Category: Providers

Jun
27

Opioid reduction in work comp and the impact on patients and prescribers

Posted by Joe Paduda on Thursday, June 27th, 2024 | Comments

A just-published research study examined the impact of reductions in opioids on workers’ comp patients and prescribers in Ohio and Washington.

(our research which includes payers’ opioid spend is here)

Key takeaways:

  • Providers reported more limited and cautious prescribing than in the past
  • Both patients and providers reported collaborative pain-management relationships and satisfactory pain control for patients.
  • Despite the fears articulated by pharmaceutical companies and patient advocates, opioid review programs have not generally resulted in:
    • unmanaged pain or reduced function in patients,
    • anger or resistance from patients or providers, or
    • damage to patient–provider relationships or clinical autonomy.
  • Other insurance providers with broad physician networks may want to consider similar quality-improvement efforts to support safe opioid prescribing.

From Milbank Quarterly:

The data analyzed in this study were a subset of data collected within a larger parent project—a comparative effectiveness study of the WC agency ORPs [opioid reduction programs] implemented in WA and OH.

I’d note that some Ohio patients and providers surveyed had real and significant challenges with access to care, approvals and care management. The report noted:

The fact that some of the problems described above seem to be particularly acute in OH could be a result of the fact that most WC claims in OH are handled by MCOs, whereas in WA, claims are processed directly by the L&I. The uniquely negative experiences of patients and providers navigating injuries and pain management in OH could be because of MCO dynamics, such as staffing challenges, management issues, or other operational problems. In addition, some MCOs are for-profit companies, which may render them more likely to deny expensive medications, procedures, or consultations.

Note – I was a member of the Advisory Committee for this research project; it was funded by the Patient-Centered Outcomes Research Institute.

What does this mean for you?

Overall, efforts to reduce inappropriate opioid use have been:

  • effective,
  • helpful in getting patients and providers to collaborate, and
  • have not resulted in unmanaged pain. 
Jun
19

Facility cost does NOT equal quality – part 4

Posted by Joe Paduda on Wednesday, June 19th, 2024 | Comments

Back to Florida… the home of many workers comp payers’ nightmares.

This time in Miami – where we find Kendall Hospital.  A large teaching hospital, level 1 trauma center, and…the most costly facility within a 10-mile radius.

Combining scores for patient safety, clinical outcomes, patient engagement and cost, Kendall Hospital ranks 6th out of 7 local facilities with a score of NEGATIVE .17 – largely due to its high cost but also because of its unpopularity with patients and below average clinical outcomes.

Kendall earns the worst score possible of -10 for cost – and for years has been one of the most expensive facilities in the area. Of the facilities in the area receiving a grade for patient satisfaction, Kendall ranks last with just a .8 out of 10 and scores a 3 out of 10 in clinical outcomes.

There’s one nearby hospital that scores waaaaay better on Health Strategy Associate’ proprietary Facility Assessment Tool; Larkin Community Hospital.

Larkin Community Hospital, earns a 0 for relative price (the LOWER the score for price the better)– the top score for the metric. It also scores 7 out of 10 for clinical outcomes (more than twice Kendall) and has a high patient safety rating at 8.3 out of 10.

Put it all together, and Larkin comes in as one of the top-rated facilities in all of Florida.

What does this mean for you?

Two things…how many of your patients are going to a very costly hospital with poor scores on patient safety and clinical outcomes?

And what are you going to do about it?

This post penned by Jay Stith, the brains behind HSA”s Facility Assessment Tool (c).

May
7

Cost Doesn’t Equal Quality Part 2:

Posted by Joe Paduda on Tuesday, May 7th, 2024 | Comments

All over the country there are areas where the more expensive facility has poor scores for patient safety and outcomes. And with facility costs accounting for about 40% of workers’ comp medical expenditures, you can hardly afford to ignore this reality.

Today we look at Sarasota, Florida. More specifically, we are comparing Sarasota Memorial Hospital against Sarasota Doctors’ Hospital.

