Jun
8

Can Texas Mutual help Texas’ health insurance/healthcare needs?

Texas has some rather troubling healthcare problems…and Texas’ legislators are asking the state’s largest workers’ comp insurer to help solve those problems.

First, a few Texas healthcare data points…

Of course, one of the big issues is Texas refuses to expand Medicaid for reasons I must admit are confusing at best.

And the Feds are looking to cut almost $9 billion in funding; Texas has a convoluted tax-and-transfer thing in place which CMS believes is illegal…

I’ve been digging into this of late…collecting background information, interviewing the leader of TM’s new venture and reaching out to legislators behind a bill that asked required Texas Mutual to help (details below); TM is in the process of standing up a health insurance entity that will begin operations early next year.

From the State’s website:

HB 3752 allows a subsidiary of the Texas Mutual Insurance Company to provide a health insurance product to Texans. The goal is to increase access to affordable health insurance for individuals, especially those in rural communities, and employees of small businesses.

Effective Date: September 1, 2021.

The bill would also require the company to fully explore methods to increase health insurance competition, use innovation to increase quality of care for lower costs, avoid discriminating against patients with pre-existing conditions and provide transparency when developing health benefit plans.

(3)  ensuring adequacy of benefits and access to care for individuals in this state with preexisting conditions;

(4)  issuing coverage in a manner that does not discriminate against individuals with preexisting conditions;

Not later than September 1, 2022, the company shall submit to the legislature a report explaining how any anticipated health benefit coverage offerings would comply with all considerations and guiding principles for developing health benefit coverage offerings under Subsection (a).  This subsection expires January 1, 2023.

Gotta admit, this is a head-scratcher.

 


May
8

Quick takes

Stuff you may not have seen/thought much about…

Good work from the Travelers...Analysis of a very large number of WC calms found:

  • watch those new workers – those with < a year on the job account for more than a third of all WC claims
  • workers >60 cost more…a whopping 1.4x more than the 18-24 year olds (but only 15% more than the 25-59 folks)
  • but…the 60+ folks don’t get injured as often.

The report is here.

kudos to the folks under the umbrella and WorkCompWire for getting the work done and news out.

you may have missed this – Texas Mutual is getting into the health insurance business.  I’ve reached out to TM and will be interviewing the new leader. I’ve a lot of thoughts about this…

  • the just-hired leader has a wealth of experience
  • standing up a new health insurance entity in a year is a very heavy lift
  • regulatory structure is quite different from WC
  • all research shows market share is the key factor in negotiating provider reimbursement, making it hard for new entrants to gain traction

Then there’s the question: “Why did legislators want TM to get into health insurance?” If they wanted to cover more people, expanding Medicaid would have been a lot faster, far less expensive, and much more impactful.

Finally, (somewhat) new WC bill review company accuro solutions acquired Splashlight...Splashlight is also in the WC BR business.  Good to see competition in an industry sector that sorely needs it.

 


Apr
1

Medicaid for All – Biden goes big.

Medicaid for All is back on the table.  In a speech in Rolling Fork MS, President Biden revealed that his administration is working in concert with Progressive Democrats – and Sen. Mitt Romney (R UT) – on legislation that would allow any citizen to enroll in Medicaid.

Citing Mississippi as an example of major problems with healthcare access, widespread un-insurance particularly in southern states, rising healthcare inflation, and massive bad debt from medical bills, Biden sketched a (very thin) outline of Medicaid for All. (no details on cost, timing, or much else, a lot of soundbites about babies, insulin, nursing homes and affordability)

While this may seem like a bolt out of the blue, it is pretty clear Biden’s administration has been working this since before he took up residence in the White House. The latest was a major streamlining of the enrollment process back in August of 2022 intended to make it much easier for families to sign up for Medicaid and eliminate caps on child care coverage.

Biden has been teasing a major announcement on healthcare for a couple weeks, most recently during an event lauding the ACA’s birth…

from the Washington Examiner:

Public support for major changes to healthcare has grown alongside support for the ACA. Seeking to highlight Dems’ perceived strength in healthcare and Social Security well ahead of the 2024 elections, White House spokesperson Robyn Patterson noted:

note this is NOT Medicare for All (M4A), a concept that was widely circulated back when  the ACA was in development. Biden briefly alluded to M4A in his remarks, noting his team ruled it out as Medicare “is not comprehensive, is confusing to many, and is mostly focused on older Americans…it wouldn’t work for young families…”

Reports indicate VP Kamala Harris has been pushing this since Biden named her his VP. Sen. Brian Schatz (D HI) an early advocate of Medicaid for All, has been meeting regularly with Biden staff, other elected officials, and HHS leaderships in an effort to build support. Schatz is close with Utah Sen Mitt Romney; recall Romney led the charge to revamp Massachusetts’ healthcare system and establish “RomneyCare” over a decade ago.

