Apr
15

Why are you using that metric?

I’ve had several conversations with claims and managed care folks over the last few months about measuring performance, outcome metrics vs process metrics, and the challenges of data collection, aggregation and analysis.

Two takeaways.

Too often the discussion has been too focused on process, too down-in-the-weeds, too concerned about how and what to measure. While process and detail are important, they are secondary to the “why” question.

The most important question is “Why?”

Why are you doing this? Why are you using that metric? Why do you think that is the right metric?

Sometimes I’m a (very) slow learner, but I’ve finally figured out that it is far better to ask those questions than to tell the person what they should be doing. Telling someone something eliminates the chance for them to think through what they have done, why they’ve done that, and if it that was the best thing they could have done.

It forces them to take a step back and question themselves, their assumptions, their pre-conceived notions.

It’s easier – and more ego-gratifying – to tell someone what they should do. I’ve found that this can shift the discussion into a far less productive direction, one where the client may well disagree, to defend what they are currently doing. After all,  to hear someone say what you have been doing for X years is “wrong” will make anyone bristle a bit.

Second, metrics are almost never directly aligned with the organization’s overall goals.

For example, the goal of medical management is to improve the combined ratio.  Has anyone in your organization verbalized that…ever?

If they have, then you:

  • wouldn’t give a rat’s rear end about “savings” or “discounts”;
  • would focus on overall spend;
  • would evaluate providers not on how much of a “discount” they give but on what their services cost and how that compares to other providers;
  • would evaluate networks not on how big their directory is and how deep their discounts are, but on the quality of their providers and the cost of their services.

And that’s just the beginning.

Once you establish the “why” the “what” is pretty straightforward – with one big caveat – every time you settle on what you will measure, go back and see if it aligns with your “why”.

Don’t be surprised if it takes a bit to re-orient thinking. Be patient – with yourself and others. It took me 30+ years, so hopefully you’re a much faster learner.

What does this mean for you?

Asking the right questions requires one to invest time and thought. If you don’t have time to do it right on the front end, you’ll never have time to fix it.


Apr
1

Health Strategy Associates has been purchased.

When you get an offer you can’t refuse…you don’t.

A couple months ago I was approached by an investment firm looking to build a niche practice focused on non-group health medical management. Long story short, for some undoubtedly very good reasons they decided HSA was the right fit.

I never thought a highly specialized, boutique consultancy with one “employee” would have any value beyond what we bring to clients, but clearly I didn’t think hard enough.  Sure, the footprint is solid. Yes, we can bring some very skilled, smart, and experienced experts to any engagement. And we certainly have a brand. Most of the time that’s a good thing, but sometimes it most definitely isn’t.

This isn’t a firm you’ve likely heard of; it’s not even domiciled here. For that reason, we’ll keep the HSA name.  Expect there to be additional resources and expertise, a broader array of skills and knowledge “on offer.” [I have to get used to the non-American English terms, so that’s a start]. There may be a bit less snarkiness from your faithful author too – but that’s attributable more to age sanding off some of the rougher edges than any edict from on high.

Speaking of which, we talked long and deep about whether and how we could work together, and ended up deciding we could. Despite my pathologic aversion to others attempting to tell me what to do, that shouldn’t be [pause for deep breath] an issue. There’s mutual respect and an understanding that when friction does arise we’ll work through it.

Couple of items of note.

First, expect an announcement from our new owners in the coming days.  We agreed that it would be best if we kept the initial focus on HSA and how this [doesn’t] affect clients.  Shortly we will do a more formal mutual release.

Second, yes there will be changes – good ones. HSA will remain focused on niche areas and serve the same client base (payers, service providers, and related businesses). I will continue to speak out on issues, commend those I respect and admire and condemn misguided and wrong actions and results.

Expect more use of technology to aid communications with blog subscribers, more polished presentations and reports, and expand into other channels.

I’d suspect we’ll get into other communications channels – perhaps podcasting, maybe even some video stuff. There are any number of things I’ve wanted to do but just don’t have the bandwidth or expertise or diligence to actually get done.

Finally, I cannot thank clients, supporters, and detractors enough. Over the last 25 years you have helped build HSA, made it better, and made me better. Critics have challenged me and in many cases made me re-think long-held beliefs.

What does this mean for you?

Expect the unexpected.


Mar
30

Chronic pain, opioids, and other drugs – the latest research

Dr Steve Feinberg pointed me to two studies conducted by the Agency for Healthcare Research and Quality on chronic pain, both systematic reviews [reviews of published studies of a specific topic]. One focused on opioid treatments for chronic pain, the other on non-opioid pharmacologic treatment.

