Nov
17

Telerehab’s coming fast

Regardless of what happens to health reform on the national level, the healthcare industry is relentlessly and rapidly adopting technology that will revolutionize patient care.  Big players are seeking out new tech devices, platforms, and applications, buying start-ups and rapidly pushing their products and services into their distribution pipeline.

One example is Zimmer’s recent acquisition of RespondWell, a start-up delivering comprehensive at-home telerehab intended to improve patient compliance with PT and deliver better outcomes. I recently interviewed RespondWell CEO Ted Spooner.  Spooner has a long history in developing tech that delivers services faster/better/cheaper with far less human intervention.  He and his team have taken that experience and used it to build a home-based rehab solution.

The quick backstory – Medicare and other payers are bundling payments for surgical procedures, forcing providers to assume responsibility for any procedure-related care for 90 days post-surgery. In this model, a health care system might get $37,000 to do a total knee replacement; out of that fee, around $5,000 would go to physical therapy.

But there’s a problem – in some places, there’s more demand for PT than there is supply of PTs.  As a result, some patients are on a waiting list – and as a result of that, surgeons, operating rooms, and related staff are not working to full efficiency.

There’s another issue here, one that gets at an uncomfortable reality – many services can be delivered in ways that don’t require nearly as much human intervention.

Telerehab provider RespondWell has come up with a solution, one that uses existing technology, platforms, and communications to “create accessibility and convenience for therapy to patients and give providers visibility to patients to adherence to therapy. Kaiser is one of the early adopters of the Therapy@Home solution.  To date almost all customers are healthcare providers, but Spooner expects payers to be in the mix quickly.

Briefly, Therapy@Home is set up for each patient recovering from surgery; the provider prescribes a therapy plan which is “loaded” into the App. The patient sees a web-based on-screen virtual therapist that helps them perform exercises correctly, while allowing the care team to monitor patient performance and compliance via the internet-connected device’s web camera.

Sessions and communications are recorded and stored for provider access if and when needed.

Here’s one key takeaway; about 60% of in-person PT visits can be eliminated using Therapy@Home.

Considering most total knee patients are older folks, I challenged Spooner on adoption and usage by senior citizens.  He noted that the over 55 population is adopting technology very quickly, driven by easy-to-use smartphones and apps that allow them to connect easily with friends and family.

While RespondWell is focusing on bundled payment-driven care today, this technology/service model (I’m not sure exactly how to describe it) is absolutely transferrable to other types of care – both within PT and in other service areas.

What does this mean for you?

Be a disruptor. Or be disrupted.


Nov
15

C’mon, VA, do the right thing!

There are thousands of veterans waiting for the Veterans’ Administration to streamline disability evaluations.  While they wait, the VA dithers.

This has dragged on for more than a year, a year in which the GAO pummelled the VA for failing to comply with its own contracting standards when awarding contracts to a huge defense contractor – Lockheed Martin – that has almost NO experience in disability evaluations.

According to a piece in Politico earlier this year;

the GAO “citing “prejudicial errors” has directed the Department of Veteran Affairs to go back to the drawing board…the office “recommended that the VA reopen negotiations with the offerers, solicit, obtain, and evaluate revised proposals; and make new source selection decisions” [emphasis added]

Oh, and the VA “misled two of the protestors during the conduct of discussions or negotiations.  These errors led the VA to make source selection decisions…that were unreasonable…” [emphasis added].

One of the protesting bidders – Veterans Evaluation Services – published an ad in yesterday’s WSJ calling on Trump to fix this.  Here’s hoping this gets results.  (disclosure – I’ve done work for VES in the past)

And fast, because our veterans have been waiting for far too long.

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Nov
14

Trump and workers’ comp

There’s no question the Republican sweep will hugely affect workers’ comp.

There are nothing BUT questions about what that impact will be.  Here are a few thoughts based on what little we know so far.

The quick take – huge uncertainty; if Trump delivers on his campaign promises, there’s a high likelihood of higher claims frequency and increased medical expenses. 

I preface this by noting Trump is already backing off campaign promises – including repealing “Obamacare”.

The DOL “intervention” in workers comp is dead.  There will be no new National Commission, no federal standards, no study or research or advisory panel. There will be much less emphasis on OSHA enforcement and workplace safety as well.

More jobs?

