OneCall’s Halloween is going to be all treats!

Thanks to a massive restructuring, OneCall lives to fight another day. This is excellent news for the folks who work there; not so much for the original investors.

Briefly, absent a new injection of equity and major reduction of debt, OCCM was headed to bankruptcy – on Halloween. That’s when the grace period on a $15 million debt payment expired. Late Friday a deal was reached that keeps the company operating.

Look, it’s cash!

Here’s how it happened.

As I’ve reported in the past, when OCCM was put together it was highly leveraged – in English, that means it had a ton of debt. That debt, which was restructured several times over the last few years, was a big drag on the company. The $150 million a year (or so) in interest payments soaked up cash that could have been used to pay workers and invest in systems.

The use of debt by Apax, the private equity firm behind OCCM, is commonplace in this type of deal. By using debt to help buy the pieces that made up OCCM, Apax hoped to double or triple the equity it originally invested in OCCM. That works great if a business is growing and consistently profitable; the PE firm’s investors make a ton of money when an “equity event” occurs.

But that high debt load can be a real problem if the company doesn’t grow. Late Friday OneCall announced the company is going thru a complete financial restructuring. In essence, debtholders traded a big chunk of their debt for equity, which a) injected much-needed cash into the business and b) reduced the company’s debt burden, freeing up cash for ongoing operations.

Apax – the private equity firm that owned OCCM – lost control of the company, and its entire $750 million +/- investment when OCCM’s finances deteriorated to the point that it was days from bankruptcy.

At that point, control shifted to the debtholders.

Those debt holders agreed to swap much of their debt for stock – and pump more capital into the business in an effort to keep it going. This will reduce OCCM’s debt payments, freeing up cash, hopefully allowing it to a) make needed improvements to Polaris; b) reduce accounts payable and c) reward employees who have stuck with the company through some pretty tough times.

Six weeks ago I opined:

[a] debt for equity swap is also unlikely. If the covenants are breached, the debtholders likely get (some) control over the company. I don’t see why the debtholders would swap debt for equity now, when that may occur in the near future. [emphasis added]

Reports indicate the restructuring was driven by two debtholders – KKR and GSO – who recently snapped up lots of OCCM’s distressed debt. The two firms convinced other debtholders to agree to a deal to:

  • reduce annual debt service costs by $90 million, down from $150 million +/-;
  • inject $375 million in capital into the business; and
  • eliminate short-term debt.

Tomorrow – what the future holds for One Call. (I’ve asked One Call several questions, and will report back if/when the company responds.


Haven and workers’ comp

Yesterday we dove into Haven, the healthcare company formed by Amazon/JPMorgan/Berkshire Hathaway.  Today, we discuss the potential implications for workers’ comp.

Based on what we know so far, there are two ways Haven might impact workers’ comp.

Before Haven can affect WC, it has to become a viable entity of some significant size. Some skeptics don’t see that happening, citing the Byzantine complexity of the US healthcare (non)system, the size and scale of the medical-industrial-financial complex, and the bewildering maze of laws and regulations.

Those are excellent points; I’d suggest critics may be making assumptions that aren’t necessarily appropriate. Haven may well create a “de novo” healthcare delivery and financing system, leveraging the employee population, intellectual capital, technology, financial capabilities, and buying power of its owners.

If Haven becomes the healthcare delivery platform for the hundreds of thousands employed by its three owners, those employers would likely use that platform for occupational injuries and illnesses. That would enable seamless integration of care, reduce the risks inherent in the siloing of care between comp and group health, and likely upgrade non-occ disability management as well.

Efforts to deliver 24 hour care have fizzled as the opportunities inherent in integration couldn’t outweigh the legal, regulatory, cultural and political realities. It’s possible that Haven could eliminate much of these obstacles by starting fresh.

So that’s the big change.

More likely – and much sooner, is the potential for Haven/Amazon to provide drugs, supplies, and DME to work comp patients.  The companies’ push into pharmaceutical manufacturing and distribution, and distribution of medical devices and supplies means it has the supply piece in place; next step is building the distribution channels/pipes into work comp payers.

The total work comp drug/supply business is likely less than $6 billion, a relative pittance compared to the half-trillion plus dollars in revenue the three partners will enjoy this year. And, once those pipes are built, Haven will figure out how to generate more revenue.

If anyone can do this it’s Haven/Amazon.

