Insight, analysis & opinion from Joe Paduda

Jun
3

Surgeons and carpenters

A very interesting post from a surgeon defending his profession from an attack by someone stating that surgeons are no different from carpenters plumbers and engineers.
Those of us on the payer side of the table would do well to remember that there are passionate, highly intelligent, motivated and great people on the “other” side. Perhaps we should make that table round instead of rectangular?
What does this mean to you?
We are in this together, and insulting comments, intended or not, damage our mutual desire to deliver for our mutual customers.


Jun
3

Premium increases’ impact on uninsurance

If health insurance premiums continue to increase by 10% annually, the percentage of working adults in California with employer-based coverage will decrease from 58% to 53% within five years. The finding, from a study by the University of California-Berkeley, also noted:
— for every 10% increase in premiums, 910,000 Americans lose employer-sponsored coverage
— of those who lose coverage, 75% are uninsured and 20% are insured by Medicaid
— the average premium increase over the last five years has been 11% nationally
According to the Contra Costa Times, 6/2Anthony Wright, director of Health Access, said, “We’re getting close to the tipping point. … Employers who do provide coverage (now) won’t because no one else is”.
I’ve been noting the convergence of a number of factors that seem to indicate growing pressure to come up with some national consensus on health care coverage reform. When middle class voters start to lose their health insurance, the “tipping point” will be reached. And when that happens, there will be reform.
What does this mean for you?
A reform that includes universal access would have relatively little impact on total medical costs (less than $90 billion annually) with significant improvements in health status of the presently uninsured. In addition, there would likely be less incentive for providers to cost-shift, thereby reducing the “hidden tax” inherent in today’s dysfunctional health care funding mess.


Jun
2

Texas workers comp reform bill signed

Texas Governor Rick Perry signed a Workers Comp reform bill into law yesterday, authorizing the use of networks for treatment of injured workers.
To quote the Dallas Star Telegram;
“The revised law will create physician networks like those in commercial health plans and provide a small boost in benefits paid to injured workers. Texas has the country’s third-highest workers compensation costs and the highest rate of injured employees not returning to work. The law replaces the Workers’ Compensation Commission with a single, appointed commissioner housed in the Texas Department of Insurance and creates an Office of Injured Employee Counsel as an advocate for workers.”
What does this mean for you?
At long last, perhaps meaningful reform of the one of the nation’s worst workers comp environments. I’ll be taking a much closer look at this legislation and potential impacts of same in the near future.


Jun
1

Ohio Bureau of Workers Comp’s latest problem

Jon Coppelman at Workers’ Comp Insider has an intriguing post about the problems at the Ohio Bureau of Workers Comp. Kudos to Jon as he appears to have scooped the New York Times, who published their article a couple days later. To quote Jon;
“The workers compensation bureau has invested $50 million in rare coins, working through Tom Noe, a man prominent in Republican fund raising circles. Indeed, Mr. Noe has been recognized by the Bush-Cheney campaign as a “Pioneer,” as he raised over $100,000 for the President’s re-election campaign.
Realm of the Coin
At this point, it appears that some of the coins purchased by the state fund are missing. Two of the most valuable, totaling a quarter of a million dollars, were “lost in the mail” according to Noe. An additional 119 coins were “misappropriated by an employee.” The coins “went missing” back in 2003, but Noe neglected to tell anyone. The initial estimate for the missing coins was $400,000. Now, according to Noe’s own attorney, the figure is somewhere between $10 and $12 million.”
Despite the very troubling implications of this debacle, it does make for highly entertaining reading. Following the comedy of errors (being kind) perpetrated (or should I say committed) by elected and appointed officials will being a chuckle and shake of the head to most readers.


Jun
1

Medicare Part D winners and losers

Kevin Piper summarizes the good, the bad, the ugly, the winners and losers from the new Medicare Part D program in his blog “the Piper Report”. As more information has become available, it is clear that there will be substantial changes to the pharma supply chain, with most entities seeking to better understand utilization and price drivers and squeeze margins wherever possible.
Piper notes winners will include:
–low income Medicare recipients without Rx coverage today
private employers with generous retirement medical plans will reap a multi-billion dollar windfall, although legislation may reduce this.
large national insurers seeking to expand market share in this rapidly growing market of seniors
–lobbyists actuaries and consultants.
That may be true, but the fundamental problem of adverse selection still exists. It is getting lonelier by the day out here in the “but the business model just does not make sense” woods, but I have yet to hear anything that makes it sound like Part D providers will be protected from adverse selection.
What does this mean for you?
I’d be very careful of Part D; just because others seem to believe in this does not mean you should not carefully assess the risks.


