Insight, analysis & opinion from Joe Paduda

Jan
5

Good news Friday!

After a holiday hiatus, time to get back to covering some of the good news out there…

Big news – the US economy grew by almost 5 percent in Q3 2023...a rather stunning performance.

Growth was expected to slow to about 2.7% in Q4  – which is also good news as this will likely presage interest rate cuts by the Fed.

Which leads to this…

Implications

Confident consumers spend. Spending creates jobs. Lower interest rates improve construction hiring and durable goods purchases. 

AKA…a virtuous cycle.

Have an excellent weekend!


Jan
4

Stuff you may have missed…

Spinal cord stimulators...Don’t work.

More specifically, multiple high-quality studies found little evidence of pain reduction, no impact on disability, no impact on opioid use, and a relatively high risk of complications (about one in five patients required device revision or removal)

Just as bad, the SCS industry fought back with highly questionable tactics: this from JAMA reported in MedPageToday:

 “Industry-funded critics of independent studies often do not follow the usual route of scientific discourse…

Rather than respond to the journal where the original study was published, critics frequently publish in journals where they are the editors and can control the discourse (15 of 18 letters criticizing the independent studies cited in this article appeared in journals with industry-affiliated editors)…

The journal can then choose to paywall the subsequent response from the independent authors, giving critics the last word.”

and criticisms are typically narrow (but they didn’t look into the benefits for left handed red heads who speak Swahili!) and/or specious.

The net – science indicates the risks of SCS are high indeed, while the benefits of SCS are sketchy at best.

FDA approves test to assess opioid addiction risk

From the FDA

“The AvertD test is intended to be used before patients who are being considered for a 4- to 30-day prescription for acute pain (e.g., for a planned surgical procedure) are first exposed to oral opioids. It is not intended for patients being treated for chronic pain.”

Excellent news indeed!

The test is NOT yet available…check here for more info.

Net – get your Medical Director(s) on this post haste to determine coverage policies and reimbursement.

Opioid settlement dollars

are in high demand, with a bunch of companies coming up with very creative ways to stick their heads in the trough. Spiderman-type cord wraps for police, locking pill bottles, safe disposal envelopes are among the pitches governmental entities are getting for their opioid settlement dollars.

Two points – 

  1. addiction counseling, behavioral health, and other patient care is what is needed – and where dollars should go.
  2. illicit fentanyl is the big problem now – expensive locking pill bottles and disposal envelopes are marginally useful.

Texans may see rolling blackouts this winter, with implications for businesses, public safety employees, utility workers and essential workers.

In October ERCOT – the state’s power regulator, “… issued a request to increase [electricity producers] power capacity ahead of winter’s peak load season in Texas but canceled the request after it only found an additional 11 megawatts out of the 3,000 it was looking for.”

Power producers pointed to ERCOT’s request as too little, too late; University of Houston Energy Fellow Ed Hirs: “Just simply throwing some money out and hoping that people could bring a coal-fired power plant back out to operational capability within a period of weeks was really, ridiculously, ambitious.”

It’s not just Texas…with changing winter weather patterns driven by climate change other states are also at risk of similar blackouts.

 


Jan
3

2023 work comp predictions…how’d I do part 2

Here’s the second half of my predictions – and how they panned out…

6. The growing impact of global warming will force changes in risk assessment, management and mitigation; technology adoption; and claims.
The predicted (heat injuries, wildfires, hurricane intensity, sea level rise) and unforeseen (atmospheric river-driven flooding, landslides, and destruction and others) changes in climate and weather will lead to more and different injuries and illnesses, higher risks for fire fighters and public safety workers, and unpredictable problems related to polluted storm water runoff, water-borne disease and perhaps invasive species.
Expect revisions to both federal and state OSHA regulations especially around heat and outside workers along with calls for better planning to prepare for severe weather events.

False – regulatory changes take way longer than they should. California is poised to mandate heat standards for indoor workers; the Golden State has had outdoor worker standards in place for almost two decades. Oregon instituted indoor and outdoor heat regulations in 2022 and Colorado, Minnesota and Washington also have regulations in place.

