Leaving Las Vegas

After 2 1/2 days of nonstop meetings, change encounters, and talks, it is a relief to be heading out.

What was notable

Loved the way the conference planners set up the sessions in “rooms” surrounding the exhibit hall. Exhibitor attendance has been…declining for some time, with exhibitors rightly bemoaning the lack of traffic.

This generated more traffic – as did locating lunches and beverage consumption opportunities.

Newbies – lots of tech-focused entities on the floor this year. I’m not sure they all entirely understood their value proposition, what drives workers’ comp buyers, and exactly how they fit it. But hey, great to have them and their cool stuff on the floor.

Coolest premium – myMatrixx’ charger. Now, I didn’t spend a lot of time trolling for freebies – but this was far and away the best I saw. (disclosure – mM is a consulting client)

Biggest disappointment

Attendance at the session on impact of climate change on workers’ comp.

Aren’t you paying attention?

Every day there is more news about floods, fires, droughts, blazing heat and devastating storms – all of which have direct and major import for work comp.

And more regulations about heat exposure, polluted air, and employee safety.

And more discussion of unforeseen impacts of climate-change driven weather – from flesh-eating bacteria in the swampy waters inundating Florida communities to new regulations addressing exposure to smoke-filled air in western states.

Two claims professionals all-too familiar with hurricanes, floods, and wind (Jill Leonard of LWCC) and fires, heat, and drought (Jeff Rush of California Joint Powers) spent a ton of time preparing to help you handle what is coming. They know all about preparation, planning, the impact on injured workers (where’s my check!!?), dealing with new “employers” that flood an area after a hurricane, and all the things you can only learn from decades of experience.

As Jeff noted, Mother Nature doesn’t care about your opinions on human-caused climate change.

But your boss sure will when the stuff hits the fan and you aren’t ready.



National Work Comp conference – go time…

The annual gathering of the work comp tribes begins tomorrow – here’s a few thoughts from a post a few years back.

1.  Realize you can’t be everywhere and do everything. Prioritize.

2.  Leave time for last-minute meetings and the inevitable chance encounters with old friends and colleagues.

3.  Unless you have a photographic memory, use your smartphone to take voice notes from each meeting – right after you’re done – or write down key points immediately.  Otherwise they’ll all run together and you’ll never remember what you committed to.

4.  Get the app for your Droid or iPhone –  you got an email with the info…It has the schedule, exhibit hall layout, local map, and a bunch of other handy information and tools.

5.  Introduce yourself to a dozen people you’ve never met.  This business is all about relationships and networking, and no better place to do that than this conference.

6.  Wear comfortable shoes, get your exercise in, and be professional and polished.  It’s a long three days, and you’re always ‘on’.

7. Remember what your mom told you in high school…nothing good ever happens after 10 o’clock. 

This year I’ll be (mostly moderating) two sessions – one on fraud with my good friend Bill Barbato of Change Healthcare and SA Jefferson Grace of the FBI’s Las Vegas office, and

another on the impact of climate change on workers’ comp with Jill Leonard of LWCC and Jeff Rush of California Joint Powers. Hope to see you there.

Stop by the AppliedVR booth – it’s 769 right across from the networking zone – I’ll be there a good bit.

Finally, in these day of YouTube, phone cameras, Twitter, Instachat and SnapGram, what you do is public knowledge.  That slick dance move or intense conversation with a private equity exec just might re-appear – to your dismay.

And beware white man’s overbite…


Defining health plan value – what’s really important

If your health plan could show it:

  • reduced the days kids stayed home from school due to illness;
  • helped members with mental health conditions maintain a high level of functionality and engagement;
  • reduced workdays lost due to illness;
  • sped recovery from illness and injury; and
  • helped amateur athletes avoid injury and recover quickly;

would that be important?

Heck yes.

So…why don’t healthplans do that?

