Author: Joe Paduda

Jun
28

OneCall acquiring TechHealth

Posted by Joe Paduda on Friday, June 28th, 2013 | Comments

Giant workers’ comp managed care firm OneCallCare Management will announce today it is acquiring Tampa-based TechHealth.

TechHealth, which has been on and off the block several times, provides a range of services  – transportation, home health, DME, PT, pharmacy and imaging to the comp industry.  As OCS already has a robust offering in all but two of the product lines, it may well be OCS’ owners were seeking a toehold in pharmacy and PT, while adding a bit more capability in transportation and home health/DME (I don’t see TH’s imaging as material to the deal).

With revenues well above $100 million and a solid technology platform, TechHealth will also add top line revenue and a different customer mix (heavier on the smaller-payer end) to OCM.

TechHealth got its big start serving AIG’s regional claims office in Florida around the turn of the century, the value proposition defined as relieving the adjuster of the hassle of handling the multiple services needed for complex claims.

TH grew in fits and starts, primarily by selling into claims offices with a few regional carriers and TPAs using their services on a broader scale. The one-stop-shop value prop, while appealing on its face, has yet to gain appreciable traction amongst the larger (top 20) payers.  While there are several competitors with similar strategies, none has managed to become a major supplier across all (or even most) of the service lines with any of the big payers.

The OCM model is markedly different.

As the largest imaging, DME/HHC, dental, and transportation/translation supplier, it can make the argument that the promise of the one-stop shop is now reality. The addition of Harbor Health gives OCM insights into physician-ancillary service provider relationships, which it will undoubtedly use to increase the volume of services delivered thru OCM.

OCM’s model is anchored in the “original” OneCall Imaging’s expertise and deep experience in scheduling imaging; the new owners leveraged that expertise and combined it with similar services (if you’re getting an MRI, you may need transportation). The growth – primarily via acquisition – has been impressive, as OCM is now the largest single supplier of services to the WC market, eclipsing Coventry Workers’ Comp last year.

This isn’t the only deal you’ll hear about this summer; word is one – or more – of the big bill review firms are looking at a transaction, and there are at least two others expected to be announced before the kids head back to school.

What does this mean for you?

For payers, fewer choices. For entrepreneurs, an opportunity to launch something new and different, albeit a high-risk one. 

 

 

Jun
27

Should workers’ comp pay more for medical care than group health?

Posted by Joe Paduda on Thursday, June 27th, 2013 | Comments

That is the question I’m left with after reading WCRI’s latest reports.

One compares group health’s payments for outpatient hospital services to work comp’s; the other discusses the use of group health payments as the basis for a work comp provider fee schedule.  There is a wealth of insight in both studies; generally, states with fee schedules had lower work comp medical costs than those without

The latter is the subject of today’s post; it “focuses on the median nonhospital price paid for five common surgeries and four common established patient office visits in 22 large states for services delivered in 2009.”; it compares group payments to comp.  By focusing on actual prices paid, the analysis factors in network and other discounts taken, increasing the “validity” of the data.

I’ve long thought providers should get paid more for care delivered to workers comp patients than for group, medicare, or medicaid.  Comp involves disability management and all the communications, reporting, and complications inherent in considering disability in delivering care, and as we expect physicians and other care givers to take an active role in that process, by rights we should expect to pay them for that additional work.

That said, the dichotomy between pricing differentials for office visits vs. surgeries reported by WCRI strikes me as precisely the opposite of what should be.  Specifically, the prices paid for office visits under group and comp were typically within 30 percent, with a range of 15 percent in about half of the states studied; in several states comp paid significantly less than group for office visits. Office visits are where and when the “disability management’ stuff occurs as the physician discusses the return to work plan, engages with the field case manager (if one is involved), talks with the claimant about the claimant’s job functions, physical capabilities and limitations, and other factors affecting disability.  This takes time, thought, documentation, expertise.

