Insight, analysis & opinion from Joe Paduda


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. 


They lied to you.

A really scary study was just published…one that shows just how deadly healthcare misinformation is.

Not “can be”, but is.

Remember those politicians promoting hydroxychloroquine as a cure for COVID – AFTER studies showed it had little to no benefit – and was dangerous?

Well, they have blood on their hands.

A very well done meta-analysis (rigorous review of all available research studies)  estimated there were 16,990 hydroxychloroquine related deaths in hospitalized patients in six countries.

One of the studies, known as the RECOVERY trial, showed a significant increase in cardiac mortality among patients receiving hydroxychloroquine (HCQ). 

The study published in PubMed this February is here.

Two things.

First, anyone willfully lying – or passing along someone else’s lies – to people terrified of a deadly disease has much to apologize for. Would these people tell friends and family to eat rat poison?

Drive drunk?

Inject fentanyl?

Of course not – yet by pushing HCQ misinformation out to friends and family, they did much the same thing.

Second, in a case before the Supreme Court, some politicians are trying to argue that spreading misinformation – like “hydroxychloroquine cures COVID” is “protected free speech.”

What utter BS. Again, is it okay to tell kids – “hey, vaping is good for you!”… or “Sure, unprotected sex is fine!” or “No car seat needed – just carry your baby sister in your lap!”

Tobacco companies and the opioid business are just two examples of industries forced to pay billions for publishing lies.


As noted in yesterday’s post, thousands of us are dying from preventable causes…that’s really, really bad…what’s much worse is politicians legitimizing deadly disinformation. 

What does this mean for you?

Spreading deadly misinformation is NOT “free speech”. It is a cynical and disgusting abuse of power.





Good news, Friday!

Here it is, spring at last.

Well…not here in central New Hampshire where we’re going to get somewhere from 21″ of snow to…3-6″.  Gotta love the northeast in “spring”!

Income vs Inflation

Things continue to improve with worker income increases outpacing inflation.

From USAToday:

the average salary in the U.S. has grown by 5.4%, there was a gain of 3.2% in the Consumer Price Index for All Urban Consumers. This indicates that the average income increase is also an increase in people’s real income — taking into account their spending power.

Workers have seen steady increases in earnings over the last two years…

Two other items of note:

  • Black unemployment fell beneath 5 percent for the first time in history this last April.
  • There are 6 million more jobs today than in December 2019.


The CHIPS Act – bipartisan legislation that funded development of domestic computer chip research and manufacturing – is creating tens of thousands of new jobs, many in Ohio, Arizona and Nevada.

And that’s just the start.

Today, a total of zero computer chips are manufactured here…in less than 6 years, 20% of the world’s most advanced chips by 2030 will be made in the USA.

That is great news indeed for workers, families, national defense, and our position in the world as the leading innovator of next-gen technology.

Kudos to politicians on both sides of the aisle.  


One of the issues with healthcare research is studies, findings, and interpretation thereof may not factor in differences between male and female conditions, treatments, reactions to those conditions and treatments, long-term complications, and diseases and medical issues specific to either sex.

To address these disparities, The Administration announced a “new NIH-wide effort that will direct key investments of $200 million in Fiscal Year 2025 to fund new, interdisciplinary women’s health research…”

As more than half of Americans are female, this is very welcome news.

What does this mean for you?

We are getting wealthier and healthier.



Deconstructing Comp Pod!

Friends and colleagues Yvonne Guibert and Rafael Gonzalez went waaaay out on a limb and asked me to do another podcast.

I was all over the place, but Yvonne and Rafe were kind enough – and smart enough to rein me in when I diverged away from what was supposed to be the focus – impact of economics and the upcoming election on workers’ comp.

A deep dive into the economy started things off – how the House of Representatives affects physician reimbursement – and how that affects workers’ comp.

and how Medicaid dis-enrollment affects workers’ comp.

and how wage increases have outpaced inflation.

Listen on!


WCRI – the heat is on.

Kudos to WCRI – it is the first workers’ comp research organization to give center stage to the impact of climate change – primarily heat – on workers’ comp claims.

Dr David Bonauto of Washington’s Labor & Industry (state WC fund) led a session on Washington’s analysis of climate change’s affects on workers. A few quick takeaways…

There have been three studies re Heat Related Illness (HRI) in WA based on 16 years of data.  There were only about 850 accepted HRI claims out of 1.7 million…but the hidden impacts of heat are just beginning to be understood.

