Jul
27

that giant sucking sound…

Is coming from hospital trauma centers vacuuming thousands out of your wallet.

Trauma centers are supposed to handle the worst trauma cases – those from major car accidents, gunshots, airplane crashes, building collapses – you get the picture. Smelling gold, some hospital systems – including HCA – figured out that “activating” trauma centers lets them charge fees up to$50,000 per patient – even if that “trauma center” never actually treats the patient.

The fact that HCA has opened trauma centers in 90 of its 179 hospitals – many in close proximity to other trauma centers – indicates it is not a pubic health need as that “need” is already being met.

Shockingly, Florida is once again the poster child for what look to be abusive billing practices.  From Kaiser Health News:

In Florida alone, where the number of trauma centers has exploded, hospitals charged such fees more than 13,000 times in 2019 even though the patient went home the same day,

Florida trauma activation cases without an admission rose from 22% in 2012 to 27% last year, according to the data. At one Florida facility, Broward Health Medical Center, there were 1,285 trauma activation cases in 2019 with no admission — almost equal to the number that led to admissions. [emphasis added]

Work comp and auto alert…

Peter Johnson penned a deep dive into the explosive growth of trauma centers in the latest edition of Health Plan Weekly [subscription required]. In his article, Peter reported the number of Level I and II trauma centers almost doubled from 2008 to 2020, going from 305 to 567.

From his piece (Peter was quoting me):

It is abundantly clear this [the growth in the number of trauma centers] is not due to a years- or even months-long dramatic increase in apartment building fires, accidents, gun fights, or multi-car crashes.

Trauma used to be defined as high-acuity, emergent cases involving severe injury. Not any more at some of these facilities. Reports abound of patients with minor injuries requiring stitches, cold compresses, and even just a baby bottle and a nap billed for trauma activation.

What does this mean for you?

Any facility bill with a trauma center charge must be subjected to very careful and thorough review. Especially in states that allow higher payments for so-called “outliers”.

Auto insurers – pay attention!!


Jul
26

Canaries and coal mines.

Prior authorizations – aka 1-800 NURSE MAY I – are either an absolute necessity if you are a healthplan or a complete waste of time and money and affront to the medical profession if you’re a provider.

Of course, reality is somewhere in the middle.  Regardless, in what I will argue is due mostly to payers being dumb, a new law will strip most Texas payers of the ability to unilaterally set and enforce prior auth requirements.

As of September 1, Texas healthplans won’t be able to require prior authorization for certain treatments if 90 percent of the treating doc’s medical orders for those services over the last 6 months were deemed medically necessary by the insurer. The details are yet to be released; how this gets implemented, how insurers are supposed to track compliance, how the inevitable disagreements will be dealt with and all the other devilish details are TBD.

We do know that the “gold carding” of docs (the term used to describe docs who meet the 90% threshold for a healthplan or insurer) “only applies to payers that fall under the state’s jurisdiction and are not state funded.” It appears the law – HB 3549 – applies only to:

  • HMOs,
  • Medicaid plans, and
  • PPOs and EPOs offered by health insurers.

Self-insured employers are exempt as they are regulaterd under ERISA and thus outside state jurisdiction.

I’ve long argued – and strongly suggested to consulting clients – that they stop requiring good docs to submit to prior auth requirements, instead monitoring them on the back end via smart data analysis.  The vast majority of procedures that do go thru the PA process are approved – and the process can delay treatment, costs treaters and healthplans money, and add to the general frustration with healthcare and insurers.

Docs argue that PAs are unnecessarily burdensome…but I give little credence to their arguments; if they weren’t prescribing too many opioids, doing unnecessary surgeries, requesting unneeded tests and MRIs, PAs would not be necessary.

Similarly, healthplans’ argument that “The use of prior authorization is relatively small — typically, less than 15%”[of medical care] is ludicrous – the cast majority of healthcare is routine, and 15% of all “healthcare” is a gigantic number of services/drugs/procedures/treatments.

Canaries were an early warning sign of bad air in coal mines; when they stopped singing and died, miners knew to get the heck out fast.

What does this mean for you?

This is the first of what we will see in many states, and should be a wake-up call to all payers – health, auto, workers’s comp alike.

 

 

 


Jul
7

Surprise billing in workers’ comp

President Biden’s HHS Secretary announced a major new Rule addressing surprise billing for out-of-network emergency services last week. While not yet final, the Rule – and subsequent modifications – may address a major cost area for workers’ comp.

