From S&P – “An obligor rated ‘CC’ is currently highly vulnerable. 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.”
Of course, it’s not so much if you have insurance – it’s how much you have to pay out of pocket. Which, to coin a phrase, is becoming a ship-load as deductibles have exploded. Total worker cost sharing has increased about 50% over the last decade.
Posted by Joe Paduda on Wednesday, February 13th, 2019 | Comments
Yesterday’s post covered why work comp is a soft target for “revenue maximizers” – particularly facilities. Today we’ll talk solutions.
First, on a macro level, states need to develop and use fee schedules based on Medicare. For inpatient that’s MS-DRGs – and there should be no outlier provisions. A number of states do just that, and their facility costs are pretty much under control. WCRI has an excellent compendium of state fee schedules etc here.
Here’s one chart that shows how effective flat-rate fee schedules are at controlling costs (credit to WCRI’s Olesya Fomenko and Rui Yang)
Second, on a pre-claim level, payers should analyze hospitals’ and health systems’ actual paid amounts to determine what their costs are. Not the discount, the net cost.
Researchers will most likely find net costs are lower for not-for-profit healthcare systems/hospitals, regardless of the discount level. That’s because many for-profits have really high chargemaster prices that they then “discount” so payers can show a lot of “savings.”
Then, wherever and whenever possible direct patients to those lower cost facilities that have equal or better outcomes.
Third, the services have been rendered and a bill for a gazillion dollars appears.
Briefly, unlike group health and Medicare/Medicaid, many work comp payers don’t do much more than apply fee schedules, rules, some clinical edits and check for UR compliance, and perhaps do pre-payment audits. In the Medicare/medicaid/group health world there are both pre- and post-payment approaches, generally known as “payment integrity.”
Dr Pelezo: [a] key difference between group health (commercial), Medicare and Medicaid versus Worker’s Compensation involves the number of layers of payment integrity, the type of integrity, and the way those layers are implemented. In group health programs we have the core processing platform plus the implementation of at least one if not two large-scale industry editing software packages, and in some cases additional pre-payment fraud, waste and abuse software.
…there may be three or four payment integrity companies scrubbing the same bill set after payment has been made, each finding something that the prior vendor did not detect. In total you may have six or seven layers of protection in place. These key observations served as the impetus for Equian’s formation of a seamless second pass editing solution targeted specifically to Worker’s Compensation programs, one that would impact bill processing in all States. Remember, these are industry leaders in payment integrity – and this speaks to how difficult it is for any single entity or organization to detect ‘all’ improper payments, and frankly how much overpayment is present in any given environment.
I asked Dr Pelezo what payment integrity is and how it is different from bill review:
Dr Pelezo: In its simplest form payment integrity is payment to the right party, for the right medical products and services, in the right amount. In different forms every healthcare payer in the industry deploys various degrees of payment integrity – a worker’s compensation bill review engine in and of itself is a form of payment integrity.
Dr Pelezo: many worker’s compensation carriers are dependent upon bill processing systems and limited internal resources to manage the entire spectrum of payment integrity…the expertise, tools, and funding required to implement effective programs for all aspects of payment integrity is a daunting task (and a daunting ask). Even one ‘simple’ aspect of payment integrity (nothing here is simple) – bill auditing – can be subdivided into professional, outpatient, inpatient, pharmacy, durable medical equipment and supplies, etc. Securing true expertise in each of these individual areas can be difficult. Compound that issue with an ever-changing landscape of payment policies and methodologies and it is easy to see why managing payments is challenging for even the largest healthcare organizations. In bill auditing alone, one has to tackle validating/aligning new State requirements with bill processing outputs, CPT code updates, AMA CPT Assistant code clarifications, evolving specialty society guidance, National Correct Coding Initiative policy updates, hundreds of pages of CMS final rulings that impact CMS-based payment methods, medical policy updates, bulletins and banners, and all other information and reference material that impact how payment should be made.
What are some of the issues you’ve seen with outpatient services?
Dr Pelezo: I continue to see an expansion in billed amounts for outpatient surgical services, especially in those States that pay for services based on ‘usual and customary’ or percent of charge methods. Programs that participate in Medicare should not bill other payers differently than Medicare is billed for the same set of services, from a pure compliance perspective. I’m not convinced this is always the case, however, and I have encountered these variations in Worker’s Compensation data. I’m disappointed when I encounter an ambulatory surgical center bill for hundreds of thousands of dollars for surgeries that last a couple of hours; surgeries that under other programs – lock, stock, and barrel – are only reimbursed a very small fraction of the reimbursement received under Worker’s Compensation. [emphasis added]
What does this mean for you?