And the Feds are still dillydallying damn it.

source NRDC

But there were no other changes in 2023…

 7. Payers and perhaps regulators will make significant efforts to address rising facility costs.
As for-profit healthcare systems look to pad record profits and not-for-profits seek to survive, payers will be looking for better cost control answers than simply doing more of the same stuff they’ve been doing for the last two decades. Network discounts (NOT THE SAME AS SAVINGS) are declining as facilities wise up to most payers’ lackadaisical/ineffective attempts at employee direction and unsophisticated contracting strategies.
Smarter payers will deploy multiple payment integrity layers  – both pre- and post-payment. All should demand more – much more – from their bill review vendors/technology suppliers, all of whom have long refused to entertain the thought that they could do better – much better.

False. Complacency reigns supreme.

8. Premiums will increase – mostly late in the year.
As infrastructure, green energy, re-shoring of chip manufacturing and EV incentives ramp up in the fall so will employment. While there’s disagreement among economists (yeah, who woulda thought??) expect big hiring in categories from archeologists and bridge builders to wireless broadband construction workers.  Manufacturing, heavy construction, trades, logistics will all be hiring…as these tend to be higher frequency (more claims than average) and higher severity (claims are more severe and costly) this means higher premiums and more claims.

Good news indeed for my friends in Cincinnati!

Oh, and mark me down for one who does not see a significant recession in our near future.  I know, I’m no economist (who disagree a lot about this) but hiring is too strong, these major investments are on the horizon, and inflation is coming under control  – all indications that a “soft landing” is more likely than not.

Verdict – True. A soft landing appears far more likely than not, hiring remained solid in the last months of 2023.

And, WCIRB just reported premiums in California were up 2% for the first there quarters of 2023 over the same period in 2022…

Employment in manufacturing construction jumped bigly last year…

9. SB1127 – aka the CAFE Act (California Attorney Full Employment Act) will cause heartburn and consternation among Golden State employers and tax payers.
SB1127 shortens the time period for employers to determine the compensability of claims, a change which will lead to – among other problems – more initial denials and less time for injured workers to receive medical care while their employer researches the claim. Further, AB1127 appears to allow for penalties of up to $50,000 for claims that are “unreasonably rejected” by the employer – but the bill a) doesn’t define what constitutes an “unreasonable rejection” and b) doesn’t exclude claims that are already closed.

Expect attorneys to look for the Golden Ticket case – one that they think will establish precedence – and pursue it like a starving person at a Vegas buffet (or Cafe’).

There’s good news too…I don’t see much else on the regulatory horizon that is cause for concern.

Verdict — TBD. Awaiting input from folks more on top of this than I am.

10. More consolidation among payers and service providers.

Despite a major drop-off in financial investors’ interest in work comp, we’ll see  more consolidation as “strategics” aka TPAs and service providers acquire smaller TPAs and service providers. This is classic mature industry…scale is key, significant growth will mostly be driven by acquiring competitors or companies in complementary or related service and margins are in peril.

The bad news is 2023 prices will likely be a good deal less than in the recent past. Fewer potential buyers, less interest from PE firms, and a growing recognition that workers comp is a declining business (what took these people so long to see this?!) are all contributors.

Verdict – Well…deals that closed were few indeed…those that did close were all strategic not financial buyers – while I got the strategic buyer thing right, I over-estimated deal volume…so… false.

Enlyte bought Therapy Direct.

Sedgwick tried and failed to do a recap..sources indicate valuation was a major sticking point. The giant TPA wasn’t alone, as at least two other attempted sales didn’t materialize.

Ametros sold for a ton of money – but that wasn’t a “work comp services” transaction per se.

accuro Solutions acquired Splashlight, adding to accuro’s service portfolio.

The drivers noted above – fewer buyers, lower prices, less interest from PE firms were major factors – along with interest rates.

Notably, as predicted international M&A activity dropped by about 20%… with private equity and venture capital deals down almost twice that. And, prices declined as well due to the factors listed above.

Overall – 5 True, 4 False, 1 to be determined.

Reflecting on these results, it’s clear my optimism overtook my cynicism (and experience); expecting regulators and work comp payers to get their acts together and do something meaningful about worker exposure to heat and widely-acknowledged rising facility costs was just…dumb.

 


Jan
2

Predictions for 2023…how’d I do?

Yikes!

A year has passed (good riddance!), and it’s time to own up to how I did on my annual predictions for workers’ comp – and stuff that will drive WC.

A view inside HSA’s intergalactic headquarters’ predictive analytics department…

Here we go…predictions and results thereof:

  1.  The soft market continues…
    And it won’t harden in 2023. Medical costs remain very much under control (with an exception), rates continue to drop, employment remains very strong (essential for return-to-work) and there’s lots of payers fighting for market share.

