Insight, analysis & opinion from Joe Paduda

Apr
3

Brian Downs – one of work comp’s best

Brian Downs runs claims and medical management for the Work Comp Trust of Connecticut. He’s the best claims exec you’ve never heard of.

The Trust serves the healthcare industry in Connecticut with both insurance and administrative services. It may be the best-run payer in the nation; with very strong financial results, results which would be the envy of any payer, big or small, a complete and total focus on claims handling excellence, and provider relationships that are core to the Trust’s success.

Those financial results are driven by management’s single-minded focus on it’s customers and patients. Everything revolves around what’s best for policyholders and patients; preventing injuries and illnesses, and delivering the best possible medical care to patients drives the company.

I’ve never heard Brian or CEO Diane Ritucci talk about discounts or savings; those metrics just doesn’t exist. This in a state with among the highest provider fee schedules in the nation.

I met Brian over a decade ago when I was asked to audit the Trust’s medical management program. The more I learned, the more impressed I was. For a small insurer with few resources working in one small state, the Trust was remarkably effective.

The audit found a claims culture focused entirely on outcomes. A medical management approach rooted in partnering with the right providers, with a proprietary network of constantly-evaluated physicians. Results that would be the envy of any payer, large or small.

  • Combined ratio hovering around 90% for years
  • A large and growing fund balance
  • Consistent record of premium returns amounting to about 10% of premiums this year

Before anyone starts saying how easy it is for a small payer working in one state, let’s talk resources.

This payer’s IT budget is a tiny fraction of the big boys’. The staff is equally small, with many folks wearing multiple hats. It competes in a market that’s home to many other payers, ranging from the Hartford and the Travelers to Sedgwick and other trusts. It serves a market – healthcare – with high frequency and occasionally high severity.

Yet despite these challenges, the Trust is nimble, focused, and innovative. Brian meets regularly with individual physicians, groups of docs, employers and other stakeholders. He’s out and about listening and learning, while letting those providers know what the Trust expects of them. The Trust invests heavily in customer outreach, product innovation, network refinement, and staff education.

Brian is the epitome of an effective leader and manager. He has no ego, is constantly looking for ways to get better, to deliver more, to innovate. I’ve never heard Brian sound satisfied or content, he’s always asking, questioning, pushing to improve. Quiet and unassuming, engaged and calm, you’d be hard-pressed to pick him out of a crowd.

I’m lucky indeed to count him as a friend and colleague, and the Trust’s customers have benefited greatly from his competence and professionalism.

Brian Downs is one of work comp’s best.

 

 


Apr
1

Federalization of work comp; death by DOL?

Who thought the much-feared Federalization of workers comp would result in this.

A new regulation finalized by the US Department of Labor on April 1 overturns state requirements for workers’ compensation, while limiting employers’ liability for occupational injuries or illnesses. President Trump alluded to the pending change in his speech in Ohio earlier in the week.

The speech was supposed to focus on infrastructure, but it appears Trump had the new DOL regulation in mind when he noted the maze of workers’ comp laws makes it very hard for businesses to operate across state lines. Removing these “burdensome” constraints would “unleash all American businesses.”

One newspaper account noted

“a key part of his plan, he said, is to reduce a burdensome regulatory approval waiting time from as long as a dozen years to a year, by establishing one federal point of contact for a yes or no answer on a project.”

While there have been many far-reaching cutbacks in regulations directly or nominally affecting employers, this latest is undoubtedly the most significant seen to date.

According to a statement from Acting Associate Deputy Secretary for Policy Aprille Pfuehle; “The regulation essentially sets a Federal Maximum Standard for coverage and benefits for occupational illnesses and injuries. Employers with workers in any state with benefits greater than a to-be-determined Federal Maximum Standard can opt to be regulated by DOL and not that state.”

Employers who choose DOL regulation evidently will have additional protection from liability as well. While I’m no employment law expert, it appears the Trump Administration is relying on ERISA pre-emption as the lever to dis-engage occupational coverage from state regulation.

The regulation was reportedly developed and written by DOL’s Office of Congressional and Intergovernmental Affairs, under the direction of the Assistant Secretary; no other information was provided as to the rationale behind this.