To be clear, the current version only applies to “group health plans, group and individual health insurance issuers, carriers under the Federal Employees’ Health Benefits (FEHB) Program…”

The Rule happened because providers are bankrupting patients by charging ungodly fees for out of network services, and payers aren’t covering those fees.

Quick highlights on the Rule…

  • it goes into effect January 1, 2022
  • for health plans that cover any benefits for emergency services, the rule requires plans to cover emergency services without any prior authorization and regardless of whether a provider or facility is in-network
  • it applies to:
    • most emergency services,
    • air ambulance services from out-of-network providers, and
    • non-emergency care from out-of-network providers at certain in-network facilities, including in-network hospitals and ambulatory surgical centers.

I wrote about this issue a couple years ago..

While this has made headlines in the private insurance world, it has yet to get much attention from work comp insurers. That may be because comp payers are pretty unsophisticated about facility billing, despite claims from bill review departments/vendors to the contrary. (there’s legislation in Texas that deals with a very narrow slice of the issue; it will have almost no impact on the problem save for patients treated at a federal medical facility)

Congress has been blathering about “solving” the surprise medical bill problem all year – making as much progress as usual, that being none. That’s largely because the PE-owned medical service companies are spending tens of millions fighting legislation intended to stop surprise billing.

What’s clear is while the PE firms may win this battle, they will certainly lose the war. The surprise bill fiasco will generate huge returns over the short run, but lead to major reform as voters get madder and madder about this legal theft. The PE firms fully understand this. They are fighting to preserve their right to rip off patients as long as they can, and will keep doing so until voters rebel.

That “war” has now heated up – in a big way.

Work comp folks can jump into the fray by encouraging their state legislators to include work comp (and auto for that matter) in the list of payers covered by state surprise billing laws – About 18 states have comprehensive surprise billing laws today; many other states’ laws deal with parts of the issue.

What does this mean for you?

If work comp is included in the ban on surprise billing, good news indeed.

If not, expect even more charge-shifting to work comp patients. 


Jun
10

Risk management 101

There are two selfish reasons the US should send as many vaccines as possible to other countries.

Variants.  The more the virus reproduces, the greater the chance it produces a much deadlier and more transmissible version. Each person vaccinated lessens the chances this thing becomes more destructive and dangerous.  Reducing the virus’ ability to adapt and become more deadly is a very good thing.

Leadership. Increasing out country’s influence and “soft power” around the world makes it more likely other countries will support our goals and policies – and protect our interests. For the foreseeable future our main rival will be China; if developing countries see the US as an active partner, committed to helping them battle COVID, we will be in a stronger position than we are today.

Of course there are moral arguments as well; saving lives is always a compelling argument.

Then there’s the reality here – we have way more vaccine than we need, so the “cost” of sharing what we have is minimal.

What does this mean for you?

Risk management 101 – reducing risk is always better than dealing with the consequences.  

This is one of those times where doing the right thing has lots of benefits.

 

 


May
5

Comp’s culture of catastrophizing

At the height of the COVID crisis last year, some research organizations, brokers/consultants and “thought leaders” were gravely forecasting how awful this was going to be for workers’ comp.

Sure, we didn’t know what was going to happen, although careful and thorough research would have indicated things weren’t headed towards the “awful”.

Instead, we heard:

  • investment returns were going to suffer;
  • profits were in deep peril; and
  • workers’ comp was going to be the “go to” insurer for COVID due to presumption

These could have happened, but the data clearly indicated these outcomes were pretty unlikely.

Then there’s “social inflation”, a term describing some rather nebulous and ill-defined “drivers” which are allegedly increasing the cost of insurance claims. [There are a host of methodological problems with the research cited in the link and with this study as well]

Social inflation is being blamed for all manner of problems – jury awards (many drastically reduced on appeal), ‘increased litigation”, “broader definitions of liability, more plaintiff-friendly legal decisions.”

This from Fitch’s Robert Mazzouli, [emphasis added]

A high-profile litigation example in the U.S. is the so-called opioid crisis – drug companies have been accused of playing a harmful role in the extensive overuse of opioid medications, with the overuse blamed on both medical prescriptions and illegal sources.

Read that again.

“So-called opioid crisis?” What planet is this guy living on?

Not this one. There is overwhelming evidence against Purdue and other members of the opioid industry.

Not sure where these experts get their information, as research indicates the various “problems” attributed to social inflation are overstated or exaggerated.

What’s abundantly clear about these two issues is workers’ comp insurance people have no idea what’s really driving their business. Instead of doing the hard work to figure out how to address over-spending on claims, too many blame outside forces.

