Arkansas is the canary

Facility costs are the fastest growing cost in workers’ comp.

Rural hospitals are in deep financial trouble – many are shutting floors, wings, or are closing entirely.

Medicaid is all that is keeping many rural hospitals afloat – Mercy Hospital’s days are done…And work requirements will cost hospitals billions.

Arkansas has already kicked 18,000 people off Medicaid – mostly because the state’s Medicaid work requirement program is unbelievably poorly run, its leaders don’t know a damn thing about challenges faced by poor people, and no one at the state or federal level is demanding they get their stuff together.

(A federal judge just blocked the state’s work requirement.)

So, what does this mean for work comp payers in Arkansas?

  • 18,000 more Arkansans are now uninsured
  • Rural and urban hospitals are looking for pennies in the couch cushions.
  • Work comp has lots of pennies.


Why I love the CWCI Conference

The 9 reasons I love CWCI’s annual conference.

  1. Consistently great content– timely, up-to-the minute data is analyzed and presented by experts who really understand the California work comp system, have deep experience in that system, and use that experience to draw inferences and conclusions that are highly relevant. No one does it better.
  2. Topics are different than you find most anywhere else – this is a huge challenge for conference organizers, yet every year Swedlow & Co. focus our attention on key issues.
  3. Example – Dr Kathryn Mueller’s discussion of what’s needed to obtain the best possible care and outcomes for work comp patients. Dr Mueller described what good “evidence” is, how it should be used in developing guidelines, and the integration of guidelines with utilization review. She also walked thru different approaches to best practices for RTW, the critical importance of functional outcome measures, and ended with a discussion of the latest thinking on pain management.

    That’s about 4 sessions’ worth of education in an hour, delivered by one of the nation’s leading experts. Damn she’s good.

  4. It’s not just about California. While the focus is on the Golden State, we learn a lot that is just as useful wherever you work. CWCI was one of the first to come out with definitive proof that physician dispensing is a costly scam, focused our attention on compounds before most of us had heard of them, researched spinal fusion claims, and examined the impact of the new ICD-10 coding scheme on work comp.
  5. They do all this in less than a day, yet…
  6. There’s plenty of time built into the agenda to meet and catch up with colleagues built.
  7. You get to hear Alex Swedlow, who may be the best presenter in the business. I’m biased as Alex is a good friend, but his dry-as-Death Valley wit, the way he weaves in lessons learned decades ago, and ability to pick out the one most important takeaway and ensure you understand it is unmatched.
  8. There’s a bar. I don’t mean a bunch of lawyers, altho there’s plenty of them, but an actual place to get cocktails. At lunch.
  9. It’s in Oakland, which means I have to travel to the west coast, where two of our kids are living, so I get to see them!
    Molly says hello from Santa Monica



Which way is California’s work comp system headed?

There seemed to be a bit of nervous tension as CWCI’s annual meeting kicked off. After years of relative stability, and dare I say it steady improvement in many areas, it’s no wonder stakeholders are a bit trepidatious.

With a new Governor in office, new appointments in the offing, and some seemingly intractable problems still challenging stakeholders, the nervous tension is certainly understandable.

Fortunately, the first speakers addressed this head on.

General Counsel Ellen Langille led off with a summary of legal activity in the Golden State. My big takeaway was the King case.  CWCI filed an amicus brief in King v CompPartners which big win for all employers, taxpayers and yes patients. The Supreme Court upheld the exclusive remedy protection for utilization review organizations. Briefly, UR physicians were not deemed to be “treating physicians”, a sensible ruling indeed.

Ms Langille turned things over to Jeremy Merz and Jason Schmelzer for a summary of what’s coming. Both gave kudos to CWCI for providing much-needed data to help legislators understand what is really going on.

Schmelzer made a key point – politicians do not want to talk about workers compensation – they think it should just work. He also noted former Democratic Gov Brown vetoed more work comp bills viewed as problematic by employers than his Republican predecessor – Arnold Schwarznegger.  Point being, just because one is in this party or that does not mean they will hew to what you’d think is the party line.

While Gov Newsom is moving quickly on key issues, he has yet to show his hand on workers’ comp issues. The two experts opined that:

  • Significant reform in work comp is unlikely as the system is seen as generally working well
  • While it is expensive – it’s better than it was
  • Key stakeholders, e.g. labor and employers – have bigger priorities.

One potential big issue is the independent contractor issue. While several bills are under consideration, it’s not clear any will get traction over the near term.

