Insight, analysis & opinion from Joe Paduda

Jul
6

Healthcare Sharing Ministries – the latest

Healthcare costs are about to jump again, driven by exploding staffing expenses, continued healthcare provider consolidation, and the brilliant profiteering by some of the largest (mostly for-profit) healthcare systems.

So, what’s a family to do?

A few have turned to Healthcare Sharing Ministries, a thing that looks like health insurance but isn’t. HCSMs purport to “share” health care costs among members in what might best be described as a risk-pooling framework. Almost all claim to be “Christian”, they are largely unregulated (except as charities), don’t comply with insurance regulations or laws in most states, and most have requirements that members:

  • are in good health,
  • make a statement of Christian belief, attend church regularly, don’t use tobacco or have sex outside of marriage and
  • commit to taking care of their own health.

note there are ministries focused on other religious denominations.

So…sounds good right? cheaper healthcare is better…well, HCSMs also:

  • are not legally required to pay your medical bills,
  • require enrollees to do much of the groundwork to get bills paid (negotiate upfront with the provider, get all the paperwork and documentation, pay upfront then seek reimbursement)
  • medically underwrite – meaning they require disclosures of pre-existing conditions and can reject applicants for medical reasons,
  • can refuse coverage to anyone for any reason,
  • have limits on what they’ll pay for healthcare,
  • can’t guarantee healthcare providers will accept sharing ministry coverage, and
  • have appeals processes that aren’t subject to regulatory oversight.

Enrollment is a bit hard to nail down; the Alliance of Health Care Sharing Ministries claims 1.5 million enrollees although it doesn’t specify the year. Other reports indicate AHCSM reported membership was “over 1 million” in February of 2019. Other sources report membership closer to that 1 million figure.

HCSMs tend to be significantly cheaper than health insurance plans, making them increasingly attractive. However, most families that buy health insurance through the exchanges get major subsidies that significantly reduce their premiums.

There have been multiple reports of individuals and families stuck with huge bills after their “Ministry” refused to pay for care. Aliera Healthcare Inc. and Trinity Healthshares, Inc are the most visible example of what can happen without tight regulation. Regulators in multiple states issued cease and desist orders after concluding the companies violated laws; Aliera was found guilty of fraud and filed for bankruptcy late last year.

Tops among concerns is this – HCSMs are NOT required to have enough cash on hand to pay medical bills. Even more concerning, they don’t have to report their finances, cash reserves, expense ratios or other data.

There’s an effort underway to “accredit” HCSMs; the process/requirements don’t appear to address this critical issue and the accreditation board doesn’t include individuals with actuarial or financial credentials.

I’ve asked the lobbying outfit that purports to represent HCSMs for details on the financial portion of that accreditation process. So far they’ve been less than forthcoming.

What does this mean for you?

be very careful.

 


Jun
29

Mob rule.

How could anyone think a riot would overturn an election and keep an unelected person in office?

That more than two centuries of carefully nurtured democracy could be trashed in a few hours?

18 months ago we watched in stunned disbelief as our Capitol was attacked, police officers were brutalized and beaten, and bizarre characters wandered the halls, stole mementos and put their feet up on desks, ascended to the podium and eerily called for the heads of the Speaker of the House and Vice President.

For me, yesterday’s January 6 hearing made the insanity of it all stunningly clear. The testimony of a very young staffer crystallized how far we’d gone off track, and why.

Cassidy Hutchinson’s placid, calm recounting stood in stark contrast to the events she was describing, none more jarring than her description of then-President Trump’s furious and frantic effort to get his Secret Service detail to open up the Capitol, remove magnetic detectors and thereby allow his “wonderful people” to bring guns, knives, automatic weapons, pistols, bear spray, and spears to wreak mayhem on Congress’ certification of the 2020 election.

Trump’s megalomania, narcissism and bloody-minded pursuit of power at any price was on full display yesterday. Hutchinson’s recounting of agents describing Trump as irate because the agent wouldn’t drive him to the Capitol so he could “let his people in” says it all.

Five police officers died as a result of the insurrection.

Dozens more may well have been killed if the Secret Service had bowed to Trump’s  insane demands.

For what?

What made Trump think that he could stay in office, prevent Biden from assuming the Presidency, reject the will of the American people?

