Jun
8

Behavioral health is vitally important.

I posted on the slaughter of kids and Black Americans a couple weeks ago; David Vittoria, Carisk’s Chief Behavioral Health Officer sent this in as a comment  – it is well worth your time. (lightly edited; highlights are mine. Carisk is an HSA consulting client

It’s time for action.

There are always “calls to action” after these kinds of horrific events, but they’ve fallen short. It’s time to rethink the role of behavioral healthcare in helping our young people when they are suffering. Our industry should be hyper-focused on caringly confronting this head on, bringing together really smart, insightful, compassionate, and committed people, so that we can do better for our kids and communities.

I think there are many factors that contribute to gun violence in America. I definitely don’t pretend to have solutions for them all. Yet as a behavioral healthcare leader, psychotherapist, dad, and someone who’s spent many years working with children and adolescents, I know our industry can show up more and better for at-risk kids before they commit acts of violence like we saw this week in Uvalde.

By the time I would encounter these teens in residential or inpatient psychiatric facilities, they were often so aggressive and disengaged, we couldn’t really help them, no matter how hard we tried.

They typically disrupt the treatment setting more than they commit to treatment. They are at a point where they won’t take medications and are non-compliant with outpatient programs. Then it’s too late. The system of care will continue to fail teens unless we intervene earlier where they are in a better position to be helped. We need to be able to intervene early on to build the empathy they have for themselves, so that we can, in turn, help them have to have more empathy for others. But it must be thought about and acted on so much sooner than our current system supports.

As a behavioral health industry, we need to go on the offense.

We need a lot more mental health resources and support to reach all teens. Flexible, outpatient and other interventions, with evidence-based, engaging content. Interventions that are focused on skills and tools that equip teens to tolerate stress better, meaningfully connect with people and their purpose more, and see the power of their real potential. I can tell you…this is largely missing in the current approach.

We need preventative approaches and early detection. We need all the things that exist in medical care. Just as endocrinologists and cardiologists focus on diet and exercise with patients at risk for diabetes and cardiovascular disease, behavioral health should focus on giving teens the skills to develop empathy, tools to better understand their emotions, and practically-applicable ways to manage stressors in their relationships, especially at home and in school. We need to understand how critical, early, preventative attention and intervention can play a central role in saving lives. There are many more things that can be done so that a child/teen does not escalate to having the capacity to take another human life.

Will this work 100% of the time? No. 30% of the time? Maybe not. Is the problem a mental health problem more than a gun violence problem? That’s a convenient distraction. But if we go on the offense and focus our efforts as a mental health industry on lifting children up more, addressing their mental health needs earlier and better, and place the focus on information, education, support, and proper care, focused on empathy…we will have a come a long way.

Thank you David.

What does this mean for you?

Support behavioral health for all kids – especially yours and your kids’ friends. 

Personal note – we have three wonderful kids who are all employed (Yay!), have stable, loving relationships, and are contributing members of society. Without getting into details, this “outcome” was undoubtedly helped by early and often use of counseling and therapy, and intervention.

I’ve been on meds for panic attacks for 25 years and have been very open about that. The vast majority of behavioral health issues are absolutely solvable – but only if you own them.


May
19

The invasion of the techies

Artificial intelligence.  Block chain.  Wearables. Smart phones. Chatbots. Various combinations thereof.

All these tech wonder-things are working their way into workers’ comp…or at least trying to. I’ve been tracking this sporadically (who has time to monitor all the press releases announcing this revolutionary app or that whiz-bang solution??) and have come to a few conclusions.

  1. With rare exceptions, the companies developing and offering these “solutions” are founded and run by either a) clinicians or b) techies.
  2. Those run by techies seem to think they can stitch together a wearable thingie connected to a smartphone app and voila’! they’ve built a substitute for/adjunct to physical therapy.
    Of course, the techies KNOW tech, understand AI and video tracking of movements and integration of smart-phones with remote devices. What they do NOT know is medical stuff, what really happens in rehab, the role of the therapist/prescriber/patient, the realities of the therapy process, where things break down in the patient/therapist process/interaction and why. And a lot of other stuff I can’t think of this second.
    Oh, and patient engagement.  That’s kind of super-important.
  3. Those run by clinicians really understand the care process, clinical issues, the reality that effective therapy and recovery is driven largely by patient compliance. What they don’t get are the tech challenges, the singular importance of reporting information back to other stakeholders, the limits of technology and adoption/effective/consistent use of technologically-driven “solutions”.