What does this mean for you?

Service providers need to double down on service and be that indispensable partner. 






Amazon, JP Morgan, Berkshire Hathaway’s Haven – where is it today?

These giant powerhouses are working together to do something big in healthcare.  Haven, the name for the organization set up by the giant retailer, insurer/diversified company, and financial services firm will initially be focused on employees of those three companies. Later, they will “share [its] innovations and solutions to help others.”

Haven was introduced almost two years ago, albeit without that appellation.  Since then, it has been pretty quiet, at least as far as announcements of major innovations. (The company’s COO resigned after a year citing the Philly-to-Boston commute.)

There are plenty of skeptics, most citing the enormous complexity of healthcare, the Gordian knot of regulations, the lack of interconnection, perverse incentives – including for-profit stakeholders, and consumer expectations as all making it more likely that United Healthcare could build a successful commercial bank than JP Morgan will “fix healthcare.”

That’s fair, except Haven hasn’t focused on “fixing healthcare”, but rather fixing healthcare for the folks who work for the three owners.

What we know today – it looks like Haven will initially focus on drugs and virtual health.

Haven will operate on a non-profit basis.

Amazon had just over $41 Billion of cash on hand as of June 30. That hoard plus its distribution capabilities, existing customers and attractive stock make it a very capable acquirer.

Amazon is already selling prescriptions in Japan and distributing medical supplies in the US.

The company is building new product lines, and buying expertise, experience, and already-successful businesses. From FoxBusiness:

> Amazon [is launching] an exclusive line of 60 over-the-counter healthcare products, called Basic Care

> Amazon buys online pharmacy PillPack for $1 billion placing the online giant squarely against drugstore chains, drug distributors and pharmacy benefit managers.

> Amazon files for a patent for Alexa, its virtual assistant, which would detect when a user is sick and recommend and sell medications.

Aurohealth, a maker of generic pharmaceuticals, teams up with Amazon for an exclusive over-the-counter pharmaceuticals brand called Primary Health.

The common thread is medications – manufacture the drugs, encourage adherence, enable distribution.

Last month, Amazon’s Seattle-based employees were introduce to Amazon Care, which boils down to a pretty sophisticated virtual/tele-health platform using a local medical provider group. That ensures employee health records stay with their healthcare provider, and aren’t “owned” or handled by the employer.

Don’t expect that to last…from Huron:

Amazon recently established a stealth lab, called 1492, that focuses on healthcare technology. While little is known about the products being created, speculation is that the retailer is developing tools to mine data from electronic health records, new telemedicine technologies and healthcare applications for its existing products.

I would expect Amazon to do much of its building thru buying; there are a lot of great companies out there innovating different parts of healthcare and buying gets a footprint, talent, and experience that would take too long and cost too much to build.

What does this mean for you?

Nothing yet.  That will change. 

Homorrow, Haven and workers’ comp.


What I missed, and fashion statements for safety professionals

Back from a week’s holiday with my wonderful wife in France; Paris, Mont St Michel and Normandy.  A few not-surprising impressions…

  • it’s awfully hard to find a bad meal in France
  • public transit is really, really good
  • what is “old” here in the States…isn’t in Europe
  • you can find a bar to watch the Eagles game
  • a day touring Normandy makes me even more grateful there wasn’t a war for my mini-generation
  • France’s fashion industry must be targeting you risk managers and safety professionals!

OK, here’s what I missed while marveling at all things French.

WCRI’s annual conference is back in Boston March 5 and 6. It sells out every year, so sign up here.

More less-well-off folks in states that haven’t expanded Medicaid are going to die. Patricia Powers is a minister living in non-expansion Missouri across the river from Illinois, which did expand Medicaid. If she’d lived a few miles further east, her breast cancer would likely have been diagnosed much earlier.

NCCI opined on the impact of a recession on workers’ comp. Key takeaways –

  • frequency drops off sharply at the beginning of a recession, then bounces up as things start to improve
  • as there are fewer people working in manufacturing or construction these days, actual injury counts likely won’t decline as much as they did in past recessions.

(I wrote on this a couple weeks ago, noting past recessions have had a couple other characteristics not discussed in NCCI’s piece.)

In DC, a bill to reduce drug spending is progressing thru the House. Among other measures, it would require the Feds negotiate prices on 35+ drugs with manufacturers. (I would encourage readers to focus on the actual components of the bill and not get caught up in critics/supporters’ use of inflammatory language.)