I would just add that there are lots of other issues that are way more important to important people than work comp; climate change’s impact on the state, water projects, battles with the federal administration on any number of issues, taxes, education, and many more. So, unless work comp is about to implode or explode, it is not going to get any traction.

What does this mean for you?

In California’s work comp system, things are likely going to remain stable at least for this year – and likely next.


Work comp services – quick takes

Over the last two + weeks I’ve had a dozen or so calls with investors asking about the workers’ comp space.  Mostly this seems driven by the OneCall debt issuance and financial situation, but the conversations all started with a high-level view of what’s happening in work comp.

To save you investors money and me time, here’s my view from 30,000 feet.

Work comp is shrinking

Fewer workers are getting injured. Premiums continue to decline. The injury rate is declining.  Folks, we are in a shrinking business, and that isn’t going to change. If anything, when the next economic downturn hits, comp is going to get hit harder.

That means fewer medical services, fewer scripts, fewer first notices of injury, fewer claims.

Pharmacy is leading the shrinkage

Several new “work comp” PBM start-ups have emerged over the last couple of years, most of them talking “transparency” and better customer service for smaller payers.  Over the last 7 years, PBMs have done a pretty good job shrinking their top lines as they work with payers to reduce unnecessary opioid use and compete on price. Yes, there is money to be made here, but size and service matter – a lot. (more on this in a month or so when we do the next Survey of PBM in WC).

Why these folks are investing start-up funds in a business that has been declining by near-double-digits for several years is a puzzle indeed.

Big caveat – Coventry First Script won the Department of Labor PBM contract, which may well be the largest WC PBM deal awarded to date. Hats off to the Coventry folks who made that happen.

The big keep getting bigger

And that’s going to continue.  In a mature/declining business, the only way most companies can grow is to acquire other businesses, then reduce expenses.  This works even better when the businesses you acquire can replace external vendors you were using before – so you can count their revenue as top line and margin as profit. This is what Mitchell/Genex is doing with Priority Care Solutions.

Big caveat #2 – MedRisk continues to do quite well – proving that doing one thing really really well is the strategy that always works, everywhere. Of course, it’s also the hardest to get right and sustain. (MedRisk is a consulting client)

TPAs are one of the few niches that are “structurally growing”

Sorry about that terminology – but I couldn’t think of any other way to characterize the growth that TPAs are enjoying as insurers continue to outsource claims services to the industry. As premiums decline, insurers have fewer dollars to invest in people, technology, buildings, etc – so buying claims services on a variable cost basis looks a lot less risky than building/fixing/developing your own stuff internally.

And this will continue.

Yet, every work comp insurer I have spoken with is going to grow.

Which is NOT going to happen. The question is, will this quest for growth turn into a “how far over the stupid line will we jump before we figure out we’re screwed” contest.

Some will win, some will lose – and some are born to sing the blues (kudos to you if you know the band that sang these lines...) Those that are embarking on a quest up to the edge of the line may want to research Reliance Standard, Golden Eagle, Atlantic Mutual, and Kemper.

Jeez I’m getting old.

What does this mean for you?

If you’re an investor you’ve just saved a lot of money and time.


Why “Medicare for Some” may be here faster than you think

Healthcare was the top issue for Independents (and Democrats) before the 2018 midterms.

Notice the emphasis on “Independents”. Dems are going to vote blue, Republicans will vote red, so the 2020 election is going to be decided – like most elections – by independent voters.  You can expect every Democratic candidate to hammer away on healthcare in language that worked well last fall.

And they will be focusing on costs and access, issues top-of-mind for voters concerned about healthcare.

There’s a busload of Democrats who’ve announced they’re going to run for President in 2020, and it looks like the bus is going to be standing room only when Biden and perhaps others announce.

Pretty much every of the 354 announced Democratic presidential candidates have signed on to some form of Medicare for All; while I’d argue most haven’t demonstrated any real grasp of the details, the issue is clearly a winning one.

Meanwhile, the President has released a budget calling for a $2.3 trillion cut to Medicaid and Medicare. You may recall that then-President Obama called for many of the same changes to Medicare that Trump is hawking now – primarily reducing reimbursement for hospital-based providers.

Kudos to whoever put this language into the latest budget – it made sense then, and it makes sense now.

BUT – while Dems will be talking about protecting Medicare and Medicaid (which pays for most nursing home care than any other payer), Republicans will be trying to convince healthcare voters  that slashing $2.3 trillion from their Medicare and Medicaid is the right answer.