We can count on a full-throated opposition from almost all Republicans, although Romney’s reported involvement will give Biden much-needed “bipartisan” cover. I would not be surprised if Louisiana’s Sen. Cassidy also signs on; he’s been a behind-the-scenes advocate for a major revamp of healthcare for years. Long an advocate for state control of healthcare, Medicaid fits his policy views far better than Medicare.

in my view, there are a host of reasons Medicaid For All makes a lot more sense than Medicare for All; here’s what I wrote about this back in 2018…

  1. Medicaid for All will spread the cost of universal coverage across states, reducing federal financing requirements.
    Medicaid is a state AND federal program; States provide a lot of the funding for Medicaid; on average the Feds contribute 63% and states 37%. This is critical, as Congress will want to spread the cost of a Single Payer solution and there’s no better way to do this than require states to pony up big dollars [State contributions vary based on a state’s average personal income relative to the national average; states with lower average personal incomes get more federal dollars.]
  2. Medicaid is already built to cover everyone.
    Medicare covers people of all ages, Medicare is very much elder-care focused.
    Adapting Medicare to handle everyone from newborns to elderly, maternity care to pediatrics will be difficult, time-consuming, and expensive. Medicaid does all this and more – today.
  3. Generally, Medicaid is less expensive than other “systems”.
    This is due to much lower provider payment and significantly lower administrative costs. Yes, this means providers are going to be paid less.
  4. Medicaid member satisfaction is pretty good; access to care is not much of an issue.
  5. Medicaid-based Exchange programs are much more successful in the Exchanges than commercially-based plans.
    The Centenes et al [Medicaid-based plans] understand the demographics of the uninsured, have lower medical costs, and already have provider networks, customer relations operations, workflows and processes set up and operational. At the end of the day, lower cost wins – and their costs are lower.
  6. Medicaid is a simple, fully-integrated healthplan.
    Medicare’s alphabet-soup of Parts A B C and D is confusing and convoluted, with different payers often covering the same individual. This increases administrative costs, member hassles, and decreases quality of care (co-ordinating pharmacy and medical care between different payers is problematic at best.
  7. Managed Medicaid plans are working.
    These plans currently exist in most states, and many have been able to deliver excellent care at lower costs through innovation and very tight focus on outcomes. One example is using paramedics to deliver care. [disclosure – I sit on the board of Commonwealth Care Alliance, a Massachusetts healthplan that serves dual-eligible members]

What does this mean for you?

 


Mar
28

Medicaid, workers’ comp claim severity, and healthcare deserts

Medicaid is the second largest payer in the US, with spending approaching three-quarters of a trillion dollars this year.

In 2023, workers’ comp medical spend will be around $32 billion – just over 4% of Medicaid.

Medicaid is a major payer for many facilities in poor and rural areas, a financial lifeline that is thin indeed.

Ten states have yet to expand Medicaid, an ethically- and financially-unconscionable failure that has major repercussions for workers’ comp, poverty, child health and healthcare access (two – SD and NC – are in the expansion  process).

Access to care

Most rural areas in those 11 states were already hospital deserts; that will get a lot worse as over a third of rural hospitals are in those eleven states.

Average operating margins, razor thin before COVID, recovered somewhat during the pandemic but will turn negative as the pending Medicaid disenrollment takes effect.

More hospitals and their emergency and trauma units will close. Today in 40% of US counties most patients are more than an hour away from a trauma center…as more rural hospitals close even more trauma patients will be further away from hospitals.

What’s known as the “golden hour” is the first 60 minutes after an injury, when healthcare can save lives, limbs, and livelihoods.

What does this mean for you?

Claim severity will increase in those ten states. 

note – reminder, Saturday is April 1…beware.


Mar
15

Regulations – the good and the bad

Work comp and healthcare are probably the two most highly regulated sectors of the economy – and yes I’m including the financial sector.

Over the last 25 years I’ve spent a ton of time with regulators, legislators, lobbyists and the government folks tasked with implementing those laws and regulations.

Here are my learnings…

  • < 5 state legislators know anything about workers’ comp, and only a smidge more about healthcare.
  • what legislators DO know is from mass media (healthcare) or lobbyists (work comp, because there’s never any mass media coverage of work comp)
  • the laws that pass (with some exceptions) leave much to the regulators
  • Regulators are mostly thoughtful, diligent, attempt to do the right thing and generally open to input.
    • There are some glaring exceptions – Florida being the most problematic.
  • That said they rarely – and understandably – fully understand the potential impacts of their rulings, with big consequence for injured workers, employers, and taxpayers.

