Insight, analysis & opinion from Joe Paduda


I’m thankful for

The many, many good friends I’ve made over 30+ years in this business…people I would not have met if I hadn’t somehow stumbled into and stayed/got stuck here.

The passion many have to do the right thing and the privilege it has been and is to work with companies and organizations with that central objective.

Readers who challenge, confront, correct, applaud, cheer, and debate and have been doing so for 17 (!) years.

The mistakes I’ve made over the last few decades, for what they have taught me about hubris, assumptions, lack of diligence, and the power of experience.

My family – Deb, the most positive, joyful person on the planet who’s somehow tolerated me for 34 years; Erin who’s become an amazing mom, fierce advocate for her patients, and incredibly strong person; Molly whose intensity in competition is matched only by her love for and dedication to family; and Cal who has persevered in the face of overwhelming difficulties, always pushing through and never giving in.

A lot about our world is less than great these days, so it’s more important than ever to keep the good front and center.

Be well.




COVID conversations, curiosities and cures

Three-quarters of a million of our friends, family, neighbors and coworkers have died of COVID.

That is a mind-blowing number, made personal because all of us know of someone who died of the disease or has a family member that did.

Remember 9/11 killed about 3,000 of us.

Of course, the unvaccinated are dying at a far higher rate than the vaccinated, and the vaccine divide is becoming more partisan by the day. Unvaccinated English people were 47 times more likely to die of COVID than those who had been fully vaxxed for more than three weeks. 

KFF’s survey reports the race/ethnicity vaccination gap has shrunk significantly, while the partisan divide has grown over time.

Today, the most significant factor determining vaccination status is political affiliation. 

What’s sad beyond belief is this

That said, 6 out of 10 of those who identify as leaning or Republican have received at least one dose.

Thanks to Broadspire’s Marc Cunningham for hosting me on the Beyond the Claim podcast; Marc and I spoke about the impact of COVID on workers’ comp, the need for deeper understanding of medical drivers, and what the future holds.

Advocate Healthcare Aurora’s Teresa Clarke took the stage in the second episode, and dove deeper into COVID and healthcare. Teresa manages AHA’s work comp program, and has been in the trenches since day one of the pandemic.

Hat tip to Broadspire’s Chris Stephenson for handling all the heavy lifting on the pod.

Two new medications show a lot of promise in treating COVID. And no, neither are Ivermectin.

Pfizer’s Paxlovid is in the Emergency Use Authorization process; the Federal government is expected to contracted to buy 10 million doses of the medication.

When given within three days of symptoms, Pfizer’s antiviral reduced the rate of death and hospitalization by 89 percent for those at high-risk of developing severe illness.

Merck’s drug “reduced the risk of hospitalization and death by nearly half among higher-risk people diagnosed with mild or moderate illness.”

What does this mean for you?

Get vaccinated, because you might die if you don’t.


Infrastructure = jobs = premiums and claims

Three days ago President Biden signed the Infrastructure Investment and Jobs Act, a notable accomplishment coming after bipartisan support in Congress.  Pretty remarkable that this happened at all; past Administrations  – both Democratic and Republican that enjoyed majorities in Congress were unable to pass this desperately needed legislation.

There’s lots of good news in the Act; including: (source Business Facilities)

  • US$47 billion in climate resilience measures to protect buildings from the storms and fires that result from climate change
  • $65 billion to repair and protect the electric grid, build new transmission lines for renewable power and develop nuclear energy and “green hydrogen” and carbon capture technologies
  • $39 billion to continue and expand current public transit programs, including help that allows cities and states to buy zero- or low-emission buses
  • $66 billion to fix Amtrak and build out its service along the Northwest Corridor, in addition to building tens of millions for high-speed rail and other commuter rail
  • $7.5 billion to build electric vehicle charging stations;
  • $25 billion to repair airports to reduce congestion and emissions, encouraging the use of low-carbon flight technology

States are already targeting the funds for much-needed projects; North Carolina is getting $1.5 billion for bridge repairs,  broadband expansion, and transportation upgrades – and more dollars for other projects.

