Insight, analysis & opinion from Joe Paduda


Drug prices aren’t fixable

The House of Representatives just passed landmark legislation intended to reduce the cost of drugs for seniors.

The bill won’t go anywhere, because the Senate won’t consider it – and if it does, President Trump has said he will veto it (despite campaign promises to reduce drug costs).

Unfortunately, a bill advanced by Republican Senator Chuck Grassley that would cap Medicare drug price increases will be opposed by Senate Majority Leader McConnell (R).

Given the public’s focus on healthcare, and seniors’ voting power and high level of interest in drug prices, the lack of GOP support is puzzling.  It appears the main objection is reducing what you pay for drugs may result in the development of 8-15 fewer drugs. Over the next decade.

If the House bill became law, Medicare would save $345 billion over six years.

So, seniors would pay less for drugs, taxpayers would save hundreds of billions of dollars, and we may not get one new drug per year.

Only in a government ruled by pharma lobbying would this make sense.

What does this mean for you?

Once again, big business wins, and you lose.





US health care kills a quarter million of us every year.

Every year a quarter-million of us are killed by medical error.

That makes medical errors the third leading cause of death in the US.

Medical errors kill more of us than motor vehicle accidents, firearms, AND opioid overdoses – added together.

Efforts to fix this problem are woefully under-funded, poorly co-ordinated, and often ignored by stakeholders. That’s likely due to poor reporting and tabulation of medical errors and the repercussions thereof.

It is stunning indeed that a $3.4 billion industry whose sole focus is to preserve and protect our health kills a quarter million people a year – and we didn’t know this until a few weeks ago.

What’s even more disturbing is this story has been all but ignored by mainstream media.

What does this mean for you?

Ask questions, demand answers, be forceful, and don’t accept platitudes. And hold doctors, hospitals, and caregivers accountable.


Proof – health insurance saves lives

Having health insurance reduces your risk of dying.

Intuitively, this makes sense; you get cancer diagnoses and treatment, colon cancer screening, access to drugs and behavioral health treatment and flu shots.

You can read the details here, but the net is individuals who received a letter from CMS telling them they’d paid a penalty for not enrolling in health insurance were more likely to sign up than a control group that did not get a letter.

And, those who signed up had a lower mortality rate.

From NYTimes:

gaining coverage was associated with a 12 percent decline in mortality over the two-year study period (the first months of coverage seemed to be most important, presumably because people could get caught up on various appointments and treatments they might have been missing). [emphasis added]

This is the first conclusive, unequivocal research showing health insurance impacts your chance of dying.

From the Treasury Department’s study; the control group did NOT get the letter:

Two things of note.

  1.  The Trump Administration has cut the healthcare outreach budget by 72 percent.
  2. Republicans killed the individual mandate which forced people to get health insurance or pay a penalty.

What does this mean for you?

One can argue whether it is government’s role to provide or ensure coverage, one cannot argue this: more people will die due to this Administration’s policies.


Americans can’t afford healthcare

Gallup just reported a quarter of Americans have put off treatment for serious medical conditions because they can’t afford it.

They can’t afford it because:

  • US physicians make twice what docs in other countries do
  • Drug costs are much higher here than elsewhere
  • Hospitals are making bank
  • Administrative costs are twice what they are in other developed countries.

Data from Commonwealth Fund

Average physician income by specialty from FierceHealthcare.

US life expectancy is now 43rd in the world.

We pay twice as much as other developed countries for healthcare, and our outcomes are measurably worse.

What does this mean for you?

Until and unless we fix healthcare, your family and friends will face increasing costs and declining access; it’s highly likely some aren’t getting the medications, surgeries, tests, or therapies they desperately need.


in which I cover newsworthy stuff that happened this week…

Uh…that’s why you buy insurance

From Politico we hear CMS Administrator Seema Verna asked us taxpayers to pay for $47,000 worth of jewelry and other stuff stolen “during a work-related trip.” Among the valuables gone missing – that she wanted us to pay for were a $325 moisturizer (!!!) and $349 for noice-canceling headphones – plus a $5,900 Ivanka Trump pendant.