How could Trump possibly think he could stay in office?  That a bunch of weirdos, military fetishists, tinfoil-hat-wearing simpletons and assorted other nutjobs could turn the United States into a banana republic, one where a strongman could keep power because a few thousand criminally-stupid idiots wanted him to?

Did Trump actually think our entire government, our military, our law enforcement and security and intelligence operations, all of us would stand by and let him stay in the White House? Because a moron wearing a buffalo headdress says so?

Hutchinson’s testimony made it clear Trump is completely detached from reality.

Trump wants power at any price – up to and including killing police officers, destroying our Capitol, and ending the United States of America as we know it.

What does this mean for us?

We are each individually responsible. Ensuring our kids and grandkids live in a free country is up to each of us.

 

 


Jun
27

Wildly off topic #6…Strategy, not tactics

After what was a really awful/crappy/despair-inducing week, we divert into the most important story of the year – Russia’s invasion of Ukraine.

Because the news there is actually kinda good. The dominant story line in the popular press is Ukraine is getting hammered, Russia is taking territory, and Ukraine’s allies aren’t doing enough.

Well…yes and no.

Briefly…

Ukraine is getting hammered – but Russia is expending huge quantities of munitions and soldiers which it cannot replace.

Russia is taking tiny bits of territory – at huge ^ cost.

Ukraine’s allies are doing waaaaay more than the popular press would have you think. Examples…

  • monitoring Russian naval activity in the Black Sea (south of Ukraine) (the picture below shows an airborne surveillance plane circling just south of Ukraine)
  • those fancy artillery and rocket systems we are sending are having an impact – which will only increase.  Russian generals 40 mile behind the front lines are waking up dead, surrounded by destroyed equipment, fuel, and supplies.
  • Thanks to the Dutch and (FINALLY!) the Germans for their support
  • The super-capable and highly advanced rocket systems the US has provided are taking out critical Russian ammo dumps.
  • And other prime targets…

As a result, the Russians are facing a huge logistical problem – they’ve used up millions of artillery rounds/missiles/bombs, some of their remaining supplies are being destroyed, they can’t get what’s left from storage depots to the front lines, and they can’t set up storage depots far enough away from those front lines to avoid the missiles and advanced artillery rounds we are supplying (HIMARS).

More important – yet rarely reported – is the strategy behind combatants’ tactics. Think of strategy as the long game – what the combatants want to achieve at the end of the war; tactics are supposed to be (but often aren’t) the moves you make to achieve your strategic goals.

Example – Russia is using its vaunted artillery (cannons and rockets and missiles plus bombs) to pulverize Ukrainian positions, forcing Ukrainian troops to retreat or be destroyed. That’s “working”; Ukraine recently evacuated its troops from Severodonetsk allowing Putin to claim a “victory”…

“The loss of Severodonetsk is a loss for Ukraine in the sense that any terrain captured by Russian forces is a loss — but the battle of Severodonetsk will not be a decisive Russian victory,” said the Institute for War.

In fact, the Ukrainians forced the Russians to expend huge quantities of shells, missiles, rockets and bombs – and likely incur thousands of casualties – to capture what is now a bunch of rubble.

Reports indicate Russian morale is awful, drunkenness among troops is widespread, medical care is non-existent and food scarce,

History is replete with tactical decisions that cost a strategic victory; Napoleon’s invasion of Russia is a prime example.  In 1812, Napoleon marched his half a million-strong Grand Armee’ to Moscow, trying to force Russia to stand and fight. Russia refused battle and Napoleon had to march back through the Russian winter, in the process losing 9 out of every 10 soldiers.

Russia’s strategic goal was to increase Russian power and weaken the West (that’s us and Europe). Putin figured his invasion would:

  • divide the West,
  • disrupt and weaken NATO,
  • capture territory including really valuable energy and agricultural assets; and
  • make Ukraine a Russian territory.

What does this mean?

Despite murdering tens of thousands of kids, grandparents, moms and dads, Putin’s idiotic war has been an abject strategic failure. And that isn’t going to change.

Russia is:

  • much weaker than it was before the invasion,
  • its economy is in a shambles,
  • the territory it has “captured” is a hellscape of rubble from which Ukrainian guerrillas pop up to shoot Russian generals, destroy supplies and vehicles, and
  • the West is united as never before.

While Putin’s tactics are just stupid, his strategy was even dumber.


