Aug
14

1 +1 = 3

Two mostly-ignored things will have way more impact on workers’ comp than any other ten factors.

And as usual, workers’ comp is out to lunch.

Let’s quickly review the work comp industry’s failure to understand reality.  When COVID hit, the workers’ comp industry’s caterwauling and catastrophizing hit epic levels… mostly driven by

That led to far too much angst and far too little reality-based planning by the workers’ comp industry.

Fast forward to today, where the opposite is happening.

The industry is blithely ignoring the impact;

  • heat will have on claims, loss ratios, combined ratios, and claim duration, and
  • infrastructure investment will have on premiums and claims.

Heat

The massive and seemingly endless heatwave in multiple states is affecting restaurant workers, agricultural workers, folks in logistics and manufacturing.

Sure there’s heat exhaustion and heat stroke and heat prostration (which costs about $38k per claim…)

But that’s the (forgive the analogy) tip of the iceberg…Excessive heat also creates more injuries of all types…injuries to cherry harvesters in Washington State increase 1.5% for every 1 degree C above 25 C (77 degrees F) – mostly from falling off ladders.

Oh, and California data shows: compared to days with temps in the 60s,

      • on days when the temperature was between 85 – 90 degrees Fahrenheit…the overall risk of ALL types of workplace injuries was 5 to 7 percent higher.
      • when temps topped 100 degrees, the overall risk of injuries was 10 to 15 percent greater.

This means more claims in an industry that is generally unprepared to “manage” heat-related claims.

Jobs

Hundreds of billions of dollars is flowing into infrastructure, investment that has already created ninety thousand jobs in:

  • construction,
  • transportation improvements,
  • highway, bridge and road maintenance and replacement, and
  • heavy industry.

And many more jobs are on the way. (check out where this is happening here).

These are very well-paid, high-frequency and high-severity jobs.

This means premiums will increase as will claims and claims costs. And this will continue for years.

What this means for you.

At risk of belaboring the obvious, a more dangerous environment for many more workers  in already high-risk jobs. 

Heat + Jobs = more premium dollars, higher costs for self-insureds, more claims, and higher severity claims.

 

 


Jul
12

A week away from the blog is now past…here’s what I missed.

myMatrixx’ Chief Innovation Officer Cliff Beliveau – one of the smartest and most articulate tech people I have ever met – penned an excellent summary of AI’s potential uses in and impact on workers’ comp in yesterday’s WorkCompWire.

Cliff highlights key opportunities and challenges in claims, medical management, fraud detection and claims oversight…download his piece and save it.

Will automation disrupt construction? A better question might be “when will automation disrupt construction?”

Even better “when will what parts of the construction industry be disrupted by automation?”

All are addressed here.

Net is this – the author isn’t convinced we’ll see massive automation within the next decade...but points to a key use of technology that is already speeding up construction  – and making it more efficient to boot.

Surprise! medical bills and Junk healthplans – defined as plans with significant limits which often aren’t clearly identified up front – are facing increasing scrutiny. The White House is proposing strict disclosure standards and time limits on junk plans…

“The new proposed rules would close loopholes…that allow companies to offer misleading insurance products that can discriminate based on pre-existing conditions and trick consumers into buying products that provide little or no coverage when they need it most,”

The two – surprise! bills and junk plans, sort of complement each other…the junk plans don’t protect families from healthcare providers’ aggressive billing practices.

The proposed rule would highly limit duration of the plans, requiring clear disclosure of policy terms (as in written in English), and close coverage loopholes.

And one more note of interest for smaller employers looking at self-funded plans, and especially level-funded plans...AM Best’s April 28 2023 Market Segment Report indicates:

  • 2 out of 5 small employers (3 – 199 employees) are in level-funded plans
  • Just a year ago it was 1 out of 8 employers…
  • stop loss insurance loss ratios jumped to 85% in 2021 driven by new and very expensive specialty drugs and a lot more million dollar claims.

Just in the last year, 5 specialty drugs, each costing more than a million dollars annually per patient – have come to market.

What does this mean for you?

Smaller employers be very, very careful of self-insuring… 


Jun
26

Wildly off-topic…what just happened?

If you’re wondering what the heck happened in Russia, join the crowd.

Here’s what I’ve been able to “learn”…

first – the actors

The Wagner Group – a private company that is a combination of a mercenary, terrorist organization, and exploiter of poor countries that supplies Russia with tens of thousands of fighters. Wagner is the most effective fighting force in Ukraine. Wagner is really, really awful.

Yevgeny Prighozin is Wagner’s leader – he’s the former hot-dog stand operator now old bald guy commanding a huge criminal enterprise while always wearing full tactical gear even though he’s never been anywhere near actual fighting.

nice look, eh?