Energy projects will likely be fast-tracked, although there will be big battles in court as environmental concerns rally to intervene in the only way left open to them – civil suits. Pipelines, coal mines, oil will all see more jobs – although the world economy will have much more to say about that than the White House.

Trump has been touting a trillion dollar investment in infrastructure – anathema to Republicans who don’t want any increase in government spending. Where this will end up is anyone’s guess; if it does go forward, premiums, along with claims costs and medical expenses will rise significantly as these jobs are in high-claim-frequency and high-severity industries.

Trade drives jobs, consumer buying, and inflation. All of which impact work comp.

Trump will label China  – our largest trading partner – a currency manipulator (it’s been keeping the value of the renminbi low to make its exports more attractive). He has to, as that’s a big part of his campaign. BUT it’s going to be a lot of talk and NO action – this is going nowhere, for four simple reasons.

The law requires three conditions to be met for a country to be declared a currency manipulator; China only meets one.

Second, China has been increasing the value of the yuan for months.

Third, consumer demand has been a big part of our economic recovery. If Trump starts a trade war, consumer goods will get a LOT more expensive, driving down consumer purchasing power and consumer confidence. The working class that supported his election would be hurt the most.

Fourth, China owns a shipload of our debt. China can stop – or greatly reduce buying our debt, which will drive up borrowing costs, triggering inflation and more damage to consumer buying power especially for baby boomers who are already living paycheck-to-pacheck.

Oh, and we have a $28 billion surplus in the service sector. If a trade war does start, China will stop sending students here, stop importing movies and music, and its new moneyed class will find other travel destinations.

That said, even the whiff of a trade war will hurt work comp. Inflation will hurt investment returns and lower the value of claim reserves, export jobs will be lost, and the tourism, educational, and cultural industries will suffer as well.

For a brief and helpful summary of Trump and trade, click here.

ACA

Evidence suggests the Affordable Care Act has helped work comp. Work comp medical costs have declined since ACA’s full implementation despite rising employment and middling cost increases in group health. The newly-insured are in higher-frequency jobs.

If Trump rips out ACA “root and branch”, we can expect medical costs to increase and cost- and case-shifting to ramp up significantly.

There’s a lot more to this and we will be tracking it closely.

What does this mean for you?

Given Trump’s already walking back campaign promises, this is just speculation. For now, expect higher premiums, more claims, and higher medical costs.


Nov
11

The election’s impact on health care – experts opine

This is a special post-election edition of Health Wonk Review – we asked our contributors to share their thoughts about how the GOP’s sweep will affect health care, health reform, and the health care system.

I’d like to profusely thank our contributors.  For most, this was a totally unexpected result that no one i know (except Michael Moore, who I don’t “know”) predicted or even considered possible.  Our contributors have focused, dug in, and come up with some terrific insights into implications for health care.

Before we jump in, a couple key data points.

  1. Health care accounts for one-sixth of our GDP.  This is a HUGE, incredibly complex, deeply entrenched business.
  2. Unlike any other part of our economy, health care is unique because it profoundly affects us as individuals.
  3. ACA is MUCH bigger than the Exchanges; only 1 American out of 19 is covered via the Exchanges.

More on what ACA is and is not, and how it has been portrayed in the media from Daniel Dawes at healthinsurance.org.  If you’re up for more fact-checking, Daniel’s got you covered.

David Williams encourages Democrats to go ahead and allow Republicans to repeal ACA. Filibustering such a move, while possible, would delay the death by a thousand cuts from executive action and the budget reconciliation process. That being the case, let ’em at it.

David correctly notes that the GOP’s positions are often directly contradicted by (some of) Trump’s positions, and health care is no exception. He also breaks down the key “policy initiatives”, most of which won’t do anything to bend the cost curve. David concludes that once Trump figures out these initiatives aren’t going to solve the problem, he may well decide to go back to his earlier plans to adopt a Canadian-style system.

We welcome Matthew Holt back to HWR!  Somehow able to write a cogent post while watching election returns (when I was hiding under the covers), Matthew wonders how Trump is going to A) repeal “Obamacare” while ensuring everyone has access to high quality, affordable health care. The middle-aged white folks who supported him expecting he’d “fix” health care are going to be disappointed if he doesn’t deliver…

That, plus the fact that the entire health care system – payers, providers, IT, pharma – have spent six years working to adapt to ACA and there will be an awful mess if there’s a hard stop on Inauguration Day.