According to sources that know a lot about financial regulation, the collapse of Silicon Valley Bank was due in large part to laws passed by Congress (with mostly R and some D support) that loosened capital and other requirements for a lot of banks.

Incompetence added fuel to the dumpster fire. Now staunchly-Libertarian Silicon Valley investors and business owners have suddenly become huge fans of central government intrusion into private business (what a bunch of %$#(*&># hypocrites).

credit New Statesman

From the LATimes:

venture investment firms…actually launched the run on SVB on Thursday, when they suddenly urged their companies to pull their deposits from the bank, triggering the $42-billion outflow. “And they now want the Taxpayer to bailout their investments…?! Capitalism, Silicon Valley-style.”

Tellingly, SVB dropped a half-million dollars lobbying to get those laws passed…and their CEO – a huge champion of de-regulation was the biggest champion.

Now we have what just might become a global financial problem that – with better US banking legislation and regulations – would never have happened.

What does this mean for you?

If you are a state legislator, find and talk with objective and informed people in each area you’ll be voting on.

If you are a regulator, do what you can with what the legislature gives you, but be realistic…work comp is <1% of US medical spend, so do NOT expect healthcare providers to do anything different for their work comp patients – even if your regulations require them to.

If you are a Federal legislator, think a lot more about some massive effort to shrink the government.

Those Silicon Valley Libertarians sure wish they did.

 


Feb
22

Budget facts

credit Prof Galloway

The budget hawks in DC are threatening to prevent us from borrowing money to pay our bills..if we don’t agree to some yet-to-be-defined and pretty massive spending cuts.

The total Federal budget for FY 2023 is $6.2 trillion.

About $3.7 billion is pretty much off limits. So, you may want to ask yourself, where are the cuts going to come from?

$1.5 trillion of our spending is for Medicare and Medicaid, and there are hundreds of billions more for the VA and other health programs. And the GOP recently said thy’d leave Medicare alone, and more states are expanding Medicaid (North Carolina appears to be next), so it’s hard to see where cuts would be deep enough to move the needle.

Defense cuts? Defense is $900 billion…Given China’s saber rattling, Russia’s belligerence, Iran’s new air force and movies towards nuclear arms, and the North Korean’s continued aggressive posture, that’s highly unlikely

Social Security? that’s $1.3 trillion, and the GOP has recently said they won’t cut it .(after saying they’d like to figure out how to privatize it…)

What does this mean for you?

Threatening cuts is really easy when you don’t tell anyone what you’re going to cut…because one person’s waste is another person’s income. 

 


Feb
13

After 10 days away from the keyboard – family vacation in Mexico and gravel bike race in California – it’s back at it.

shockingly the world kept turning while I was unplugged…

The estimable Charles Gaba has just updated his analysis of US healthcare coverage by payer. Charles’ work is the best I’ve encountered to date…he includes everything from Medicare and Medicaid to Exchange programs to Healthcare Sharing ministries (between 865,000 and 1.5 million, Indian Health Services (2.6 million)…

Here’s the all-in-one view…

Despite all  those gazillions of people with insurance, many hospitals are having real/awful/terrible financial problems. Hospitals’ average margin – according to Kaufman Hall – was -3.4% for the first 11 months of 2022.

That said, things steadily improved during the year…

In the tiny world that is workers’ comp, NCCI released its review of medical inflation…among non-hospital providers (docs, PTs, etc).

Thanks to the good work of Raji Chadarevian and David Colon, we know medical inflation among these providers was…minimal.

As in 1.5% per year over the last decade.

Final note. Facility costs are increasing.

Most payers are doing a really crappy job addressing this; their bill review partners/operations are woefully ill-equipped to ensure your dollars aren’t being Hoovered up by healthcare systems and hospitals.

And yes “most payers”includes you.

To date those increases have been matched by a $2 billion decline in drug spending – which, by the way, has also reduced claim durations (way lower opioid usage = way more claim resolutions).

Physician costs are pretty much flat, drug costs are way down, and facility costs are headed up…net is you need to PLEASE stop catastrophizing about “severity increases” and other nonsense.

If I read one more survey or interview or discussion of workers’ comp execs afraid of “rate inadequacy” or medical inflation or some other incredibly uninformed and wrong-headed and ignorant fear mongering I’m going to call them out publicly.

Just. Stop.

 


Dec
20

Congress actually gets good stuff done!

I know – who woulda believed it?

Nothing like an end-of-the-year deadline and a looming change of power in the House of Representatives to motivate elected officials.

