Sep

Changes to Managed Care Matters

Posted by Joe Paduda on Tuesday, September 4th, 2012 | Comments

It is time to upgrade, and update, this blog. To that end, we’ll be switching to another platform – WordPress – which has several advantages over our current one.
The move will take place next week, and you’ll get plenty of notice.
This will likely require subscribers to renew their subscription – no need to do anything now. The ‘renewal’ will be very simple, merely requiring you to enter your email address on the blog’s front page.
The new platform will make it much easier to add video, images, and files to posts; manage subscribers; handle spam comments (we get about 50 a day!); and speed up the posting process.
I’m often asked how much time it takes to maintain and post on MCM; short answer is about 45 minutes a day, but that’s only because I have excellent support and guidance from Julie Ferguson and hosting handled by Chris Miller (owner of Artefact Design).

Sep

How physician dispensing companies promote their product

Posted by Joe Paduda on Tuesday, September 4th, 2012 | Comments

Why do physicians dispense drugs to workers comp patients?
To hear them tell it, it’s all about convenience, better outcomes, lower cost, faster return to work – all assertions made without a shred of evidence.
The reality is rather less noble, but best to use their own words to show how they pitch their programs to docs…
MedX Sales
“Workers Compensation (Incredibly Profitable)
Physicians that work in occupational medicine and pain management typically handle workers compensation cases and therefore submit claims to workers compensation insurance. Unlike the other scenario where the physician collects cash for prescriptions, in the case of workers comp, the physician would submit claims to the insurance company for payment of the drugs. Here the physician’s payment reimbursement is based upon Average Wholesale Pricing or (AWP). Each repackager creates their own AWP for each drug that is sold by the physician. Each state also has different reimbursement policies relating to AWP but rest assured the potential profitability is staggering. A physician paying $6.00 for a prescription could be reimbursed as much as $100.00 or more based on AWP.”
also from MedX
You could be losing $50,000 or more each year by not dispensing today!

Physician Dispensing Solutions
Learn how to generate over $100,000 annually with our physician dispensing program.
Do you treat workers compensation patients? Unlike regular patients, dispensing medication to workers compensation patients requires submitting a claim to insurance in order to get paid. Physicians that dispense medication to their workers compensation patients earn revenue base [sic] upon the state’s insurance reimbursements schedule and the Average Wholesale Pricing (AWP) for that drug. It is not unusual for a physician to earn over $100,000 or more every year by dispensing medications to workers compensation patients.
Clinical Rx Solutions

A physician who dispenses medication to their workers compensation patients earns revenue based upon the state’s reimbursement schedule and the average wholesale pricing (AWP) of that medication. It is not unusual for a practice to earn over $100,000 or more in additional income per year by dispensing to workers compensation patients.
[check out the income calculator, a tab pops up when you hover your mouse on the “Workers Compensation Dispensing Program” button top left]
Physician Partner
Benefits to the Practice
Maximize Profitability
Reduced Claims Processing Workload
Increase Monthly Cash Flow
RxBranch
Can I really earn $50,000 or more each year by dispensing? Yes but that all depends on the size and type of practice as well as the number of patients seen each day. Based upon averages, the average physician will see 100 patients and write 100 prescriptions or more each week. Asking yourself simple questions such as how many patients you see per day or per week will quickly give you an idea how much money you could be earning by dispensing. Wholesale cost per drug and what you charge the patient is the final determining factor on calculating potential earnings. Most of the generic drugs will cost you about $5.00.
A-S Meds
7. What is the profit potential for my practice?
The new revenue source can be very significant. As with any program, utilization is the key. We provide you with a personalized Proforma based on your customized formulary, number of daily patients and number of prescriptions per patient. This will more accurately predict your potential profit. We have clients ranging from $1,000 to $50,000+ profits per month, with an ‘average’ profit of around $7 per script.
The practice earns all of the cash profit, the workman’s compensation profit and the managed care profit.
[emphases added]