The GOP may figure out how to get seniors and others to support slashing their healthcare – a feat that is possible as Republicans are way better at messaging that Democrats.

Democrats may be able to stick to their message – as they did to telling effect in the 2018 mid-terms. If they do, and if they win the White House and Senate, the first thing they will do is pass Medicare for Some legislation. The major candidates are all talking about doing big things, they need to deliver big results early, and healthcare was – and is – a winning issue.

What does this mean for you?

For healthcare, 2020 will be the most consequential election ever.



Why “Single Payer” is inevitable, take 2

Because a) voters want it and b) no one cares about the federal budget deficit or national debt.

Seriously, that’s all there is to it. If you want more details, read on!

I’ve had numerous email and phone conversations about my series of posts on Single Payer and Medicare for All. Unlike past dialogue, it’s been generally apolitical and more fact- and less emotion based.

What’s striking is the conversations haven’t been about how awful “socialized medicine” is, rather what’s preventing Single Payer from happening. There’s been a bit of nonsense – the typical apocalyptic scare stories about pharma not developing new drugs because we don’t keep overpaying for the ones we take today, visions of patients dying while waiting to see a doctor, uninformed comparisons to Canada and the UK – but overall most people want to talk about why Single Payer can’t or won’t happen.

Deficit? No one cares.

Republicans have long branded themselves as the part of fiscal responsibility; that went out the window when they passed into law the Trump Tax bill. Screw the deficit, just cut taxes and growth will explode so all will be fine – a theory that been totally discredited in theory and has never worked in practice.

The thick black line show the budget deficit exploding due to the Trump Tax cut

Plus, the average voter is profoundly ignorant – including about deficits. So, deficits don’t matter.

What voters want

Voters do. And polls clearly show voters are warming to Single Payer.

And, they have opinions on different versions, with big majorities wanting a public option.

Yes, I know when you tell people that it will cost more in taxes, or possibly eliminate their employer plan, they like Single Payer less.

But they REALLY like the Public Option.

So, what does this mean for you?

Some form of Single Payer – likely a public option allowing folks over 50, those who don’t get health insurance thru work, to buy into Medicare or Medicaid. – is going to happen.


It’s different now

When did you last:

  • buy a newspaper or book
  • use a real camera
  • plug in your Garmin and stick it on the windshield
  • shop in a mall, or
  • use your home phone?

That cellphone you are reading this on? It’s replaced entire industries – landline phones, books, newspapers, white noise machines, handheld recorders, calculators, radios, bank visits, cameras, video cameras, stereos, maps and satellite navigation devices, paper tickets, even desktop computers.

Your Lyft/Uber account? For many, it’s replaced a personal vehicle.

That box on your front step? It’s taken out thousands of local retail establishments and hundreds of malls.

These are just three of the all-but-invisible ways technology has radically changed our world – and your business – over the last decade.

It is well worth stopping to consider this when planning for the future. Here are a few takeaways.

Construction is affected by much lower retail construction coupled with a very recent spike in home ownership. After years when millennials chose to live in small apartments, group homes, or with relatives, it looks like getting your own place is back.

Maybe they can convert malls to apartment complexes?

The net – lower commercial construction will be balanced out by more residential building.

Manufacturing employment is growing much more slowly than manufacturing output, driven by the Administration’s tariffs, the “cellphone effect”, and accelerating use of robotics and sister technologies.

We may have reached peak auto manufacturing, with significant structural implications for the auto industry and its entire supply chain and service infrastructure.

What does this mean for you?

Is your business model prepared for the future? 


BernieCare – No; Single Payer 2.0 – Yes.

I don’t see how BernieCare makes it to the serious consideration stage – much less becomes reality. Not because it isn’t a way better healthcare answer than the mess we have today. It just isn’t do-able.

When we do finally ditch the completely unsustainable, inefficient, and idiotic “healthcare system” we have today, I’m convinced it will have most of these components.

  1. This won’t be “Single Payer” as commonly defined, rather it will be a tightly managed, measured, and defined health insurance product administered by various governmental and non-governmental entities.
  2. Everyone will be enrolled.
  3. These will be both not-for-profit and for-profit entities competing in defined markets. Similar to Medicare Advantage, ACA Individual Exchange, Managed Medicaid and other current programs, these entities will bid for programs on a multi-year basis.
  4. Certain populations will be defined separately and bidders will have to demonstrate expertise and capabilities unique to each population. Medicare/Medicaid dual-eligibles will be the most significant of these defined populations.
  5. Winning bidders will have to comply with most of the current ACA requirements such as no medical underwriting, a standardized benefit plan, significantly reduced member cost-sharing, open access to providers.
  6. There will be one universal reimbursement mechanism – likely based on Medicare’s MS-DRGs for facilities and Physician Fee Schedule for other providers. This will be an “all payer, all product” fee schedule, meaning it covers all types of care – including auto, workers’ comp, liability, etc.