Bob Laszewski tells us the GOP does have a written plan, and it’s ready to go.  He also believes the Dems will work with the GOP to replace ACA because there are a lot of Democratic Senators up for election in 2018.

Thanks to Peggy Salvatore for her contribution; she notes that for many voters “Obamacare” may well have been a big reason they pulled the lever for “anyone else”. She also hopes Trump will assemble a team of experts to plan the new health care laws.

Brad Wright notes that while most may think ACA will be repealed, most also thought Clinton would be our next President.  The real question is what will happen to the 20 million + who have coverage due to ACA.

Tim Jost of Health Affairs reminds us that the simplistic statement “repeal Obamacare” is not going to happen.  Most Americans equate the Exchanges with “Obamacare”; ACA is much more than that.  An outright repeal would impact everything from pharmaceutical pricing to biosimilars to Medicare reimbursement to hospital financing; the entire system will grind to a halt if the “replacement” plan isn’t carefully thought out and well planned. 

Given Trump’s wildly inconsistent stances on health care and the low likelihood that the Ryan plan’s policies will do anything to bend the cost curve, I don’t see a solution coming that will make Trump voters happy. 

Thanks to Roy Poses for his post on how the current system is “rigged” to enable companies to sell useless stuff.  The FDA finally caught up with a company shilling its “beads” as a drug delivery tool, when it had been explicitly prohibited from doing just that. Perhaps we need MORE regulatory enforcement, not less.


Nov
11

TrumpCare – initial takes

Okay, time to dig into what this election means for health care.  I’m still working thru how this will affect workers’ comp; my first post next week will focus on that.

To my loyal readers, thanks for your patience while I diverted from health care and work comp and used MCM to discuss the election and its impact on me. For those friends and colleagues who thoughtfully and kindly contributed to the conversation, I deeply appreciate your insights and views. We may not agree and that’s fine as long as we seek to understand.

I’m really working to keep my inner snark under control here, so bear with me folks.

The biggest problem in crystal-balling about the election’s impact on health care is Trump has been all over the place.  He’s advocated for a Canadian-style system, vowed to repeal Obamacare, lauded single-payer, and gone off in other directions enough to convince me he doesn’t have any firm plan.

His party does have a “plan”, at least current Speaker Paul Ryan detailed one earlier this year.  It includes

  • Selling insurance across state lines (an air sandwich if ever there was one),
  • block grants for Medicaid;
  • no mandate but no coverage for pre-existing conditions without continuous coverage;
  • cap employer tax break for health insurance;
  • refundable tax credit for individual purchase of insurance;
  • end the Independent Payment Advisory Board.

Here’s the problem.  Nothing here will reduce the cost of health care. 

The voters who backed the GOP and Trump expect health care costs to come down, insurance to be cheaper, less complicated, and provide better coverage, and the whole system to function better/easier/faster with less hassle.

But mostly they want it to cost less.

These initiatives will not do that.

Reducing cost will require narrower networks (you can’t keep your doctor), lower benefits (what, this isn’t covered?!), price controls (anathema to conservatives) and/or tight utilization control (don’t get between me and my doctor).

Yes, forcing people to buy insurance and not covering pre-existing conditions if they don’t is going to make more people buy insurance and that’s good.  But it’s still unaffordable for many, and they will won’t sign up.

What does this mean for you?

It’s easy to criticize; now that Trump et al own this, they’re going to see just how hard it is to fix health care.

 

 


Nov
10

The optimist’s case for Trump

In an effort to get my head around Trump’s victory, I’ve spoken with several good friends with diametrically opposite political leanings, folks in the demographic that used to be called Northeast Republicans. The conversations have been long, heartfelt, passionate, and courteous. Here’s what I’ve learned.

The depth of disgust for the Obama years is deep.  One very knowledgeable colleague described economic growth under the President as “zero”.  While GDP growth has not been anywhere near as robust as one would like, it has averaged 2.1%. A detailed and dispassionate perspective is here. Job growth has been anemic indeed, labor force participation is low – but improving, while wages have improved markedly – if only recently. And, the last 8 years has also been a time of relatively low growth in world GDP, much lower than it was during the Reagan, GW Bush, and Clinton eras. Tough to grow a very mature economy when our buyers and sellers aren’t growing at all.

The discussions have been wide-ranging but all come back to this sense that the country is somehow on the “wrong track.”