So, tech-centric approaches rarely address patient engagement, compliance, or the obstacles thereto.

It doesn’t matter how great your tech is if people a) can’t figure out how to download it; b) don’t have a smartphone; c) can’t figure out the app/wearable/bluetooth connection/whatever; d) it isn’t specific to the needs of each individual patient (language, physical characteristics/comorbidities/functional limitations/pain levels, reading level, therapy needs and evolution of same…).

And it doesn’t matter how great your clinical expertise/knowledge/experience is if: a) the tech is clunky, b) your staff has to onboard/explain/coach/be tech support for your patients, c) the data collected isn’t automatically shared with stakeholders, and d) the data isn’t entirely secure yet accessible for reporting/analysis/research.

On that last point, no device/app/tech is helpful if other stakeholders (the therapist/prescriber/case manager/claims handler/employer) don’t get reports on progress and alerts on potential problems – especially if those reports and alerts aren’t easily accessible/pushed to them so they don’t have to go looking for them.

What does this mean for you?

Apple beat Microsoft because it made using a computer easy. Adoption of tech-enabled “solutions” requires making the entire process/use by all stakeholders “easy”.

Put more succinctly, Ideas don’t matter – execution does.

 


May
13

Medical cost drivers in work comp – NCCI’s take

Sean Cooper and Raji Chadarevian delivered perhaps the most useful presentation I’ve seen at any NCCI Conference…There’s a LOT 0f important – and very timely – information in their presentation, so I strongly encourage you to watch it  – or watch it again here.

Let’s start with the top line – facilities and physicians (which includes physical medicine as well as MD costs) are by far the biggest chunk of spend. Note that NCCI reports annual drug spend is down to 7% of total spend. This aligns closely with what I’ve been reporting for some time.

The key takeaways…

The discussion focused on medical prices – which are the single biggest driver of total US healthcare inflation (see here for more details on this) – and utilization. Disaggregating cost increases provides/ed the audience with a deeper understanding of drivers – well done.

We are approaching network saturation.

Fully 75% of Physician services were delivered in-network – and, as in-network prices grew much more slowly than non-network, this helped reduce overall medical inflation.

Physical medicine is increasing…which is good.

The cost of physical medicine has been increasing while costs for surgery costs have not. What’s driving PM costs is mostly more utilization – indicated by the light green shading below. That is NOT necessarily – or even likely – a bad thing…A course of PT is way less expensive than the costs associated with a surgical episode. 

Facilities

Sean noted facility costs have been “the biggest driver of increased medical costs in workers comp” – increasing twice as fast as physician services. (Long-time readers will recall I’ve been banging on this drum ad nauseam.)

There are a host of reasons for this – led by consolidation in the healthcare services industry (also covered in detail here at MCM). Net is when a hospital or health system buys physician practices, it gets to add a facility charge to the what used to be just a physician office bill.

Voila!  Instant profit simply by changing the “place of service”. That’s why private equity firms, large health care systems, UnitedHealthGroup, and dominant hospitals have been snapping up physician groups – they are gaming the system.

There’s more to unpack here – which I’ll do early next week.

What does this mean for you?

It’s facility costs.


May
9

Wildly off-topic 5…Russia is losing

Putin is losing.

The West is winning.

Ukraine and Ukrainians are what we should aspire to be.

There is no way Russia will “win” in Ukraine; Putin is running out of troops, ships, armor, money and time.

Meanwhile his objectives for the war on Ukraine, namely:

  • easily capture Kyiv and install a puppet government in Ukraine;
  • split the West using his oil and gas as leverage,
  • damage NATO; and
  • scare smaller countries into abandoning the US-led alliance

are further away than ever.

Putin has strengthened NATO and the European Union, unified the West, pushed once-nominally neutral countries including Finland, Sweden, and Moldova into embracing the West, and shown the world that his armed forces are weak, poorly led, poorly equipped, and no match for a country a quarter the size of Russia.

A couple of things worth noting.