Yep, the person who runs the biggest insurance entities in the world wants the government to bail her out because she decided to NOT buy insurance. (update – good news, we aren’t paying for Ms Verma’s bling)

Physical therapy in workers comp

MedRisk released its third annual report on PT in WC earlier this week.  560,000 work comp patients were served by MedRisk so far this year; the average duration of care has shrunk to 11.2 visits over 48 days.  Better news – 98.1% patient satisfaction rate and 97.7% of providers agree with MedRisk’s clinical recommendations.

There’s an old business meme that comes to mind – “stick to your knitting.”

At a time when other service companies were seeking to become everything to everyone, Shelley Boyce, Mike Ryan and their colleagues at MedRisk went the other direction, focusing narrowly on work comp physical medicine. Along with the best management team in the business, they executed the plan to perfection. (While MedRisk is an HSA consulting client, all the credit goes to those folks).

Meanwhile all the caterwauling about drug prices turns out to be much ado about nothing (I’m looking at you, AARP) . This from the estimable Adam Fein PhD’s discussion of CMS’ review of healthcare costs:

    • For 2018, spending on outpatient prescription drugs grew by 2.5%—below the spending growth rate on hospitals, physician services, and overall national healthcare costs.
    • CMS significantly lowered its previously reported drug spending figures by billions after incorporating new data on manufacturers’ rebates.

More news showing hospital consolidation raises your healthcare costs.

From NIHCM comes a terrific slideshow – my favorite is this one – key takeaway is prices ALWAYS GO UP after mergers.




AARP, healthcare costs and drug prices

AARP has rather strange positions on drug prices and healthcare costs.

AARP positions itself as an advocate for seniors (and no, while I’m eligible, I’m not a member). The latest PR effort by the huge organization touts its lobbying to “help Americans afford high healthcare costs.”

Rather than lobbying for extensions on tax breaks for healthcare costs, AARP would serve its members better by doing something to actually reduce the cost of healthcare. Here are a few suggestions:

  • vigorously promote value-based care with reimbursement more closely tied to valid outcomes including functional ability
  • aggressively regulate healthcare system expansion, and specifically require reductions in costs after mergers
  • promote higher reimbursement for primary care, reduced reimbursement for questionable specialty care
  • focus attention on transparency in drug pricing – including rebate payments to plan sponsors

On this last suggestion, I’d note that AARP consistently moans about the retail price of drugs, while refusing to acknowledge the very real impact of rebates on brand drugs – which aren’t passed on to consumers.

Frankly, AARP’s stance on drug prices is misleading.

AARP’s “research” doesn’t discuss rebates – and the fact that plan sponsors are getting rebates, which drastically reduces the prices those sponsors pay for drugs.

As a result, consumers pay the higher retail prices, while plan sponsors – AARP partners among them – keep the rebates.

(thanks to Adam J Fein, PhD, for his work on this.)

I emailed AARP, indicating my concern with this.  This was the response:

“While AARP appreciates the potentially distorting effects of rebates, evidence indicates that plan sponsors are sharing rebates with consumers in the form of lower premiums. For example, a recent CBO analysis of a proposal to eliminate rebates under Medicare Part D that found that premiums would increase for all enrollees and that federal spending would increase by nearly $200 billion, primarily due to increases in federal subsidies for premiums.

“Further, AARP has consistently said that it would be happy to run these analyses based on net prices. Unfortunately, no drug manufacturers have been willing to take them up on the idea.”

Well, no.

First, there’s a megaton of evidence out there that some individual/group health and Medicare Part D insurers are getting rebates, and are NOT passing them on to consumers.

This from the estimable Dr Fein; (note the rebate percentage accruing to Plan D (senior drug card) sponsors):

Second, AARP could easily ask its “partners” (Part D plan sponsors among them) if they are getting rebates (which they are), and if so are they passing the savings along to consumers and what is the impact on those consumers’ drug costs. That would allow AARP to ” run these analyses based on net prices.”

AARP positions itself as an advocate for seniors. I’d suggest failing to address this is not helpful to their members.

What does this mean for you?

Does AARP benefit from rebate payments? I dunno…



Who are those guys?

That’s the question many have asked when told a handful of California physicians file most of the UR and IMR requests. Who are the 122 docs who file 44% of IMR disputes?  The ten physicians responsible for 9.5%? And what are the results of those filings?