Friday:

  • Prighozin called for the firing of Russia’s top two military leaders,
  • Wagner Group troops took over critically important supply bases near Ukraine,
  • advanced on Moscow with convoys of his troops,  artillery and armored fighting vehicles;
  • was met with cheers, flowers, food and drink by Russian citizens;
  • shot down a super-sophisticated Russian surveillance plane and several Russian helicopters;
  • then Prighozin abruptly turned those convoys around and ostensibly went into exile in Belarus (a neighboring country that is essentially a Russian protectorate) after
  • Belarus’ president – a Putin lackey – negotiated some kind of deal between Putin and Prighozin.

Yeah, the entire US and NATO intelligence world is as confused as we are.

As I am far from “expert” in eastern European politics and “strategery”, I’ll just share what credible experts are saying:

  1. Putin is much weakened…he relied on a lackey/puppet – Belarus’ president – to end the crisis.
  2. Russia is also weaker than many including me thought – and likely getting weaker…
  3. Hard to see how merging Wagner’s troops into Russia’s Army will make the Army stronger – there’s too much mutual suspicion and distrust…
  4. Our efforts to recruit Russian intel sources seem to be ramping up…

Lastly, there’s this.

“Mr Putin was counting on a long war in which the West would grow tired of arming and funding Ukraine. There is now strong evidence that the war’s prolongation is also accelerating the fragmentation and decay of his regime.

 


Jun
12

Texas Mutual foray into health insurance…part 2

Last week we talked about Texas’ healthcare problems and the Texas legislature’s decision to force Texas Mutual to jump into the health insurance business.

Like you, I wondered mostly “why”…

  • why force a very successful workers’ comp insurer to get into a business it knew nothing about
  • why not look to other health insurers, or
  • why not just expand Medicaid (like most states have)

So, I reached out to all the original sponsors of the legislation with several questions about the whys…even with four days to respond, none bothered to address my queries (one  – an office worker for James Frank (R) – responded to my email, saying he wasn’t “available to respond”).

To be clear, Texas’ healthcare problems include: 

  • bad-and-getting-worse access to care…especially in rural areas;
  • a quarter of working-age people don’t have health insurance; and
  • healthcare affordability is among the worst in the nation.

Fortunately, the CEO of TM’s new venture was very responsive to my request for an interview.  Meredith Duncan is a highly experienced, very knowledgeable and quite forthcoming executive with decades of experience in health plan operations.

Here’s our interview.

  1. MCM – Why is TXM getting into health insurance?
    The legislature created TM to help stabilize WC 30 decades ago. The passage of Texas House Bill 3752 in 2021 allowed Texas Mutual to create a subsidiary to provide health benefits coverage.  Through the creation of the subsidiary, we aim to create  additional health coverage options  for small business in TX.    Texas Mutual is a mission-driven organization, and I am excited to bring that same orientation to support small businesses in Texas.
  2. What made you decide to accept this position?
    [For a] couple reasons – I’m a native Texan, and my family is as well, I got into healthcare because [some] family [members] had health issues.  I chose this role becauseI am passionate about reducing the number of uninsured in Texas… [I’m] looking to solve that so business can get coverage for employees and families…I enjoy work that requires me to build and design, so this role seemed like a great fit.
  3. When do you expect to launch?
    Looking to quote new business in the first quarter of 2024 and issue policies in Q2, depending on regulatory approval.Our immediate plans are applying to the state to be a licensed stop loss carrier. Assuming we receive TDI approval, we’ll launch stop loss and self-funded plans in the first half of 2024 – using level funding mechanisms, medically underwritten…a level funded product looks like insurance but financials are trued up at end of the year… Over time, we will evaluate opportunities to enter other lines of business
  4. There are several key components of any health insurance program – claims, underwriting, medical management, provider networks, compliance, policyholder service – will you be looking to handle these internally or outsource specific functions?
    For most part outsource to start – more efficient to outsource for TPA services, PBM, and technology to interface with agents, customers, providers, members…also outsourcing actuarial services for short term, underwriting we are evaluating…[it] may be either inhouse or outsourced”
  5. Are there synergies [with Texas Mutual] that will be beneficial?
    Immediately [we] will keep our businesses very separate, evaluate opportunities down the road where we could support businesses together in markets outside major metro areas that are underserved.
  6. You’ve been on the job for several months, what’s been the biggest surprise?
    I am impressed with the TM leadership team and having a new set of colleagues to collaborate with has been a great surprise. Second, market feedback has been very positive, in general brokers are pretty tough on payers but they have been supportive and excited about what we are designing; there’s incredible loyalty to TM on broker side.
  7. What will TM will learn from group health…
    What they may find over time is keeping employees healthy and insured and making sure they have ability to get primary care, manage diabetes and MSK health will help outcomes on comp side as well…

What does this mean for you?