It is highly likely US intelligence assets (satellites, NSA, communications intercepts, aerial surveillance) have and are playing a major role in the war (as are the UK’s and almost certainly other western countries’). Reports indicate:

a downed Russian plane (likely a fighter)

Ukraine is showing the world how an incredibly motivated, really smart, and very creative people can defeat what used to be thought of as the world’s second strongest armed forces.

A few examples

Ukrainians have made drones – big ones, small ones, tiny ones; armed ones; ones with cameras and ones adapted to carry explosives; commercially-available ones and military-only ones – a major part of their arsenal.

Much of this is appears to be the work of regular Ukrainians…many of whom were are not in the military before Russia’s attack.

A drone drops what appears to be a mortar shell through the sunroof of a car stolen by Russian soldiers

A Ukraine-developed anti-ship missile is likely the weapon used to sink two of Russia’s biggest warships and destroy a troop transport.

Now that Ukraine has the latest artillery (thanks to France, Canada, the UK, the US, the Netherlands and other countries) it is using it to deadly effect.

Meanwhile Russia is calling up retired service members to fill “administrative” roles in its army. This shows just how deep into the morass Putin is, and how willing he is to keep digging himself even deeper.

What does this mean for you?

There are so many lessons we can learn from this…

  • preparation and constant attention to detail are critically important and way under-valued,
  • never under-estimate the power of very motivated people,
  • leaders that employ only those that agree with them will fail miserably.

Apr
12

Wildly off-topic 4…

The war in Ukraine has entered what could be an even worse phase, primarily because Putin cannot afford to admit what has turned out to be a monumental mistake.

Russian rulers that screw up this bad sometimes end up dead – and not by suicide. Most recently Stalin thought he was about to be shot when the Germans invaded in 1941; Czar Nicholas II and his entire family were slaughtered during World War I.

And that, dear reader, is why Russia is “regrouping and resupplying” in preparation for a much-more-limited battle to take and hold territory in eastern Ukraine near the Russian border.

That is NOT to say this will be less intense or awful than what’s already happened – in fact the opposite appears likely. Putin has appointed a leader for his war on Ukraine – a general who oversaw the genocide in Syria, mass destruction of entire cities, towns and villages, and use of chemical and incendiary weapons against civilians.

No, this is going to be worse than we could imagine.

As far as “regrouping” goes, there’s a lot more to this than just getting a couple nights sleep, a hot shower, and some more gas and bullets. The Russians have two basic problems:

  1. not enough soldiers and
  2. a really bad supply situation.

Soldiers

There’s pretty credible data indicating the Russians suffered about 50,000 to 60,000 casualties so far – in six weeks of fighting. We don’t know precisely how many were killed, wounded, or taken prisoner, but that is a really high casualty count, so high that it renders a lot of the Battalion Tactical Groups that invaded “combat ineffective”.

Other evidence indicates Russia is trying to solve this by:

  1. calling up more recruits;
  2. using mercenaries (e.g. the Wagner group);
  3. stripping troops from other areas; and
  4. asking their allies to send fighters (Syria, Chechnya etc).

That’s not going to make much of a difference; recruits need a lot of training or they’ll just get in the way and do stupid stuff that results in them and others getting lost, hurt, in accidents, or killed.

There aren’t enough mercenaries or “volunteers” to make much of an impact.

Soldiers need a LOT of training to become effective, and mixing together units with diverse abilities requires a LOT of careful planning and oversight, two things in which the Russians have been notably lacking.

Supplies

see here.

Strategy

Russia relies on Battalion Tactical Groups, which for non-nerds is a name for a unit that includes tanks, infantry, and artillery – along with support elements (medical, logistics/transport etc). Without getting too deep in the weeds, BTGs have a ton of firepower but relatively few infantry. That’s fine when you are moving fast, but is very much NOT fine when you are stuck on roads and need infantry to protect your vehicles from enemy infantry.

Now that most of the BTGs that invaded are in pretty rough shape, Russia will have to mush together units that haven’t worked, trained, or operated together. This will be a big problem.

The other probably bigger problem is BTGs are NOT what you want to use in urban setting – all those vehicles are sitting ducks, and the lack of infantry makes them even more vulnerable. Since Russia appears committed to destroying cities, this leaves them with one option.

Sit back and level cities with rockets, bombs, and artillery.

Devastation in Kharkiv

This is why things are going to get awful fast.

What does this mean?

There will be a global food shortage that will likely lead to famine in Africa. 