  • Heat increases absorption of chemicals thru the skin and potentially increases toxicity, a major concern for ag workers working with insecticides and fertilizers
  • Heat and wildfire smoke increases cardiovascular disease; it appears the mechanism is chronic inflammation.
  • Excessive heat leads to “incredibly diminished productivity”
  • There is a much higher [67%] risk of injury when temperatures are above 82-86 degrees compared to a baseline of 76 degrees.
  • The most vulnerable industry?   Public administration…my guess is this is driven by first responders and fire fighters.

thanks to MTI America’s Nikki Jackson for the slide pic

WA L&I isn’t the only organization doing credible research – WCRI research found 14% more claims occurred at times of high heat – think of these as indirectly related injuries. Falls off ladders are an example.  Great to see WCRI dig into this, although it would have been even better if we had this information several years ago.

The second employer session provided much-needed perspective from executives dating with the fallout from climate change.

Joann Moynihan from Travelers said the industry needs to broaden this dicsussion…it’s not heat claims specifically, but heat-related claims…Ms Moynihan’s words to the effect of “this is an indication of where the. industry is headed” should be a wake-up call to stakeholders who are mostly sleepwalking through massive changes to the work environment. 

Chrissy Lynch of the Massachusetts AFL/CIO described how workers in Mass are now dealing with forest fires…”we never thought we would”…that and it “doesn’t really snow here any more…we are trying to figure things out on the fly.

What does this mean for you.

Wake the *&^%** up. 


Good news Friday!…jobs and pay are both up!

275,000 new jobs last month – VERY good news indeed!

Since the beginning of 2021, over 10 million jobs have been created.

Yesterday’s jobs report showed strong employment growth across multiple industries;


Over the last 3+ years, 800,000 manufacturing jobs have been created..

Along with big job increases, wages are up too.

Last month average hourly earnings rose to $34.57 – a 4.3% increase YoY. (that’s about $69,000 a year)

From USAToday:

“Since the spring of last year, pay increases have outpaced inflation, giving consumers more purchasing power.”

What does this mean for you?

More jobs + higher wages = more payroll + more consumers buying more stuff.

Note – thanks very much to several folks at WCRI who thanked me for doing the Good News Friday posts – I appreciate you.

J.  – thanks for sharing that even though we may have different political views, you appreciate the posts.

Have a most excellent weekend!


To know why some think the US healthcare system is going to get better and cheaper – and why I strongly disagree, read on.

David Cutler PhD led off the WCRI’s confab with a discussion of the future of healthcare. It was GREAT that a conference has finally tried to educate work comp people about healthcare – after all that is the biggest driver of workers’ comp.  Sorely needed.

But…(more on that in a minute)

Dr Cutler noted that US healthcare is about as unstable as it has been for some time. And there is much more uncertainty to come.

He then asked the audience to vote on whether healthcare will get better and cheaper, stay the same, or collapse.

I voted collapse.

He also differentiated between “Trend” and “Wiggle”, noting it is important to consider what is actually a trend vs what is more likely slight ups and downs – need to differentiate between one-time factors and overall structural issues with long-lasting implications.

Cutler attributes consolidation among small providers to the drop off in patient service demand; that is, demand for providers’ services declined and therefore the smaller providers needed to merge or be acquired. I’d note that Cutler did not mention other factors driving consolidation, namely:

  • Interoperability (CMS IT requirements that can be a big lift)
  • small office staffing woes,
  • office operational expense increases, and
  • PE buyouts that make owners wealthy overnight.

Why Cutler is positive about the future of the US healthcare system

  • Delivery of medical care (number of services rendered) fell off during covid and really hasn’t fully recovered, which implies there are fewer unnecessary procedures/visits/treatments these days. (assumes the decline was mostly in unneeded services)
  • Elective stuff didn’t come back – such as hip replacements, shoulder surgery, etc.
  • Staff shortages are less of an issue of late

Dr Cutler also noted that in his view, medical staff burnout and labor force withdrawal from healthcare delivery roles will be temporary…Employment is coming back.

Very briefly, Dr Cutler’s thinking is that hospitals have too many beds; a lot of care has moved to outpatient facilities and ambulatory surgical centers (ASCs)…as a result hospitals will close floors, other hospitals will close, and the need for nurses in hospitals will thus decline.

Notably, Dr Cutler provided data from CMS to build a case that healthcare itself is better controlled – Medicare growth has been relatively flat over the last few years, and some analysts believe this has reduced total spend by several trillion dollars.

Finally, Dr Cutler also discussed value-based care and the move to bundled care, I suppose as evidence that healthcare is getting more efficient.

So here’s the “But…” in which I respectfully disagreed – and and still do disagree – with Cutler’s optimistic outlook.

Cutler – Shift of care away from and hospital closures will reduce costs and staffing needs

MCM – I don’t have the data, and I’m sure Dr Cutler does, but there’s both anecdotal “evidence” (family members have left patient care for other jobs in healthcare) and actual research that clinical staff shortages are NOT moderating.