It’s doable – if they stopped focusing on and worrying so much about star ratings and patient experience and net promoter scores – which research shows consumers don’t really pay attention to or care about

(conclusion – no.)

and focused on what consumers really care about – staying healthy and able to do the things we want to do:

  • play with our kids and grandkids
  • do chores around the home
  • do our sports
  • shovel our walks, rake leaves, coach youth sports
  • lift stuff and move it around
  • got to the bathroom without help
  • dress and undress without help
  • go for a walk
  • oh, and work.

What’s even more puzzling is why employers don’t demand health plans complete on the basis of delivering fully functional, engaged workers.

What does this mean for you?

The most important component of any organization is its workers.

No employers hold their health plans accountable for ensuring those workers can actually, you know, work.

And that is why our healthcare system is so dysfunctional, ineffective, and expensive.


How we measure “value” in healthcare is all wrong.

The most popular formula for calculating the “value” of healthcare is pretty simple…

If you want to get a bit deeper into details, there’s this…

It’s about the “quality” of the medical procedure (was it done right? was the patient re-admitted? was there a surgical error or infection), perhaps the appropriateness of that procedure, and the “patient experience” – measured…somehow.

Pretty much every formula, discussion, or description of the healthcare value equation is focused on “outcomes” defined as the result of a surgery or treatment (did the patient get better?) or avoidance of sickness or injury (did the patient stay “healthy”).

None – as in none – focus on what’s really important to you and me –

Did the healthcare we received maintain/improve our ability to function – to raise our kids, work, exercise, function in society, do things we like to/have to do.

Functionality is the only “value” metric that matters, yet pretty much no one in healthcare and no healthcare organization – except in workers’ comp – talks about functionality, measures their results based on functionality, reports member functionality, studies it or seeks to improve overall member functionality as a core goal (except for a few unique healthplans).

Further, employers, who pay hundreds of billions of dollars on healthcare insurance premiums don’t even think about the impact of that healthcare on employee functionality/productivity.


Procurement, CFOs, finance departments and management are constantly challenged to show a return on investment on any project, hire, new initiative, acquisition or investment.

But never when they are buying healthcare – which, after payroll, is the biggest single part of the budget for most service companies and a major cost for every type of employer – public, private, not-for-profit.

Nope, it’s the thickness of the provider directory, whether or not some health system is in that directory, perhaps some “quality” rating, plus the biggie – cost.

What does this mean for you?

We are buying healthcare all wrong.


The problem with primary care?

It doesn’t generate profits for the medical-industrial complex.

From a societal perspective primary care is wildly undervalued – and wildly under-appreciated – because primary care doesn’t make money for anyone, especially primary care providers.

Which makes no sense on every front but the profit one. If everyone had good primary care,

  • they’d be healthier,
  • their health risks would be identified early and a plan developed to address them,
  • they’d have a provider who treats them as a whole person, who understands that we are a bunch of tightly-interrelated organ systems that have to be considered as a whole, not as individual organs,
  • they’d understand non-physical issues can be just as impactful as physical ones,
  • there’d be a lot less need for specialists, and
  • healthcare costs would likely be a lot lower.

Healthier people don’t need as many medications, devices, treatments, injections, therapies, surgeries, rehab, inpatient beds or surgical centers as unhealthy people.

And that’s where the money is.

Kaiser Permanente has generally excellent primary care – yet it can’t/hasn’t been able to translate that excellence into a sustainable competitive advantage.

I believe that’s because KP – and pretty much everyone else – is thinking about the “value” of healthcare the wrong way.

Tomorrow – how we define value today – and why that is wrong.


Private health insurance – can it be fixed?

I’ve been thinking long and hard about why our health insurance and healthcare systems are such a clustermess. Hugely costly, lamentable outcomes, a morass of bureaucracy, red tape and stupid rules enriching a few and impoverishing many.

So, I think I have a solution – and it involves workers’ comp.

First, the problem.

Today I’m reprising a post from a couple years back – if anything it is more accurate today than it was way back then.

If you had “government” health insurance for the last decade, your costs would be 20 – 25% lower today.

That’s because private insurers have not controlled spending nearly as well as Medicare and Medicaid have.  This from KFN via Axios.

