Nov
20

Workers comp is A) doing great, or B) a big problem

Where you sit determines what you see; this adage applies to the work comp industry.

For payers, employers, and taxpayers, all is great.  Rates are low and dropping, insurers are enjoying record profits, frequency continues to trend down, medical costs are flat.

The very things that make payers happy have the opposite effect on service companies. For most entities involved in medical management, pharmacy management, investigations, technology, claims systems, Medicare Set-Asides, and litigation defense the drop in frequency and flat medical costs are unwelcome news.

The trickle-down effects of this dichotomy are many and varied.

  • There is little-to-no pressure to revise state workers’ comp laws and regulations.
  • Insurers are looking to increase their work comp business as it is a big profit maker.
  • Claims execs are trying to balance hiring and training new claims adjusters while planning for long-term decreases in claim volume.
  • Execs are also extremely careful about investments in new IT projects, as the long-term payoff is also challenged by structural declines in claims.
  • The consolidation of service companies continues unabated; IMEs, bill review, specialty networks, PBMs, investigations, case management, cat case management services are all subject to this consolidation.
  • Selling services to payers is getting increasingly difficult.  Payers aren’t seeking solutions to major problems; they are reluctant to switch vendors unless there are serious service problems.
  • Work comp conferences are struggling due to the structural issues above; the lack of big problems driving intense interest in solutions and an arguably-over-saturated conference market is hurting attendance.

So, what to do?

If you are a service entity, you’ve got to differentiate. You must also deeply understand what individual buyers want, why they want that, what their decision process is, and who else is involved.

Unfortunately many service entities are cutting marketing budgets and pressuring sales staff to deliver deals. While sales targets are important indeed, they must also be realistic.

If you are a payer, I’d echo the last sentence above. Many payers are planning to write more workers’ comp, an obvious impossibility.

 


Nov
19

In which I read current research and summarize key takeaways so you don’t have to…

Stress over healthcare costs doesn’t go away when you are on Medicare

HealthAffairs reports that more than half of Medicare recipients with a serious illness reported “serious financial distress” due to medical bills. Drugs are the most common cause, followed by facility bills.

This is important because:

Medicare for All is NOT a panacea; politicians advocating for MFA should understand Medicare needs major improvements before it is “ready for prime time.”

Oh, and a third of all credit card holders are in debt due to medical bills.

Immigration and healthcare

If you or a parent have a healthcare aide, listen up. The bruising battle over immigration and the “Dreamers’ will affect healthcare – particularly for older Americans who rely on home health aides and other lower-level clinical support.

27,000 Dreamers work in healthcare and healthcare support, many providing individual care. The Trump Administration is trying to end this program and force Dreamers to leave the U.S.

The shortage of home health workers is particularly acute in older states such as Maine and the upper midwest. With immigrants filling one of every three home health positions, ending DACA and further restricting immigration would leave thousands of older Americans without care. 

What does this mean for you?

When a politician says something is simple, or their claims just seem to make sense, your alarm bells need to ring.

Medicare will need huge and expensive changes to work for all of us. 

If you don’t want immigrants in the US, then you get to care for your parents without any help.


Nov
18

Work comp rates are still too high – and will continue to drop

Today, I’m going to convince you that despite years of continued decreases, work comp premiums are still too high.  And will likely remain too high for the next few years.

That’s how long it will take the impact of reduced opioid consumption to work its way through comp financials. Sure, continued declines in frequency and high employment along with declining worker benefits are also factors – but I’ll argue what’s way more important is the drop in opioid prescriptions.

A decade into this, the dramatic drop in work comp opioid prescriptions is continuing unabated.

  • CompPharma’s 16th Annual Survey of Prescription Drug Management in Workers’ Comp [free to download] shows payers have slashed opioid spend by 40% over the last two years.