Wyoming’s roads, dams, water systems and bridges will get $2.5 billion in repairs and upgrades.

Arizona’s rapidly expanding population desperately needs new infrastructure – and big improvements to utilities especially water as well as ports of entry along the border. 

The federal Transportation Department “plans to open competition for the first round of port infrastructure grants funded by the bill within 90 days, as part of a broader effort to ease supply chain bottlenecks slowing down the delivery of goods.”

That will impact Long Beach, Savannah, Houston, Los Angeles, Miami, Mobile, Seattle, Norfolk and other critical ports.

The question is – how fast will these dollars translate into employment? I’d say next summer we will see a noticeable impact as plans that are already under development get funding commitments.

The Federal Highway Administration projects each billion dollars in highway funding supports 13,000 jobs.

S&P estimated a:

 $2.1 trillion boost of public infrastructure spending over a 10-year period, to the levels (relative to GDP) of the mid-20th century, could add as much as $5.7 trillion to the U.S. over the next decade, creating 2.3 million jobs by 2024 as the work is being completed.

The Act is about $1.7 trillion in spending, so we’re looking at about 1.9 million jobs. 

Of course, that is an estimate – it could be higher or lower. However, there’s no question workers’ comp will see:

  • higher premiums;
  • more claims; and
  • higher severity.

What does this mean for you?

Prepare for some much-needed growth. 


Medical drives everything

The “claim-centric” approach to handling workers’ comp claims is misguided.

Hear me out.

You’re a parent of a sick child. Her pediatrician wants her to get ear tubes and an antibiotic. The insurance company’s claims rep denies the request, instead requesting an X-Ray and Tylenol, telling you to call back in a few days if that doesn’t work.

Of course, the claim rep thinks she’s doing the right thing and has decades of experience – but no medical training, no RN or any other designation.  You appeal to your daughter’s case manager, who agrees with the pediatrician.

And the claims rep rejects the case manager’s recommendation.

24 hours later, your baby daughter has a fever and is hoarse from screaming and you are at the local ER, about to lose your mind.

This is how almost every workers’ comp payer “manages” medical treatment.

Claims reps/adjusters/examiners with zero formal medical training decide what medical care your claimants get.

They approve opioids and spinal cord stimulators because they don’t want to hear from an attorney.

They deny surgeries because, well, because they don’t think they are necessary.

They refuse to pay for behavioral health because they don’t want to “own the psych.”

They “certify” 24 visits of PT because, well, because…

Medical drives claim outcomes. Medical drives claim costs.  Medical drives recovery and return to work. Medical drives litigation. Medical drives everything.

What does this mean for you?

Would you let a claims rep determine the care your baby or grandbaby gets?

Then why do you have claims reps determining the care your claimants receive?

(shout out to an anonymous good friend who got me thinking more about this)


for hospitals, Cost ≠ Quality

Some hospitals are efficient – defined as delivering excellent care at relatively low cost, while others are quite inefficient – high cost, not great care.

Then there are the high cost and unknown quality of care facilities – but the net is this – cost ≠ quality, and quality does not cost more.

The Lown Institute has done some great research on this, and identified the nation’s 10 most efficient hospitals – the criterion being how much Medicare was charged compared to how many patients died 30 and 90 days from admission. OK, that isn’t by any stretch a comprehensive definition, but the results were revealing.

Costs ranged from $9,000 to $27,000 per patient…and if all hospitals operated as efficiently as the top 10, we taxpayers would save $8 billion each year.

Of course private payers are charged more, and pay more than Medicare. Nonetheless, efficient hospitals are going to be efficient for all payers.

Here’s the top ten.