Jun
17

Things work comp can/should learn

In addition to my focus on work comp medical management I’m deeply involved in governmental programs (Medicare/Medicaid/dual eligibles) and related businesses.

Here’s a few things work comp would do well to understand/explore/pursue.

  1. Auto-adjudication of medical bills – the standard target for auto-adjudication of medical bills is 90%.  That’s far higher than any workers’ comp bill process, and about twice as high as the average.
  2. Medical bill turn-around time (TAT) – average is at or below 20 days from receipt of complete “claim” (defined as a medical bill and needed documentation)
  3. Administrative expense ratio – <10%. yes, I understand work comp is a lot more litigious, blah blah blah. But seriously – 28-35%??
  4. Value-based care – is taking over the big governmental programs and corporate plans as well. Yes there have been a ton of misjudgments, errors, problems and failures, but make no mistake – in the near future VBC will be the dominant form of contracting and basis for reimbursement. (those who declare VBC isn’t going to happen in work comp may want to look outside their bubble)
  5. The impact of provider consolidation – this is one area where recent articles/briefs/research are starting to scratch the surface – but only just. Reality is consolidated markets are much more expensive and WC payers have way less ability to “manage” care in those markets. WC needs to get a whole lot smarter and more agile.

Whether this actually happens is up in the air. We veterans with decades in this business recall all too well what happens to claim counts/claimdurations when recessions hit.

What does this mean for you?

This is rarely helpful.


Jun
16

Massacres, mental health, and the Senate’s “plan”

“Plan” is in quotes because as of now, it’s not legislation – just a list of programs and funding mechanisms that are very much a work in progress. It’s anyone’s guess if any legislation will actually become law…although as of now it seems a bit less likely.

Ed note – in my view the provisions of the legislation wouldn’t have much effect at all as they don’t address many of the core issues driving gun violence – except it would allow Dems to say they got a bill passed, and Republicans to tell independent moms that they care about kids.

Gun violence is a public health issue; it fits right into the purpose of public health, namely “reducing and preventing injury, disease, and death and promoting the health and well-being of populations through the use of data, research, and effective policies and practices.”

What’s appalling to me (a gun owner and hunter) is this:

  • More kids are killed by guns than by car accidents – child seats and restraints are the law in most if not all states because elected officials recognized kids were being killed and maimed in accidents.
  • This is especially true for Black kids – guns have been the leading cause of death for black boys over 15 for more than a decade.
  • Laws were passed decades ago to protect kids from lead paint.
  • Backyard pools must be fenced in most areas.
  • Kids can’t buy alcohol or tobacco products because of health risks.
  • When guns are present, suicides are far more likely to result in death; in fact there are far more gun deaths by suicide than homicide.

Yet most states do pretty much nothing to protect kids from gun violence – in fact in many states laws have been passed that increase the risk to children.

The holdup seems to be about two things; so-called red flag laws and the “boyfriend loophole”.

Red flag laws allow for/enable the temporary seizure of weapons and/or prevent weapons purchases by individuals deemed to be a danger to themselves or others. States with effective red flag laws have saved lives; “58 people who threatened mass shootings were disarmed during the first three years of California’s six-year-old red flag program. At least 12 school shootings were averted.”

GOP Senators are raising due process concerns; that is, they want to make sure individuals have their day in court before their guns are taken away.

More problematic is that there are 31 states without red flag laws; Sources indicate a GOP Senator assured his colleagues that “there would be no federal mandate to implement the laws”. Without that “mandate” the red flag provision would be pretty much toothless; states that have been busy making it easier for anyone to get and carry firearms wouldn’t be affected.

Sure those states wouldn’t get the federal funding needed to implement the red flag provisions, but elected officials would tout their willingness to refuse those dollars s evidence of their steadfast opposition to any gun control measures.

The “boyfriend loophole” is also problematic…today unmarried partners who commit domestic violence can buy/keep firearms while spouses who commit domestic violence can’t. (Note it’s not merely “threaten”…in most cases a spouse has to actually do something violent to potentially lose their guns.)

Health care payers

Behavioral health is how this affects health plans and payers.

All kids should be screened for BH concerns – no matter where they live. Care should be provided where needed. This will require additional funding, changes in benefit design for Medicaid, duals, and exchange/group health, and more behavioral health clinicians.