May
31

Federal government and pharma pricing

Legislation has been introduced in the US Senate that would prevent pharmaceutical companies from including the cost of advertising in calculating drug prices for governmental programs. Moreover, the legislation also requires that the HHS and Veterans Affairs Departments “negotiate reduced prices on drugs that are advertised directly to consumers in other programs” (quote from California HealthLine).
The legislation is sponsored by John Sununu (R NH) and Ron Wyden (D OR), senators that are not exactly on the same philosophical plane on many other issues.
According to Wyden, since companies’ advertising expenses are already a tax deduction, “[t]axpayers shouldn’t have to further subsidize the drug companies’ marketing efforts through Medicare and Medicaid.”
My sense is this is a backdoor way for Congress to encourage HHS to negotiate prices with pharma. The Medicare Reform Act specifically prohibits HHS from negotiating prices, a situation that rankles many legislators and taxpayers. Of course, Sununu et al are quick to claim this is not the intent. Regardless, it is a clear indication that some in Congress are looking for creative ways to reduce the cost of pharmaceuticals to the government, and taxpayers as well. With the present budget deficit and focus on same, look for this motivation to result in some meaningful price discussions.
What does this mean to you?
Watch pharma pricing carefully; due to the “flexible” nature of Average Wholesale Price (AWP), (sometimes referred to as “Ain’t What’s Paid”) price reductions in one sector can often be offset by increases to other payers. And as we have noted before, price is but one component of the pharma cost equation of price X utilization X frequency = total cost.


May
31

Emergency department usage increases

There has been a substantial increase in the use of emergency departments in recent years. A new report from the Centers for Disease Control indicates the number of ED visits reached an all-time high of 114 million in 2003.
The increase was attributed to adults, and more specifically Medicaid recipients who used EDs four times as often as those with private insurance. One of the report’s editors noted that the ED has become the provider “of first resort” for many of the poor and uninsured.
With the present political wrangling over the future of Medicaid and the uninsured, this report points out one of the most troubling aspects of the “delivery systems” used by the poor. Care delivered through the ED is typically more expensive, time-consuming, and less coordinated than care delivered through a primary care provider. Tests and imaging are often duplicated, there are often problems with continuity of care, and patients with chronic conditions seek care for acute episodes in the ED rather than through their primary doc.
It is impossible to calculate exactly how much money is wasted in this process, but it is certainly in the billions of dollars.
Clearly the industry needs to do a better job of directing patients to appropriate levels and locations of care. Having been involved (albeit years ago) in a state Medicaid reform effort, I have some understanding of the problems involved. However, it is clear that the quality of care delivered is too low and the cost of that care is too high when it is provided at an emergency department.
What does this mean for you?
Redouble efforts to direct patients to primary care. Work with providers to set up streamlined primary care access next to the ED. Yes this is a big problem with lots of issues, but we can’t afford to not address it.