  1. Pinnacle Hospital (Crown Point, Ind.)
  2. Saint Mary’s Regional Medical Center (Reno, Nev.)
  3. MercyOne Dubuque Medical Center (Dubuque, Iowa)
  4. Encino Hospital Medical Center (Encino, Calif.)
  5. Park Ridge Health (Hendersonville, N.C.)
  6. Oroville Hospital (Oroville, Calif.)
  7. Saint Michael’s Medical Center (Newark, N.J.)
  8. UnityPoint Health-Meriter (Madison, Wis.)
  9. East Liverpool City Hospital (East Liverpool, Ohio)
  10. Maple Grove Hospital (Maple Grove, Minn.)

Curious about another hospital?  Click here to find out how it ranked.

What does this mean for you?

Knowledge is power – but only if you use it.


Big doings! and natural immunity vs vaccination

Well. that was welcome indeed.

Looks like the Dems in Congress have reached a deal on controlling (some) drug prices. As with all legislation, it is far from perfect, no one is particularly ecstatic, but then again, politics is the art of the possible, and the deal WILL help control drug price increases. Especially for older Americans who now get out-of-pocket spending on drugs capped at $2,000 a year and diabetics who will get a cap on insulin at $35.

Will this effect workers’ comp? Unlikely. WC drug fee schedules are based on AWP except in Cali, where it is based on Medicaid.

The Labor Department’s jobs report this morning showed over half a million people were hired last month, a major jump over prior months. Over 5 million (!) have been hired since January.

This means – higher payrolls = more people insured, more payroll, more consumption.

I expect employment will be a topic of conversation at WCRI’s annual meeting, slated for March 16 – 17 in Boston. Save that date and make sure you are on their mailing list as this always sells out.

All things COVID

Two drug manufacturers reported positive results for their new COVID treatment medications.  Just-released data from a clinical trial indicated Pfizer’s Paxlovid cut the risk of hospitalization or death a whopping 89 percent when administered within three days after the start of symptoms. Paxlovid won’t be widely available for several months, and then will likely be prescribed mostly to high-risk people.  Treatment will cost about $700 per patient.

Merck’s  molnupiravir will cost about the same; it has been approved for use in the UK and the manufacturer has applied for an Emergency Use Authorization (EUA) here in the US.  As reported in the Economist, research

“found the interim results of a trial found that patients with a risk factor for covid-19 were 50% less likely to be hospitalised or die if the oral antibiotic was taken in the first five days after symptoms.”

While neither is available just yet, expect both to get EUA approval shortly.  BTW, remember the vaccines were also administered under EUA.

We are learning more each day about long COVID, and much of what we are learning isn’t good (note that’s not surprising, as first we need to understand the problem and only then can we work on solutions). Significant GI problems are one issue, and the more severely affected patients also present with anxiety and sadness. That’s not surprising either, as nothing makes you more miserable than a severe GI problem.

BUT… one of the report’s authors noted “We do not know whether the psychiatric symptoms are a cause or a result of the GI symptoms, but we suspect it is likely to be both,”

About 20 million of us have experienced symptoms such as difficulty breathing, pain, hypertension and fatigue that are consistent with long COVID. Get the latest on November 17 at noon eastern when the National Institute for Health Care Management hosts a time of a webinar on the “Implications of Long COVID for patients and the health care system.” Register here.

Alert for some readers advocating “natural”immunity… A new study found “unvaccinated US adults who previously had COVID-19 contracted the disease at more than five times the rate of those who were fully vaccinated.”

What does this mean for you?

Get the shot.



Reimbursement is changing – nerd alert…

CMS – aka Medicare – has published details on the pending cut to physician reimbursement and some physician groups are howling.  The cuts aren’t uniform; Any changes to the fee schedule done via rulemaking must be budget neutral; if some payments go up, others must go down.

Overall reimbursement is slated to drop by about 4%.

Surgery and radiology are two of the specialties especially vocal about the changes, which MAY be altered or retracted if Congress passes a law revising the reimbursement change.