Conversely, reimbursement for surgeries was generally much higher when the payer was workers’ comp than when a health plan was on the hook. Remember, the payment is specific to the surgical procedure; it does not include visits pre- and post-surgery. A knee arthroscopy is a knee arthroscopy; yes, there may be a little different documentation for WC surgeries, but the surgical notes should consider functionality, rehab plans, and prognosis regardless of who the payer is. Yet in only one state – Michigan – was the reimbursement essentially identical, while in the other 21 states, the reimbursement was higher for comp – in seven states comp reimbursed at least twice as much as group health. 

Surgeons may argue that the higher reimbursement is necessary to ensure access; that argument, should it be made, is easily addressed by noting physicians are willing to accept much lower reimbursement for the identical procedure for most of their patients; there’s no access problem for group health patients despite the lower reimbursement.

In contrast, reimbursement for office visits should be higher for workers’ comp, for the reasons noted above.  If not for the office visit code itself, than perhaps states should institute a different code for disability management (some payers already do this).

What does this mean for you?

From here, this looks like another example of under-valuing primary care and patient – physician interaction, while over-valuing procedures; doing stuff TO patients.  

Jun
26

Immigrants and health care – who’s paying, who’s getting

Posted by Joe Paduda on Wednesday, June 26th, 2013 | Comments

Immigrants Contributed An Estimated $115.2 Billion More To The Medicare Trust Fund Than They Took Out In 2002–09 – that’s the headline from a piece in Health Affairs this month.

“immigrants may be disproportionately subsidizing the Medicare Trust Fund, which supports payments to hospitals and institutions…In 2009 immigrants made 14.7 percent of Trust Fund contributions but accounted for only 7.9 percent of its expenditures—a net surplus of $13.8 billion. In contrast, US-born people generated a $30.9 billion deficit…

Most of the surplus from immigrants was contributed by noncitizens [emphasis added] and was a result of the high proportion of working-age taxpayers in this group. Policies that restrict immigration may deplete Medicare’s financial resources.”

When one considers that birth rates among citizens are declining, and thus there will be fewer young working folks to support us aged people, the current anti-immigrant/nativist stance starts to look a little problematic.

Fact is, Medicare and Social Security depend on contributions from working age people; if we drastically restrict immigration and deport all undocumented aliens those two programs will be in dire financial straits much sooner than anticipated.

Conversely, a more “open” policy would go a long way toward reducing the strain on Medicare and SS.

Just saying.

Jun
25

Workers’ comp rates are up, but still no profit.

Posted by Joe Paduda on Tuesday, June 25th, 2013 | Comments

While workers’ comp premiums have been increasing steadily for two years, the industry is still not profitable.

Why not?

There are a bunch of pluses and minuses influencing profitability; premiums were up 7 percent in 2012, driven by higher rates and growing payrolls.  Rates have been trending up for eight consecutive quarters and increases are now in the double-digits. That helped improve 2012’s combined to 110.

On the negative side, today’s historically-low interest rates get part of the blame, but their impact is somewhat offset by declining frequency (down 5 percent last year).  Fitch’s latest report noted the industry still suffers from reserve deficiencies, making the current combined ratio a bit optimistic.

The industry’s performance is simply a composite of all insurers, and here’s where it gets really interesting.  Couple things stand out from Fitch’s analysis (access is free to registrants).

  • Companies with weaker underwriting performance shrank their books; specifically, all insurers with combineds over 100 reduced their premiums over the last five years.
  • Liberty Mutual is once again at the top of the market-share list, despite dropping from 11.1% share to 9.9%.  AIG has reduced its exposure by over $3.5 billion over the last half-decade.
  • Fitch notes that the implementation of health reform under PPACA will likely affect “volatility in workers’ compensation claims costs”; that’s certainly true, but I’d suggest the impact of long-term opioid usage will be rather more significant.
  • The report authors also note “the industry will continue to report unfavorable reserve development” in work comp over the next several years.  In English, they are saying insurers haven’t set aside enough money to pay for the future medical and indemnity expenses of claims that have already occurred.  