Here’s rather compelling evidence that the shortage is NOT going away.

According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country through 2030. In this state-by-state analysis, the authors forecast a significant RN shortage in 30 states with the most intense shortage in the Western region of the U.S.

Perhaps Dr Cutler is talking over the very long term – and perhaps the Journal’s authors are not accounting for the shift in care to outpatient facilities.

Perhaps. On the other hand, change is very, very slow in healthcare.

Also, hospitals are major assets, assets which are providing a ton of revenue to the health system or hospital’s owners. Sure, many owners might like to walk away…but they can’t – not without huge pressure from unions, workers, communities and politicians. So, they’ll do anything they can to keep the patients coming, to keep the hospital open – if they don’t they will go belly up – oh and some of the hospital’s execs will not have jobs.

Cutler – Value-based care is saving money…

MCM – There is very little evidence that VBC actually saves money, and a lot of evidence that it doesn’t. In fact, a CBO study indicates that overall, well-funded, well-designed and well-run VBC initiatives actually resulted in higher costs. I’d note that some disagree with CBO’s results. – however those disagreements generally focus around better outcomes, health indicators and the like – NOT on cost reductions.

Cutler – Medicare spending is below predictions thus healthcare is less costly

MCM – But other payer spend has not.

Yes, Medicare’s costs have been below predictions…but that’s NOT the case for individual insurance, group health and Medicaid spend – which has has increased.

To be fair, Cutler agreed with my comment (which I made after his talk), but noted Medicaid spend per enrollee has declined.

He is correct…however in my view but likely because the expansion of Medicaid involved more healthier people being signed up before and during the COVID emergency.  And, their costs prior to enrollment were likely uncompensated care…so my take is overall medical costs weren’t reduced, just shifted to a different payer.

At least for the next few years – and likely longer – the “shiftee”, dear reader, is often workers’ comp.

Finally, good friend and colleague Gary Anderberg PhD of Gallagher Bassett commented that all of us are getting older and sicker and how does that factor into predictions re cost. Cutler indicated he sees it as a mixed picture as cognitive and CV health are improving while others – obesity-related such as diabetes in particular – are declining.

What does this mean for you?

I still vote collapse.



WCRI – Employers weigh in…

Good decision to add three very different employers to the conference; Publix, Disney and Duke University.

[As a Syracuse alum, I thought WCRI could’ve made a better choice than Duke…]

Here’s my quick take…there was a ton of content with which your faithful reporter could not keep up…so apologies for the somewhat disjointed post.

None of the three are doing pre-employment drug testing (except as required by law)

Publix self-administers work compMichele Maffei has over a hundred employees managing the program. Michelle and her colleagues are very involved in the entire process, work diligently to engage with local operations, and focus tightly on return to work. They handle clinical management, claims, and bill review inhouse. RTW is a huge priority; they try to get everyone – even amputees – back to a job at Publix; during Covid a transitional job was checking in folks showing up for vaccination.

Publix identifies the medical providers they want to provide care to their associates and in some cases contracts directly with those providers; “we are very purposeful about what we do.” Oh, and consistent with earlier findings, telemedicine usage has dropped off post-Covid.

Sharon DelGuercio noted Disney can pay above fee schedule if they need to get specific specialties in central Florida to treat associates. Still it can be difficult to ensure ready access. Disney focuses on the full scope of recovery drivers, striving to keep them in their home location, a strong transitional program with over 400 job descriptions.  Disney’s focus is, quoting Sharon; “nobody goes home”

Duke University’s Charles Kyle weighed in on behavioral health, a main focus of the worker’s recovery program. Return to work is also key; as Duke is very de-centralized different units have their own priorities however costs are tracked back to those units.

A recent focus and rising concern among healthcare professionals [Duke has a major medical center as well] is violence, especially gun violence.  Other forms of physical violence seem to have increased as well across both the medical facilities and University operations. Duke has a task force assigned to this and is steadily improving prevention and recovery initiatives for workers injured by violence.

Panelists acknowledged that in general there’s a higher level of violence, a higher level of incivility, they are just meaner than they used to be.

Michele mentioned physician dispensing (PDD) as a key priority; with their operations in Florida this is NOT a surprise.  MDs should not be allowed to give patients drugs as they are not pharmacists.





Vennela Thumula PharmD and Randy Lea, MD doves into the presence and influence of psychosocial factors on recivery.

Dr Thumula led off by noting psychosocial barriers are the number one obstacle to recovery.