Normally when regulators institute UR and associated appeals processes, there are a lot of UR appeal requests in the first few months, after which the volume drops off dramatically.  As providers learn the guidelines and understand the process, they change their practice patterns to comply with those guidelines.

This has been the pattern for decades, ever since UR started with hospital pre-auths in California in the early 1980’s.

Workers’ comp is no different, as the same trend occurred when Texas implemented guidelines and UR, and other states as well. For those wondering how this could be, a few reasons are provided below, courtesy CWCI…

Things are certainly different in California, where the volume of UR filings and IMR appeals actually increased by about 30% in the years since adoption. This makes no sense, as 9 out of 10 times a doc files an IMR appeal, that appeal is rejected. This adds millions of dollars to employers’ and taxpayers’ costs, extends disability, and slows down the patients’ recovery process. [of course, most of these UR/IMR requests are filed by applicant attorneys, based on the treatments are prescribed by physicians)

(chart courtesy CWCI)


Till now, the top offenders, the docs who don’t want to comply with evidence-based treatment guidelines, the ones who slow down the recovery process by continually requesting inappropriate drugs, unnecessary surgeries, unneeded injections and unproven therapies have been able to hide behind a wall of anonymity.

That’s over; SB 537 is why you’re about to find out who these bad actors are.

Specifically, Section 3, 138.8 requires DWC report individual providers’ UR and IMR filings and the results thereof.

From the Senate Analysis of the bill:

Recent research from the California Workers’ Compensation Institute suggests that medical disputes in the workers’ compensation system are not widespread: rather, they are uniquely concentrated among a few providers. For example, in 2015-16, the top 1% of providers who filed IMR requests (97 providers) filed twice as many requests as the bottom 90% of providers (approximately 40,000 providers). [emphasis added]

the strict protections on the use of individually identifiable information means that it is likely illegal for the DWC to reach out to these providers and find out why there is such a concentration of medical disputes among such a small provider group. SB 537 will address this concern by implementing the same data reporting requirements as are in the federal Medicare system.

DWC is tasked to do this on or before January 1, 2024; sources indicate DWC will likely publish data well before that date.

And when it does, we’ll know the name of the PM&R doc in northern California who filed IMR requests resulting in 2,800 IMR letters and 4,441 Medical Decisions. Oh, and 85% of those appeals were rejected. For those keeping score at home, that’s 11 letters per working day.

What does this mean for you?

Employers and insurers, make darn sure your MPN is on top of this.





Time for an effective workers’ comp opioid solution for Louisiana

Today’s WorkCompCentral arrived with William Rabb’s report on the use of opioids by workers’ comp patients in Louisiana. [subscription required]

A few notable findings:

  • Louisiana work comp patients get more opioids, and they get them for longer periods of time than any other state studied
  • Employers and taxpayers pay significantly higher prices for drugs than in other states
  • 7 out of 10 claims included an opioid prescription
  • Louisiana patients get twice as many opioid scripts than the average state.

For some reason, some “claimant attorneys” don’t see the wisdom of formularies/guidelines intended to reduce inappropriate opioid use, citing spurious claims from the pain industry in attempt to validate their complaints.

Louisiana has had treatment guidelines in place for several years, however they have not been revised or updated in memory and are very difficult to enforce. Compared to other states, the Pelican State has made little progress reducing inappropriate opioid use by work comp patients.

Back in 2017 I cited Sheral Kellar, Director of Louisiana’s Office of Workers’ Compensation Administration discussing the opioid issue in her state.

Ms Kellar knows a formulary is NOT a panacea, rather a critical tool in the armamentarium which includes:

  • Prescription drug monitoring programs that require and facilitate pharmacist and physician participation,
  • Strong and well-designed utilization review programs,
  • Flexibility for PBMs and payers to customize medication therapy to ensure patients get ready access to appropriate drugs and reduce risks from inappropriate medications,
  • Carefully-planned implementation,
  • Drug testing, opioid agreements, and addiction/dependency treatment

Over the last decade I have spoken with many individuals heavily involved in Louisiana workers’ comp; each frustrated and saddened by the lack of meaningful progress in attacking the overuse of opioids by workers’ comp patients. 

What does this mean for you?

Here’s hoping Louisiana is able to make real progress on reducing opioid usage. Families, communities, employers, and providers have all waited long enough.




What’s up with Paradigm?