According to Health Strategy Associate’s Facility Assessment Tool (c) – Sarasota Memorial Hospital scores:

60+% higher on Clinical Outcomes

50+% higher on Person and Community Engagement

75+% higher on Patient Safety

than Sarasota Doctors’.

And Memorial is a whopping 7 points better on Relative Price – which means you are paying much less for a much higher-scoring facility.

When combining all 5 metrics the Facility Assessment Tool considers, Sarasota Memorial Hospital scores 2.94 against just .16 for Sarasota Doctors Hospital.

Oh, and these two facilities are just 6.4 miles away from each other with Sarasota Memorial Hospital closer to the beach!

Take a look at your network and see just what facilities you are utilizing – and what they are costing you.

May
1

Cost Doesn’t Equal Quality

Posted by jay on Wednesday, May 1st, 2024 | Comments

In the ever-changing world of healthcare economics, one thing is becoming more of a norm – high hospital costs. Crazy facility fees coupled with hospital/health system consolidation are leading to higher prices for payers.

Facility fees, viewed by some as the latest gimmick to generate additional revenue for hospitals, help hospital costs to account for upwards of 40% of countrywide workers comp medical expenses.

Making matters worse is hospital/health system consolidation.  Consolidation often leads to higher prices – The Federal Trade Commission’s Director of the Bureau of Economics said that some consolidated hospitals have raised prices as much as 50%. Consolidation/M&A took a bit of a pause during COVID but has reemerged and is expected to keep going due to financial pressures and desire to gobble up market share.

Workers’ comp is already vulnerable due to its inability to rival group health’s scale along with unfavorable regulatory dynamics…

As the smallest payer in healthcare, it is critical for WC payers to make sure they are utilizing high quality facilities with reasonable costs.

Consider the following example:

In Jacksonville, Fl:

Two facilities. 21 minutes apart, same side of the city center, but different profiles. The Mayo Clinic – widely regarded as one of the best hospital systems in the world vs. an HCA hospital – Florida Memorial Hospital.

According to Health Strategy Associates’ proprietary Facility Assessment Tool ©, the Mayo Clinic scores the same on Patient Safety, but much higher on Clinical Outcomes, Person Satisfaction, and Efficiency all while being SIGNIFICANTLY less expensive than nearby Florida Memorial Hospital.

*Higher the grade the better*

Using data provided by CMS and state entities and HSA’s proprietary algorithm to best reflect the medical treatment of worker’s comp injuries, the Tool enables adjusters and case managers to ensure patients avoid poor quality facilities and employers pay a fair price for excellent care.

For a demonstration of the Facility Assessment Tool, email JStithATHealthStrategyAssocDOTcom.

Apr
30

Walmart is shutting down its healthcare centers…which means…what?

Posted by Joe Paduda on Tuesday, April 30th, 2024 | Comments

Three things.

First, healthcare is a very complicated and complex business, nothing like Walmart’s core business 

Walmart’s culture, ethos, business practices, priorities, and people built a multi-gazillion dollar consumer business by TBH, beating the crap out of vendors to deliver really low prices.

That is diabolically different from building a service-oriented, one-at-a-time, people-based interaction around a very complex need – healthcare.

So, yeah, healthcare is about as different from Walmart’s core culture as you cold possible get. 

Walmart’s failure comes after Haven Healthcare, the joint venture of giants Amazon, Berkshire Hathaway and JP Morgan went belly-up early in 2021.

Haven CEO Atul Gawande MD lacked the intimate, deep knowledge of healthcare infrastructure, reimbursement, regulations and management required to be successful. A brilliant writer, insightful analyst, and highly visible public figure, Gawande didn’t have the management chops. He also didn’t give up his other jobs and had no experience as CEO of a start-up.

Many who think they know healthcare – don’t.

Then there’s commitment. Gawande was committed to Haven – and frankly the three founding companies were as well – like the chicken is committed to breakfast.