Into this comes Donald Trump, a candidate with a chequered business career, well-documented behavioral issues that would disqualify him from being hired by most employers, is notoriously thin-skinned, and has policy positions that are, at the very least, confusing and ideologically inconsistent. And that’s leaving out the really ugly stuff.

Among his policy ideas/positions/stated plans:

  • building the wall – consistent with GOP orthodoxy
  • renegotiating NAFTA – not consistent
  • declaring China a currency manipulator – not consistent
  • raise the minimum wage – not consistent
  • ramp up fossil fuels – consistent
  • friendship with Putin – not consistent
  • spending a trillion dollars on infrastructure- not consistent
  • reduce taxes on the wealthy – consistent
  • repeal “Obamacare” – consistent
  • climate change is a hoax – consistent
  • add $10 trillion to the debt to accomplish varied goals – not consistent.

Point here is not to get into policy details, but rather to note Trump doesn’t toe the ideological line, rather he jumps back and forth with amazing rapidity.

When I ask my friends why they voted for Trump, it clearly isn’t about policy. Trump’s “policies” are decidedly NOT conservative. They say things like:

  • “I hope he surrounds himself with people smarter than him and listens to them”
  • “he didn’t mean those things, he just says crazy stuff”
  • “the legislature will do most of the policy setting work”
  • “he will get the best SecDef (Secretary of Defense) and he (Trump) will lead from ahead”

I don’t see it.  Trump won by ignoring all experts, by going his own way, by following his own genius. And that has brought him to the most powerful position on the planet. Why would he listen to anyone else?

If anything, these conversations have gotten me even more bewildered. Middle-aged successful intelligent professionals decided to vote for – and support – a candidate with many views directly contrary to theirs, with serious behavioral issues, and with a temperament they acknowledge is highly concerning instead of a pretty ordinary but highly experienced center-left politician with a long reputation for working well with Republicans.

The risk:reward thing is what stumps me.  Trump will have the nuclear codes.  He will have the “trade-war codes”. He has control over foreign policy. All areas with huge risks – some of them existential. Yet none concerning enough that my colleagues didn’t vote for him.

I very much hope my colleagues’ optimism is well-placed.

And very much fear it isn’t.


Nov
9

Shock

That’s the only word that describes my reaction to the election.  Kudos to Bob Wilson, who bet me months ago this would happen – he was right, and I was very wrong.  I owe you a drink; make mine a triple.

I’ve heard from many of like and opposite political mind today, and will be the first to admit I cannot get my head around what happened.  It’s not so much that the professionals got everything completely wrong. No, it’s that we elected a person who, according to many members of his own party is totally unqualified to be president in so many ways.

After reading JD Vance’s Hillbilly Elegy, I’m beginning to understand the large swath of the population that is pissed off, feeling left behind and abandoned.  I also absolutely get that we Democrats are partially or perhaps largely to blame.  I don’t buy some of their complaints, but that’s irrelevant; they feel aggrieved.

So they voted to “drain the swamp”, to change Washington. Interesting thing about change; it can be good, or it can be bad.  In this instance, it may well be really, really bad. To get an idea, of what we can look forward to, take a look at the disastrous Kansas Experiment.

There will be huge repercussions for the healthcare industry.  Rand Paul has promised to put an ACA Repeal bill on Trump’s desk week one.  We’ll see if that gets thru the filibuster, but even if it doesn’t there’s much Trump can do administratively to alter ACA.  

Now’s not the time to get into this in detail; I’ll be hosting a special post-election Health Wonk Review Friday that will dig deep into the issue. For now, I’ll leave you, dear reader, with a message I sent to our three wonderful, smart, caring, adult kids.

Ok family. We have today to feel miserable and angry and disgusted. Tomorrow we get to work on fixing it. 74 years ago your 19-year-old grandfather flew through fighters and flak above Germany to save our country. It’s our job now. I had become complacent and lazy about preserving what we are so lucky to have. I see that very clearly, now that the consequences of that inaction are so apparent. It’s on us.

 


Nov
7

Thanks, Jimmy.

(Edited to correct my error, Jimmy Morales is a woman.  MY apologies to Ms Morales for mis-identifying her.)

This morning’s WorkCompCentral brings us a report that Miami Beach’s City Manager is rejecting two police officers’ work comp claims for coverage due to Zika infections.