COVID and “social inflation”‘s impact on work comp is insignificant compared to opioids and facility costs.

Opioids drove up workers’ comp rates and claims and claim duration. Yet few work comp insurers have figured out how to help long-term patients reduce or eliminate opioids.

Facility costs are the fastest-growing part of medical spend, driven by:

  • the failure of some states to expand Medicaid;
  • (mostly for-profit) health systems’s amazing ability to over-charge workers’ comp payers and get away with it;
  • changes in reimbursement by Medicare;
  • reliance on PPOs to address facility costs; and
  • grossly inadequate medical bill review

What does this mean for you?

Instead of blaming external issues, work comp execs should focus on understanding medical drivers and how healthcare impacts workers comp.


Mar
8

Data ≠ Insight, Questions ≠ Answers

Data is great, but it is no substitute for seeing the world through someone else’s eyes.

That’s my takeaway from a great piece in today’s Harvard Business Review – timely indeed as it comes on the heels of Friday’s post re the decline in service at many workers’ comp “service” companies.

The piece discussed a financial services firm looking to better understand what their customers actually wanted; the firm “conducted a series of client interviews structured in a way that allowed the customer to do the talking and the company to do the listening.”

Here’s a smack-to-the-head finding:

the questions they’d been asking [in previous surveys] were built on managers’ perceptions of what clients needed to answer. They weren’t constructed on what clients wanted to express. This resulted in data that didn’t reflect clients’ real requirements. The list of priorities obtained via client interviews compared to management’s assumed client priorities coincided a mere 50 percent of the time. [emphasis added]

A smart tech exec said we:

“…focus on what customers want to accomplish, not necessarily how they want to accomplish it.” [emphasis added]

That’s point one.

Which leads directly to Point Two – You cannot just do what the client says they want you to do.

The problem with most account managers, and managers of account managers, and customer service goals, and the execs that are responsible for customer happiness/retention/success is they focus on what the customer says – not what they mean.

You know way more than your customer does about your business, your abilities, the supply chain, workflows and processes, which regulations apply and which don’t. You probably know a lot more than your customers’ execs do about:

  • how their IT systems work and don’t,
  • workarounds and the impacts thereof,
  • how and why front-line workers are negatively impacted by archaic processes and management approaches,
  • how your work product is accessed and integrated into outputs, and
  • how you could simplify processes and speed things up and reduce errors.

Your job is to do that – not to do what the customer says, but to deliver what they really need – not what they say they need.

[As one who has conducted dozens of surveys over the last two decades, this will force me to re-think how we do this…]

What does this mean for you?

Asking the right questions is about identifying the problems your customers want to solve.

You – not your customer – are responsible for figuring out how to solve those problems.

 


Feb
9

We have a very long way to go.

The first step to recovery is admitting you have a problem. Well, America, we have a problem. That problem is our healthcare delivery and payment system/industry.

Our healthcare system is a mess.

It is unfathomably complicated, far too expensive, and delivers results that are generally good for wealthier White people and not so good for poorer and non-White people.

This is just the high level stuff…

But wait, Medicare is simple…right??

Then there’s our crappy results.

Americans’ life expectancy has dropped while people in every other developed country are living longer.

Oh, and it’s stupid expensive…Americans spend twice as much on healthcare as the average developed country.

But our healthcare is great…right??

Not for Black babies.

But all of us get far fewer doctor visits…

From far fewer doctors…

While Purdue and the rest of the opioid industry make tens of billions of dollars killing our relatives and friends

The result  – we pay waaaay more than other people and die sooner.

What does this mean for you?

Demand better. And do something about it.


Nov
9

Updates on the ACA

With the GOP attorneys general’s case to overturn the ACA pending before the Supreme Court, you may want a refresher on what the ACA is, where it is working and when it isn’t, what the problems are.

And more importantly how we can fix it.

One of the nation’s leading experts on the ACA- Charles Gaba – will cover all that stuff tomorrow in a webinar.

The Milbank Quarterly will also be publishing experts’ views on the ACA.

As I mentioned last week, Biden will likely be limited to administrative orders, as the GOP-run Senate (pending the Georgia runoff) is not likely to help him implement structural improvements.

What does this mean for you?

A lot of boring wonktalk about the ACA which is nonetheless really important.

 


Nov
6

Friday catch up

Election week in America – the never-ending show continues…

Here’s what else happened this week.

Online registration for the CompLaude awards opened up; you can sign up here for the December 3 virtual event. Congratulations to all the nominees.