  • myMatrixx [HSA consulting client] reported a 15% drop in opioid spend in 2018.
  • Optum Workers’ Comp reported a 2.9% reduction in opioid spend for the first half of 2019 compared to the first half of 2018.
  • CWCI’s just-released report analyzes data from lost time claims incurred between 2008 and 2017:
    • the percentage of claimants receiving opioids dropped 51% over that time period
    • chronic opioid use dropped by 77 percent, from 13% of claimants to 3%
    • acute use declined by 40 percent

My key takeaway from CWCI’s report isn’t the drop in opioid usage, it is that claims without opioids are much less costly, therefore the drop in opioid prescriptions is driving lower claims costs.

Those reductions have yet to be fully factored into work comp rates – so rates will continue to drop.

Key data points:

  • Average benefits for claims without opioids were 30% less than for claims with opioids (at 12 months).
  • Claims without opioids had 25% fewer TD days than claims with opioids.

The net – “Cumulative savings from the decline in opioids are projected at $6.5 billion for 2010 – 2017 claims.”

Report authors Steve Hayes, Kate Smith, and Alex Swedlow provide suggestions for actuaries on page 15 and in Appendix 4.

What does this mean for you?

Rate reductions haven’t caught up with the reality on the ground. 

Barring major unforeseen events, work comp rates will continue to drop for several more years. 

For those so inclined, an extensive discussion of rate-making is here.

 

 


Nov
15

The most important thing you aren’t paying attention to

Is the ACA case in Texas.

Briefly, Republican Attorneys General have sued to overturn the ACA.  The AGs’ claim the entire law must be thrown out because the individual mandate — a penalty imposed on people who chose to remain uninsured – was killed by Congress in 2017.

You may recall that, in addition to the mandate, the ACA:

  • expanded Medicaid to more low-income families and individuals
  • reduced seniors’ drug costs by closing the “Donut Hole” in Part D plans
  • reduced insurance costs for older Americans
  • increased funding to fight healthcare fraud
  • increased funding for rural healthcare
  • increased tax credits for small businesses providing health insurance
  • provided insurance subsidies for families making less than $88,000
  • required insurers to offer complete insurance coverage to all without discriminating by medical condition, age, or sex

If the Republican Attorneys General prevail, the ACA will be overturned, and health insurers will be allowed to:

  • stop covering pre-existing conditions; 
  • stop covering your adult kids;
  • limit your maximum dollar benefit;
  • exclude different types of medical care
  • medically underwrite small groups; and 
  • subsidies for folks buying health insurance go away.

Meanwhile, there is NO alternative plan if the judge rules in favor of the AGs. While HHS Secretary Seema Verna says there will be a replacement plan, there are no details about this “plan“, and no information whatsoever from the President or Congress.

photo credit Leslie Boorhem-Stephenson for the Texas Tribute,

I don’t understand how the entire law can be overturned because one part of it is no longer in effect – but I’m no attorney and will leave that to those readers who are.

From a political perspective, this doesn’t seem too smart on the part of Republicans.  People hate losing things they already have – much more than they don’t like not getting things they wish they had. And if the ACA is overturned, millions of voters – including millions of seniors – will be really mad.

What does this mean for you?

If you’re a Medicare recipient, parent, make less than $88,000 a year, are a small business owner, have pre-existing condition, and/or need comprehensive insurance coverage…

nothing good.


Nov
13

Opioids and work comp premiums

Two seemingly-unrelated papers hit the inbox yesterday; CWCI’s just-completed analysis of opioid usage in the Golden State, and NCCI’s report on 2019 workers’ comp financials.

The key takeaways from NCCI’s report include:

  • Premiums are expected to drop 10 percent in 2019, driven by rate/loss cost filings. In other words, losses are declining which leads to lower insurance costs.
  • This marks the sixth consecutive year of decreased premium levels.
  • Not coincidentally, 2019 is the sixth consecutive year of underwriting profitability.

So, even though premiums are dropping like a rock, insurer profits are better than they’ve ever been.

Why?

Well, declines in frequency are certainly a big contributor. Reduced worker benefits are likely a factor as well – and a big problem we’ll address in a later post.

If anything, investment profits are a drag on profitability (NCCI reports 2018 investment gains averaged 9.2%.