I remain convinced most insurers don’t have a firm grasp on medical costs and drivers thereof.  Fitch’s comments about reserve inadequacy support that belief, as do anecdotal discussions with executives.  I detect a distinct uneasiness when discussing medical costs, a sense that things are not as under-control as one would think from reading industry reports and company press releases.

What does this mean for you?

Rates will continue to go up; more employers will go self-insured; and the carriers we expect to be the biggest will likely not be in a few years.

Jun
24

The true cost of opioids

Posted by Joe Paduda on Monday, June 24th, 2013 | Comments

A workers’ comp claim with no opioid scripts costs about $13,000.  Those with long-acting opioids like Oxycontin?  $117,000.

This and other factoids were reported in yesterday’s NYTimes in a revealing piece by Barry Meier; you may recall Meier was responsible for two articles last year in the Times on opioids and workers’ comp physician dispensing.

  • There were 16,651 deaths associated with opioids in 2010. My best guess is several hundred of those were workers’ comp claimants.
  • The price-per-pill for Vicodin dispensed by docs was roughly three times that of Vicodin purchased at a retail pharmacy.
  • Opioid sales more than doubled to $8.34 billion in 2012; workers’ comp accounts for about 18% – 20% of total opioid costs
    (remember workers’ comp medical is less than 2 percent of total US medical expense…)
  • The number of patients in drug treatment – inpatient, outpatient, or using drugs intended to address addiction – has increased dramatically over the last ten years.

What does this mean for you?

Do you have any idea what opioids do to your claim costs?  Not just the cost of the drugs; the other medical expenses, extended disability duration, legal expense, and settlement costs?

 

 

Jun
21

PPACA/Obamacare and Medicare fraud

Posted by Joe Paduda on Friday, June 21st, 2013 | Comments

Among the hundreds of pages of the PPACA are passages addressing provider fraud, a far-too-common and far-too-costly issue that has long plagued the program.

The good news is, things seem to be getting better.

CMS just reported they recovered a record $14.9 billion in 2011 and 2012 from anti-fraud prosecutions and judgments.  The number of providers kicked out of Medicare more than doubled in the two years after PPACA was passed. And the most recent large action saw 89 individuals charged with $223 million in false billing.

One occurred in Miami (shocking, I know), where a local TV celeb was busted for allegedly falsely billing Medicare some $20 million for home health care services for diabetics…(you gotta see this picture of the alleged perp…)

There are a bunch of reasons for the increased success;

  • PPACA allocated an additional $350 million over ten years to anti-fraud efforts;
  • the FBI has dedicated more resources to the effort,
  • CMS investigations staff and resources have been increased and given more authority and a more prominent position in the Department;
  • computer programs designed to identify potential fraud have been developed and improved, and
  • rewards for tips may be drastically increased – up to a maximum of $9.9 million.

That’s all good – but every time I see a TV ad for that hoverround chair I think there’s still  some rather significant “opportunities” to reduce taxpayers’ burden.

If those companies can afford to stuff my cable box full of adverts, they are making too much profit.

Jun
20

HWR welcomes summer

Posted by Joe Paduda on Thursday, June 20th, 2013 | Comments

Wing of Zock (a great blog name and one you’ll have to click on to understand) has the last edition of the spring – or as I like to think of it, the first of the SUMMER!!

Jun
20

Pharmacies’ self interest v silos v ignorance

Posted by Joe Paduda on Thursday, June 20th, 2013 | Comments

$1.7 billion in workers’ comp drug costs are for drugs dispensed by physicians.  

Why don’t the big retail pharmacies care about physician dispensing in workers’ comp?

Why isn’t Walgreens, and CVS, and Rite-Aid, and Medicine Shoppe up in arms about this?

After all, claimants who get their drugs from their docs don’t visit a drug store, don’t pick up those other essentials, don’t establish a relationship with a pharmacist and possibly a store.