The fine folk at WCRI continue to pump out relevant research; I have a lot of catching up to do but did manage to dive into their analysis of New York’s work comp systems and the results thereof. Quick takeaways:

  • Medical inflation has been pretty flat since 2014, driven by decreasing costs for non-hospital providers. You read that right; costs dropped by about 1 percent per year from 2014 – 2019.
  • Hospital outpatient payments per claim went up 2 percent per year over that period
  • Drug costs in the Empire State have dropped by 9 – 12 percent per year, driven by
  • a 48% drop in morphine equivalents per claim, and a 23 point decrease in the percentage of claims with an opioid script.

Way to go New York.

Addiction treatment

A great piece in WaPo about contingency management, a treatment approach that is yielding promising results. Essentially it rewards drug users with money and prizes for staying abstinent. Some folks don’t like it on moral grounds; they feel its wrong to reward addicts for staying clean.

I’m no ethicist, but this strikes me as a reasonable objection. However, it has to be balanced against the good that comes from helping people recover. Critics’ high morals kind of pale in comparison to keeping people alive.

For now, only the VA is paying for this. It’s long past time private insurers and Medicare/Medicaid stepped up.

All things COVID

I haven’t been paying nearly enough attention to the eruption of COVID; will do a couple posts next week to catch up.  In the meantime, here’s treatment news.

From MedScape, good news; it appears the risk of cardiovascular problems in young athletes recovering from COVID isn’t as high as once thought.

Okay, that’s the good news. The not-good news is the most common version of the virus has mutated and is now more contagious. However, we appear to have dodged a bullet – this version of the virus also mutates much more slowly than other common viruses. It’s really hard to attack a virus that’s constantly changing as scientists are constantly playing catch up.  A relatively stable virus means the development of vaccines and treatments should be a lot more productive.

Lastly, there’s been a lot of misinformation that doctors and hospitals are over-counting COVID cases because they make more money. In a word, that’s a lie. Hospitals do not receive extra funds when patients die from COVID-19. 

Miscoding patients and deaths would be fraud and could result in criminal prosecution.

For the relatively small percentage of patients that don’t have health insurance, there is Federal money available, HOWEVER, healthcare providers can only submit claims that list covid-19 as a patient’s primary diagnosis. Patients with COVID often die of sepsis and other conditions; in those cases providers get paid nothing.

Net – there is zero evidence to support that assertion. None whatsoever.

I find this incredibly offensive; one of our daughters is a nurse working in a major hospital and her husband is a clinician at a VA facility. 1700 healthcare workers have died of COVID – 200 of them are nurses.

These lies are reprehensible.


Nov
5

Enough obsessing…here’s what the election means for healthcare.

Like many, I’ve been spending far too much time obsessing over election results.

It’s a waste of time and energy…and completely useless; rather than dive into Maricopa County absentee ballot trends, time is far better spent figuring out the election’s implications.

I’ll stipulate that come January there will be a Democrat in the White House, a Democratic majority in the House of Representatives, and probably a very narrow Republican majority in the Senate (although that depends on Georgia’s Ossoff – Purdue results and the Warnock – Loeffler runoff).

Here’s what this means for healthcare.

The ACA is here to stay – whether it gets fixed is up to the Senate.

The Affordable Care Act needs work, but gridlock may keep it stumbling along.

Biden’s wish list includes:

  • lowering the eligibility age for Medicare to 60,
  • allowing the federal government to negotiate with pharmaceutical companies over prescription drug prices,
  • spending $775 billion on caregiving to address the need for home health,
  • expanding financial assistance for health insurance,
  • creating a “public option” government health plan, and
  • changing the individual mandate to ensure folks are incentivized to get health insurance.

Without a Democratic Senate, much of the list (lowering Medicare age, public option, $ for caregiving) is unlikely to happen...but Biden can use Executive Orders to address some key problems.

Expect a slew of Orders on issues including:

  • expanding family planning services;
  • expanding value-based care to – perhaps – include pharma (a backdoor way to partially address drug costs);
  • free and expanded testing for COVID,
  • transparency on medical billing, and
  • a mechanism to address surprise bills.

A Biden Administration will double down on the opioid crisis, taking much more aggressive action to make profiteers such as Purdue pay huge penalties. Criminal charges may well be levied against those profiteers along with efforts to reclaim dollars parked overseas by the Sackler family (owners of Purdue).

Of course, this depends on the Georgia runoff, scheduled for January 5 with early voting starting December 20.

What does this mean for you?

Its a lot more productive to focus on the implications and how they may affect you, your family, your community and your business than to worry about stuff we can’t control.