One of the fun things about working in this business is finding people like Dr Pelezo whose depth of knowledge and level of expertise reminds me that there’s always a lot more to know – and a lot more we can do.
The simple answer is from Willie Sutton; when asked why he robbed banks, he said “because that’s where the money is.”
While it is indeed true that facility bills are orders of magnitude more expensive than most comp services, there’s a lot more to this. I asked Dr Anthony Pelezo of Equian to expand on Mr Sutton’s meme.
Dr Pelezo runs Equian’s Payment Integrity operation. A physician by training, Dr Pelezo’s depth of knowledge of all things coding, billing, reimbursement, and facility revenue cycle management coupled with his clinical background brings a level of practical expertise I’ve not seen anywhere else. (I consult with Equian’s Clinical and Coding Logic operation).
Here’s part of my conversation with Dr Pelezo about the soft target that is workers’ comp.
Briefly, “following the path of least resistance is a common theme for many things, and healthcare payment is no exception. As a simple matter of physics (Newton’s third law of motion), every action has an equal and opposite reaction. Market pricing pressures from both government programs and group health programs places pressure of other available revenue sources (such as Worker’s Compensation).
From a purely financial perspective Worker’s Compensation is generally off the radar of many of the larger payment integrity companies. Overall Worker’s Compensation may represent 1% of the $3-4 trillion in U.S. healthcare payments…we add to this fact that Worker’s Compensation payment programs are unique State to State (like Medicaid)…[and] Programs like Medicare and Medicaid make up around 60% of the nation’s healthcare spend. Group health plans make up another third of healthcare payments. The result has been that many worker’s compensation carriers are dependent upon bill processing systems and limited internal resources to manage the entire spectrum of payment integrity. Worker’s Compensation payment has certainly not fallen off the radar of the provider community.
Dr Pelezo elaborated on work-comp specific issues:
Policy foundations (or lack thereof) are also an issue inside of Worker’s Compensation…Payment, administrative, and medical policies are all part of this equation. Some States have more comprehensive policies than others, though almost all lack any meaningful library of medical policy. In group health programs there are hundreds if not thousands of medical and administrative/payment policies in play; medical policy sets alone can number near 1,000 in some group health programs. Only a handful of States’ Worker’s Compensation programs have true fraud, waste and abuse legislation; insurance fraud is addressed, though healthcare billing fraud is rarely addressed. We also have the issue of State-specific code use, which contradicts the standard transaction code set adopted in 2003 as part of HIPAA; a lack of a standard transaction code set creates opportunity for confusion and errors within billing practices.
The net – most payment integrity firms focus on the big payers – group health Medicare and Medicaid because workers’ comp medical spend is tiny in comparison. Add to that the inter-state variation in policies, coding, reimbursement regulations and the lack of consistent payment policies along with providers’ ever-more-sophisticated billing techniques and the problem becomes apparent.
Tomorrow – solving revenue maximization. Also known as how to get Willie Sutton to look elsewhere.
Posted by Joe Paduda on Monday, February 11th, 2019 | Comments
I caught up with WCRI CEO John Ruser PhD last week to find out why the WCRI Conference is in Phoenix, what we’ll learn, and why this event sells out every year. (register here)
Why move this to Phoenix?
Traditionally, our conference has been held in the Boston/Cambridge area (east coast). This year we want to make it easier for our members and others interested in our research who live on the west coast to attend. We know traveling can be expensive in time and money, so we sought to lower the threshold for those on the west coast to join us. Although we will be back in Boston next year, we will review the success of having this year’s conference in a different location and, based on that review, consider moving it around to other cities.
(Paduda comment – and Phoenix is a lot sunnier than Boston in March…)
What is the hot topic this year?
Coordinated services – getting employers, providers, patients to work together. We have two sessions on this.
The second session features Dr. Cameron Mustard, president and chief
scientist at the Institute for Work & Health, who will discuss the challenges
and successes a large acute-care hospital system and it’s three unions faced in
developing an innovative and collaborative return-to-work program.
How did Coordinated Services become the lead topic this year?
Whether it is in the political realm, the boardroom, or the
workplace, when people fail to work together, it is difficult to innovate and
address complex challenges. The workers’ compensation environment is no
At this year’s conference, we are featuring some of WCRI’s
latest research, as well as engaging sessions on the latest trends and examples
of industry stakeholders coming together to tackle some of the system’s most
important challenges, such as opioid misuse, return to work, and providing the
worker the highest standard of care.
into a broader focus of many stakeholders in workers’ compensation who see the
benefits of collaboration and working together to improve injured worker
On the topic of erosion of benefits, my guess is the lower frequency rate is a factor. Is this a correct assumption? And have worker indemnity benefits on a per-claim basis actually eroded?