A variety of factors are barriers including:

  • Poor recovery expectations, fear of pain
  • Catastrophizing
  • Perceived injustice
  • Family system support issues, pre-ex psych factors
  • Job dissatisfaction

Multiple guidelines recommend early identification of psychosocial risk factors. WCRI looked into prevalence of psychosocial factors in LPB patients seeking PT. do they recover differently

These factors were common, strongly associated with functional recoveries after PT care, and WC patient had more psycho risk factors and these facts were more strongly associated with functional outcomes.

Dr Thumula laid out the various screening tools used in the research and described the variation between WC and other payer types

Key takeaways:

  • WC patients had high levels of fear avoidance and negative coping, both of which might impede return to work.
  • Workers with higher levels of psychosocial risk factors (PF) had smaller functional improvements than those with lower levels.
  • And, workers with elevated psychosocial risk factors were less likely to make meaningful improvements in function
  • And, they had a much higher likelihood of “very limited” function at discharge from PT.

Dr Randy Lea summarized the findings and provided attendees with what they can tell colleagues upon return from the Conference.

  • First, WCRI’s study is the most robust that focused on WC.
  • Prevalence of PF was high – 1/3 to ½ were high risk.
  • High risk factors result in 40% less improvement than workers without those factors.

So, stop, take a step back, and understand these are frequent, do occur, and are impactful.

Then, you may want to:

  • refer the patient to a mental health professional, and/or
  • make sure the treating clinician knows about the PF factors, and/or
  • use the research to predict those who are most likely to benefit from care.


CWCI’s annual conference is almost here

I connected with CWCI President Alex Swedlow  – and good friend and colleague – to find out what’s been going on in the Golden State and what the annual confab will feature.

Here’s the registration info.

note highlights are mine.

MCM – Please briefly describe the workers’ compensation industry in California…frequency, disability duration, cost drivers, outcomes, market share of major payers.

AlexCalifornia has the biggest WC system in the county, bar none.  Whether it’s premium, frequency, medical care delivery volume, expenses.  We’re a high litigation state with significant friction costs. 

That said, our state has accomplished some remarkable changes and improvements through legislative reforms, regulations, and payer’s delivery systems that have significantly improved the efficiency and effectiveness of benefit delivery to CA injured work force.

MCM – I hear there are concerns about access to care in California for workers’ comp patients. What does the research say?

AlexAccess to care is a national crisis that is just now reaching full awareness.  We are all waiting longer for access to specialists whether you are hurt on the job or during a weekend softball game.

The concerns about access within WC has been a research topic for CWCI for 25 years.  Our most recent studies show that during the acute care phase (90 days) and the first year of treatment following the injury, the CA WC system delivers most services within a few days of the injury with little change in the mix or volume of professional services over the past 5 years.    Expensive, yes. But a remarkable and stable result.

Let’s remember that workers’ compensation represents less than 2 percent of the CA healthcare economy.

Also, the National Institutes of Health project CA will be short 35k physicians and 45k nurses by 2030 with almost 1 out of 3 physicians retiring within 5 years.  So right out of the gates, our system has very little leverage for addressing this problem.  This makes our current medical delivery systems all the more remarkable.

MCM – Thinking about the various sessions, which one will have the most long-term impact on workers compensation and why?  I noted a panel will explore the impact of exogenous influences on workers comp…can you give our readers a couple of examples and their impact?

Alex – The theme of our 60th Annual Meeting is “An Altered State”.  We will explore how our system has expanded well beyond the original “Grand Bargain” and into its current form and function.  We will also focus on key bread-and-butter issues including fresh research on claim development, medical service delivery and dispute resolution, the controversial medical legal fee schedule, COVID, and that great, unique to CA imponderable, Cumulative Trauma claims. These are all issues that originate within our system.

CWCI just published a study on this (free to all here); here’s a top takeaway:

In 2022, CT claims represented more than one out of three litigated claims. And, as Alex notes, CT is a “condition” unique to California. 

I smell something…and it isn’t a rose.

(back to Alex)

We will also explore exogenous influences, trends and issues that originate outside of our system that nonetheless have a significant influence on CA WC. We will preview the results of one of the first studies to use our state’s CURES system (California’s prescription drug management program) which captures all control substance prescriptions issued to all Californians across all payer groups.  The results show state-wide changes in opioid use over a 5-year trend.  The study also provides a look into simultaneous prescribing patterns across payer groups.

Other sessions will address our state’s economy, political climate, the looming $70B budget deficit, workforce migration, access to care, and some key interstate comparisons that show how much CA WC has changed over time.

Joining our staff, we have two great guest speakers from the Public Policy Institute of CA, Sarah Bohn and Eric McGhee, who will present new data on specific external forces that impact the vitality of our WC system.  In addition, our long-time colleague, Ramona Tanabe, President of WCRI will discuss interstate comparisons to show how CA WC has evolved relative to other states.

What does this mean for you?

If you want to know, you’ve got to go.






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