I’ve been stumped by this for years.  Here’s why.  About 65 percent of a chain drug store’s sales are for drugs; for independents its 93 percent.  The margin on most of those medications is pretty thin, and almost non-existent for Medicaid drugs in some states.  Chain drug stores sell drugs to get people to come in and buy toothpaste and magazines and convenience foods and cosmetics, where they do make a decent profit. And independents live and die on drug sales; and these days, most are dying. 

Yet anyone who’s tracked anti-physician dispensing efforts in Florida, Maryland, Hawai’i, Michigan, Illinois – anywhere, has not seen hide nor hair of anyone remotely associated with a drug store.

Is this a case of silos, where the department/person responsible for workers’ comp drug sales has no power or influence or is measured on percentage margin and not total sales or profits (because WC drugs are VERY profitable for pharmacies; the margins are many times those of drugs dispensed for group health plans).

Or is it ignorance, where the powers-that-be don’t care about WC drugs because they only represent a couple percentage points of scripts?  Of course, the total would be a lot higher if physicians weren’t dispensing, and this ignores the much higher profits on those drugs, but hey, ignorance is bliss, right?

Whatever the reason, it is abundantly clear that insurers, employers, PBMs, and others (me, for instance) have been fighting chain and independent pharmacies’ battles for them.

If independents don’t sell drugs, they’re dead.  And more are dying every day, as overall drug sales level off, and they are increasingly unable to compete with the chains and huge food-and-drugs.  Yet I’ve never seen anyone from an independent pharmacy, or their national trade group, engaged in the issue.

Folks on workers’ comp are either employed or getting a check to cover lost wages; they need toiletries and food and other medications and batteries, stuff they’ll likely get from the Big Box store if they don’t come in to the corner drug store to get their workers’ comp meds.  Yet NACDS and the other “advocacy” groups are nowhere on this issue.

It isn’t like I – and others – haven’t tried, multiple times, to get drug stores engaged.  For whatever reason, there’s been no response.

Meanwhile, the investment and provider communities have figured out that workers’ comp is a great business – profitable, with relatively low regulatory risk.  Comp is an “insulator”, a payer type that is removed from PPACA, Medicaid, Medicare, and all the changes coming down from Washington; a service line not affected by budget cuts or Obamacare.

At some point, perhaps when the last independent drug store is about to close up shop, someone may say “gosh, those dispensing docs sure killed our comp business; we could have used those dollars to stay open and profitable.”

Or a chain store exec may wonder “gee, why is my average profit per script lower than ever?’

Or, more likely, Not.

 

Jun
18

Implementing health reform, random report 1

Posted by Joe Paduda on Tuesday, June 18th, 2013 | Comments

Today brings another in our random reports on progress and stumbles in implementing reform, starting and running Exchanges, and sussing out the reality from the BS.

It looks like there will be more competition for individual insurance come 2014 than there is in today’s market – “the number of carriers offering non-group insurance plans [in the 10 states where data is available] will increase substantially, from 52 to 70–an increase of 35 percent. Six of the 10 states will see more insurers operating on the non-group exchange compared to the number of significant competitors pre-reform.” Four will see no change.

One example is Colorado, where there are 243 individual and group plans available come October.  Rates are in, and while they aren’t lower than current rates, the additional benefits and (in some cases MUCH) lower out-of-pocket maximums make for much better coverage.  Individual rates for lower-end plans range from around $200 for young’uns to $250 or so for 40 year olds, and that’s BEFORE any subsidy, which about 466 thousand Coloradans qualify for.  The folks who know waaaaay more than I do about Colorado health plans are Louise and Jay; they’ve done quite a bit of research into costs, benefits, and the balance between the two.

Louise notes that the demise of medical underwriting makes it impossible for insurers to keep individual insurance rates much below small group premiums; on the other hand, many more individuals will be able to get coverage who can’t today.  And, those unfortunates who are stuck in one job because they need the insurance will be able to move, start a new job, or a new business after 1/1/14.

Gotta love that free market!