No details on what entity is going to develop the Federal Maximum Standards were provided, nor was there any timeframe given. Given the magnitude of this change, we can expect it will take months to make any progress, and any change will certainly result in legal challenges.

Part of the Trump Administration’s ongoing effort to reduce the impact of ‘unnecessary regulations” on businesses, this follows earlier moves to delay or eliminate a host of workplace safety regulations, including beryllium exposure standards, medical benefits for US Energy Department workers exposed to radiation, and cutbacks on enforcement of wage/hour regulations.

While we knew the Trump Administration has been very business-friendly, this latest goes much further than these earlier efforts.

 

 

 

 

 

 


Mar
30

Cirillo takes over at myMatrixx

myMatrixx, Express Scripts’ workers’ comp PBM brand, will name Mike Cirillo President on Monday April 2.

Cirillo most recently led Injured Workers’ Pharmacy’s effort to enter the PBM space. He has deep experience in work comp claims from his days at the Hartford’s SRS TPA, along with 5 years’ pharmacy experience at IWP.

He will replace myMatrixx CEO Artemis Emslie, who, as we’ve noted previously, announced her decision to step down at the end of last year. Those are some big shoes to fill, as Artemis is universally well-liked and well-regarded for her depth of knowledge and long experience in work comp pharmacy and related businesses.

The changeover comes at a critical time. Currently there are multiple payers deep into the RFP process, more so than I’ve seen at any one time in recent years.  Several are seriously evaluating switching PBMs.

IWP’s effort to launch a new work comp PBM started just over a year ago. The PBM, branded SpecialtySolutionsRx, did not gain much traction, perhaps due to payers’ views of IWP as part of the problem, not part of the solution to work comp drug issues. There is no current information available about Specialty Solutions on IWP’s site.

It is likely SSRx is in a holding pattern for the time being.


Mar
28

919,400 people aren’t working because of opioid use

My best guess is about a quarter of those are work comp patients.

Opioid use disorder (OUD) drains the workforce of qualified, experienced workers, costing our economy $40 billion.

Healthcare costs for OUD alone were $28 billion in 2015 – and all but $2 billion of that was paid by insurance – mostly Medicaid (which is taxpayer funded).

If you are 50 or younger, you’re more likely to die from opioid use than anything else – not a car accident, not cancer, not a heart attack, not diabetes.

Solutions

Medication-assisted therapy (MAT)- using methadone, buprenorphine, vivitrol to help victims get off and stay off opioids – is, for most folks, a key part of recovery. Yet most states have far too few MAT facilities, and many facilities only provide one or two of those medications (not surprisingly, different people seem to do better on different therapies).

Yet there are far too few providers trained and able to provide MAT.  From Inflexxion:

Data shows that less than half of privately funded treatment programs offer any form of medication-assisted treatment. That number falls to 23% in publicly funded programs. According to the 2013 National Survey on Drug Use and Health, of the 2.5 million opioid-dependent or opioid abusing Americans, fewer than 1 million received MAT.

MAT, coupled with counseling and patient-centric, individualized treatment plan can be quite effective.  A solid study found over well over half of patients using MAT were not using the illicit drugs 18 months into treatment – a remarkable success.

However workers’ comp payers are often unable to find MAT facilities, lack the understanding needed to develop a comprehensive, long-term treatment approach, and are loathe to go down that path, as they’re afraid it will make the employer liable for all manner of additional services.

What does this mean for you?

States can and should come up with novel ways of encouraging treatment while limiting future liability.

This will save thousands of lives and billions of dollars for employers and taxpayers.


Mar
27

Victor on Comp

Workers comp in a dozen years MAY look a lot different that it does today.

That’s the take from Rick Victor PhD, former CEO of WCRI, who discussed a number of potential factors that might actually increase work comp claim counts a LOT at the WCRI 2018 conference.

One was case-shifting, an oft-cited but generally poorly-researched factor that most of us think happens all the time. I’m not so sure.

According to Dr Victor, factors that might increase case-shifting include:

  • weakening of the ACA = 20 million more uninsured
  • higher proportion of the population is on high deductible plans – and they can’t afford the deductible.
  • providers looking for higher reimbursement

Another is the shortage of labor, driven by an aging workforce and current tight labor market. Factor in the possibility that the workers left to be hired are not as strong, motivated, employable, and diligent as the ones already working, and therefore are more likely to file work comp claims, and Dr Victor posited injuries may increase.