Apr
11

I’m not at RIMS

Thanks to the friends, colleagues, and to-be-friends who’ve asked if I have time to meet at RIMS.

I gave up attending the massive P&C event years ago; it was yet another conference among several that were more useful, interesting and focused on work comp.

RIMS is more or a P&C generalist event, covering everything from cyber to terrorism (back when terrorists didn’t invade the Capitol) to marine and D&O – sure there’s a bit of comp but those sessions were pretty thin.

Instead, I find CWCI, WCRI, and NCCI far more productive – but that’s just me.

Also heading back from the Bay Area where I watched my beloved Syracuse University men’s rowing team take on the best crews on the west coast. Here’s our varsity 8 leading last year’s national champion U Washington halfway through the  course…UW won by a second…kudos to the Huskies.

Enjoy San Fran – a terrific and wonderful city.

 


Mar
22

Wildly off-topic 2…

Again my fascination with the minutiae that brings defeat or victory causes me to diverge from managed care stuff to dive into what’s happening in Ukraine, why, and guess what the end result will be.

(Here’s my first post which dives into the why crappy vehicle maintenance and mud season are really helping Ukraine)

The damage Russia is doing to Ukraine and the Ukrainian people is immeasurable.  Yet it pales in comparison to what it is doing to itself, its future, its world standing, its economy . And it will get worse, because

Ukraine is still winning (or perhaps more accurately Russia is not, which is the same as Russia losing), and

The western world is unified as it has never been.

First, the no-fly zone. Unfortunately this is a no-go because:

  • Russian planes are not doing nearly as much damage as artillery and rockets – which CANNOT be stopped by a no-fly zone.
  • Implementing a no-fly zone would require NATO countries’ airplanes to:
    • bomb Russian ground radar and anti-aircraft assets – some of which are INSIDE RUSSIA
    • shoot down Russian air assets (planes and helicopters)
    • shoot ordnance (missiles, rockets, shells) that might cross the border into Russia)
  • Direct confrontation of Russian assets by NATO forces would support Putin’s claims that it’s Russia vs NATO and the west, thereby:
    • solidifying his position in Russia and
    • making the use of nuclear/biological/chemical more defensible  – at least in Putin’s mind and others in Russia.

Also, we (NATO, that is) are about to send some very capable ground-to-air missile systems to Ukraine, systems which Ukrainian soldiers are likely familiar with and will need little additional training on. Some of these systems have the ability to shoot down cruise missiles as well as planes and helicopters.

the contrail is from a Ukrainian rocket about to hit a Russian attack helicopter.

and here’s the helicopter as it hits the ground.

Second, “we should be doing more to help the Ukrainians” Well, like what?

Anti-tank rockets? Drones? Medical supplies? Anti-aircraft missiles?

check, check, check and check.

I’m also guessing our intelligence services are helping a LOT by sending data on Russian military movements to Ukrainian forces, data that those forces use to target precision munitions, identify potential threats, and better understand the tactical situation. Of course you’ll never hear about this.

[note more than two dozen (!) Republican Senators voted against legislation providing $13.6 billion in additional aid to Ukraine, then blasted the Biden Administration for “not doing more” to  help the Ukrainians.]

Okay, here’s what I’ve learned from untold hours of reading twitter feeds from some very well-informed and knowledgeable posters…

Logistics

Russia is having logistical problems – for we civilians, that means their supply chain is in very bad shape. If we don’t get our drill bits, Etsy order, or several pair of shoes to try on, that’s a tragedy.

If an invading army runs out of artillery shells, food, medicine, rockets, medical supplies, and most importantly – fuel – it’s much worse. Hard to fight a war if your:

  • soldiers are hungry,
  • you can’t patch up your wounded, and
  • your tanks, trucks, command vehicles, and mobile artillery run out of fuel.

Which appears to be happening.

Couple issues here –

  1. the Russians can’t get the stuff they have on hand to the troops that need it because those Ukrainians who were supposed to welcome them with open arms didn’t get the memo. And,
  2. Putin and his generals evidently didn’t stock up on everything a modern army needs because they assumed (1.) above was reality.

There are reports that Putin has been asking China for food, artillery shells, medical kits, and probably everything else. (That’s why President Biden told Premier Xi Jinyang – in no uncertain words – to NOT send military goods to Russia)

Okay, back to 1…

Fuel. 