May
27

HMOs and Workers Comp

Why isn’t workers comp a good business for group health plans? Several clients and industry types have asked for my take on the recent move by Aetna, Coventry, Wellpoint, and possibly UnitedHealth into workers comp. Without giving away too much (as a consultant I have to make a living), here’s the synopsis.
1. The group health world is saturated. It is rapidly approaching oligopoly status, wherein a few players control most of the market. Therefore, market share is tough (and expensive) to come by.
2. Health plans are seeking alternative revenue sources, and workers comp seems attractive – it is, after all, health care delivered to insured workers by physicians, hospitals, etc.
3. Health plans are arrogant – most look at the workers comp field with disdain, as a modern homo sapiens would consider a Neanderthal. Managed care in comp is behind the times, networks are sloppy, systems are antiquated, and medical management is poorly done. No argument there.
Sound good? Not so fast.
While there are many factors that should give a group health entity pause, the most important one is the tiny size of the potential market.
Total annual medical spend in workers comp, from all payers is around $30 billion. Let’s say one health plan captured all that revenue from all payers. Here’s how the numbers work, or rather don’t.
Out of that $30 billion, about 60% will flow through a network, or $18 billion. Of that $18 billion, a very good health plan will save about 10%, or $1.8 billion. The health plan will be paid up to 20% of those savings (likely considerably less), or $360 million.
So, if one health plan has 100% market share in workers comp networks, the total revenue (not profit) is $360 million.
By way of comparison, Aetna’s annual revenues are around $20 billion and net profits of about $1.6 billion. United HealthGroup’s revenues are $44 billion, $3.6 billion in profits; Wellpoint also has $44 billion in revenues and $2.4 billion in profit.
So, while $360 million sounds good, it is about 1% of the average annual revenues of one of the top HMOs. And that is only if one HMO has 100% market share, a rather unlikely scenario.
More like a rounding error than a business opportunity.

What does this mean for you?
If you are a WC payers, beware health plans bearing gifts. If you can get by their talk of “members” and pricing based on “per member per month” and interest in including ob/gyns in their network and inability to understand the “tail” of workers comp, remain skeptical of their long term staying power.


May
27

HMO profits up 33%

Although health plan profits were up substantially in the first 9 months of 2004, only five companies were responsible for over half of those profits. Weiss Ratings’ (along with Fitch, my favorite rating firm) analysis excluded Kaiser, which had gains of $1.2 billion primarily from a regulatory change.
Four of the top five were HMOs owned by Blues plans, with the leader Blue Cross of California posting over $400 million in profits for the period.
Even more notable was the overall improvement in the industry’s financial condition, Weiss upgraded 65 HMOs and only downgraded 3. This improvement was driven by a 33.6 percent increase in profitability.
Other reports indicate the decline in the rate of medical inflation coupled with increased premiums have been largely responsible for the improvements. United HealthGroup, Coventry, Aetna, and others have all reported this “decrease in the rate of increase”.
Good times never last; consolidation in the industry has led to its’ present oligopolistic condition. Thus, health plans have three choices if they are to grow – take market share by cutting price; acquire other health plans; or seek other sources of revenue. Actually, there is a fourth – seek to reduce “cost of goods sold” by reducing reimbursement to providers, but this is highly unlikely to succeed.
The pace of acquisition will likely slow for the simple reason that there are fewer health plans to acquire. Potential candidates include Coventry, but their high-flying stock price likely precludes any move in the near future.
Plans are actively and aggressively, seeking new sources of revenue. The move into workers comp network rental by Aetna and Wellpoint are but two examples. However, it is highly unlikely that there is enough revenue in the ancillary lines to please the Street’s demands for ever-increasing growth.
That leaves price cutting. Yes, all will claim they will never repeat the mistakes of the past, and most will do so anyway. Good times never last, especially in the insurance industry.
What does this mean for you?
Three things.
1. If you are a provider, watch the new contract offers carefully.
2. If you are a workers comp payer, lock these new entrants into long term contracts with significant exit penalties – their interest will likely wane when they figure out how little money there is in workers comp, leaving you high and dry.
3. If you are an analyst, monitor pricing and medical inflation, especially the components of inflation (frequency and utilization) more than unit price. That is where renewed inflation will first appear.


May
26

Generalists v specialists

Roy Poses MD has posted an insightful, brief, and trenchant look at the trend for new physicians to select specialties other than internal medicine, family practice and the like.
To quote Dr. Poses,
“However, as demonstrated by the issues discussed on this blog, not only are generalists at the bottom of the economic pecking order, they seem particularly impacted by the huge rise in health care bureaucracy, and particularly vulnerable to challenges to physicians’ professional values instigated by large organizations lead by leaders with conflicting interests. They will need more than new “chronic care models” to survive these threats.”
The continued trend to more highly compensate specialists is driving physicians to select specialties. The root of this is compensation, followed closely by the hassles inherent in today’s managed care bureaucracy.
What does this mean for you?
For once, this is simple – the more specialists, the more specialty care, the more expensive the care, the higher the medical expense.


Joe Paduda is the principal of Health Strategy Associates

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