.

From USNews…

the Administration is pushing changes in “three specific areas to lower fees for Americans preparing for retirement. These are related to closing loopholes in the purchase of any investment product, advice given about IRA rollovers and recommendations for 401(k)s and other company-sponsored plans.” [emphasis added]

Colleges and junk fees..

Colleges and universities have gotten pretty darn good at sucking money out of students’ accounts with some pretty outrageous stunts.

From USNews:

Student flex fees are a target..some colleges are keeping left over funds after graduated.

SHOCKER!

Congress may actually get something done...I know, who woulda believed it. A bi-partisan effort to address stupid- and unconscionably high insulin costs, appears to be gathering steam.

From WaPo:

their bill would extend Medicare’s $35-per-month cap on insulin prices to individuals with private insurance, rein in the business practices of prescription drug middlemen and make it easier for new generic and biosimilar drugs to enter the market. [emphasis added]

What does this mean for you?

Government gets stuff done…


Jan
9

MedRisk acquires Medata

MedRisk and Medata just announced the former has acquired the latter.

Pretty interesting move…note I’ve worked with Medata in the past and worked with Medrisk for decades – and still do.

The official release is below – here’s my take.

Synergies

Data – Medata has a wealth of data on all types of medical services; MedRisk has data on millions of (physical medicine) episodes of care. Together, there are several potential benefits:

  • More information is good, helping identify best practices and providers with – and without – good outcomes. This will help improve patient outcomes.
  • Medata has data on post-PT costs, medical care, provider usage and other very useful information. This will help MedRisk better understand care delivered after a therapy episode and identify opportunities to improve return to work, transitional duty practices, and issues that may arise post therapy.
  • Network development – Medata has a wealth of information spanning decades on  physical therapy, occupational therapy, and chiropractic services’ prices, reimbursement, utilization and trends. These data will further help improve MedRisk’s network and enable it to provide better information re provider performance in- vs out-of-network.
  • These benefits will be felt soonest by mutual customers, but over time will improve results for each company’s unique customer base.

Efficiency

MedRisk is the largest manager of physical medicine in work comp and does a LOT of bill review in that space. Now that it owns a BR company, BR costs should decrease, improving margins albeit it on the margin.

With bill information coming into Medata, MedRisk will be better able to identify out-of-network therapy and where possible and appropriate either enroll the therapist if credentialing approves or divert the  patient to an in-network therapist. This will improve patient outcomes, increase payers’ network penetration and likely reduce cost of care.

Here’s the press release…

MedRisk acquires Medata to further improve the claims experience for customers, patients, and providers

 

King of Prussia, Pa. (January 9, 2024) — MedRisk, the leader in managed physical rehabilitation in workers’ compensation, has announced its acquisition of Medata, one of the leading providers of cost management and clinical solutions in the United States.

With this acquisition, customers of both companies will have access to expanded care management and cost containment offerings in workers’ compensation.

“We are excited to add Medata to our team,” said Sri Sridharan, MedRisk CEO. “This will further enable us to deliver superior claims outcomes and experience for our customers, for the patients we serve every day, and for our provider partners. In addition, we will now be able to leverage our inventory of data from both organizations so we can deliver unique insights and additional innovative solutions.”

Based in Irvine, California, Medata provides the most comprehensive cost containment and document management solutions in the workers’ compensation and auto liability industries.

“We are thrilled to become part of MedRisk,” said Medata President Tom Herndon. “Our companies recognize customers want greater alignment among their service partners, and this change strengthens our foundation and will drive investment into product innovation. Together, we will leverage our collective resources to continue delivering exceptional products and services to our customers.”

“For 30 years MedRisk has focused on creating a better experience for patients, our customers, and the entire industry,” said Mike Ryan, MedRisk Executive Chairman. “The addition of Medata is a natural and exciting step forward for us to further accomplish that mission.”

About MedRisk

Based in King of Prussia, Pennsylvania, MedRisk is the nation’s largest managed care organization dedicated to the physical rehabilitation of workers’ compensation patients. For more information, please visit www.medrisknet.com or call 800-225-9675.

About Medata

Based in Irvine, California, Medata provides the most comprehensive cost containment and document management software and solutions for the insurance industry. The company serves insurance carriers, self-insured companies, third-party administrators, state funds, and public entities in the workers’ compensation and auto liability industries. For more information, please visit www.medata.com or call 800-854-7591.

# # #

Media Contact:  Helen King Patterson, King Knight Communications, 813-690-4787, helen@kingknight.com


Jan
9

Prior auth – are you flying blind?

A pending CMS rule may lead to major changes in the use of Prior Authorization, changes that would reverberate across all payers – Medicare, Medicaid, group health, Exchange plans and workers’ comp.

Remember work comp is the flea on the tail of the healthcare elephant:

  • WC is 0.7% of total US medical spend and
  • a tiny portion of most providers’ patients and
  • the draft regs have no exemption for workers’ comp.

The proposed rule is now under review after public comments; there are a wealth of implications and potential issues including:

IT

  • requirements re new APIs (electronic links) in PA IT applications including payer and provider interfaces  – idea being to streamline flow of information between payers and providers
  • payer-to-payer data exchange requirements – essentially linking payers together so a specific patient’s entire health record is kept by its current payer (given patients’ high propensity to switch payers, this will be darn challenging.
    • work comp would have to integrate with many other payers...
  • build automated processes for providers to determine if a PA is required –  idea being to reduce confusion as to what procedures do and do not require a PA

PA processes

  • tight time frames for PA processes and possible reduction to 48 hours for expedited requests
  • mandatory requirement for payers to include a specific reason for denials
  • mandatory reporting for most providers

There’s a lot more to this…I’ve just scratched the surface here.

What does this mean for you?

if you aren’t paying attention to what’s happening in the larger healthcare world, you’re flying blind.

Make no mistake, what CMS does – whether its fee schedules, interoperability requirements, Medicaid eligibility, drug pricing, reimbursement policies, network adequacy or PA changes – affects you.

 


Joe Paduda is the principal of Health Strategy Associates

SUBSCRIBE BY EMAIL

SEARCH THIS SITE

A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.

 

DISCLAIMER

© Joe Paduda 2024. We encourage links to any material on this page. Fair use excerpts of material written by Joe Paduda may be used with attribution to Joe Paduda, Managed Care Matters.

Note: Some material on this page may be excerpted from other sources. In such cases, copyright is retained by the respective authors of those sources.

ARCHIVES

Archives