Yes, correct assumption. I will present National Academy
of Social Insurance data to show that workers’ compensation benefits as a
percent of covered wages are at their lowest level since 1980 and that this
share has been declining for over a quarter century. Some say that’s an erosion
of benefits, but there’s much more to it.
In my presentation, I will highlight contributors to this trend,
emphasizing the ubiquitous declines in injury rates and workers’ compensation
claim rates that are partially offset by increases in injury and claim
severity. I will also identify factors responsible for these offsetting trends,
including improvements in safety, changes in the mix of jobs and compensability
rules, the aging workforce and economic conditions.
What other sessions should we know about?
I am very excited about
our keynote speaker, Princeton University Professor Alan Krueger, who is
considered one of the 50 highest-ranked economists in the world.
He will be giving a
presentation on the economics of the opioid epidemic and how it affected the
labor force participation rate. Then he will sit down with me to discuss his
research and thoughts about the future of work and the impact of technology on
I will also ask him about
his experience working in Washington, D.C. as the former chair of the White
House Council of Economic Advisers (CEA).
What will those attending the conference come away with?
Apart from networking with experts and other high-level workers’ compensation professionals, we want our attendees to walk away from the conference having learned valuable things they didn’t already know.
This conference sells out every year – so get your registration in soon here.
Rebates reduce what payers’ and PBMs’ pay for expensive branded drugs; the problem is patients that need those drugs don’t get the benefit of this cost reduction. While PBMs and payers argue that they use rebates to reduce the total cost of the pharmacy benefit, reality is the folks who need a lot of expensive branded drugs end up subsidizing everyone else’s pharmacy benefits.
Yesterday’s post on facility costs elicited several emails from hospital and health system folks asserting their billing practices and discount arrangements result in lower costs for workers’ comp payers. None provided any data supporting those assertions; hopefully that is forthcoming.
Next week I’ll be publishing an interview with Equian’s Anthony Pelezo MD; it is a deep dive into the world of hospital “revenue maximization” and what you can do about it. (Equian is an HSA consulting client)
in the period 2007–14 hospital prices grew substantially faster than physician prices. For inpatient care, hospital prices grew 42 percent, while physician prices grew 18 percent. Similarly, for hospital-based outpatient care, hospital prices grew 25 percent, while physician prices grew 6 percent. [emphasis added]
While there are any number of public policy changes that could address the problem, group health and workers’ comp payers can’t wait for legislative or regulatory action – they need solutions now.
First, we have to know why and where prices are increasing to come up with viable solutions. The study referenced above used case-mix adjusted data from 3 large health insurers – Aetna, Humana, and UnitedHealthcare, using the actual prices negotiated by these giant healthplans. (these plans cover over a quarter of all Americans with employer-sponsored health insurance.) I won’t get into the nits of the research – for wonks, it’s all in the link (subscription required).
Hospitals and health systems are able to raise prices because – in many areas – they have close to monopolistic pricing power. That is, even giant health insurers aren’t able to negotiate low prices because health systems have dominant market share.
If giant healthplans don’t have much bargaining power, workers’ comp networks and payers have next to none. Remember, the total amount of medical spend from all payers in the US is about 1.25 percent of total US medical spend. From another HealthAffairs article:
other insurers [defined as auto and work comp] typically lack sufficient patient volume to establish network contracts with hospitals because they usually insure only a small proportion of a hospital’s patients.
The article is well worth purchasing, however it does have a possibly significant limitation; it uses Florida data – the Florida work comp fee schedule is easily and usually gamed by hospitals, so the research may not be applicable to other states. That said, here are the key takeaways:
For-profit hospitals charge significantly higher prices than not-for-profits
For-profit hospitals generate almost a quarter of their margin from “other payers” (that’s you, auto and work comp)
Hospitals affiliated with HCA had the highest price increases during the study period and the highest prices for “other payers”
So, what to do? There are two issues here – what facilities your claimants use, and how those facilities bill you.
Review your PPO contracts to identify for-profit health systems
Do a quick analysis to compare what you pay (NOT THE DISCOUNT, WHICH IS IRRELEVANT) different facilities for similar services
Direct your patients to the lower-net-cost facilities.
Or, skip the analysis and just direct patient to not-for-profit facilities.
Tomorrow, we’ll focus on cutting costs on individual bills.
What does this mean for you?
Work comp and auto is a very soft target for profit-maximizing providers – but you aren’t powerless.