Moving a thousand miles plus to the east, data on insurance premiums from the D.C. Exchange are in; rates for the four insurers filing to date are “in line with current rates”; a bronze plan for youngsters can be had for $124, the older folks can get one for $296 on the individual market, with group rates somewhat higher.

Finally, there is growing evidence that the ACOs working in Medicare are beginning to have a measurable impact on outcomes; readmissions fell by one percentage point last year, the first drop in five years. Anecdotally, some hospitals participating in ACOs are reporting decreases in ER visits for Medicare recipients enrolled in ACOs.

Jun
17

The latest workers’ comp intel

Posted by Joe Paduda on Monday, June 17th, 2013 | Comments

 

 

The weather is heating up, and so is the workers’ comp services industry.  Here are a few of the latest and greatest.

The big news remains CWCI’s report on opioid usage; some are using the headline that use is “leveling off”, which, to be completely factual, is, well, factual.  It is also just like saying “new cases of bubonic plague in (insert your home town name) have leveled off after hitting an all time high and killing lots of your neighbors.”

Oh goodie.

On the upside, Accident Fund Insurance Company just received a patent for “evaluating medical service providers and directing claimants using a computer and a database…”  The rationale, in patent-ese, is this:

“a method and system is needed to transform the processing of claimants. Without the additional step of directing certain types of claimants to specific medical service providers, not provider networks, the success of directing claimants cannot be effectively measured and used to redefine medical service provider groups and claimant groups in order to improve efficiency and optimize medical costs at the claim level.”

As a consultant, it is rare indeed to see something you actually worked on years ago reach full implementation.  And immensely gratifying as well. Kudos to Jeffrey Austin White, Craig Bilinski, Pat Walsh, Marsha Fenton, Lisa Riddle, and their colleagues at AF.  While others continue to talk, you guys are actually doing it.   

Healthcare Solutions has hired industry pro Rich Leonardo to run PBM sales.  Rich is a highly-experienced and well-regarded exec with a long track record of success.  He’s a good guy too.  Good move by HCS; Rich’s experience running sales for Express’ WC PBM will be invaluable.

PMSI continues on a roll; heard they landed the State Fund of Wyoming PBM contract.  Word is this is in the “several million dollar” range; implementation is underway.

Saw a press release recently that Medata had won the bill review business for a Florida-based auto insurer; that got me interested in re-visiting the medical bill review business to see what’s been going on.  Lots of private equity attention being paid to this space of late; word is one or more of the jumbos are for sale.  Not surprising; if anything the investor activity in P&C services is – if anything – heating up.

Of note, auto insurers in some states (Michigan and Hawai’i in particular) are seeing a big increase in physician-dispensed medications, an unfortunate occurrence that is not only driving up medical costs and will lead to higher settlements, but adding confusion and delay to medical bill processing.  Insurers are wrestling with how best to address bills for physician dispensed drugs, as some are extremely costly and their medical appropriateness (Prilosec et al) can be rather questionable at times.  And yes, this is hitting the PIP/auto insurance lines – and in many cases completely using up the available medical coverage.  

Then there’s this…A Michigan company is hiring 50 (!) reps to sell a compound pharmaceutical narcotic pain cream. Sources indicate a local doc is behind the venture, undoubtedly designed to bring much-needed relief to those poor souls who can’t swallow pills.  Both of them.

Proving that I’m waaaay behind in my mandatory reading and reporting, a few weeks back Chris Walsh wrote a great piece in WorkCompWire about improving workers comp outcomes with systems automation.  Chris started his career in the HMO IT business and knows of what he speaks.  Well worth a read.

Finally, now that Aetna’s completed the legal/financial part of acquiring Coventry, the real work begins.  Well, actually, continues – because the two companies have been working on integrating/combining their operations for months.  Don’t expect to see Aetna sell off the workers’ comp business – because a) it makes a ton of money; b) it is a regulatory risk mitigator; and c) even if they wanted to – which they do NOT – they can’t.