Here are the big items and what it means for you. Hint – work comp stuff is at the end…

  • a bipartisan bill to greatly increase our ability to prepare for and deal with future pandemics will become law this week.  The Prevent Pandemics Act was pushed by Democratic and Republican Senators…details at the link above.
    This means – the Feds will be much better prepared, activities will be better coordinated, and (hopefully) fewer of us will be affected by the next pandemic.
  • Improvements to Medicaid are great news for new moms and infants, (quoting WaPo) including:
    • allowing states to permanently extend postpartum Medicaid coverage for 12 months and
    • barring children from getting kicked off Medicaid or the Children’s Health Insurance Program for a continuous 12 months
      This means – kids will be healthier and off to a better start  – with big time implications for their future (and ours)
  • and good news for our fellow citizens in Puerto Rico...federal funding for Medicaid in the territory has been extended for 5 years, welcome news for an island that has been devastated by hurricanes and other weather-related disasters.

But all is not good news…the really dumb way we pay providers treating Medicare patients leads to unnecessary, counter-productive, and completely waste-of-time fist fights pretty much every year. Physicians face a 4.5% cut in Medicare reimbursement starting January 1st, and boy are they mad.

I doubt the entire 4.5% cut will go into effect…and the latest news indicates the cut will be 2% in 2023 with a smaller reduction in 2024.

What this means…

Work comp fee schedules tend to be driven or at least affected by Medicare’s fee schedule. States such as California will see an almost-immediate impact.


Nov
9

Here’s a quick-albeit-still-somewhat-up-in-in-the-air take on how the midterms may/will impact healthcare. Much depends on final results in several key elections (Senate in GA, NV, :

Medicare and Medicaid

Drug prices – Biden’s Inflation Reduction Act will reduce seniors’ drug prices; if the GOP takes control of the House (which appears likely) it may try to hold up/block/hinder Medicare drug price negotiation through oversight on how HHS implements the new policy.

If Dems hold onto the House (which is highly doubtful),  we can expect legislation that would expand Medicare and Medicaid.

South Dakotans voted to expand Medicaid; this is a big win for rural hospitals and the uninsured – 40,000+ South Dakotans will now have access to health care. For South Dakotans, the impact – healthier people and financially healthier hospitals = healthier economy.

Abortion rights

Ballot measures in 5 states addressed abortion rights with voters in California, Vermont, Michigan, and Kentucky (!) passing measures to protect women’s right to choose; as of early this morning no word on Montana.  Note there are nuances specific to each state; CA MI and VT’s votes enshrined a right to an abortion in their respective state Constitutions while KY defeated a measure that would have explicitly stated nothing in the state’s Constitution creates a right to abortion.

impact – while the votes in CA and VT were no surprise, MI was less certain and KY’s result is notable indeed; Kentucky joins Kansas as another relatively red state whose voters protected abortion rights.

These wins may well drive anti-abortion candidates and politicians to re-think their stance or risk voter backlash.

Investigations, oversight, and the like

If Republicans gain control in the House (likely) and/or Senate (maybe/maybe not) expect a raft of investigations into all manner of Medicare, Medicaid, COVID response, drug pricing and other issues real and imagined.

The biggest thing no one is talking about

Voters in Arizona overwhelmingly backed a measure intended to protect people from medical debt collections and collectors. 

From the Arizona Mirror:

Prop. 209 would reduce the maximum interest rates that could be collected from 10% to 3% annually. Currently, up to 25% of wages can be garnished by creditors, but Prop. 209 would limit that to just 10%. Courts would also be allowed to reduce the amounts being garnished in cases of extreme economic hardship, a power they don’t currently have.

I fully expect activists in other states to jump on this; it is hugely popular and desperately needed.

What does this mean for you?

Watch the updated results to see what happens with the House and Senate. That will drive what really happens…

 


Nov
3

Republicans planning to force Medicare cuts

House Republicans are planning to impose massive cuts to Medicare, raise Medicare’s eligibility age, and withhold payments to early retirees and retirees earning more than a certain limit.

News sources indicate the GOP will use the upcoming debt limit to try and force Medicare cuts, a reprise of earlier efforts supported by 175 House Republicans to slash Medicare spending. The effort is also gaining traction among Senate Republicans, with Senator Lindsey Graham planning to use the Republicans’ leverage in Congress to cut Social Security and Medicare.

Sen. Rick Scott’s 11 point plan goes a lot further; it would end Social Security and Medicare if Congress doesn’t take specific action to renew those programs every few years (see Scott responding to Fox News question at 1:09 of the video here.)

You may well recall that Scott was sued for Medicare fraud back when he ran Columbia/HCA. Columbia/HCA was ordered to pay the Feds $1.7 billion in fines and penalties.

What does this mean for you?

If you and/or your parents are on Medicare, this means a lot.