Key takeaway – it would reduce Medicare costs by $345 billion over the next six years (that sound you hear is taxpayers clapping…)

Other key takeaway – the public is really focused on drug prices.

Non-medical use of opioids will cost our economy about $200 billion this year.

The finding came from the Society of Actuaries’ report (available here). Almost half of the costs are from health care expenses and lost productivity, issues that are key concerns for workers’ comp.

Have any work comp insurers sued the opioid industry?

What does this mean for you?

Drug pricing and opioid litigation should have a major impact on workers’ comp. Note emphasis on “should”.


See you next week

Off to Paris for a week with my lovely bride…will be studiously avoiding anything resembling work  till we return Thursday.

Most excellent flight over on Delta.

I’m  sure the world will get along just fine till then!


Quick update on One Call

Late this afternoon Standard and Poor’s downgraded One Call from CCC to CC.  According to S&P:

An obligation rated ‘CC’ is currently highly vulnerable to nonpayment. The ‘CC’ rating is used when a default has not yet occurred but S&P Global Ratings expects default to be a virtual certainty, regardless of the anticipated time to default.

S&P also stated:

We are placing the ratings on CreditWatch Negative as One Call may not make its interest payment on its second-lien notes during the 30-day grace period.

There is an overall rating (referenced above) and individual ratings on specific bonds. Readers will recall that One Call has three levels of debt; the most senior is rated CCC, while second lien (the most junior) is rated at C.  S&P does not rate the middle level aka the 1.5.

From S&P;

We lowered our debt ratings to ‘C’ from ‘CC’ on One Call’s second-lien notes due 2024 and senior unsecured notes due 2021, and placed the ratings on CreditWatch Negative. The recovery ratings on these debt issues are ‘0’, indicating our expectation for negligible recovery (0%) in the event of a payment default.

S&P on the senior debt’s CCC rating:

In the event of adverse business, financial, or economic conditions, the obligor is not likely to have the capacity to meet its financial commitments on the obligation.

We will know by Halloween what the future holds for One Call – likely before then.  It is unlikely One Call is currently in compliance with its debt covenants.

From my June 26 post:

The issue at hand is a “7x first lien leverage covenant” which kicks into action when the company draws down its revolver debt by 20%.  According to a DebtWire article, OCCM had a “razor-thin” margin at 6.9x as of March 31.

I do NOT know what those specific covenants are, however in my experience debt holders put covenants into contracts so the debt holders can take control – partial or total – of a company that is at risk of defaulting on its debt.

Debtwire also indicated OCCM had drawn down $50 million of the $56.6 million revolver.

Allow me to translate into language we non-financial wizards understand.

Among other debt instruments – bonds etc – OCCM has “revolving” debt, which is kind of like a line of credit. The company can borrow from it and pay it back as cash flows dictate.

The “7x” is calculated by dividing the total long-term debt – which was reported to be $1.375 billion on March 31 – by cash flow (adjusted EBITDA) – which was $200 million over the 12 months preceding March 31.

So, as of March 31 OCCM had drawn down its revolver by way more than 20%, but had kept its revenue-to-debt ratio just below 7, which prevented the covenants from kicking in.

Things have deteriorated since then.


Credit cards, mortgages, and workers’ comp

There are several things that will affect workers’ comp in the next couple of years. Perhaps the least obvious, but most significant is consumer spending.

Here’s why.

Consumer spending drives travel, cars, homes, clothes, tools, food, retail; pretty much everything except government, heavy industry and infrastructure construction.

In fact, consumer spending amounts to two-thirds of our economy, manufacturing just a tenth. When we consumers sneeze, the economy catches the flu.

So far, consumer spending is holding up. This from Bloomberg

Easy credit drives a lot of this via credit cards. Essentially, some folks use their credit cards as consumer loans, allowing them to buy stuff they can’t pay just now.

That works great while wages are increasing and jobs plentiful – both true today.

While that spending is a bit shaky, what caught my eye was a report that those risky mortgages that cratered the economy a decade ago are back.

Nerd bomb alert – The Feds are backing $7 trillion in mortgages, way more than they (us) did before the debt crisis of 2008. With taxpayers holding the bag, mortgage lenders have no reason to not give mortgages to people who can’t afford them to buy over-priced houses. The Feds then package those loans and sell them off to other investors.