Doesn’t matter what your economic or political ideology is – that’s a fact.

You and your insurance company pay your doctors and hospital more than twice what Medicare does. Yes, the Feds can exert pricing power – but why can’t United Healthcare, or Aetna, or Blue Cross?

Those healthcare giants should be able to negotiate better deals with providers; they have massive buying power and millions of members to leverage. They should be able to use that power to give you lower insurance costs – but they can’t.

Those private insurers are (theoretically) more nimble, smarter, better run, and more efficient than the government. And they have hundreds of billions of healthcare dollars to leverage.

Yet they’ve failed to outperform a bunch of bureaucrats.

I won’t dive into the “whys” today, because that would take away from the over-arching truth – government has been much more effective than private insurers.

What does this mean for you?

Cutting your health insurance costs by a quarter = more dollars you could have spent on other stuff.

note – happy to hear other thoughts; please use citations to back up any assertions.


Work comp drug spend – profiteering rampant in LA FL and PA

WCRI’s webinar on interstate variations in drug payments reminds us that lax regulations and absent legislators cost taxpayers and employers millions.

Slides are here – and are free to access. The report itself is here – available free to members and a nominal fee for non-members.

There’s a ten-fold variation across the 28 states studied by WCRI, with WI MN and MA around $22 in quarterly drug spend per claim, but LA and FL right around $200. A far higher percentage of claimants get scripts in the two high-spend states than in those on the lower end – and I’ll bet most of those are from dispensing physicians and attorney-represented workers using mail-order pharmacies.

WCRI looked at data from non-COVID claims less than 3 years old in 28 states from Q1 2018 to Q1 2021.

Top takeaway – overall quarterly drug payments dropped from $102 in Q1 2015 to $68 in Q1 2021 – but PA FL and CT – states with physician dispensing and/or mail order pharmacy problems – actually saw an increase – and that increase was largely driven by dermatological agents.

Want more evidence of the rampant profiteering enabled by lax regulations and compromised legislators?

  • Dermatological payments account for about 20% of payments in the median state – although there’s a wide variation, from 6% in the lowest state to over half (52%) of payments in the highest state.
  • These dermatological agents are almost always combos of lidocaine, menthol, diclofenac sodium and other generics – profiteers mix ’em up and bill at a huge markup.
  • PA is especially egregious – the vast majority of these dermatologicals are pharmacy-dispensed, and the average price paid was over $300.
  • Physician dispensed drugs accounted for more than half of drug costs in several states including Florida
  • It’s not just dermatologicals…California saw a big jump in NSAIDS driven by fenoprofen and ketoprofen…both questionable medications that have become darlings of the physician dispensing/mail order profiteers.

There’s good news too…after dermos, NSAIDs have the next highest payment across all drug groups at 18%…while opioids account for about 7% in the median states – way down from 13% in the same quarter three years ago.

I’d note that this is for claims <3 years old, and likely reflects the successful effort to avoid prescribing opioids to patients better served by other therapies.

What does this mean for you?

PA FL LA and CT  – stop screwing employers and taxpayers.




You have to go

to comp laude.

It’s unlike any other work comp conference – it is focused on what people and organizations are doing right, the right way – and the impact that has on the people we serve – injured workers.

There are some pretty emotional moments…injured workers sharing their stories about horrific accidents and their months if not years of recovery. One came from Brance Tully, a young man of eighteen who fell through a skylight two years ago – when he was 16.

After dozens of surgeries, untold hours of therapy and what could have only been an incredibly painful and seemingly-interminable journey, he is back at work. He called his adjuster the day he returned to be met with incredulity – justifiably so.

That was just one. Injured workers recovered from shootings, fires, vehicle accidents, falls and all manner of accidents.

There are several other reasons to attend:

  • plenty of time to connect and network
  • solid attendee list with folks from large employers, payers, and other buyers
  • terrific location – the Pasea Hotel is pretty nice.