Which brings us to CWCI’s report “The Impact of Declining Opioid Use on Lost-Time Claim Development & Outcomes in California Workers’ Compensation” [emphasis added; disclosure – I provided input as a peer reviewer for the final report]

Key takeaways:

  • “from 2008 to 2017, chronic opioid use…declined from 13% to 3% of all lost-time claims (a relative decline of 77%)”
  • the strength of the opioids dispensed within the first 12 months of treatment, measured in cumulative morphine milligram equivalents, declined 59% for chronic opioid use claims

Tomorrow – the connection between opioid reductions and premium levels – and what it means for the industry and you.

 


Nov
12

Haven Healthcare’s next step

Is partnering with two big insurance companies to offer creative plans to two of its owners’ employees.

30,000 JPMorgan workers in Ohio and Arizona covered by Cigna and Aetna will be offered a plan that has no deductibles, with copays ranging from $15 to $110 depending on the service; facility copays will likely be higher.

Amazon’s also offering a Haven Healthcare plan in a handful of states. The giant seller-of-everything also just bought Health Navigator for an undisclosed sum.

From Motley Fool:

it will fold [Health Navigator] into Amazon Care, its new employee healthcare benefit that gives users access to virtual doctors and nurses…Amazon Care users (currently limited to employees in the Seattle area) can fill prescriptions through the e-commerce giant and choose between having them delivered or picked up at a participating pharmacy. By providing healthcare services to its employee base Amazon gets to test the waters and make fixes before the program is offered to a wider market.

Evidently Health Navigator uses an AI-based health bot which helps members diagnose illnesses, determine the right course of care, and then routes the member as appropriate.

While JPMorgan and Berkshire are likely funding Haven to help reduce their healthcare costs, Amazon’s got bigger plans.

With annual revenues around $340 billion, the giant company needs a really, really big market to keep growing. Healthcare is $3.4 trillion, massively screwed up, and just the kind of target Bezos et al need to keep the good times rolling.

What does this mean for you?

If you think Haven won’t succeed, did you ever think you’d be getting your groceries, tools, video, toiletries, prescriptions, car parts, medical devices, batteries, dog food, shoes, and music from an on-line bookseller?


Nov
1

What’s up?

The inbox has been stuffed with important new research and news; here’s what most interested me.

Work Comp

Perhaps the best annual summary of the state of the workers’ comp world is just off the press.  The National Academy of Social Insurance’s report is here. Free to download, NASI’s latest finds:

  • Employers’ costs have fallen from just over $1.50 per $100 of covered wages in 1997 to $1.25 in 2017.
  • Worker benefits decreased even more, from $1.17 twenty years ago to $0.80 per $100 of covered wages in 2017.

My takeaway – workers are getting less in benefits than they have in the past – and that’s a bad thing.  It is great that employers’ costs are declining, but that shouldn’t be at the expense of injured workers and their families.

The fine folk at CWCI published their latest research on UR in the Golden State. Despite what some on the applicant attorney side argue;

Results show that 94.1 percent of services performed or requested from January 1, 2018 to October 31, 2018 were either approved (92.5 percent) or approved with modifications (1.6 percent)…

Yup, 17 out of 18 services were approved. 

WCRI’s annual conference returns to Boston – register herenow.  Or risk missing out, as the event fills up every year. Don’t be one of these people!

[I don’t think the guy on the right is Andrew Kenneally…]

Check out WCRI’s upcoming webinar on medical prices paid and work comp fee schedules – lots of great information on facility costs – the biggest problem (outside of opioids) in work comp today.

Drugs!

From Alan Fein at DrugChannels, a most excellent video by John Oliver on everything you should know about compounding pharmacies. You gotta watch this… [can you believe Oliver actually knows about stuff we work comp pharmacy nerds think about???]

The video is both hysterically funny and terrifying. Watch it.

From the funny to the deadly serious; if you haven’t read Gary Anderberg’s most recent GB Journal, you likely don’t know this:

research showed that “57% of those who died from opioid-related deaths had at least one prior workplace MSD. [musculoskeletal disorders]

I’ve long opined the opioid industry has done horrendous damage to the work comp industry, injured workers, taxpayers and employers. Gary’s reporting shows it is even worse than we thought.