Potential variables

  1. This may take the form of Medicaid for All – albeit using a different name (the point made by Dr Jake Lazarovic in a previous post.) I don’t see using Medicare as the basis. Medicaid involves partial state funding – key to get states involved in funding the program. Medicaid also provides a relatively seamless program across all services including long term care, unlike Medicare which separates facility, physician, supplemental, and prescription services into distinct service lines – and doesn’t include long term care beyond relative brief rehab stays. To say these separate programs are confusing and irrational is to be kind indeed.
  2. Employers may be able to provide financial support for their workers, or decide to give their workers higher wages in lieu of a healthcare benefit plan.

However, it’s either this, or BernieCare. And BernieCare is death to insurers and many other stakeholders, while Single Payer 2.0 will be the best of the alternatives.

Next week – yes, this is affordable, and YES, the healthcare industry is going to go berserk.

What does this mean for you?

Massive changes are coming. Survival favors the prepared; extinction is the fate of the willfully ignorant and ideologically blind.


Why BernieCare won’t happen

Sure, there’s lots to like about it – no paperwork, see any doctor you want, no cost for any services, covers nursing home and long term care, dental, vision, you name it.

It will cost a good bit more – at least initially, but over a decade we’d actually spend a couple trillion dollars less than if we stick with the current clustermess. Despite the initial sticker shock, as voters get increasingly scared and frustrated by the crappy “health system” we have today, the balance may well tip towards BernieCare.

Except it won’t, and here’s why.

Infrastructure – There is no current wholly-government infrastructure in place that would be a platform to handle BernieCare. Much of Medicare and Medicaid is administered by private or not-for-profit organizations. It would take years and tens of billions to build that infrastructure. Sure it may well be more cost-effective than using private entities, but I just don’t see us collectively agreeing to spend the sums needed to make it happen.

Impact on employment – BernieCare would essentially eliminate 99% of private insurance. The 540,000 people employed in that business would no longer have a business to employ them. I don’t see Congress voting to vaporize over a half million jobs; and that’s only to start. As things got more automated, many more admin roles would be eliminated.

Big money’s control over politicians – Citizen’s United killed the last faint hopes we could keep dirty dark money out of politics. Fact is, healthcare is by far the biggest political contributor, led by big pharma. Add in device manufacturers, healthplans, physician groups and health systems – all in healthcare collectively pumped about $650 million in cash into political coffers last year alone.

Recall what makes our healthcare so damn expensive is that for-profit entities are heavily involved in healthcare services, devices, drugs, and everything else – BernieCare would crush their profits if not eliminate them altogether.

If you think the healthcare industry contributes a lot now, wait to see what happens if BernieCare gets just a bit of traction.

What does this mean for you?

If we were starting from scratch, BernieCare is by far the best model. We aren’t, so it won’t get off the ground.

That’s not to say some form of MFA/Single Payer isn’t viable. More on that in a future post.


Single Payer – time to get real

So, what would the most expensive version of Single Payer cost? Eliminating all deductibles, copays, coinsurance, premiums for Bernie Sanders’ super-duper Rolls Royce plan would run about $32,000 for a family (a gross simplification to be sure).

There are 22 million jobs in the US healthcare and related industries (that includes mine, one of our daughters, and her husband – they are nurses.) Let’s add all the college and grad school institutions that employ tens of thousands to educate people on healthcare administration, and the support infrastructure  – IT companies, paper form printers, App developers, pundits and commentators, real estate occupied by insurers…you get the idea. The health care industry is at least a fifth of our economy.

The private health insurance industry alone employs 540,000 workers.

If we switched to a true single payer system, millions of administrative jobs would disappear.  Remember what happened to manufacturing in the rust belt? That happened over 30 years; this would affect a much bigger share of the economy over a much shorter time.

The result would be an economic collapse that would surpass the Great Depression and devastate the economy.

Lest you think this is hyperbole, Taiwan employs a grand total of 300 people to administer a single payer healthcare system for a population of 24 million.

Using Taiwan as a basis, we’d only need 4,125 people to administer a universal single payer system.