(Details on this are here…)

A couple other things of note…

  • Of interest to workers’ comp are new codes (CQ and CO) and payment for services rendered by PTAs and OTAs supervised by PTs and OTs at 85% of the PT/OT rate. there are modifiers and time requirements, so make sure your BR entity has got this coded correctly.
  • The CPT Codebook listing of bundled services are not separately payable.  I’d note that this is NOT universally understood by work comp bill review entities; yes it is complicated and yes it changes, so payers would be well-advised to make darn sure they are handling these bills correctly.
  • Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Again, this is why reviewing provider notes is key, because facilities/practices often bill these separately in the hope that the payer won’t catch the “unrelatedness” issue. Separately, a denial of payment for critical care services should NOT result in an additional fee to the payer; that is basic bill review – or should be. Also, watch out for PPO fees attached to those separate charges – BR and PPO companies make money on those “reductions” while they DON’T make more $$ on just denying the critical care service as part of a code review.

So, what does this mean/what are the implications?

Watch out for creative billing/increased utilization as providers look to make up for lost revenue/lower reimbursement from Medicare and Medicaid.

Ensure that A)  your bill review program is prepared to handle these changes and B) you aren’t paying extra for that “management.”

(for more on the issue of how Sequestration effects reimbursement, go here.)



The death of office work.

Ok, that was a bit clickbait-ey…

but just a bit

Lately I’ve had several conversations with work comp and health plan executives that lead me to believe office work is changed forever  A recent survey of workers by Grant Thornton concluded:

  • 40% will look for another job if forced to return to the office full time
  • 56% are looking forward to returning to the office
  • 51% would give up a salary increase for more flexibility in when and where they work
  • 34% believe their manager is the most stressful part of the day

Here’s the key takeaway…

It “appears the requirement to be in the office full-time is a driving factor that is motivating record resignation. According to the survey, 79% of survey respondents say they want flexibility in when and where they work…”

And this isn’t unique to the US.  Employers in India look likely to adopt a hybrid work model.

Tech and telecoms are already embracing the new model, and I’d bet the rest of us aren’t far behind. For work comp this isn’t anything new as many payers already have long had adjusters and case managers WFH (working from home). Full-service insurer Strategic Comp’s always had field-based adjusters; the carrier’s excellent performance adds serious weight to the argument for remote work.

Then there is quality of life.

You’re an adjuster for a major payer in California. Your commute is over an hour, traffic is awful, you have kids at home, and childcare is darn near impossible to find. You’ve been working remotely for over a year. Your performance is solid, your finances are in the best shape they’ve been in years, and the thought of getting back in the car and listening to the Morning Zoo makes you break out in a cold sweat.

oh, and your employer is desperately short of adjusters and case managers and can’t afford to lose you.

What does this mean for you?

Don’t invest in commercial office buildings.



What happened while some of us were in Las Vegas

WCRI posted lots of excellent research, and topped it off with a webinar…I’ll be diving into these later this week, but for those chomping at the bit, here’s a brief summary.

The research included a:

…and an excellent webinar o the effects of Opioid-related Policies on Opioid Utilization after Work-related Injuries – you can watch the webinar here – no charge!

PhRMA appears to be holding off efforts to enable the government to negotiate drug prices for Medicare and Medicaid members; the $22.4 million it spent on lobbying is a pittance compared to the profits the industry is generating. Three Democrats in states with lots of Pharma companies appear to be holding things up, soaking up big bucks in campaign donations in the process.

And then there’s COVID

New research indicates “natural immunity from a COVID-19 infection fades quickly, leaving individuals susceptible to reinfection.” Published in The Lancet, the study found a previous COVID infection does not provide much protection against re0infection.

Research published by the Kaiser Family Foundation indicates 90,000 of our family members, dear friends, colleagues and co-workers didn’t have to die of COVID.  That’s the estimated number of additional deaths due to failures to be vaccinated.