Posted by Joe Paduda on Tuesday, February 5th, 2019 | Comments
On its third CEO in four years and facing a tough financial picture, it’s time to think thru the challenges facing OneCall in 2019.
First, workers’ comp is a declining business – claim counts continue to fall. When you’re as big as OCCM, structural factors tend to have a bigger impact than they do on smaller companies. The Net – Fewer claims mean fewer specialty services needed.
Second, the list and type of competitors is changing as firms including Mitchell/Genex diversify. With Genex buying PCS (Priority Care Solutions), it would be logical for Mitchell to switch customers from OCCM to Genex/PCS (where this is possible). This would make sense for two main reasons: a) increases Mitchell/Genex’ top line revenue as the entire service cost is counted as revenue (for most services); and b) increases M/G’s total margin. Word is M/G has moved/is moving specialty business from OCCM to Genex/PCS and this will continue over time. Other entities such as VGM/HomeLink, HomeCareConnect, Paradigm Outcomes, and MTI America (HSA consulting client) are also working aggressively to gain market share. The Net – OCCM will likely see additional loss of revenue and associated margin.
Third, the new CEO doesn’t appear to have any experience with or expertise in workers’ comp. Rone Baldwin’s last job was with Centene, a health plan company with deep expertise in Medicaid, Medicare and some individual marketplace business. He’s also had stints at other benefits and insurance firms, but nothing I saw in property and casualty insurance or claims. Mr Baldwin left Centene in 2016; I asked OCCM what he’s been doing since then; they weren’t able to respond. The Net – With the workers’ comp business flat to declining, OCCM owners have brought in a new CEO who is a healthcare guy.
OCCM has been trying to push into the non-workers’ comp sectors for some time now, with limited success. Come to think of it, I can’t name any work comp entity that has had any appreciable success moving into healthcare.
The Net – I’ll repeat what an investment firm asked me about OCCM – What’s the end game? And I’ll repeat my reply – Either it gets sold intact to a strategic buyer (perhaps Optum or Mitchell), gets broken up and sold off piecemeal, or creditors take it over if/when it runs out of cash.
Note – I sent several emails starting yesterday at 8 am to OCCM asking for comment. As of press time there’s been no substantive reply.
Posted by Joe Paduda on Monday, February 4th, 2019 | Comments
CEO Dale Wolf is no longer with OneCall Care Management.
Wolf’s departure is to be announced internally early this afternoon; word is he was informed Friday that he would no longer be needed at OneCall.
In his two years at the helm, Wolf was unable to fix OneCall; frankly that was a Herculean task against long odds. From its inception as the combination of Align, SmartComp, OneCall, and various other bits and pieces, OCCM was a business based on an ill-conceived investment thesis hampered by crushing debt that – in my view – forced a strategy that was doomed to fail and, in my view, was poorly executed.
As CEO, one could blame him for a failure to right the ship – but I’d be loathe to lay it at his door. Wolf took over a business headed in the wrong direction, tied to a faulty business plan authored by his predecessor. The actions he took had to recognize a) the reality that debt service costs were a huge limiter and b) the “whitespace” touted by OCCM buyer APAX and former management was much smaller than they opined.
While at best unpleasant and at worst cruel. the layoffs under Wolf cut expenses. (that said, the way some of the layoffs were handled still rankles.) Layoffs and the investment in tech solution Polaris were designed to reduce admin expense, increase profits, and improve customer service, thereby allowing OCCM to continue to pay its debt costs while hopefully gaining revenue and margin to, perhaps, one day, allowing owner APAX to sell at a profit. (That looks increasingly…unlikely.)
Polaris is still months away from full implementation at all customers, and consuming lost of free cash flow. If OneCall is to survive intact, it will have to complete Polaris, have Polaris live up to expectations, reduce admin expenses, and add new business.
One bright spot – transportation. Partnering with Lyft, OCCM is making significant progress shifting a chunk of rides to the rideshare company while reserving higher-complexity cases for its standard WC transportation network. That’s the good news; the bad news is margin on those Lyft rides may be significantly lower than the rides they are replacing. Nonetheless, kudos to OCCM for working through this.
Having worked at a declining company in this space and still bearing the scars, I feel for the people in JAX going thru this.
2018 has been a tough year; an investment industry source indicated Q3 EBITDA was down15% from the prior year’s quarter, while revenues actually increased 3%. Annual EBITDA saw a smaller decrease of about 10% for the 12 months ending 9/30/18.
Reports indicate total debt is just shy of $2 billion, and debt service (the interest OCCM pays to its creditors) is about $160 million annually.