Kudos to Yvonne Guibert – a dear friend and colleague, and the best marketer in workers comp – for making this happen. Shout out to GB and Greg McKenna – his engagement with the “stories” folks are remarkable.


One Call’s credit rating – nerd alert

Fielded several calls and emails yesterday re the Moody’s credit review of One Call…while always (ok, mostly) happy to talk, rather than answering the same questions multiple times I’ll lay my thoughts out here.

These are in no particular order…

A colleague noted the possibility of a recession might affect One Call’s credit worthiness as a recession would affect employment – thus reducing claims.

Well, not exactly..

I’ve written extensively on how economic ups and downs impact workers’ comp; posts are here. Here’s a quick summary..

At the early stage of a recession, employees who get hurt are less likely to file a workers’ comp claim. While we don’t know why that happens, research suggests it’s because workers are concerned their bosses will eliminate their job while they are out on disability, and they’ll have no job to return to.

graph courtesy NCCI

As the recession deepens, frequency tends to bump up as employees realize their jobs are in real jeopardy.  Claims increase as a result, and it is tougher to find re-employment opportunities for workers ready to resume some level of work. This extends to part-time or other limited duty work that is essential to recovery and return to full duty. So, duration increases too.

In the final stages, as the economy recovers frequency appears to accelerate. Employers put older, less-safe equipment back on line, require workers to put in big overtime hours, hire temps who have minimal training on safety, and the pace of work picks up speed. The result – more injuries.

***If we are in a “recession” it’s a pretty weird one; employment continues to grow, employers are hiring anyone and everyone who applies, and there are more job listings than potential workers to fill them…not exactly what one expects in a recession***

Another suggested the current owners can “just give One Call more money” thereby alleviating cash flow worries.

That’s a possibility – but I’d suggest a pretty unlikely one.

The current owners took over One Call when it was on the brink of bankruptcy; if OC had gone down that route it would have made it less likely OC’s bondholders/lenders would recover all their funds. In my admittedly limited experience, credit investors are much less likely to send more cash to assets that are struggling than private equity investors. And PE firms aren’t exactly enthusiastic about bailouts.

One insightful question focused on whether OC has debt with variable interest rates; those of us with fixed rate mortgages are protected from rate increases while our friends and neighbors with variable rate mortgages are seeing pretty significant increases in their monthly payments.

nerd alert…

OC has several different debt vehicles/types/forms

The First Lien (think of this as your house mortgage) of $700M is Libor+550 Floor <.75 which means that when Libor moves so does their interest payments. Libor moves when the Fed moves so, away you go.

For example in the beginning of the year OC would have been paying the Floor and for September about 2.52%. With the recent Fed increase, that will be going up to over 3%.

Note that One Call may have bought financial instruments that protected it (either in whole or in part) from interest rate changes – these are known as hedges.

[if memory serves One Call also has to pay down principle every quarter to the tune of around $2.1 million; that’s pretty small potatoes for a $1 billion+ enterprise]

Finally word is One Call had recently been awarded new business from a large payer, and this would certainly benefit the company going forward.

This is definitely good news for OC and congratulations are due to the C-suite and sales team (as well as the behind the scene folks involved).

That said, work comp payers are notoriously risk-averse; its too early to tell if Moody’s announcement will give the new customer pause.

What does this mean for you?

This stuff is complicated and one has to be careful making assumptions (I continue to learn to question mine!)

note – if I got anything wrong or you have another view please comment below.


The latest on One Call

Since its last-minute recapitalization three years ago, things have been quiet on the financial front for One Call. That changed yesterday; credit rating firm Moody’s released the results of a credit review – which were not good. [you can access the review by registering with Moody’s – there is no cost]

Historical corp rating changes from Moody’s

First, the summary. [I’ve written about One Call extensively; you can find other posts here]

Moody’s downgraded One Call’s Corporate Family rating to Caa1. According to NASDAQ, Caa1 is:

“A rating within speculative grade Moody’s Long-term Corporate Obligation Rating. Obligations rated Caa1 are judged to be of poor standing and are subject to very high credit risk.”