Spoiler alert – beware of seemingly well-intentioned legislators…


May
25

Patient satisfaction ≠ Quality of care

Health care quality is a huge issue in the US; despite claims that we have the best healthcare in the world, reality is far different.

Why?  I’d argue its because healthcare consumer behavior drives our for-profit system.

What makes patients happy is completely unrelated to the actual quality of medical care they receive – or how likely they are to die.

Research article is here.

the horizontal axis indicates hospital performance by deciles for each category…note patient satisfaction doesn’t vary by hospital mortality and varies just a little by medical quality, but varies a LOT by nurse communication.

The effect of nurse communication on patient satisfaction is four times larger than the effect of the hospital’s mortality rate. Yup, as long as the nurse smiles, is responsive and nice, we’re satisfied. Never mind if we’re a lot more likely to die.

Another oft-measured factor, the quietness of the rooms, has a 40% larger effect on patient satisfaction than medical quality.

This is because hospitals provide two separate and distinct kinds of services  – the technical delivery of medical care and “room and board-related” services. Patients are much better at observing and rating the “hospitality” part of their hospital stay than the medical care they get.

To quote the authors;

Hospitality is the fast track to customer satisfaction in medicine. 

What does this mean for you?

Customer satisfaction is the fast track to profits… not to good medical care.


May
22

Wildly off-topic…F-16s

Russian general when he learned about F-16s heading to Ukraine…

Вот чёрт!!

From Phillips O’Brien…

Its impossible to exaggerate the intensity with which Ukrainians from all walks of life, from the top of the state and military to civil society, were focussed on getting F-16s for the Ukrainian Air Force.

Why F-16s are critical…

  • Ukraine’s Air Force is woefully behind the times, their main fighter – the Mig-29 – has been around for 40 years and is beyond obsolete. 
  • Getting spare parts for the UAF’s Migs is getting harder and harder.
  • F-16s are very, very capable – military-speak for they can do lots of things well.
    • shoot down other planes
    • support ground operations
    • launch missiles to hit targets hundreds of miles away
    • shoot down incoming rockets and missiles
  • Unlike the Mig-29, F-16s have constantly upgraded
  • Unlike many other planes, they are relatively simple to maintain and there is a huge stockpile of spare parts

The net is there is no other single airplane that fits the bill as well as the F-16.

Okay, it’s gonna take a very long time to train Ukrainian pilots on the F-16…

Well, no.

An internal US Air Force document indicates Ukrainian pilots  – with almost no training – could execute complicated maneuvers albeit it in an F-16 simulator. Multiple sources indicate Ukrainian pilots can be flying the F-16s in combat a few months.

And…

It’s unlikely the F-16s will have much of an impact on the already-started/upcoming Ukrainian offensive, but they will play a major role in Ukraine’s likely long war.

What does this mean for you?

More good news for Ukraine, and bad days for Russian butchers.


Apr
21

What business are you in?

Hint – if you are a specialty network, you are NOT in the specialty network business…

Over the  last few weeks I’ve been talking with Rita Wilson of Tower MSA: Rita’s been attempting to educate me about the MSA world, a Herculean task to be sure.

What struck me about our conversation is Rita kept referring back to Tower’s purpose, which is claim settlement. From Tower’s website…

Tower focuses on the settlement of claims as we deliver measurably better Medicare Secondary Payer (MSP) compliance. We identify cost drivers and other barriers to closing claims, recommend and implement clinical interventions, and benchmark our performance against CMS responses [emphasis added]

Tower is not in the MSA business…it is in the claim settlement business.

Work comp payers don’t care about MSAs, they care about settling claims – once and for all.

By clearly defining Tower’s focus, the company speaks directly to the problem its clients and prospects are facing, demonstrating Tower knows what payers want and need.

Back to a specialty network…

NO ONE CARES ABOUT YOUR NETWORK.

What buyers care about is their combined ratio (if an insurer) or controlling costs and return to work (if a self-insured employer).

If you can directly show how your PT/imaging/DME/whatever network reduces combined ratios, controls costs and improves RTW, then AND ONLY THEN should you talk about HOW you do that.

What does this mean for you?

Be like Rita.


Apr
17

Wildly off topic #15 – Leaks and the coming offensive

There’s much rending of clothes and gnashing of teeth in the mass media about how Jack Teixeira’s criminal stupidity will:

  • help Russian generals defeat Ukraine’s pending attacks by identifying attacking units and eliminating surprise
  • really tick off our allies
  • reveal key shortages of materiel (military-speak for ammunition, spare parts, supplies and weapons systems)

Uh, no. Let’s take these in order. (much more detail at Phillips O’Brien’s excellent substack postings.)

The upcoming offensive

Is the worst-kept secret since Trump’s sexual antics with porn stars.