    True
    . The fine folks in Oregon’s helpful analysis of state work comp rates…indicate once again rates were down. For years work comp rates have been artificially high; that continued in 2023 driven in large part by the opioid hangover.
  2. Medical spend is NOT a problem – and will NOT be in 2023.
    With a couple notable exceptions – to be covered in a future post – medical inflation will remain under control. In part this is driven by much lower drug spend and more specifically the continued decline in opioid spend. The latter has a big impact on claim closure and total medical spend.

    True.
    Client data and early indicators point to relatively modest increases – if any – in medical spend. Facility costs are the exception, but a shift in location of service has – for now – moderated the impact.
  3. Behavioral health and its various iterations will gain a lot of traction.
    More State Funds, carriers and TPAs will adopt BH programs, more patients will benefit, and more dollars will be spent. There’s a growing recognition that medical issues aren’t hindering “recovery” near as much as psycho-social ones. This is great/wonderful/long-needed and will really benefit patients and payers alike. Kudos to early adopters, and LETS GO to you laggards!

    True – although there is not enough infrastructure to support BH. Sure there are companies that have BH-specific experience and expertise; Carisk among the leaders, AppliedVR is the only FDA-authorized virtual reality chronic pain solution and is gaining significant traction…unfortunately there are no national or even regional provider networks providing full BH services.This is in large part because payers want discounts (do NOT get me started on the stupidity of this) coupled with a national shortage of providers. (Carisk and AppliedVR are both HSA consulting clients)

  4. One Call will be sold. 
    I keep forecasting this…and one day I’ll be right.  It has to be this year. CEO Jay Krueger and colleagues have OCCM on a better track, but structural problems (i.e. declining claim volume) and internalization of One Call-type services by Sedgwick and others make the future…less than promising. Couple that with recent ratings actions by Moody’s and S&P and it’s time to do the deal.

    Wrong – Again.
    Well, can’t seem to win this one.  Any interested parties have run away –
    because OCCM’s current owners are suing each other. Gotta feel for Jay Krueger and colleagues…I’m quite sure if the circular firing squad hadn’t pulled out their guns OCCM’s staff, clients, and customers – and the investors as well – would be in a much better place.

  5. New technology will make its impact felt.
    Wearables, chatbots (I HATE THEM), and Virtual Reality-driven care are three ways tech platforms/systems/things will significantly ramp up in ’23. Expect several large/mid-tier payers to adopt new tech in a major way – aka not just a small pilot.
    Structural issues with health care (try to find a LCSW or Psych-trained counselor), lack of trained adjusters, and frustration with rising rehab expenses are all contributors.

    True – AppliedVR is working with several workers’ comp payers today – as well as the VA; Plethythe recovery support company – is rapidly expanding its client base, and many payers are trying other tech – with quite mixed results.
    Plethy’s data indicates consistently high patient adherence to home exercise and remarkable outcomes. Other wearable tech that requires provider
    training, uses vision technology to monitor movement and the like are struggling with low adoption and adherence. (Plethy is an HSA consulting client)

Tomorrow  – the other five predictions.


Dec
21

The Ametros deal – details and perspective

Ametros just sold for $350 million in cash, a rather stunning haul for the MSA administrators’ owners.  There’s a lot detail on how and why Ametros’ value was that high in the interview below,

Along with the Carisk recap, this was one of the (very) few recently-attempted sales in the industry that came to fruition. In the parlance of private equity Ametros may be a unicorn – from here it looks like its valuation wasn’t based on an earnings multiple, rather the company’s massive bank deposits and growth potential.

I spoke with CEO Porter Leslie earlier this week – he was refreshingly open and candid; I didn’t have to dig through gobs of corporate-speak to get to the real stuff.  Here’s our conversation.

Questions for Porter Leslie

MCM – Talk about how Ametros has grown to over $800 million in [bank] deposits.

Leslie – It has been a long grind, we identified something that the market needed, to take care of Injured Workers [IW] after settlements, over time a lot of large payers and attorneys came around… CMS highly recommends it, it helps IWs, and helps settlements happen – it all makes sense – it took time to scale and to get story out there, nothing fancy, just focused on building strong relationships

MCM – One aspect of Ametros I’ve been consistently impressed with is your marketing – talk about how leadership thinks about marketing and investing in brand.