The non-opioid research reviewed 190 studies, of which 185 were RCTs. Researchers concluded:

improvement in pain and function was small with specific anticonvulsants, moderate with specific antidepressants in diabetic peripheral neuropathy/post-herpetic neuralgia and fibromyalgia, and small with nonsteroidal anti-inflammatory drugs (NSAIDs) in osteoarthritis and inflammatory arthritis.

The takeaways include there are some benefits from some drugs, often dependent on the patient’s medical condition.

The opioid treatment for chronic pain study was based on a review of 162 studies; “115 randomized controlled trials (RCTs) [the gold standard of clinical research], 40 observational studies, and 7 studies of predictive accuracy.”

Note that for research purposes, chronic pain is described as pain that lasts more than 3 to 6 months.

There was more credible research available to assess short-term outcomes vs longer-term outcomes; there was no RCT comparing opioids to placebo for medium or longer-term periods.

Takeaways included (and these are direct quotes):

  • There were no differences between opioids and nonopioid medications in pain, function, or other short-term outcomes
  • Opioids were associated with small benefits versus placebo in short-term pain, function, and sleep quality.
  • There was a small dose-dependent effect on pain, and effects were attenuated [reduced] at longer (3 to 6 month) versus shorter (1 to 3 month) followup.

Most concerning, “there is evidence of increased risk of serious harms that appear to be dose dependent” [the higher the dose, the greater the risk].

This crossed my desk the day before a good friend’s brother died of an apparent opioid overdose, adding a painful exclamation mark to the study’s conclusion.

Extensive research in Australia focused on long-term opioid use in patients with chronic non-cancer pain found that:

Despite limited evidence of efficacy, there has been a considerable increase in the long-term prescribing of opioids for chronic non-cancer pain in several countries

Here’s the thing; the research we do have clearly demonstrates the risk of opioids is high, and the benefits are limited. However, there isn’t near enough research on the efficacy of long-term usage of opioids for chronic pain.

Anecdotal evidence indicates some patients can do well on opioids for extended periods.

That said, the evidence we do have suggests that overall, efficacy may be limited at best, and the risks are high. Fortunately more research on opioid efficacy and risks and chronic pain has already been funded.

What we cannot do is force patients off opioids; this is dangerous and unethical.

What does this mean for you?

Opioids have their place – but be very careful, especially when use is long-term. Life is precious. 

 


Mar
26

Friday catch-up

Swamped with WCRI’s annual confab (more posts to come on that event) and client work. And the ubiquitous Zoom/Teams/Webex meetings…my high is 6 in one day.

Hoping that’s more than you – for your sake.

Okay, here’s a few items of note.

WCRI’s sessions are recorded and available to registrants here. There’s a ton of great info on fee schedules, the impact of state regs on opioid usage, projections on the future of employment, and treatment for COVID.

Risk transfer

Tuesday I’m co-hosting with Carisk Partners’ CEO Joe Berardo a webinar on Risk Transfer Strategies. We will dive into the key to successful risk transfer programs – behavioral health. Usually it’s not the medical that’s the real issue – it takes a unique approach to get to the real drivers.

If you’re a claims exec, claims or risk manager, or medical director please join us; take a brief survey here before hand so we can be sure to cover the issues you’re most concerned with.

Vaccine effectiveness

Very good news indeed out this week – Medscape reported:

Testing (in California) showed new cases among 2.5% of those tested within the first week after the first dose, 1.2% during the second week, 0.7% in the third week, 0.4% during the week after the second dose was given and less than 0.2% in the second week after the second dose.

In North Texas, where workers were also vaccinated in the midst of the largest COVID-19 surge the region had seen, 2.61% of unvaccinated employees developed the infection versus 1.82% of partially-vaccinated workers and 0.05% of fully-vaccinated employees.

Put another way, you’re fifty times more likely to get COVID if you aren’t vaccinated than if you’re fully vaccinated.

I’ve got my first – hope you have both.

If you’re not at the table, you’re on it.

Great piece in Harvard Business Review on the impact of the pandemic on health system consolidation. This is going to be a major driver of facility costs for workers’ comp. Key excerpt:

Studies to date tend to rebut the argument that acquisitions improve efficiencies, reduce costs, and lead to better care coordination. Instead, they show that consolidation increases prices and fails to improve the quality of care. For example, hospitals’ acquisitions of physicians’ practices in California has been linked to higher prices for primary care and specialist services and to increases in insurance premiums.

Back to work next week – enjoy the last weekend in March.