Of course this is politically driven

Sen. Kevin Cramer, R-ND, on Tuesday. “I think we’re more interested in the red wave than we are in red flags, quite honestly, as Republicans and we have a pretty good opportunity to do that,” seemingly a reference to the possibility of Republicans taking control of Congress this fall.

Nice to see a politician publicly state that he cares more about votes than public safety.

What does this mean for you?

Depends – do you have kids? 


Jun
15

Single Payer health insurance and worker’s comp

A couple days ago NCCI’s Laura Kersey penned a piece about key legislative trends, one of which was Single-Payer health insurance. Good research work.

First, let’s define “single payer”. “Single Payer” – by definition – is government-financed and government-managed health insurance. (note Ms Kersey focused on state efforts; for reasons I’ll discuss below states CANNOT have a “single payer”.

Single Payer is a catch-all term for universal health insurance coverage. In some cases there isn’t a “single payer” in an entire nation – our neighbor to the north being one example, Switzerland and Germany are two others. In Canada, each Province is it’s own single payer; in the two European countries there are a variety of independent companies that provide health coverage. Taiwan has one payer for all residents.

There are a LOT of different versions of “single payer”; a discussion is here. Pretty much every country with Single Payer is unique, each with its own nuances. For example,

  • most don’t have government-employed healthcare providers; in many single payer systems, physicians, therapists, hospitals and other providers are private.
    • The UK is an exception; providers are (mostly) employed by the government
  • many are not government-operated; in many systems private insurers contract with the government to handle administration of health insurance – similar to our Medicare
    • Again the UK is an exception

Typically:

  • the government sets pricing/reimbursement policy and actual prices – similar to our Medicare
  • funding comes from some combination of employee, employer, and other taxes; in some countries, insureds pay some form of premiums – similar to our Medicare
  • it covers everyone
  • there is little to no paperwork for patients/consumers; all that is handled by the administrative agency
  • there are minimal or no deductibles, copays, or co-insurance requirements
  • people can buy into supplemental insurance through private insurers

Ms Kersey’s article notes several states have pending or tabled legislation related to single payer.

A key issue here is a very large chunk of spend in each state – as in more than half – comes from the Feds. Thus, unless a state gets waivers from the Feds (which will never happen) exempting Medicare and Medicaid from that state’s Single Payer program, most of the medical dollars aren’t going to be in that state’s program.

I’d suggest how Single Payer would affect comp depends on two core issues:

  • whether care for occupational injuries/illnesses is covered by Single Payer, and
  • whether there is a universal fee schedule.

If WC care is included under Single Payer, it is likely work comp would evolve to an indemnity-only system. This currently exists in several other countries, and seems to work pretty well.

If WC medical care is NOT included in Single Payer, the impact would be driven largely by the presence – or absence – of a universal fee schedule. 

Without that universal fee schedule, providers would likely continue to do their revenue maximization thing, although they’d supercharge those efforts. Why? Because reimbursement from all other payers would drop significantly, and providers would look to comp to replace as much of that lost income as possible.

What does this mean for you?

There will NEVER BE A STATE-BASED OR STATE-SPECIFIC SINGLE PAYER PROGRAM.


Jun
14

It’s getting real, real fast

The impact of global warming on climate change is happening faster than anyone thought.

And that will lead to more occupational injuries and illnesses.

Today’s early heat wave is smothering much of the country in brutally hot and oppressively humid conditions; as the heat and humidity shifts west and north, the southwest is getting a bit of a reprieve while the eastern US is blanketed with heat warnings.

It’s not just the heat – it is the unexpected/unprecedented storms, droughts, high winds, and resultant floods and fires that are becoming all too common.

credit CNN

Yellowstone is closed, and some roads are impassable  – and will remain impassable for some time due to flood damage. The Yellowstone River reached an all-time high Monday – more than 2 feet higher than the previous record. This in an area that’s been parched in a drought.

flood damage in Gardiner Montana, credit CNN

Hundreds of thousands of Ohioans and West Virginians are without power.

Winds gusting north of 80 mph hit Chicago yesterday – exceeded by a 98 mph guest in Fort Wayne Indiana.

Six months ago I wrote this:

the biggest long-term concern for workers’ comp is global warming...yet this is getting zero attention.

There’s going to be an inevitable increase in issues related to heat, flooding, fires, drought, tornados and hurricanes. This is getting more real every day yet remains all-but-ignored by pundits, policy-makers  and rate-makers.  We can expect more heat-related claims. Hurricanes, fires, and tornados will increase in number and severity; affecting logistics, labor, construction, and claims. The research is clear.