If you want to take on something as daunting as reforming healthcare, you’d best be committed to the task like the the pig is committed to breakfast.

Second, reimbursement.

Despite a partnership with giant UnitedHealthcare, Walmart Health was unable to attract enough customers paying enough for care at its 51 centers. This MAY have been due – at least in part – to the venture’s focus on Medicare Advantage members…

This from UHG’s announcement back in 2021:

(the partnership will launch in) 2023 with 15 Walmart Health locations in Florida and Georgia and expand into new geographies over time, ultimately serving hundreds of thousands of Medicare beneficiaries in value-based arrangements through multiple Medicare Advantage [MA] plans. [italics added]

MA has been having a rough time of late which may have factored into a non-produdctive partnership…As the payor, UHG would want WH to agree to low reimbursement rates…as the provider, WH wanted high reimbursement…

Third, providers.

Primary care providers are expensive, rare, and thus have a lot of bargaining power. Oh, and you can’t have a business without them.

Which – to return to the lede, runs directly counter to Walmart’s…everything.

What does this mean for you?

Fixing healthcare requires understanding healthcare.

 

 

Apr
29

Hospital goings on…

Posted by Joe Paduda on Monday, April 29th, 2024 | Comments

Couple things you need to track…

First, hospital mergers and acquisitions soared in the first three months of 2024.  From Fierce Healthcare…

Among the quarter’s 20 deals, four were “mega mergers” in which the smaller party had annual revenues exceeding $1 billion, per the report. This pushed total transacted revenue “near historically high levels” at $12 billion…

Kaufman Hall’s report is here.

Some of the big for-profit chains sold off lower-performing facilities; a few big not-for-profit system mergers were announced.

Unsurprisingly financials drove a lot of these deals; a lot of hospitals are on shaky financial ground while most of the big for-profits are making bank. Some not-for-profits’ numbers are improving although the sector as a whole is still struggling.

Meanwhile, giant for-profit HCA reported a big jump in earnings.

From Reuters:

HCA posted quarterly revenue of $17.34 billion, beating estimates of $16.78 billion and reported an adjusted profit of $5.36 per share for the reported quarter. Analysts on average had expected a profit of $5.01 per share, according to LSEG data.

What does this mean for you?

Facility costs are going up because not-for-profits (in general) are struggling, while for-profits (in general) are jacking up revenues. 

Apr
3

Wednesday catch-up – data breach, hospital cutback, and the ACA 10 years on.

Posted by Joe Paduda on Wednesday, April 3rd, 2024 | Comments

For those I caught with my April Fool’s post…I hope you took it in the spirit in which it was intended…

Okay, back to reality (oh no….)

Hospital closures and cutbacks

Another hospital in a non-Medicaid expansion state is closing its ER and shuttering its inpatient care facility. The facility was acquired by a competitor a mile away a few years back…if this goes like most acquisitions folks around Anniston Alabama will likely have poorer outcomes and pay higher prices…

Ignore the corporate happy speak from the owners…this is the same stuff every exec that buys a rival hospital says.

Oh, and here’s research showing the link between Medicaid expansion and hospital closures.

Consolidators are doing just fine…the CEO of CHS just “earned” $8.3 million in pay and perks.

Obamacare…aka the ACA.

Remember way back when folks got all worked up about the ACA, how it was going to kill off old folks, destroy the “best healthcare system in the world”, cost millions of jobs and bankrupt thousands of small employers…and lots of people hated it?

News flash – Americans like it.  A lot.

That’s because:

  • Pre-existing conditions are covered.
  • Kids can be covered under the parent(s)’ insurance till they are 26.
  • 45 million Americans get insurance thru Obamacare and/or benefit from its provisions.
  • Provisions ensure adequate benefits for mental health, emergency care, maternity and child care and seven other key healthcare needs.
  • People who actually had Obamacare plans realized it saved lives.

Oh, and since people with health insurance are healthier than those without, if they’re hurt on the job, they recover faster and employers don’t have to pay to treat co-morbidities. 