Here’s Moody’s summary:

The ratings downgrade reflects the company’s challenges to grow earnings and reduce its very high leverage which stood at over 10x as of June 30, 2022. Despite initiatives to improve operating performance and preserve cash, and Paying-In-Kind interest on the second lien notes, Moody’s expects One Call to generate small positive free cash flow which will not allow for material debt repayment. Without a material improvement in operating performance and meaningful debt reduction, Moody’s expects One Call’s capital structure to become increasingly unsustainable.

There’s a lot to unpack here – here’s my attempt to translate the summary into English (corrections/suggested edits welcomed).
  • One Call has a LOT of debt – as in almost 11 times more debt than it has in EBITDA (earnings) – and it is growing.
  • One Call has to use a lot of its cash flow to pay interest on part of the debt.
  • it does NOT have to pay interest on another chunk of the debt, but if it doesn’t, the missed payments are [usually] added to the principal – which increases the amount of debt (this is known as Payment-in-Kind or PIK debt); this is kind of like credit card debt)
  • as this debt increases it constrains One Call’s financial flexibility, making it hard to invest in technology, people, product development, and other stuff.
  • Moody’s goes on to note that a lot of One Call’s revenue comes from a relatively few customers – this concentration (in Moody’s view) increases pressure on One Call as the loss of one or more of these customers would make it even harder to pay down the debt.
[Moodys also refers to “the loss of a large contract”; no, I do not know details ]
Notably, Moody’s did indicate the rating is “stable” and expects One Call to grow earnings “modestly” over the next 12-18 months.
Okay, nerd alert. One could find fault with one of Moody’s statements regarding a governance issue:
Governance risk is further exacerbated by private equity ownership, which increases the risk of shareholder friendly actions that come at the expense of creditors and has used debt exchanges and recapitalization transaction.
Not mentioned in the Rating action is the fact that the equity owners (affiliates of KKR, Blackstone and Chatham Asset Management) – who control the Board – also own a lot of One Call’s debt. That being the case, it’s hard to see why the Board would screw (sorry, easiest way to convey the point) debt holders.
I spoke with Jay Krueger, One Call’s CEO and a person I consider a friend and he was kind enough to provide responses to several questions.  These are provided verbatim below.

MCM – What impact – if any – will the rating change have on One Call’s customers?

JK – None. We have positive cash flow, strong liquidity, no pending debt maturities, and the backing of some of the world’s largest, most respected investment firms. We talked with many clients yesterday who expressed this was not a concern for them. They continue to be pleased with our strong value proposition, commitment to service, and superior solutions for them and their injured workers.

MCM – After One Call’s recapitalization two years ago, did the current owners (shareholders) continue to hold a significant amount of debt? If so, it strikes me that Moody’s concern about governance risks may be overstated. Thoughts?

JK – Our current owners hold nearly 50 percent of our debt. This is a very real symbol of their commitment to our mission of getting injured workers the care they need when they need it. I believe we are the only company in the industry with an ownership group that also supports the company by participating in the debt structure at such a high level. The shareholders have a high amount of confidence in our team and strategy. So yes, I believe Moody’s concerns are overstated.

MCM – As hiring has continued to increase, and employment as well, it appears likely that claim volumes may also see a slight increase. Any observations or trends relative to claim volumes you can share?

JK – Over the last three months, we have seen month-over-month, low to mid-single digit increases in referral volumes. Some of this increase is seasonal, some of it is related to the macro-economic factors you mentioned, and some of it reflects market share gains we have achieved in 2022. September volumes month-to-date are consistent with this trend, setting us up for a strong fourth quarter.

MCM – Can you elaborate on the large customer “loss” referenced in the Moody’s report?
JK – The Moody’s report referenced some minor adjustments to that customer’s vendor panel. The customer referenced is a large, national TPA that continues to be one of our largest and most important customers.  
Tomorrow, I’ll discuss factors not directly addressed by Moody’s that may impact One Call’s future.