Oh, and the number of vaccinated people who died of COVID was tiny by comparison, so don’t believe that BS about Colin Powell.

Health systems are ramping up terminations of  workers who refuse to get vaccinated  – but the number of employees fired remains pretty low.

What does this mean for you?

WCRI does great work.

Get vaccinated and wear a mask.


National Work Comp – general impressions

Yes, attendance was way down.

Yes, the exhibit hall was pretty quiet.

Yes, it was really good to see old friends and colleagues, to re-connect and just smile at each other live, in person, and not in 2D.

Yes, it was a bit hard to connect names to faces when those faces haven’t been seen live in a too long and were mostly covered by masks…and

Yes, dealing with reading glasses, hearing aids (yep, that’s me) and masks can be pretty challenging.

What’s new.

Mental Health/behavioral health were big topics – and that is excellent/terrific/welcome indeed. Carisk announced a partnership with Tower MSA and Ametros to help resolve and settle claims; behavioral health issues are often the primary reason claimants are reluctant to settle. (Carisk is an HSA consulting client)

AI. Lots of AI. Tons of AI. Fraud detection AI. Claim processing AI. Voice Response AI. Chatbot AI. My bet is we’ll be seeing even more of it, as the biggest challenge most payers have these days is staff.

Catching up with colleagues in the payer world, every one noted adjusting talent is:

  • getting older,
  • getting crankier (well, this is a bit unfair, but adjuster dissatisfaction was definitely a topic),
  • leaving for better pay,
  • leaving for better conditions (be careful, the grass may well be greener because there is more fertilizer on it…)
  • and really hard to find.

So, here comes AI to hopefully increase job satisfaction and reduce the number of low-value clerical-type tasks so adjusters can actually, you know, manage claims.

And, adding behavioral health expertise to the claims management process will help reduce claim inventory, further reducing adjusters’ work load.

Enlyte is the new name for the Mitchell/Genex/Coventry business...personally I’m not a fan – I would have preferred Magic as that’s way cooler and kind of ties back to the MGC thing.  Also not a fan of the consolidation of all customer facing stuff into a central entity. In a past life I sold group insurance for Liberty Mutual; While I was really good at selling group health and disability, I was way less than any good at selling retirement plans  – which I had to do if iIwas going to get the commission multiplier.

No one else was any good at it either, so much so that Liberty dropped the requirement that we sell retirement plans.

Nina Smith has the unenviable task of trying to get Mitchell bill review people to sell Genex stuff, Coventry’s network experts to sell Genex stuff… you get the picture. Ok, you say, Mitchell has been “selling” networks for a long time, Coventry used to sell bill review, Genex has been doing both. While this seems pretty straightforward, it is not. I can assure you it will take a lot of time, a lot of handholding, and a lot of patience.

Masks were required, but I saw too many people, including some I know well who didn’t wear them. That is disrespectful at best and just not smart. The reason:

  • attendance was way down,
  • many companies didn’t attend, and
  • this country hasn’t gotten back to “normal”,
  • which means claims counts are still low
  • and premiums are too

is because too many people have listened to claptrap and nonsense (I know, I really want to swear…) and for whatever dumb and completely unfounded reason won’t wear a mask to protect the rest of us – and themselves.

I feel for the event planners and folks behind this; while I don’t have official attendance numbers, this place is nowhere near as busy as it has been at past events. No taxi line, no problem getting a table for breakfast, fewer folks walking around in business casual.

Putting on a conference is a shipload of work, especially these days. While I lament the very real issue of pay-to-play, the conference owners need to make a buck, something they haven’t for far too long.

What does this mean for you?

Until and unless we all get vaccinated and wear masks we will not put COVID in the rear view mirror.

I thanked Denise Algire and Michelle Kerr for all the work that went into this – and you should too.



Joe Paduda is the principal of Health Strategy Associates



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.



© Joe Paduda 2021. 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.

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