Its mud season, and melt season, which means many roads are impassable which forces vehicles to go cross country – which means crossing streams/rivers. Armies have specialty vehicles intended to do this, but…

As we discussed a while back, vehicles require roads, which are narrow, can be mined, and offer lots of opportunities for the Ukrainians armed with man-portable rockets to blow them up.

The classic tactic is to destroy the front and rear vehicles, trapping the rest in the middle. Drivers then have a Hobbesian choice-  stay on the road and risk getting blown up by rockets or head off road where they risk getting blown up AND/OR stuck in the mud.

Which seems to be happening.

2. Those fancy hypersonic rockets Putin is using? he doesn’t have that many. And they cost about $100 million EACH. Using them now – against a nation that should have surrendered weeks ago, may be an indicator of desperation.

He’s actually been forced to use anti-ship rockets against land-based targets. Which implies he’s running out of regular rockets. And artillery shells. and lots of other stuff.

Here’s the worst part – Russian casualties – killed, wounded, missing, taken prisoner – are staggeringly high. 

Typically, for every killed-in-action (KIA) there are three wounded (WIA). If this holds here, we’re talking over 50,000 additional casualties.

This is stunning.

By way of comparison, in 9 years in Afghanistan – a brutal war indeed – the Soviets lost 9500 KIA.

So in less than a month the Russians may have almost twice as many KIA than in 9 years in Afghanistan.

“Worst” because many of those soldiers were conscripts with little education, poorly fed and trained, unaware of where they were going and why, but told they would be welcomed with open arms.

Where do we go from here?

  1. Will Putin use WMD (weapons of mass destruction)?
    I don’t know – and no one else does either. But I’d say it is likely he does something horrific, because he’s Putin and will likely be shot if Russia fails in Ukraine.
    Chemical is the likeliest as he will try to blame it on Ukrainians blowing up an ammonia or chlorine storage facility.
    Due to massive corruption in Russia it is highly unlikely Russian troops have protective gear. That implies Putin will use chemicals on civilians and do so far from his own troops. Then again, he does not care if his guys get slaughtered and could blame that on Ukraine.
  2. Stalemate
    Russia is making some progress in the south, and appears to be stalled in the north and west – if not losing ground.
    It is nearing bankruptcy, has lost massive amounts of equipment, and cannot get critical components to replace that equipment and has suffered more than 50,000 casualties.
    Ukraine’s morale is high, its civil and professional forces are performing incredibly well, supplies are coming and its people are unified yet it has a much smaller air force, is fighting an enemy that does not care who or what it kills.

Where does this end up?

No one knows.

What does this mean?

Support Ukraine. 

Please consider a contribution to Care. Care is a very reputable and highly effective NGO with a rich history of successfully mitigating disasters and helping people. They are doing great work in Ukraine.

Screenshot your contribution and put it in comments. I’ll post it – and my ever-lasting thanks.


Mar
3

Wildly off topic…why Ukraine is winning

As the son of two parents in the CIA who grew up on military bases all over the world, I’ve had a special fascination with the minutiae…the (seemingly) minor and (seemingly) random things that cascade into defeat or victory.

After hours in the TwitterSphere, here’s my totally amateur take on why the Russians are losing despite an overwhelming advantage in military technology and hardware and personnel and the West’s absolutely correct decision to NOT intervene militarily.

stick with me here…the journey is worth it.

You’ve seen lots of photos and video of that gigantic convoy sitting on the road north of Kyiv…one that will ensure the total destruction of the capital and pretty much everyone in it.

Except that column hasn’t moved in three days. Two reasons…tires and rasputitsa.

Tires.

If you don’t keep tires inflated, move vehicles around, and minimize exposure to sunlight, they rot.

If tires fail, what was a HUGE asset – mobility, and a logistics train (supplies of fuel, food, water, ammunition, medical supplies, spare parts) – becomes a HUGE liability…modern armies consume gigantic quantities of everything, and when that runs out, they stop moving, shooting, and surviving.

A military tire expert(!) posted this…

If that column had been able to move quickly, Kyiv and Ukraine would be flying the Russian flag…sure the Ukrainians have done everything humanly possible to slow/stop it, but AK-47s and molotov cocktails are no match for masses of T-90s.