Interesting thought experiment, especially given the current Administration’s remarkable ability to not understand that our economy:

  • benefits from immigrants,
  • desperately needs them today, and
  • even more desperately needs them in coming years.

The central premise, that labor shortages and a robust economy will dramatically increase claims, perhaps as much as 50%, just doesn’t make sense.

The rise in robotics, replacement of human intelligence with Artificial Intelligence, autonomous vehicles and trade policy all are very powerful arguments that claims will actually decrease – at a rapid rate.

What does this mean for you?

Unless technology stops evolving, claims will continue to drop.


Mar
26

Value-based care in Work Comp

Randy Lea MD of the Dartmouth Institute (one of the nation’s leading healthcare research organizations, and my personal favorite) just completed research on value-based care (VBC) in work comp – a timely and much-needed project. Dr Lea presented at last week’s WCRI Conference.

Here are my takeaways.

Spoiler alert – value-based care is not getting much traction – and I don’t think it will.

First, the research was more of a survey of what stakeholders want, expect, can do, and think is necessary to bring VBC than a detailed description of what actually exists today. In that way, it’s helpful as it indicates what factors may/will lead to more VBC in work comp.

As much as I respect the Dartmouth Institute and appreciate Dr Lea’s insights, I found the presentation hard to follow. There was just too much information crammed into too little time.

Stakeholder readiness

Providers – only one engaged in a WC VBC pilot program; many were prepared and waiting, but “there’s no opportunity for them to engage at this time.”

Payers – only one is doing VBC – and that is bundled payments. Payers were more focused on high-performing networks, not real VBC. Also doubt the model will be sustainable.

Regulators – again, only one doing VBS, that one has seen positive results, and is ready to expand. access, quality, and are coordination. Not much going on, but many are at least thinking about it.

Now into the meat – their thinking about how VBC might actually occur in workers’ comp.

Conditions that were popular for inclusion in a VBC model included spine, shoulder, knee, CTS, and co-morbidities plus the condition.

First, we need a regulatory environment that is favorable to VBC. No surprise here, although all recommended employer direction, mandated medical treatment guidelines, reduced fee schedules (?!), reduced UR.

Second, providers need enough patients.

Third, there was a lot of concern around RTW, causation, and impairment and who is involved and how decisions around those key issues will be made and on what basis.

Development guidelines

  1. Need a set of values that are shared by the stakeholders that guide development
  2. Rewards for good performing providers
  3. Transparency across all stakeholders
  4. Outcomes focused, not discount-driven
  5. Adaptability to current programs and regulatory conditions
  6. Fair and quick reimbursement of providers
  7. Reimbursement based on guidelines and compliance w MTG
  8. Eliminate fee schedules
  9. Need real steerage of patients
  10. Tight definition of outcomes is mandatory, need real specificity around things like RTW.

Payment types – participants reviewed a variety of types of reimbursement, with most payers looking for bundled payments  – no surprise.

 

I also have to note that my main takeaway was thiswork comp is a couple of decades behind the rest of the world – and it isn’t catching up. If anything, we’re falling further behind.

I say this because this is some pretty basic stuff compared to what we see in Medicaid or Medicare.

My view is there are any number of reasons VBC is not going to happen in WC.

  1. There are not enough cases; providers won’t be interested in risk-taking if there aren’t enough cases to spread the risk.
  2. Providers don’t have to take risk; in many states there’s no or limited employer direction, so no guarantee they’ll get a minimum number of cases.
  3. Litigation – providers may have to provide documentation and perhaps testify, something no one wants to risk.
  4. Payers are far too wedded to the percentage of savings profit machine.

What does this mean for you?

Bundled payments aren’t really value-based care. And even those are few and far between, for good reason.


Mar
23

When people use cannabis do they stop using other drugs?

There’s been some good research into this – which may be THE key question when it comes to medical marijuana.

The answer appears to be – some do stop using other drugs. And, even better, fewer people die.