It didn’t have to be this way, but thanks to big oil and its ability to manipulate people and pay off politicians, we failed to take action.

And let’s not forget people were willing to be manipulated.

Now, we are paying the piper. More specifically, workers in public safety, manufacturing, healthcare, construction, logistics, agriculture, forestry, mining, transportation and other sectors will be the ones suffering from the lack of foresight and inability/unwillingness to believe science exhibited by far too many of us.

As of last summer, only three states had adopted standards for workplace heat exposure – kudos to California, Minnesota and Washington. The Feds have yet to set federal requirements.

Jeff Rush of California Joint Powers Insurance Authority and I will be discussing the impact of global warming on workers’ comp at National Comp 2022; thanks to Michelle Kerr and her colleagues for inviting us to speak.

What does this mean for you?

  1. Denying the reality of human-caused climate change will have devastating effects on all of us – with worse consequences for our kids and grandkids.
  2. States and the Feds will enact heat/humidity exposure standards, which will drive big changes in risk management.

 


Jun
8

Behavioral health is vitally important.

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

It’s time for action.

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

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

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

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

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

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

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

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

Thank you David.

What does this mean for you?

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

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

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


Jun
7

Those damn facility fees

If you are a work comp payer, you don’t have to pay those ridiculous facility fees when care is delivered outside the hospital – at least not in Pennsylvania.

That’s the decision rendered by the Pennsylvania Bureau of Workers’ Compensation in a case dating back to 2017. The case arose when a hospital (which I promised not to identify) tried to get reimbursed for care delivered by an affiliated provider, which was NOT “located within XXX hospital”.

The details

The hospital, a “Part A provider and billing entity” didn’t provide the billed services, rather a

“part B provider whose clinic [was] not located with[in] XXX hospital performed, billed, and was reimbursed for services.  XXX hospital is not entitled to payment as XXX hospital provided no medical services…”

The actual provider – a “part B provider” affiliate of XXX hospital, delivered the services, submitted a bill and supporting documentation, and was reimbursed.

The hospital also submitted a bill along with documentation that the treating provider had a professional services agreement (PSA) in place with the hospital.

Notably, the PSA “designates that all care and treatment is rendered by [the affiliate’s] personnel, therefore the payer’s attorney questioned exactly what XXX hospital was “providing.”

There’s a LOT more to this; location codes, provider details, Medicare regulations, bill types and the like are all important. The knowledge level required to correctly reimburse and successfully uphold a denial of payment for facility fees in PA is quite impressive; the entity providing that expertise has a wealth of experience and expertise in the Keystone State.

The cost reduction is equally impressive .

What does this mean for you?

  1. If you are paying facility fees for care delivered outside of a hospital (Part A) provider, you better get your act together.
  2. Expertise is way more important than price or throughput.

May
27

Things I missed while despairing

We’ll get to what we missed in a second; first this – The slaughter in Buffalo and Uvalde had me focused elsewhere, as it did for many.

That focus must not shift as we celebrate Memorial Day with friends and family; we cannot just move on, as tempting as that is. Rather I’d encourage you to commit to doing something, to be a difference maker.

Please don’t just move on. Please.

  • Get the facts about gun violence here.
  • Support the Sandy Hook parents’ efforts here.
  • Support Moms Demand Action here.

WCRI published two excellent studies this week…thanks to Andrew Kenneally for sharing the news.

The craziness of workers’ comp extends to the prices you pay doctors and therapists for carehow crazy you say?

Bonkers.

Docs in Florida are getting screwed (but FL hospitals are rolling in dough), while their counterparts in Wisconsin are making bank. Like so many things in comp, this makes zero sense.

Download Rebecca (Rui) Yang PhD and Olesya Fomenko PhD’s insightful study – for free – here.

There’s far too little information on the outcomes of chiropractic care. WCRI just published a multi-pronged analysis of chiropractic care’s impact on low back pain, with a comparison of costs and disability duration for patients treated by chiros vs other care givers.

An intro video is here.

The study, authored by Kathryn Mueller, Dongchun Wang, Randall Lea, M.D., and Donald R. Murphy is available for purchase here.

Have a safe weekend, and remember – Democracy depends on your involvement.


Joe Paduda is the principal of Health Strategy Associates

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