Leslie – what we do is pretty complicated, no one understands WC or MSAs or professional admin of MSA – [so we’re at a] third level of complication – thrust has been to make it simple – mission is to make healthcare easy for IW, everything we do is thru lens of making it simple and practical – if IW can get it, then the expert that advises them can understand it

[we have] great people on the marketing side – Melissa [Coleman] works well with Helen [Knight of KingKnight]– we give them room to run, there are a lot of ideas and creativity across social media, websites, wherever they see opportunity to connect. We focus a lot on telling the stories of IWs that go through a settlement and how we can alleviate burden for them.

We do play in a lot of traditional publications, if you go to our website we highlight members. Few organizations really emphasize the human element and story around it – that’s what people care about – our people understand the space, we don’t spend on conferences so much as getting to people that matter to them and share story – message is around why do they give a darn about this and why should they – service is beneficial to all involved.

MCM – Has CMS done anything recently to increase payer interest in MSAs and professional administration?

Leslie – [recently there’s been a] Steady drumbeat from CMS on tightening up oversight and MSAs and professional admin…for instance, a few years ago with CMS’ electronic portal to submit reporting – we worked hard with CMS to make it work. Last year CMS put out messaging re MSAs in an attempt to move the market towards submitting MSAs for CMS’ approval– CMS did a webinar last month saying that in 2025, CMS will mandate that when you settle a case you have to put a $ figure for moneys that were set aside to protect Medicare …now the payer has to tell CMS when they settled the case, even if the MSA was not formally submitted to CMS for approval, the payer has to tell CMS [explicitly] the amount that was set aside to protect them. All this effort to drive extra visibility shows CMS is watching settlements and wants to make sure the injured workers’ medical funds are properly set aside and administered after settlement.

MCM – Unusual for a bank to acquire a workers’ comp services entity; talk about the rationale.

Leslie – Don’t think of ourselves as WC services business – receive business from WC but once injured workers land with us, the individual is a cash pay member of the healthcare system – in the [sale] process we did not want to be typecast into WC business – we do fair number of general liability and accident claims as well

Webster is top 25 bank and the largest bank-run administrator of HSA [Health Savings Accounts]. Webster acquired an HSA admin company that was tiny, now it is close to $13 billion in deposits…Webster held majority of Ametros’ deposits and made a loan to the business, knew Ametros well and was accustomed to investing and growing this type of business. The deal really was the natural evolution of a partnership that was years in the making.

MCM – While there haven’t been many transactions of late, in general valuations have declined from those a few years ago…this transaction bucks that trend. Valuation of $350MM was quite impressive, as was the all-cash purchase.

Context is Webster is a [recent] combination of Sterling Bank and Webster [which] doubled its size…they have been pretty active looking for differentiated source of deposits…Webster is not trying to be expert in WC…know Ametros has a team of experts that do that know that.

MCM – How will Ametros operate going forward?

Leslie – No team changes or system changes or tech changes – vision from W is to remain independent similar to HSABank – questions Webster is asking [of management] are how to grow faster; need people, systems, etc? – Ametros administers 8-9% of MSAs that are settled today, and we should be handling 80-90%…[expect we will] put forth budgets to really propel the business.

 

MCM – What changes will customers see?

Leslie – Keep same brand, same products, invest in making them better, no changes to staff

[There is] Not a workers’ comp dedicated bank out there, so may be other opportunities for Webster in WC.

[There are] Other entities [in MSA administration] that are 1/5th the size of them that could be acquisition candidates

What does this mean for you?

Great business ideas with great marketing executed very well can be very lucrative. 

You need all three.

 

 

 


Dec
18

Provider consolidation = Higher workers’ comp costs, longer disability

Healthcare provider vertical integration increases work comp medical costs, increases disability duration, and does not deliver better outcomes.

And, provider consolidation continues to increase.

The lede is the one-line summary of WCRI’s latest – and quite useful – research.

Olesya Fomenko and Bogdan Savich collaborated on a very well done study of vertical integration of providers’ impact on work comp, and their research bodes ill indeed.

Summarizing the experts’ findings, vertically integrated providers had: 

Some detail…courtesy WCRI

And if you think that’s bad…here’s the impact on disability duration…

These conclusions generally align with what we’re seeing from other payer types…consolidation leads to higher prices and negative to neutral impact on outcomes.

That isn’t stopping consolidation  – far from it.

What does this mean for you?

Find out how consolidated provider markets are where your business is. And watch for more consolidation, as that will predict higher costs.