Key findings using Medicare data:

  • States with medical marijuana laws saw about 10% fewer daily doses of opioids than those without those laws.
  • States with dispensaries only (no home cultivation) saw a 14% decrease in opioid doses
  • Total savings to Medicare and Medicaid would be about $3.4 billion if all states adopted Medical Marijuana Laws – but the folks buying the marijuana would pay for their cannabis out of their own pockets.

Studies using Medicaid data saw somewhat greater reductions in opioid usage.

Couple observations – there have been massive changes in PDMPs, increases in naloxone usage, tighter state laws and federal guidance on opioids (CDC et al), which may well have had some impact on death rates and lower opioid usage overall (Brian Allen of Mitchell made this point just after I wrote this). Dr Bradford noted that their analysis considered these possible confounding issues.

My big takeaway – there’s a significant reduction in the number of deaths due to opioids when states have access to cannabis. Like a 25% reduction.

Dr David Bradford of the University of Georgia presented this information; he and Ashley Bradford published much of this in a piece in HealthAffairs two years ago; they used Medicare and Medicaid data.

Dr Bradford noted he and Ms Bradford hope to be working with WCRI on a workers’ comp-specific study soon.


Mar
23

WCRI on Physical Medicine

Physical medicine – chiropractic, occupational and physical therapy – accounts for about one out of every six dollars of workers comp medical spend.

Key takeaways from DR Rebecca Yang’s discussion of the latest CompScope(tm) report:

The location of PM services has shifted from hospital outpatient to non-hospital locations since 2003.

PM accounted for almost 18% of WC medical costs, with non-hospital totaling 14.6%.

Part of the reason is likely reimbursement; non-hospital care averages $41 per unit, while hospital is almost 50% more expensive at $60; this varies quite a bit by state.

Anecdotally, several payer clients have told me their PM costs have been increasing; some are concerned and others see this as likely – and not unwelcome. This latter group sees PM as a replacement or substitute for more invasive/riskier and expensive care – specifically surgery and opioids.

Don’t have any data to support these anecdotes, but hope to hear from anyone who’s looked into this.

What does this mean for you?

Increasing physical medicine costs may well be a good thing.


Mar
22

Opioids and disability duration

On a panel discussing opioids, Dr Bogdan Savych of WCRI opened with a review of WCRI’s latest research looking at the link between opioid prescribing and the duration of disability.

It is great to see WCRI spend a big chunk of time and research dollars on this – which I believe is the biggest problem in workers’ comp today – and will get worse long before it gets any better.

Couple quick data points…

  • One of 10 workers who get opioids are still taking them after 90 days.
  • And, between half and 85% of workers (not surgical cases) who had pain medications were still getting scripts for opioids 3 months later
  • There’s really significantly different prescribing patterns depending on geography – NOT evidence-based guidelines, severity, injury type, etc – but simply where the patient is treated. (so much for the science of medicine…)

That’s just nuts. (editorial comment)

Dr Savych’s study looked at low back pain cases, noting that most guidelines do NOT recommend opioids for low back pain – and certainly not for long term treatment.

Workers with longer-term opioid scripts had more than triple the duration of disability of those who did not use opioids over the long term.

Yet there is NO evidence that opioids are appropriate for long term treatment of low-back pain

Takeaway – Do everything you can to prevent workers from taking opioids over the longer term.


Mar
22

How to prevent and stop opioid use in work comp

It can be done. And it is being done – by a state governmental agency, no less.

Ohio BWC (the state workers’ comp fund in Ohio)’s Medical Director gave background on just how bad things were at BWC in 2011, before just-hired pharmacy director John Hanna took over.

One patient was taking 4000 Morphine Equivalents per day.

40 million opioid doses prescribed in one year.

After five years, the number of opioid dependent patients, opioid doses, and patients taking opioids were all cut in half.

Here’s an even better view…

Ohio allows for treatment of opioid dependence for 18 months without it being allowed in the claim.

I can’t say enough about what Ohio BWC has done. While the data is telling indeed, I think of the families that are still intact, the moms and dads still alive, the employers still staffed by able and capable workers, the first responders somewhat less stressed.

Thank you, John Hanna, Dr Steve Woods, Dr Nick Trego, and Dr Terence Welsh – and your bosses at BWC and in state government, including Gov Kasich (R).


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 2018. 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