Okay, but it’s just tires, you say?

Rasputitsa

Rasputitsa is the Russian word for mud, which in the steppe country is bottomless. The incredibly fertile and deep soils of eastern Ukraines turn to mud when the spring thaw hits.  Reports indicate Putin bowed to China’s demand that Russia not invade Ukraine until after the Olympics…after the weather had turned just a bit warmer.

The Ukrainian defense, coupled with lousy Russian vehicle maintenance, likely caused breakdowns at the head of the column. So, the Russians had to get off the road to make any progress.

But…

Tires that work really well on roads have to be de-pressurized to get through mud, and when you lower the pressure, sidewalls flex, crack, and fail, and gazillion-rouble mobile air-defense vehicles, troop carriers, and fuel trucks get stuck.

Which allows very mobile, incredibly brave, and highly motivated Ukrainians to either fix and then use them to fight Russians or destroy them.

So, the rest of the convoy is stuck on the roads, where it runs out of fuel, food, water, and esprit de corps.

 

Well…Russia’s still got a huge and deadly air force…right?

Good question.

If the Russians didn’t take care of tires, what else did they ignore? Modern military equipment is incredibly maintenance-intensive. US fighter jets need more than 30 hours of maintenance per flight hour. 

The Russian air force has 4 times more planes than the Ukrainians, yet hasn’t achieved air dominance over Ukraine – a situation that has puzzled every “expert” pundit.

While I haven’t seen any current insights into Russian air force maintenance practices, there have been a LOT of problems of late, problems due to crappy maintenance, inexperienced crews, and a lack of training.

Net is, there’s a lot more to fighting and winning than lots of troops and fancy equipment.

Back story

There’s a LOT more to this, as in why the Russian military is so poorly maintained, trained and led (hint – Putin’s buddies are oligarchs that get huge contracts to provide tires to the military, contracts they fill by using cheap, crappy Chinese knock-offs so they can spend the rest on superyachts and apartments in London).

What does this mean?

Support Ukraine. 

Please consider a contribution to Care. Care is a very reputable and highly effective NGO with a rich history of successfully mitigating disasters and helping people.

Screenshot your contribution and put it in comments. I’ll post it – and my ever-lasting thanks.


Feb
24

The Ukrainian War’s impact

Equity markets are getting hammered, the bond market is up substantially, and energy prices and assets are zooming.

Those are the immediate effects of Russia’s invasion of Ukraine.

What will happen now is anyone’s guess, but here’s how I see it.

  • Putin is all in.  Attacks are hitting cities hundreds of miles from the Donbass and eastern Ukraine, signifying Putin’s intent to take over the entire country.
  • The western countries – Europe and North America, as well as some Asian nations will rally around severe penalties for Russia – blocking access to the SWIFT system, banning trade in Russian debt and equities, and instituting a broad ban on exports to Russia.
  • This isn’t going to end anytime soon.
  • Ukraine will be very hard-pressed to hold off Russian forces; the Ukrainian military is much smaller, has fewer armored vehicles and airplanes, and isn’t positioned well to fend off attacks from the north and southwest.
  • China is a bit of a wild card; it
    • consumes a lot of Russian foodstuffs, gas and oil,
    • sees Russian aggression as a not-very-big-deal,
    • likes the strategic problems the invasion creates for the West (China could move aggressively on Taiwan), but
    • knows Russia’s financial situation is going to deteriorate quickly,
    • has tens of billions invested in Russia, and
    • understands that Putin is playing with a fairly weak hand.

So, I’d expect:

On the scarier side, expect Russia to launch cyber attacks in retaliation for Western sanctions, attacks that will very likely target financial institutions, infrastructure and commercial entities.

What does this mean for you?

Uncertainty breeds stasis…until we see where this is headed, expect interest rates to rise which will increase the cost of debt and reduce private equity investment.


Feb
10

Wait…what??

Science denial – or perhaps a total absence of common sense – is nothing new – if anything it has gotten more pervasive of late.

Here are a few examples of willful ignorance guaranteed to make you smack your head (I hope…)

This from Scott Galloway…

I

Here’s the map they use…

Belief in Evolution

Belief in creationism

This is NOT a Right vs left, Liberal or Conservative issue.

an almost-comprehensive view of the many, many examples of nonsense…

What does this mean for you?