Ukrainian officials, military leaders, Allied intelligence, Russian military bloggers have all talked about this. Heck, they even know the military units that will do the attacking. What we don’t know is when and where…and Teixeira’s documents don’t give a date or location..

Angry allies

What? An ally is spying on us? How…common.

Reality is everyone spies on everyone else all the time. There will be outrage and histrionics from politicians from Israel to Norway, all furious at such conduct.

All will be for public consumption, this will die down pretty quickly, and really…does anyone think allies will abandon the US or Ukraine over this?

Materiel shortages and impact thereof

This is perhaps the most ridiculous “disclosure.” There have been hundreds of public reports, news articles, blog posts and stories about this over the last few months.

Lastly, among the “revelations” in Teixeira’s documents is that our intelligence community has doubts about whether Ukraine’s upcoming offensive will achieve much.

Hardly.  With some notable exceptions (e.g.the timing of Russia’s initial attack) US intel has a rather poor record of predicting what’s going to happen in Ukraine. And that is being kind.

What does this mean for you?

Top Secret…isn’t.

More than 1.3 million individuals have Top Secret clearances.

You can bet your house the Russians knew everything in Teixeira’s documents long before they hit Discord.

 


Mar
30

Benchmarks and outcomes

So what exactly are “benchmarks”?

Yesterday we dove into outcomes vs process metrics, and why focusing on process measures (e.g. call abandonment rate, three-point contact timeliness, savings below fee schedule) instead of outcomes can result in the classic…

Benchmarks are standards by which outcomes can be measured or judged. Outcomes drive process improvements, financial results, and most importantly, healthy, fully functional patients.

In work comp, you’ll most often see vendors or payers comparing their results to ACOEM and/or ODG...while that can be somewhat useful, it’s important to recognize several issues/potential limitations…

(beware of comparison’s to the vendors’ clients…while that can be helpful and illustrative, it’s usually a very small sample set, and begs the question – “just how good are the vendor’s overall results?)

  • median values are typically used…but they reflect average, run-of-the-mill performance, which is NOT the standard we should be aiming for.
  • data comes from a limited number of payers and other sources and may not reflect your injured worker population’s demographics, locations, injury types and other factors
  • case-mix adjustment tools can be very helpful – IF the tools are:
    • used with robust data sets that reflect your patient population,
    • specific to the time frames you are evaluating,
    • relevant to payer type, and
    • straightforward, with limitations explicitly acknowledged and explained.

This can get pretty complicated, as in migraine-inducing complicated. Don’t obsess…and unless you are a statistical whiz, Do NOT get caught up in the minutiae, it is up to the vendor to help you understand, not to baffle you with BS.

(very helpful to have a statistically literate person on your team to clarify, help explain, and when necessary call BS…there’s a LOT of it out there)

Rather, challenge the vendor to explain in layperson’s terms specifically and in detail why and how these benchmarks are relevant to your population, their limitations and strengths, and where you fall on the spectrum from worst to best. Also, get written documentation of their analyses and the methodology you can share internally and with your customers as necessary.

Vendors who cite benchmarks must be able to explain all of this...just don’t expect them to do this the first time around, as it is likely they’ve never been challenged.

What does this mean for you?

Know your outcomes.


Mar
27

Vendors – read this.

B2B sales is NOT about “value”, RoI, relationships, or anything else you think it is.

It is about meeting the emotional/psychological needs of the key buyers.

You may have sensed this, or interpreted it as “relationships” that make deals happen  – but that is a misread. The reason relationships work is they reflect the sales person’s deep investment in getting to know the buyer(s), understanding what drives them (outside of obvious business goals), and mitigating their fears.

A terrific piece in Harvard Business Review speaks directly to this…(quotes from the article)

  • findings indicate that B2B customers prefer interactions that fuel their psychological needs — even if they require more time or cost more money.
  • Among vendors who provide “poor” service, only 33% of respondents reported that the vendor knows them personally. In contrast, among vendors who provide “good” service, respondents indicated the vendor knows them personally more than twice as often (70%).
  • Even when you have an effective solution in mind, provide your clients with options so they’re reminded that they’re in control.

  • (this is directly supported by our most recent survey of prescription drug management in workers’ comp…respondents overwhelmingly want PBMs to provide them insight so they can fix problems collaboratively)
  • Our study also included some interesting findings around empathy. Expressing empathy, a common way of increasing connection with our friends and family, can backfire if customers perceive it to be disingenuous. Too often, service providers script empathy into customer interaction, assuming it’s what customers want to hear. That’s a mistake. Our research indicates that customers far prefer a service provider who responds knowledgeably over one who “feels their pain.”

What does this mean for you?

be genuine.

ask questions, don’t present.

don’t schmooze.