Aug

How NOT to use social media for business

Posted by Joe Paduda on Friday, August 31st, 2012 | Comments

While I don’t profess to be an expert in the use of social media for marketing/brand development, there are a few things I’ve learned in the eight years I’ve been blogging.
1. Don’t inundate bloggers with press releases that are, at best, tangentially related to the blog’s subject matter. I don’t need nor want to know which institutions are the top ten for dental hygiene nor do I care that your company just convinced another company to use your electronic self-care product.
2. Don’t swamp LinkedIn and other groups with posts and topics clearly intended to market your firm. I’ve seen some marketers post a couple times a day to LinkedIn groups – all that does is get you labeled as annoying and your company a reputation for mindless mailbox filling.
3. Don’t use comments on blog posts to pitch your company or tout your services. Sure, you can opine and sign your name and your company affiliation, but don’t use someone else’s blog as your marketing forum.
4. Be mindful of the potential to offend. I know, shocking that someone who’s demonstrated a well-honed ability to do just that has the temerity to advise others, but note I did not say “don’t offend”, just be conscious that your words may have that effect.
5. Don’t disagree without citing some support for your position; the corollary is to not opine without providing links to material upon which you base that opinion. Opinion based solely on personal belief is not likely to convince anyone of the merits of that opinion or belief.
6. Be respectful – when that respect is merited.
7. Recognize that the social medium you use has to correspond to the audience you seek. Few executives in the health plan or insurance world spend their days trolling (pun intended) Facebook or Twitter, but more and more are reading blogs. While younger folks are definitely moving in the Facebook/Twitter/media du jour direction, people who write the checks aren’t there yet. And may not be for a good while.
8. If you begin a social media campaign, be patient, be persistent, and manage those expectations. It has taken me eight year to reach almost 3500 subscribers, and the work has absolutely paid off. That said, it is infinitely harder to build a brand these days than it was back in the 00’s, so be creative, be smart, and hire someone who really understands social media.

Aug

What’s a “conservative”?

Posted by Joe Paduda on Thursday, August 30th, 2012 | Comments

This isn’t a rant, a polemic, a diatribe. It’s a question.
I had breakfast yesterday with a highly-regarded executive at a top-shelf TPA, and during the course of our conversation we got to talking about the Republican convention.
From there the talk turned to the current GOP platform of small government and government-controlled social engineering and then to a discussion of how the party has evolved from small government, low taxes, controlled entitlements and social libertarianism to where it is today – using entitlement expansion to schmooze specific constituencies (Part D, pharma, and senior citizens), using social issues to motivate groups (abortion, immigration), and what can only be described as fiscal irresponsibility (current antagonism towards any increase in taxes despite huge deficits).
As a self-described Democrat, I long for the “olden days” of the GOP, the party of adults who trusted individuals to make their own decisions about their lives, relationships, religion, sexual choices, procreation. The GOP of the sixties railed against Medicare as an intrusion into the private health insurance/care industry, a principled stand (OK, with a bit of pandering to the AMA, but pandering consistent with their ethos of the time) that stands in sharp contrast to the GOP passage and promotion of Part D.
Part D is moment the GOP went completely off the rails. A sop to seniors passed by Republican Congress and signed by a Republican president, Part D has added $16 trillion to the ultimate deficit.
The party of Goldwater would no more have passed Part D than substituted la Internationale for the Star Spangled Banner. It would have been unthinkable.
Now that same party condemns the opposition for its own expansion of health coverage, citing a (highly inaccurate) projection that Obamacare would add a trillion dollars to the deficit (a projection that is directly contradicted by CBO figures).
Sure, that’s politics, and this is convention time, and it’s all about winning the election.
But at what cost? The GOP has strayed so far from their fiscally-responsible roots as to be more like the Democrats than the Democrats are these days.
What does this mean for you?
When thoughtful, educated, influential executives like my breakfast companion are gravely concerned about the party that used to be their’s, one wonders where the GOP will be in the future.

Aug

Workers comp bill review – key findings from the latest Survey

Posted by Joe Paduda on Wednesday, August 29th, 2012 | Comments

Many payers’ bill review systems are still not electronically connected to medical management applications; bill review prices are lower than they were three years ago, and payers are increasingly interested in bill review applications’ rules engines.
Those are three of the key findings from the latest Survey of Bill Review in Workers Compensation, and result from answers provided by 24 respondents from payers large and small.
We last conducted the survey back in 2009, and waited three years to see how quickly the industry would evolve. In some ways there’s been a good deal of change; in others, not so much.
The connectivity issue is perhaps the most visible. While there’s no doubt more payers have done a lot to tie bill review to medical management systems, many are still relying on “manual” processes to ensure bills for unauthorized or denied care are not paid or otherwise handled correctly. This greatly increases the chance for error, thereby increasing costs and wasting the time and money spent in the UR process.
Prices have declined, both for outsourced bill review and for payers leasing vendors’ systems, this despite the consolidation among application vendors that’s removed several once-significant players from the industry.
What has changed is the focus on auto-adjudication and interest in rules engines, driven – according to respondents – by a quest for greater efficiency and consistency.
With prices for bill review coming down, it’s not surprising interest in efficiency and automation is up; the soft market and pressure on admin expense is certainly a factor as well along with the desire to more consistently – and accurately – pay medical bills.
I expect the Survey report will be available by the end of next week. More to come.