Mar
11

The latest workers’ comp drug scheme

CWCI released a report detailing the latest in what’s been a long line of schemes to manipulate workers’ comp regulations to suck money out of employers’ and taxpayers’ wallets.

CWCI’s Bob Young, Jackie Secia, and Steve Hayes conducted the research, which found opioid scripts dropped from three of every ten prescriptions in 2011 to one out of nine today. That’s the good news – or rather, great news.

The research also identified two drugs – fenoprofen calcium and ketoprofen as the other primary reason NSAID costs jumped from 14.2% of total drug spend to 23.5% in less than two years. Oh, and these meds aren’t wonder drugs that grow hair while curing low back pain and strengthening joints and rejuvenating shoulder cartilage…they are similar to aspirin, ibuprofen, and naproxen.

OK, here’s how the scheme works.

First, both drugs are exempt from prospective Utilization Review (also known as Prior authorization) requirements, so prescribers don’t have to get approval before prescribing, and dispensers don’t have to worry about getting paid. 

Second, neither drug is on the California workers comp drug fee schedule, so employers and taxpayers have to pay 83% of the “average wholesale price”. AWP is a number made up by the drugs’ manufacturers, and can be anything they want it to be. Over the last four years, the average cost of fenoprofen calcium (FP) sextupled (is now 6 times higher); ketoprofen’s costs jumped more than ten times.

So, some smart schemers figured out that they could make a shipload of money by a) jacking up the price of a drug that costs pennies to make, and b) convincing a few docs to prescribe it to workers’ comp patients.

FP and ketoprofen are the main reason “not listed” drugs suck up more of employers’ and taxpayers’ dollars than other drug categories.

graph courtesy CWCI

It’s not just California.

PBM audits we’ve recently completed found both drugs showing up in New York; I’d expect they’ll appear in other states soon enough.

There’s a lot more we need to know – who’s pushing these drugs, why are docs prescribing them, what does the supply chain look like, are FP and ketoprofen also gaining traction outside of workers’ comp.

That said, we know enough right now to know we’ve got a big problem on our hands.

What does this mean for you?

Every PBM program must have an early warning capability to identify emergent drugs, and an ability to adapt quickly to ensure abuse is minimized. 

 

 

 


Mar
5

It’s not that hard, people.

Over the last few years I’ve been involved in multiple engagements with workers comp payers where their “vendors” just weren’t performing.

Responsiveness was…poor.

Problem solving was more client-blaming than taking responsibility.

“Proactive” was a word used in stewardship reports and entirely absent from actual account service.

Platitudes.

Excuses.

Sure, every service entity has problems – I’ve dropped the ball more than once myself. And there’s no question a client’s performance may be part of the problem and/or expectations may be unrealistic.

That’s not what I’m seeing, rather consistently poor performance seems to be OK with the execs at some service providers. My sense is there are two general problems. First, some service companies focus on what’s important to them, not to the customer. Increasing revenue, raising prices, selling other services, pulling back on commitments/turnaround times, adding fees for services that were previously part of the package – all are seemingly more important than just making the customer happy.

I recall a site visit to a client’s then-vendor where a senior exec proudly pointed to a wall of accolades for employees. The exec voiced delight at the many notes lauding employee performance. I looked closely…every one referenced an employee adding services, billing more, creating revenue. None referenced a delighted customer, a happy patient, an employer with a solved problem.

Is this what your customers are doing when the video feed is off?

“Success” = more vendor $.

Second, execs – and their subordinates – are not listening to customers. And if they do, all they are listening for is opportunity to sell more stuff. The execs are NOT asking how the client is doing, what they are focusing on, what problems the client is facing, where the client is heading – and what the vendor can do better and how they can improve.

Is this your client?

Many vendor execs aren’t seeking to understand what makes the individual they are working with successful, how they are measured, what is important to them.

Most recently this may be driven by COVID’s impact on claims volumes and the trickle-down reduction in medical services producing fewer visits, fewer medical services, fewer bills, less need for UR and case management and everything else.

But this was happening long before COVID hit.

What does this mean for you?

Understand and solve your customers’ biggest problems, and do it without adding to their workload.

Or fail. 

 


Mar
2

The CDC’s Opioids for Chronic Pain Guidelines; Myths and facts

After my posts last week it is clear there’s a lot of misinformation and misunderstanding about the CDC’s opioid and chronic pain guidelines. At MCM we take the old-school approach to these things; we focus on the facts.

So, here they are.

The CDC’s guidelines mandate strict limits on dosage and require tapering  for patients on long-term opioids.