In fact, fully half of new FHA mortgages consume more than half of the borrower’s monthly income. 

If all this sounds familiar, it’s because it is. This is precisely what happened a decade ago.  Remember this?

If people run into trouble paying those really expensive mortgages, they’ll stop going out to eat, traveling, buying cars and furniture and washing machines and snowmobiles and anything else they don’t really really need.

The trickle down effect would hit trucking, manufacturing, retail, autos, hard goods, restaurants. Hours would be cut, workers furloughed, payroll slashed as employers conserve cash in an effort to stay afloat.

How does this affect workers’ comp?

We can expect a reduction in claim frequency at the outset of an economic slowdown as workers avoid filing work comp claims because they don’t want to lose income or be replaced. Severity also goes up, because those already out of work don’t have jobs to go back to – and can’t find new jobs.

Over time, frequency rises as we come out of a recession.

What does this mean for you?

Stay informed, and carefully monitor economic conditions in states where you do business. 


The Purdue Opioid “settlement” – key takeaways for workers’ comp

Reportedly Purdue Pharma, the fine folk behind OxyContin, is nearing a settlement with 23 state attorneys general and thousands of other governmental entities.

Here are the key takeaways:

  • this does NOT appear to be a universal settlement; other state AGs, local governments, employers, and other affected entities will almost certainly seek their own compensation from Purdue.
  • The Sackler family, Purdue’s owners, will lose up to $3 billion of their personal fortunes estimated to total $13 billion – most of which came from OxyContin sales.
  • Purdue Pharma will enter bankruptcy and future earnings will go to addressing the awful repercussions of the opioid crisis

What wasn’t included are criminal charges for the Sacklers; that is an outrage.

It is crystal clear many members of the family were intimately involved in Purdue’s efforts to shove more and more opioids down more and more throats. Not satisfied with those billions, the arrogant bastards were going to make yet more treating the addicts they created. (Note not all of the Sacklers were involved in the opioid disaster)

This from NY’s opioid lawsuit (credit Vox)

The unmitigated gall of the Sacklers is stunning; they knew their drugs were killing tens of thousands, and now wanted to profit from the untold damage they had done.

For workers’ comp, there are a couple of implications.

First, as the tort industry dives deeper into this, they will sue more and more participants. My informed opinion is payers are pretty safe for several reasons;

  • state regulations are the primary and ultimate driver of work comp coverage;
  • work comp entities led the charge to reduce opioids when they first grasped the size of the problem;
  • payers did not receive rebates from opioid scripts so there was no financial benefit to allowing the scripts; and
  • payers were damaged by the opioid industry due to much higher medical costs, extended disability duration and death claims.

I haven’t heard of any workers’ comp entity being sued for damages related to opioids – but it is possible.

Second, work comp payers have been damaged by the Sacklers and their ilk. While state funds may be involved in some of the suits seeking compensation for damages (it’s impossible for me to unpack all the plaintiffs in all the filings), I have yet to hear of any suits involving commercial insurers or reinsurers.

I’ll admit to being surprised at the work comp insurance industry’s seeming lack of interest in taking on the opioid industry. Every day:

  • Insurers go after claimants for double-dipping and false claims,
  • Insurers go after employers for falsifying payroll data,
  • Insurers go after providers for fraudulent billing for practices, and
  • Insurers sue each other over coverage issues and reinsurance claims.

Before anyone else could spell opioids, work comp payers saw the damage being done and took action.

What does this mean for you?

Work comp insurers must be a highly visible part of the solution; we owe it to policyholders and taxpayers, we owe it to patients, and we owe it to all of the insurer staff, regulators, researchers, and other stakeholders who’ve dedicated untold hours to fixing the damage done by the Sacklers and their ilk.

Need more incentive? Here’s David Sackler’s $22 million Bel Air mansion your workers’ comp dollars helped pay for.



No, hospital mergers do NOT reduce your costs

The takeaway from the American Hospital Association’s “study” of hospital mergers is NOT that mergers are good for patients, employers, and taxpayers.

It is that all of us should be skeptical readers of research conducted/paid for by entities that have a stake in the results.

The report authored by Charles River Associates – and funded by the AHA – on mergers and acquisitions in the hospital made several claims, all focused on the hospital that was acquired:

  • mergers reduced expenses at the acquired hospital;
  • quality at the acquired hospital improved; and
  • revenue per admission decreased.