We’re going to dive deep into the ACA in a coming week…stay tuned for more facts.

Change Healthcare cyber attack

It isn’t over. Owner United Healthcare recently stated patient data had been stolen by hackers.

This is a much bigger story – with much wider implications – than many think.

What does this mean for you?

More stuff affects you and your business than you may think. 

Feb
20

Rural hospitals – and healthcare – are in deep trouble.

Posted by Joe Paduda on Tuesday, February 20th, 2024 | Comments

With the unwinding of Medicaid post-COVID emergency, rural healthcare is falling deeper into financial trouble.

Consulting form Chartis just published their review of rural healthcare…among the findings

The unwinding issue is exacerbating problems in states that failed to expand Medicaid…the vast majority of which are those with the most hospitals in financial distress.  Simply put – they have to deliver way more healthcare to people without health insurance.

FromChartis:

Across the 10 remaining non-expansion states (Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming), the percentage of facilities with a negative operating margin increased year-over-year from 51% to 55%. These states are home to more than 600 rural hospitals…Several of these states are among the most severely affected by hospital closures and a loss of access to care.

The percentage of America’s rural hospitals operating in the red jumped from 43% to 50% in the last 12 months.

418 rural hospitals are “vulnerable to closure” according to a new, expanded
statistical analysis.

Healthcare deserts are a huge problem for rural America, especially in areas with lots of extractive industries (mining, energy, agriculture. Workers in those industries are much more likely to suffer severe occupational injuries, injuries that benefit greatly from care delivered in the “golden hour”.

What does this mean for you?

Not expanding Medicaid is killing rural healthcare.

Feb
14

Facility costs and quality – are you operating in the dark?

Posted by Joe Paduda on Wednesday, February 14th, 2024 | Comments

Probably yes.

Facilities account for between a third and half of work comp medical spend – and that share is increasing as health systems and hospitals consolidate.

Reality is there’s major variation between hospitals  – some are stupid expensive, others quite reasonable; some have crappy quality, others excellent quality.

Example…

Here’s a good one for our colleagues in Louisiana…two hospitals less than 15 miles apart, with VERY different costs and similar quality ratings.

Note costs are for MSK conditions…pretty relevant to workers’ comp.

So, you can send your injured workers to a VERY expensive facility  – Tulane – that does a handful of complex surgeries OR…

To a MUCH less expensive facility – Ochsner – that does 14 times more surgeries (practice makes perfect…)

Let’s add a CMS quality metric...for our friends in the Sunshine State, you can send injured workers here…

solid quality, and very reasonable pricing…

or…here (just a few miles away)

to a facility with a bottom-of-the rating by CMS and costs more than double its higher-quality neighbor.

These data are available from a few states and CMS (takes some digging); HSA also has developed a national tool enabling instant facility comparison across multiple quality, patient safety, and cost metrics – drop a comment below if you want info.

What does this mean for you?

Do you want to spend $98,000 at a  facility that does few procedures, or a quarter of that at a facility that does hundreds?

 

 

Jan
18

Hospitals are…

Posted by Joe Paduda on Thursday, January 18th, 2024 | Comments

a) in desperate financial shape, on the verge of bankruptcy…

b) doing quite well thank you, enjoying very healthy profits…

c) both.

The answer is…C.

For-profits – HCA, Tenet et al are doing great, while (most/many) not-for-profits are really struggling, with some on the verge of/going into bankruptcy.

Why?

Very briefly, for-profits (there’s lots of nuance here, but generally);

  • don’t take Medicaid patients,
  • have very strong orthopedic and cardiac surgery practices which are very profitable;
  • do their best to avoid/transfer/not care for the uninsured.

Not-for-profits…

  • include inner-city and rural facilities that must take Medicaid and
  • serve as primary care providers for the indigent and uninsured and
  • deliver lots of babies and provide general med/surgical services which are marginally profitable

What does this mean for you?

Hospitals of all types are looking to maximize revenue, especially from very profitable payer types.

Is that you?