When are you going to hold the opioid industry accountable for their criminal actions?

That’s it for now…for those attending the NWCDC next week in Vegas – make sure to say thanks and farewell to Peter Rousmaniere and Roberto Ceniceros.  These gentlemen are both retiring, and our industry will be much the worse for it.

I’ve known them both for decades, learned much from them, and deeply respect their contributions to our industry. They’ve certainly earned a respite…here’s hoping Peter and Roberto weigh in from time to time. Their wisdom and experience are irreplaceable.

I won’t be there – family vacation in Zion Utah…with three grown kids, we have to work around their schedules, proving once again that I am completely not in control of anything.

 


Oct
29

What’s next for One Call.

One Call’s got a cash injection and reduced its debt burden (so the company doesn’t spend most/all its earnings on interest payments).

Congratulations to the debt holders for coming up with a very creative solution – and for doing a masterful job of cat herding.  KKR, GSO, and their advisers somehow convinced all the debt holders to agree to losing millions of their investment – and got some debt holders to dump hundreds of millions more into One Call in return for ownership stakes.

Darn impressive work.

So, what’s next?

Well, I tried to find out from One Call…I sent One Call several questions early yesterday; Jessica Taft, OneCall’s VP of Marketing and Branding,  was kind enough to send a statement earlier today.  I’d note the response was not very “responsive” as it didn’t fully address my questions; I’ve pasted the communication in at the end of this post verbatim so you can judge for yourself.

Management

In response to my question about management changes, Taft said there are “no planned changes to the management team.” Ms Taft may not have full visibility into the new owners’ plans – and I don’t either. Now that Apax is no longer involved, the new owners will undoubtedly install their own Board; I expect major changes to, if not wholesale replacement of ,the Board of Directors.

It would be surprising if the new Board didn’t install new folks in the C-Suite.  (As I mentioned in an earlier post, execs were dealt a pretty poor hand to start with, so it’s unfair to blame the entire mess on them.)

Business lines

I asked:

What business lines will OCCM focus on going forward, and which lines will be de-emphasized? For example, there have been recent efforts to sell the hearing business; will those efforts continue or be halted?

OCCM responded:

One Call will continue to focus on delivering products and services to enable our customers to get injured workers the care they need when they need it…Finally, there are no plans to sell our hearing business…

I don’t expect One Call to sell any of its businesses at this juncture, although the new owners may look to do so after things settle down. It may be that the parts are greater than the entire operation; time will tell.

Provider reimbursement

I asked;

Management acknowledged extending payments to some providers out an additional 15 days in a recent call. When will OCCM reduce days outstanding for provider payables, or is that not being contemplated at this point?

OCCM responded:

Our provider network is one of our most valuable assets, and we intend to continue to enhance the value we deliver to our provider partners and continue to pay them timely.

I would expect One Call to work on strengthening relationships with providers, but don’t know what to make of Taft’s response.

Polaris

I asked a question about future investments in Polaris; the response was marketing-speak.

My view

With somewhere north of $300 million in the bank (if the entire equity payment went to the company’s coffers, and not to any other entities) and the annual debt load reduced from around $150 million to $60 million, One Call is in waaaaaay better shape than it was before the infusion.  

That’s good news indeed for the company’s workers and customers – and for the industry at large.  More competition for payer business is better than less.

The next steps are critical.  The industry wants to see a highly credible exec installed, one with deep experience in workers’ comp and a very strong brand. The company would also benefit greatly from more IT strength; it’s reliance on Polaris(r) for much of the customer-facing functions makes that platform essential to One Call’s future.

Happier and more connected workers would also be a big plus; sharing equity or otherwise rewarding workers who’ve stuck by the company during a very tough time is relatively inexpensive and would get more folks to buy in to the future.

 

 


Oct
28

OneCall’s Halloween is going to be all treats!

Thanks to a massive restructuring, OneCall lives to fight another day. This is excellent news for the folks who work there; not so much for the original investors.

Briefly, absent a new injection of equity and major reduction of debt, OCCM was headed to bankruptcy – on Halloween. That’s when the grace period on a $15 million debt payment expired. Late Friday a deal was reached that keeps the company operating.