Reportedly the officers work in Zika-infected areas, but the mosquito has not been found where they live.

City Manager Jimmy Morales refuses to cover these cases, saying:

“He/she must show that the exposure/bite took place while on duty and identify the specific infected mosquito,”

To be fair to Ms Morales, she claims that the two officers have yet to comply with requirements to submit full medical documentation.  If that is the case, then they need to do so. HOWEVER her “requirement” that the officers bring the the specific infected mosquitoes isn’t just ludicrous, it also makes her – and her city – out to be heartless, uncaring bureaucrats.

If Ms Morales wants to perpetuate the meme that workers’ comp folks are heartless, penny-pinching, claim-denying, conniving, scheming bastards,s he’s nailing it. I don’t think that’s Ms Morales’ intention, and I’m hoping she mistakenly relied on a legal interpretation in a misguided attempt to stick to the “letter of the law.”

Ms Morales has not only damaged her relationship with his City’s police force, she’s also provided system detractors with yet another iconic example of how work comp is grossly unfair. And she’s done this in Florida, where the workers’ comp system is already on shaky ground.

Thanks, Jimmy. 

What does this mean for you?

People, please think before you act. You can’t unring the bell, take back what you said, or in this case claim you were misquoted.

 


Nov
4

Friday catch-up; CorVel, deals, & drugs

Good morning all.  Out in SoCal for the CompLaude event; looking forward to two days of great discussion about the good things in workers’ comp.

More evidence that WC medical trend is flattening

WCRI released it’s Indiana CompScope report earlier this week. Headline is medical trend flattened in 2014, with the change to facility reimbursement a likely contributor.

You can order it here.

CorVel

The TPA/managed care company released its Q2 earnings report yesterday; revenues inched up 3%, while earnings per share were down almost 16 percent. 

EBITDA dropped from 14.8% to 8.8%.

According to the company, TPA revenues were up 13%, but:

“…staffing and adjusting to the new laws for time management resulted in recruiting expenses and legal fees. The Company is also experiencing extended sales cycles due to the economic uncertainty in the healthcare marketplace caused by the election and the evolving conditions under the Affordable Care Act.”

CorVel is primarily a work comp player. I don’t know why ACA would effect CorVel’s work comp business; I can speculate that the soft work comp market (except in California) is not helping TPAs grow top line or earnings.  While CorVel’s 13% increase in TPA revenues is exemplary, one has to wonder if they are buying business. The precipitous margin decline indicates pricing is indeed an issue.

You can read the earnings call transcript here.  Suffice it to say there’s a lot of talk about structural issues extending sales cycles and blame placed on external factors.

This means – CorVel still hasn’t figured out how to effectively compete in the TPA business.

Deals…

Mitchell just announced they completed two acquisitions. Specialty bill review firm Qmedtrix and work comp PBM IPS were added to the portfolio. IPS joins CogentWorks, CompToday, AutoRx and Jordan Reses under Mitchell’s Pharmacy Solutions business; Brian Anderson will continue to lead that (congratulations Brian).

Qmedtrix will become part of Mitchell’s SmartPrice Solutions; that business includes FairPay Solutions and National Health Quest.  Looks like the individual names will go away as Mitchell rebrands the offering under the SmartPrice name.

This means – more consolidation in the work comp PBM business, and a more viable PBM offering for Mitchell

Work comp drugs

Today’s WorkCompCentral has a great piece by Elaine Goodman about the reduction in opioids enjoyed by Optum’s work comp payer customers. According to Optum:

  • the percentage of patients using opioids dropped by almost 5%
  • average morphine equivalents decreased 4.7%
  • the number of scripts per claim dropped 1.7%

Optum isn’t the only PBM delivering results; Coventry and Express Scripts helped their payer customers reduce the use of compounds by almost a third. 

And, continuing a six-year trend of reductions in drug spend, Optum data indicates drug costs per claims fell another 4.6% in the first seven months of this year compared to last.

This means – PBMs continue to deliver for work comp patients and payers.


Nov
3

Cubs Win! Implications for health care…

Brad Wright is a master blogger, and a terrific writer as well. He’s put together a synopsis of all you need to know about health care heading into next week’s election; complete with graphs, charts, and data, while somehow tying it all to the Cubs’ historical World Series victory.

As a White Sox fan, I’m happy if for no other reason then those Cub fans will finally feel the joy we did in 2005!