Paradigm is evolving rapidly – and none too soon.  A data-driven firm known for taking risk on catastrophic claims, Paradigm has strengthened its behavioral health offerings, and added case management, specialty and network services, all intended to make the company one of the major players in workers’ comp medical management.

I’ve tracked Paradigm for more than two decades, watching the company evolve from one stubbornly stuck in a business model that precluded growth to a diversified provider with a broad array of service offerings. In conversations with Paradigm execs several years ago, I wondered why the company wasn’t solving client’s problems, instead focusing narrowly on a highly-selected group of catastrophic claims.

While this made sense from Paradigm’s perspective – it wanted to focus its expertise on a very select type of claim – there was a big problem with this approach.

Namely, Paradigm wasn’t thinking about this from its customers’ perspective. Customers gave Paradigm a big list of claims which Paradigm winnowed down; typically relatively few were actually “accepted” by Paradigm.  The customer had a bunch of problematic claims, but Paradigm wasn’t interested in solving the customer’s problem, it just wanted to cherry-pick claims.

That’s changed.

I caught up with Paradigm Catastrophic Care Management CEO Kevin Turner a couple weeks back to get updated on the company.  Here are my takeaways (Paradigm Outcomes is one of three divisions).

Paradigm is moving down the severity scale, applying the expertise and experience it has gained handling big cat claims to less-complex claims. In so doing, the company is embedding itself deeper and broader into its clients – and growing revenues.

Turner spoke at length about Paradigm’s core asset – the wealth of data the company has amassed over the last three decades – and how that informs the company’s approach to managing cat – and “near-cat” claims (my words, not his).

We also dove into bio-psycho-social issues, including the patient’s “whole family situation” (again, my words) and the critical importance of the family in the recovery process. Marital status and satisfaction, financial stability, relations with children are all key considerations that can impact the recovery process. That just makes sense; if a patient has a difficult home life and kids with issues, it is going to be that much harder to get better.

The company recently launched a home-grown IT application – EDDG – designed to help care managers use the company’s historical data and lessons learned along with bio-psycho-social indicators to manage claims.

Of note, Paradigm is no longer the only company in the cat claims risk taking business. Carisk Partners has gained traction with its Pathways 2 Recovery program, leveraging the company’s deep expertise in behavioral healthcare and workers’ comp experience. Carisk takes risk both on individual claims and for entire portfolios of claims. (disclosure; I work with Carisk)


Workers comp is A) doing great, or B) a big problem

Where you sit determines what you see; this adage applies to the work comp industry.

For payers, employers, and taxpayers, all is great.  Rates are low and dropping, insurers are enjoying record profits, frequency continues to trend down, medical costs are flat.

The very things that make payers happy have the opposite effect on service companies. For most entities involved in medical management, pharmacy management, investigations, technology, claims systems, Medicare Set-Asides, and litigation defense the drop in frequency and flat medical costs are unwelcome news.

The trickle-down effects of this dichotomy are many and varied.

  • There is little-to-no pressure to revise state workers’ comp laws and regulations.
  • Insurers are looking to increase their work comp business as it is a big profit maker.
  • Claims execs are trying to balance hiring and training new claims adjusters while planning for long-term decreases in claim volume.
  • Execs are also extremely careful about investments in new IT projects, as the long-term payoff is also challenged by structural declines in claims.
  • The consolidation of service companies continues unabated; IMEs, bill review, specialty networks, PBMs, investigations, case management, cat case management services are all subject to this consolidation.
  • Selling services to payers is getting increasingly difficult.  Payers aren’t seeking solutions to major problems; they are reluctant to switch vendors unless there are serious service problems.
  • Work comp conferences are struggling due to the structural issues above; the lack of big problems driving intense interest in solutions and an arguably-over-saturated conference market is hurting attendance.

So, what to do?

If you are a service entity, you’ve got to differentiate. You must also deeply understand what individual buyers want, why they want that, what their decision process is, and who else is involved.

Unfortunately many service entities are cutting marketing budgets and pressuring sales staff to deliver deals. While sales targets are important indeed, they must also be realistic.

If you are a payer, I’d echo the last sentence above. Many payers are planning to write more workers’ comp, an obvious impossibility.


Joe Paduda is the principal of Health Strategy Associates




A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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