False.  As Dr Beth Darnall of Stanford University noted recently;

some health care organizations and states have wrongly cited the 2016 CDC Guideline as a basis to substantiate prescribing “dose-based limits” or to mandate that physicians and prescribers taper patients taking long-term opioids to specific thresholds (eg, < 90 mg, or < 50 mg). Such dose-based opioid prescribing policies are neither supported by the CDC, nor do they account for the medical circumstances of the individual patient. [emphasis added]

Further;

The CDC [issued] a clarifying statement that derided the misapplication of the opioid guideline and discouraged the dose-based policies and practices that fall outside of its scope, as well as use of the guideline to substantiate tapering.

The Guidelines for Prescribing Opioids for Chronic Pain were developed in secret.

False.  The process fully complied with CDC and AHRQ requirements and standards, and the results were shared with the public and public comment sought prior to promulgation of the final guidelines in 2016.

The Guidelines aren’t working; look at all the opioid-related deaths.

False.

  1. The big increase in drug poisonings (technical term for overdosing) is driven by a rapid increase in the use of synthetic opioids, both prescription and non-prescription. The synthetic opioid death rate increased over 1000% from 2013 to 2019, with the biggest increase in the western US. Fentanyl and Tramadol are examples of synthetic opioids
  2.  There’s been a small but measurable decrease in the death rate (4.4 to 4.2) from prescription opioids that correlates with the guidelines’ publication date.  Of course, correlation is not causation, but clearly the guidelines have been impactful.

3.  Further, when you count the deaths due solely to prescription opioids, the drop in the prescription opioid death rate is even more remarkable. The bold line is prescription opioid-only; the guidelines were introduced in 2016.

The net is those who claim the guidelines are somehow “failing” are conflating law enforcement issues with public health issues, and are ignoring the very real post-guideline decline in deaths from prescription opioids.

The guidelines are killing people.

The guidelines are just that – guidelines.

The guidelines do NOT require or mandate dosage restrictions or tapering. Blaming the guidelines – and those who developed the guidelines – for physicians not following the guideline’s explicit recommendations is wrong, and does nothing to solve the problem of bad legislation and poor physician behavior.

Here’s what the CDC actually said:

Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. [emphasis added]

There are a lot of anecdotal reports of patients unable to get prescriptions renewed or otherwise forced off their opioid regimen, many with awful consequences. Yes, the guidelines did suggest/encourage/support these tools in certain circumstances, but – as you can read above – these are NOT requirements and require clinicians to evaluate and balance risk and harm.

What does this mean for you?

The real problem with Opioid Guidelines is states, insurers, and other entities – as well as prescribing physicians – failing to use the guidelines as intended.

reminder to commenters – valid email addresses are required, and disagreements are welcome as long as they are supported with credible citations.

 


Feb
5

Why don’t workers’ comp execs embrace change?

The short answer is – they have little incentive to do so.

Here’s why.

  1.  Workers’ comp insurance is mandatory in all states save Texas. Pretty much all employers have to carry workers’ comp coverage, so sellers of insurance and self-insurance services (albeit to a lesser extent) know their prospects have a budget, timeline and decision process, and selection criteria. It’s not IF they buy, it’s whose they buy. That removes a big problem in sales – finding prospective customers.
  2. For most of the last decade, insurance rates have been dropping. Workers’ comp costs are at or near historical lows in almost every state. As a result, with rare exceptions, buyers aren’t focusing on workers’ comp – it is way down the list of things CFOs and Treasurers are worried about. So, they aren’t pushing insurers or TPAs to improve, get creative, develop new products and solutions and improve existing processes.
    No problem – no need for a new solution.

  3. That’s driven primarily by two key factors – frequency and medical cost.
    Frequency – the percentage of workers suffering an occupational injury or illness – has been dropping pretty steadily for decades. With fewer people hurt or sick every year, there’s fewer problems to solve. And yes, claim counts trended up till last year, but that upward trend was driven by increased employment.
  4. Despite what some vendors claim, medical cost trends are very much under control. Sure facility costs are increasing, but the decline in drug costs and related medical expenses seems to have offset that…so far. So, little incentive to come up with creative/fresh/different medical approaches.
  5. Risk:reward. With some notable exceptions workers’ comp execs are pretty satisfied with the status quo. Put another way, they are highly risk-averse. Most have ascended to their executive positions by not taking risks, by avoiding mistakes. Any new, creative, different approach is inherently risky and therefore anathema to folks who have succeeded in part by tightly managing risk.