Aug

The Florida comp conference – quick takes

Posted by Joe Paduda on Monday, August 27th, 2012 | Comments

With a weekend to recover, here are the quick takes from the WCI Conference in Orlando.
The ‘Headline’ keynote – Kathleen Madigan – was terrific. Glad I didn’t have to follow her; my “Industry Keynote” didn’t inspire many grins or guffaws, but did generate some outright hostility from the physician dispensing/repackaging folks.
Good.
Liberty’s physician meeting was very well attended; word is there were almost a hundred physicians at the get-together, a credit to Jean Feldman, their local Florida managed care exec. Kudos to Liberty for reaching out to treating physicians to strengthen relationships.
Saw an interesting piece of technology from CORA rehab – an iPad-based tool that serves as a teaching tool, enables patients to record and document their home exercise, and communicates w the PT and others involved in the case. Will be in use in January; they’ve invested a great deal of thought into the app and it looks promising.
The emphasis on broadening the conference’s appeal to a national audience looks to be paying off. There were attendees from everywhere, including Hawai’i, and topics of interest to people from all around the country.
Progressive Medical’s analytics capabilities are pretty impressive – that’s the report from a couple folks who attended their luncheon.
One of the strengths of WCI is a bit of a shortcoming as well; the plethora of audience-specific tracks (regulators, judges, medical issues, claims, etc) means there are not nearly enough “cross-stakeholder sessions” where judges hear from doctors and regulators and vice versa. This is a medical-legal system, and the more perspective we have on the various pieces and parts of the “system”, the better.
Definitely a younger and hipper crowd than at other conferences, but that’s to be expected when adjusters make up a big percentage of the audience. I have no idea how women walk in those five inch heels, but there were lots who somehow managed. And what’s with all the shirt tails out?
I know, showing my (advanced) age…
Overall – a LOT of information available, many excellent sessions, plenty of opportunities to party in the suites; need more cross-stakeholder discussion and better attendance at some really solid presentations.

Aug

Taxpayers’ profit on AIG bailout

Posted by Joe Paduda on Friday, August 24th, 2012 | Comments

Yesterday brought the welcome news that the Fed completed the sale of the last of its AG holdings, generating a profit of $6.6 billion.
In total, taxpayers have earned almost $18 billion dollars from the Fed’s investment in AIG and subsequent sale of the company’s assets. We still own 53% of AIG, whose stock is up 46% so far this year.
The highly-controversial decision to use federal funds (taxpayer dollars) to prevent the meltdown of what was then the largest P&C insurer in the nation required $125 billion.
I – and everyone else – am happy and relieved that our dollars didn’t disappear. That said, I’m sure we’re all hoping we don’t have to make that kind of a bet again. What happened to AIG – a relatively tiny subsidiary somehow bankrupted a huge company – can’t be allowed to happen again.
AIG was so deeply entwined in international finance and business that we had no choice but to bail the company out when their investments in credit derivatives went horribly bad. While some would argue that government should have let the chips fall where they may, the cost – to individuals, taxpayers, governments, the economy, businesses – would have been catastrophic.
If the catastrophe was limited to AIG and its shareholders, fine – let ’em suffer. But it wouldn’t have been. In fact, thousands of companies, millions of individuals, hundreds of governmental entities would have been bankrupted/forced out of business/left without pensions if AIG had disappeared.
It’s one thing to talk tough about some fat-cat finance guy losing his Bentley and Gulfstream; it’s a whole different thing when your neighbors lose their pensions. And there’s no question an unmanaged bankruptcy of AIG would have led to that, and other consequences. Such as:
– AIG had very close financial ties to many European banks, ties that would have brought those banks down and done major damage to that continent’s economy.
– AIG provided the underpinning for many pension funds and retirement plans; its financial instruments guaranteed the returns for pensioners.
– It owned many of the airlines’ airplanes, planes that might have been repossessed if AIG went under.
– AIG insures many Fortune 500 companies, and is among the largest writers of workers comp in the nation.
– It was a large individual auto insurer as well.
– AIG insured billions of dollars of cargo in transit across the world’s oceans; a bankruptcy would have increased costs significantly.
– AIG insured many other financial institutions against the risk of loss from those institutions’ investments. If that insurance was no longer there, the other financial institutions would have had to dramatically change their financial projections – which may well have led to their demise.
I’m no economist but it is abundantly clear an unmanaged bankruptcy could well have led to a world-wide depression of frightening proportions. The feds had to choose between a bad choice and a horrible one – and they chose the bad one.
Of late AIG has been a big buyer of non-government backed mortgage securities, adding stability to the housing market – a key to continuing the economic recovery.
What does this mean for you?
Let’s hope our elected officials are paying attention.