Clearly the intended message is that mergers are good for us – quality goes up and the cost to us – the patients and employers and workers comp insurers, go down.

Except that’s highly misleading.

First, the study drew conclusions directly contradicted by every other study of hospital/health system consolidation.  This is likely because the study focused on the hospitals being acquired, and not the overall results of the newly merged entity. (Here is a very good review of mergers’ impact on costs and quality, here’s what NCCI had to say.
And here’s what happens to patients – spoiler – you get to pay more.
If the authors had included results from the acquiring hospitals this would have been much more useful.  Overall, the report provides no useful insights into the changes in costs, revenues, or quality resulting from mergers.
Second, the study reported expense reductions from mergers are relatively small at 1.5% to 3.5% of total expenses. As I mentioned to WorkCompCentral’s Elaine Goodman, most every merger outside the hospital industry produces expense savings at or very close to double digits, thus the “cost-reduction” benefits touted by the AHA are rather less than impressive.
Second, claims about improvements in quality of care are not convincing for two reasons.  First, statements about types of improvements consist of examples cited by interviewees. Second, as the acquired hospital may transfer, or more likely, not accept higher-acuity patients, it is not surprising that their quality measures (re-admissions, mortality rates, etc) improve. Healthier patients = better quality ratings.
Third, the report indicates ” acquisitions are also associated with a reduction in net patient revenue per admission “ at the acquired hospital. There could be many reasons for patient revenues to decline, including moving more critical patients  – who cost more to treat – from the acquired hospital to the acquiring hospital. Changes in Medicare and Medicaid reimbursement could also be a factor. Notably the report did not discuss revenue reductions across the newly merged entity.
Here’s what REALLY happens to hospital revenues…
What does this mean for you?
For workers’ comp payers, don’t think this is good news..
Hospital costs are hurting workers’ comp payers.  Revenue maximization efforts by hospitals and healthcare systems in non-Medicaid expansion states, are driving comp medical costs higher.

Note – For years I have been doing research on several issues important to work comp – pharmacy, bill review, claims systems, utilization review. Some of have been sponsored by companies active in the space – but they’ve never had access to respondent-specific data nor any input into the analysis or report writing process.

Still, you should read all my research with a careful eye – as you should read all research.


Chronic pain, opioids, and workers’ comp

The hammer is starting to fall on the opioid industry and the repercussions are echoing thru the comp industry.

  • J&J owes Oklahoma $573 million after losing its case in the state
  • Purdue Pharma’s owners are trying to settle all suits for $10-$13 billion
  • the huge case in Federal Court in Ohio will go to trial next month

In work comp, opioid spend has been cut in half over the last three years, but the reductions are not consistent across the states. WCRI’s latest report has insights into where the problem is most severe – which helps you figure out where to allocate resources. Kudos to authors Dongchun Wang, Vennela Thumula, and Te-Chun Liu for putting together the report.

Meanwhile, we’re being inundated with “alternative” treatments for chronic pain. One just-published study (hat-tip to Steve Feinberg, MD) shows that invasive procedures are pretty much useless; here’s the takeaway:

There is little evidence for the specific efficacy beyond sham for invasive procedures in chronic pain…Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain.

BTW for clinicians, Steve wants you to consider attending the CSIMS meeting coming up next month.

As we transition away from opioids, how do we help patients with chronic pain? What works, what doesn’t, and why? And most importantly, how do we work with treating physicians to solve the problem?

Of course, a key reason docs have over-prescribed invasive treatments is financial; there’s a ton of money in doing stuff to patients, compared to a few pounds of money for working with patients. But that’s only part of the story.

Simply walking into a physician’s office with a fancy dashboard and telling the physician that doing X is in their best interest does not work.

To get docs to change behavior, you have to understand why they are doing what they are, provide them accessible data showing why that’s not helpful, and get them involved in change.

Is that a lot of work? Well, maybe. Break it down into chunks and it’s not so daunting.  Identify a few docs you want to work with, talk with them about the issue, and develop solutions together. This takes time, patience, and most of all a commitment to listening and understanding.

The payoff is trust between you and the treating physician, which leads to a lot less work for your front-line staff, and a lot better outcomes for your work comp patients.

What does this mean for you?

You need a plan to help patients with chronic pain. And that plan has to include treating physicians.