Look, it’s cash!

Here’s how it happened.

As I’ve reported in the past, when OCCM was put together it was highly leveraged – in English, that means it had a ton of debt. That debt, which was restructured several times over the last few years, was a big drag on the company. The $150 million a year (or so) in interest payments soaked up cash that could have been used to pay workers and invest in systems.

The use of debt by Apax, the private equity firm behind OCCM, is commonplace in this type of deal. By using debt to help buy the pieces that made up OCCM, Apax hoped to double or triple the equity it originally invested in OCCM. That works great if a business is growing and consistently profitable; the PE firm’s investors make a ton of money when an “equity event” occurs.

But that high debt load can be a real problem if the company doesn’t grow. Late Friday OneCall announced the company is going thru a complete financial restructuring. In essence, debtholders traded a big chunk of their debt for equity, which a) injected much-needed cash into the business and b) reduced the company’s debt burden, freeing up cash for ongoing operations.

Apax – the private equity firm that owned OCCM – lost control of the company, and its entire $750 million +/- investment when OCCM’s finances deteriorated to the point that it was days from bankruptcy.

At that point, control shifted to the debtholders.

Those debt holders agreed to swap much of their debt for stock – and pump more capital into the business in an effort to keep it going. This will reduce OCCM’s debt payments, freeing up cash, hopefully allowing it to a) make needed improvements to Polaris; b) reduce accounts payable and c) reward employees who have stuck with the company through some pretty tough times.

Six weeks ago I opined:

[a] debt for equity swap is also unlikely. If the covenants are breached, the debtholders likely get (some) control over the company. I don’t see why the debtholders would swap debt for equity now, when that may occur in the near future. [emphasis added]

Reports indicate the restructuring was driven by two debtholders – KKR and GSO – who recently snapped up lots of OCCM’s distressed debt. The two firms convinced other debtholders to agree to a deal to:

  • reduce annual debt service costs by $90 million, down from $150 million +/-;
  • inject $375 million in capital into the business; and
  • eliminate short-term debt.

Tomorrow – what the future holds for One Call. (I’ve asked One Call several questions, and will report back if/when the company responds.


Oct
25

Haven and workers’ comp

Yesterday we dove into Haven, the healthcare company formed by Amazon/JPMorgan/Berkshire Hathaway.  Today, we discuss the potential implications for workers’ comp.

Based on what we know so far, there are two ways Haven might impact workers’ comp.

Before Haven can affect WC, it has to become a viable entity of some significant size. Some skeptics don’t see that happening, citing the Byzantine complexity of the US healthcare (non)system, the size and scale of the medical-industrial-financial complex, and the bewildering maze of laws and regulations.

Those are excellent points; I’d suggest critics may be making assumptions that aren’t necessarily appropriate. Haven may well create a “de novo” healthcare delivery and financing system, leveraging the employee population, intellectual capital, technology, financial capabilities, and buying power of its owners.

If Haven becomes the healthcare delivery platform for the hundreds of thousands employed by its three owners, those employers would likely use that platform for occupational injuries and illnesses. That would enable seamless integration of care, reduce the risks inherent in the siloing of care between comp and group health, and likely upgrade non-occ disability management as well.

Efforts to deliver 24 hour care have fizzled as the opportunities inherent in integration couldn’t outweigh the legal, regulatory, cultural and political realities. It’s possible that Haven could eliminate much of these obstacles by starting fresh.

So that’s the big change.

More likely – and much sooner, is the potential for Haven/Amazon to provide drugs, supplies, and DME to work comp patients.  The companies’ push into pharmaceutical manufacturing and distribution, and distribution of medical devices and supplies means it has the supply piece in place; next step is building the distribution channels/pipes into work comp payers.

The total work comp drug/supply business is likely less than $6 billion, a relative pittance compared to the half-trillion plus dollars in revenue the three partners will enjoy this year. And, once those pipes are built, Haven will figure out how to generate more revenue.

If anyone can do this it’s Haven/Amazon.

What does this mean for you?

Service providers need to double down on service and be that indispensable partner.