Aug

What comp insurers will pay for

Posted by Joe Paduda on Thursday, August 23rd, 2012 | Comments

The Hartford wants to pay for what works, not pay for stuff that doesn’t and doesn’t want to argue.
That was the one-line statement from Medical Director Rob Bonner in his talk at the just-concluded WCI.
Bonner went on to discuss how the Hartford defines “what works” and how they evaluate treatment plans that deviate from generally-accepted standards of care/Evidence Based Medicine (EBM).
I reviewed my notes from Dr Bonner’s talk after several comments on yesterday’s posts lamented/complained/squawked/expressed outrage that insurers had any right to determine the medical necessity of treatments much less not pay for treatments deemed not effective.
When you consider the wide variation in practice patterns reported by WCRI’s Dr Rick Victor yesterday, the weakness of the commenters’ arguments become crystal clear.
Notably, Dr Bonner said guidelines don’t work for all patients in all situations; treatment outside of guidelines may be appropriate but only if treatment within guidelines has failed.
Bonner concluded with a very interesting discussion of how payers should – and the Hartford does – look at guidelines and the interaction with providers based on guidelines. It is clear they are central to the way the Hartford medically manages WC claims, and that the use of guidelines is based on driving to better outcomes. It is equally clear that the onus is on the treating doc to develop a treatment plan that gets to a defined result if and only if standard EBM guidelines don’t work, with “work” defined as functional improvement.
I’d add that insurers have this thing called “fiduciary responsibility” that requires them to pay only for services that are deemed appropriate and necessary. That doesn’t include procedures that have been demonstrated to show no positive impact on outcomes; examples may include some cold therapy devices, passive motion machines; certain drugs and surgical procedures.
I’d also add that some insurers are “bad actors”; denying treatments arbitrarily, losing documentation, and generally doing whatever they can to avoid paying as much as possible. That said, in my experience these crappy companies are in the minority.
What does this mean for you?
Practice within guidelines, and if you don’t, be prepared to show why it makes sense to do something different and describe where the treatment is headed.

Aug

Is there unnecessary medical care in workers comp?

Posted by Joe Paduda on Wednesday, August 22nd, 2012 | Comments

That’s defined as care that does not improve patient outcomes, and it was the subject of Dr Rick Victor’s concluding remarks at the WCI conference. And the answer is, well, let’s consider the data first.
First, who cares? Not my problem, right? Consider that other research indicates the average household is working 4 weeks just to pay for the estimated total amount of dollars spent on unnecessary care.
When you put it in that perspective, it becomes very, very real. Dr Victor went on to discuss various indicators of wide variations in medical practices in comp. For example, docs inassachusetts are ten times more likely to prescribe schedule ll narcotics when prescribing narcotics than physicians in texas.
If you are prescribed narcotics in Louisiana you are four times more likely to become a long-term user of narcotics than in the lowest ranked state.
If you have a disc problem, you are almost three times more likely to get back surgery if you are in Tennessee than if you live in California.
Why?
Well, perhaps there are financial motivations at play. Victor reported their research indicates surgeons that own a surgery center do 76 more surgeries each year than non-owners.
And yes financial ownership is a driver, but owned ASCs are more efficient so they can do more, and owners were usually operating more often before they became owners.
But with all that, there are still 20% more surgeries done by docs who own ASCs when you account for these confounding factors.
Are they unnecessary? Well, Medicaid patients weren’t getting more surgeries, work comp patients were. And by the way, the same 20% increase was seen in colonoscopies.
And that’s not even getting into the huge differences in prescribing patterns exhibited by docs who begin to dispense drugs out of their own offices.
What does this mean for you?
Returning to the headline question, I’d suggest there is ample evidence that suggests there is indeed a lot of unnecessary medical care.
And every year you work until January 29 just to pay for that unnecessary care.

Aug

And where were you??

Posted by Joe Paduda on Wednesday, August 22nd, 2012 | Comments

Yesterday afternoon the medical directors from two of the three largest workers comp
Insurers told listeners at WCI precisely what providers needed to do to get paid.
And you were…where?
Providers’ and vendors’ complaints about getting paid are constant and loud. Waaaah waaah waaah is what payers hear from providers far too focused on billing and not near enough focused on delivering services intended to speed healing and return to work.
So Dr Rob Bonner’s brief talk detailing exactly what the Hartford would and would not pay for was exactly what providers needed to hear. There were very few providers in attendance, far fewer than have booths on the trade show floors, advertisements hanging from the rafters, events in their suites.
I guess it’s far more important to pass out trinkets to every Tom Dick and Mary walking y your booth than actually listen to the medical director of a top-four insurer tell you what he wants to buy. Or break away from that lunch date to hear David Deitz of Liberty Mutual tell you how he defines quality in medicine.
Why are you even IN Orlando?

Year: 2012