By no means is this true of all execs; I’m privileged to be able to work with several payers that are pushing the boundaries, working very hard to come up with new and much better ways to help the injured workers and employers they work for.

What does this mean for you?

Workers’ comp buyers are mostly not interested in innovation or change. 


Jan
14

Haven Healthcare’s demise – lessons for workers comp

Haven Healthcare – the Amazon-JPMorgan-Berkshire Hathaway joint venture intended to re-invent healthcare – is no more. The quest to improve access to primary care, simplify insurance coverage, and make prescription drugs more affordable ended after three years.

We don’t know why Haven is now in heaven; it could be that three of the most powerful and well-run organizations in the world could not figure out how to build a better healthcare system.

Or it could be that they each had different motivations, different needs, and different priorities and could not figure out how to work together. That would not be a surprise. Or that their well-known, accomplished, and brilliant CEO was not an effective CEO (that’s not a slam; I’m no operator either).

Or more likely – all of the above plus more.

Regardless, it’s dead. Workers’ comp execs can learn three lessons from Haven’s failure.

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.

Implications – Two things – knowledge and commitment.

Do you know anyone in workers’ comp with deep knowledge of healthcare? Someone who understands reimbursement, infrastructure, process, the regulatory environment? Medical drives workers comp, and very few comp execs have that knowledge and understanding. 

Many who think they do – 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, market share. With about 1.6 million employees – and perhaps 5 million insureds – the three giants had a lot of lives to cover, a lot of healthcare dollars to leverage (about $24 billion in employer costs and a total of about $30 billion). BUT, the proverbial mile-long-and-inch-deep problem meant Haven didn’t have local scale.

Healthcare is local – facilities and medical practices want insured bodies, the more the better. Outside of a very few markets where Amazon has big distribution centers, Haven didn’t have enough bodies to leverage big changes.

Implication – Total annual medical spend in workers’ comp is about the same as Haven’s – $31 billion. That is less than 1 percent of US medical spend. Haven tried to leverage all those dollars. It failed.

Unlike Haven, there are lots of workers’ comp networks all trying to negotiate deals – the largest may have $8 billion in spend nationally.

That is small potatoes indeed…A mere tablespoon of hash browns.

What does this mean for you?

The workers’ comp industry cannot “solve” healthcare. But that’s not the point.

The point is this – organizations and leaders that know more about healthcare, that are more committed to doing better, will far outperform their competitors.


Jan
12

I wish I could.

It is times like this that determine if people have souls.

To those who say stay out of politics, I say – I wish I could [see comments at link].  What happened last year, and last summer, and last week make that impossible.  We can’t just continue on as if nothing had happened.

Our country – lauded by self-described “patriots” as the greatest country in the world:

photo credit Daily Mail, circled object is fire extinguisher thrown by rioter that struck and killed Officer Brian Sicknick

 

American Carnage indeed.

I get that people are upset when their candidate loses a critical election – millions of Americans – your fellow citizens – were crushed when Trump won in 2016. I was – and still am – among them.  As much as it hurts to say it, Trump won in 2016 – and we accepted that victory. We did not riot, lie, provoke, build scaffolds on the Mall, threaten to hang the Vice President and shoot the Speaker of the House. We did not file 60 lawsuits seeking to overturn our fellow citizens’ votes.

I accept and understand that Trump supporters are distraught, angry, even terrified – as I was in 2016 (and still am of the damage Trump has done and will do). I do not accept and cannot allow the anti-American behavior of many to pass unremarked and unchallenged.

I applaud the businesses that have stopped contributing to politicians lying about election fraud. Among those organizations fed up with Trump and his enablers are AirBnB, Amazon, BestBuy, the Blue Cross Blue Shield Association, Commerce Bank, Dow, Marriott, GE, Hallmark, AT&T, MasterCard, Verizon.

I decry CVS, Berkshire Hathaway, Facebook, Goldman Sachs, JP MorganChase, Microsoft, Google, BlackRock, Charles Schwab, VISA and others who have suspended all political contributing to all politicians – this smacks of false equivalency when it is blindingly obvious that the Ted Cruzes and Josh Hawleys are guilty of fomenting insurrection – not the Sherrod Browns and Jason Crows.

My family has agreed that we must do more. So, I will contribute 10 percent of my income to organizations dedicated to righting wrongs. The Southern Poverty Law Center, BLOCbyBLOC, FairFight, and the Native American Rights Fund are the ones we’ve chosen.

This may well cost me readers, business, income, and prominence – and I am totally fine with that. What we are on the verge of losing is immeasurably more important.

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Tomorrow – back to health care and related topics.