Dec
15

Well that was a GREAT Thursday.

The FED announced that not only is it not raising rates, it plans on cutting interest rates next year. While that’s great news indeed, what drove the FED decision shows the economy is doing well – and will get better.

From Reuters quoting FED Chair Jerome Powell:

  • “We are seeing strong growth that … appears to be moderating.
  • We are seeing a labor market that is coming back into balance …
  • We’re seeing inflation making real progress,” [emphasis added]

In fact, personal consumption expenditures inflation is seen ending 2023 at 2.8% and falling further to 2.4% by the end of next year

And, betting markets predict the FED rate will drop 1.5 points – below 4% – over the next 12 months.

Stock markets boomed, with the DOW hitting an all-time high and the S&P close behind.

And home mortgage rates are back below 7%, and headed down from there.

What does this mean for you? 

  • Lower credit card interest rates so consumers will spend more,
  • cheaper mortgages will mean construction will increase,
  • which means more jobs.

 


Dec
14

Electric grids, infrastructure, jobs and payroll

In which we briefly discuss the power grid, jobs and what it means for you.

The good news is the Inflation Reduction Act (IRA) and bipartisan Infrastructure Investment and Jobs Act invest billions of dollars to upgrade the nation’s electrical grid.

courtesy Carbon Collective

(a connected grid enables operators to send power from places where there is plenty of electricity – say Arizona – to places where demand is super high – say Oklahoma during a deep freeze)

Dollars going to infrastructure are a major reason construction spending has jumped..it’s now more than a third higher than pre-COVID

Paralleling investment, construction employment has dramatically increased and is well above pre-pandemic rates..

source – FRED

What does this mean for you?

More investment = reliable infrastructure + more jobs = higher payrolls = higher premiums.

A very good explanation of the grid, transmission, and electricity production is here.


Dec
13

Optum employs(?) more doctors than any other organization

The giant subsidiary of United Healthcare employs [>]90,000 MDs and 40,000 more advanced practice clinicians – far more than any other entity.

That’s more than one out of every ten physicians, and a far higher percentage of practicing MDs.

While that’s pretty amazing, its just one of the many investors, healthplans, private equity firms, large healthcare systems, and insurers snapping up all manner of healthcare providers.

In fact, almost three-quarters of all physicians are employees of companies or healthcare systems/hospitals – not members of physician-owned practices.

As with everything in healthcare, location makes a big difference.

One of the biggest drivers has been Optum’s acquisitions, which included Kelsey Seybold, a very large practice in Texas…Optum reportedly paid $2.2 billion for the business.  And, that happened AFTER the time period in the graph.

What does this mean for you?

Your healthcare will be driven by investors’ goals.

note – Optum’s communications folks asked me to publish a correction, because not all of the 90k docs are “employees”…I asked how many of those 90k docs are “employees”; Optum’s reply was “We don’t break out the numbers because we focus on the total number who serve our risk-based patients.”

I’m quite sure Optum knows the number. why they won’t release it is a mystery.

I also asked – twice – whether the “physicians who contract directly with Optum” (which make up some/part of the 90k docs):

  • exclusively contract with Optum,
  • are allowed to contract directly with other payers, and/or
  • is Optum the contracting intermediary?.

I didn’t get an answer.

So, all I can tell you, dear reader, is Optum directly employs ≤ 89,999 physicians, and may or may not allow those “non-employed” physicians to contract with other payers.


Dec
11

Healthcare regains the political stage

Healthcare has not been on the political landscape since the last attempt to overturn the Affordable Care Act aka ObamaCare failed…and then-candidate Trump talked up his very-hard-and-actually-impossible-to-locate HealthPlan.

Just-released polling indicates several healthcare issues are top-of-mind for voters across the political spectrum.

  • 4 out of 5 voters say it is “very important” for candidates to talk about healthcare affordability...making healthcare the second most important topic among respondents.
  • The ACA is back in voters’ minds with almost half of poll respondents stating the ACA’s future is “very important issue”.
  • Medicare and Medicaid are also top of mind for voters as is access to mental healthcare with 75% and 70% of respondents respectively stating these issues
  • Related, about a quarter of voters (24%) say they would only vote for a candidate who shares their views on abortion.

What does this mean for you?

As America ages and healthcare becomes increasingly unaffordable, more voters are more about healthcare. 

 


Joe Paduda is the principal of Health Strategy Associates

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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.

 

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