Insight, analysis & opinion from Joe Paduda

Sep
8

Consolidation in work comp services – speculating on Paradigm’s future

Last week we pondered Mitchell’s future; as (perhaps) the largest WC entity outside the TPA space Mitchell/Genex/Coventry has an enviable position – albeit one that is by no means dominant.

Today our attention turns to Paradigm, a company I’ve written about…a lot.

I wrote this four years ago...

I’ll admit to wavering between being impressed with Paradigm and thinking it won’t ever become a significant force in the industry. As noted previously, the company has been around for the better part of three decades, and throughout that time has seemed to be just a year or so away from really breaking out.

Today’s no different.

While a lot has happened since then, it hasn’t changed my mind.

Paradigm was acquired by Omers, a Canadian investment firm three years ago; since then it has:

  • bought up several case management companies,
  • acquired some assets from Best Doctors,
  • bought some network and specialty companies, but
  • by no means has it become a “big player in the musculoskeletal [MSK] space.”

Becoming a big player was the plan back in 2018 according to CEO John Watts (a good guy with an impressive background), and I thought it was a good one – focus on using analytics and care management expertise to drive business to the case management and specialty assets, relieving adjusters of the hassles of managing, coordinating, and monitoring medical care for potentially expensive conditions, improving outcomes and reducing total cost.

One of their better deals was Adva-Net, a “pain management network” that reportedly has been a pretty solid earnings driver. Sources indicate Foresight – which reputedly went for 40x earnings (!!!) – has not been as profitable.

Problem is, Paradigm has not become a “big player” in MSK; rather the company is still seen as a catastrophic claim management firm, albeit one with other service offerings. MedRisk (HSA client) and OneCall dominate physical medicine. Relatively few surgeries happen outside traditional PPO networks (looking at you, Coventry).

Paradigm’s landing page focuses on cat cases, touting the company’s internal results. I’d also note it describes itself as

“an accountable care management organization focused on improving the lives of people with complex and catastrophic injuries and diagnoses.”

That description makes me think Watts et al are attempting to move Paradigm into the group health/medicare/medicaid business. Recent hires in top positions have extensive experience in those sectors, and Watts himself has deep experience in health insurance.

Work comp is tiny – less than 1% of US medical spend – so moving into the broader payer world makes sense. Problem is, I can’t recall any work comp services company that has pulled that off. Many have talked about it, done the work, hired the execs, and…crickets.

Meanwhile, Paradigm is facing serious competition in its core catastrophic risk transfer business from Carisk (HSA consulting client).

Methinks there’s a few intertwined reasons the company has not become that “big player.”

  1. The core message – we can do claims better than you – is still kind of a problem.
  2. Few employers care about workers’ comp, so there’s no push from big influential buyers to buy smarter.
  3. Few buyers have any idea how to intelligently “buy” work comp services.
  4. Few buyers want that kind of “innovation” – even if they say they do, they’re just mouthing words they haven’t thought through.
  5. TPAs don’t make enough margin on Paradigm’s services – and as we all know, fee-splitting is pretty damn important.
  6. Paradigm hasn’t made a compelling case.

But the real reason is #1.

Employers. do. not. care.

I just don’t see Paradigm “breaking out” and becoming a major player in worker’s comp claims management – or MSK management. Is it going to acquire more stuff?  I don’t see it – prices are too high, and Paradigm’s M&A record is mixed at best.

Meanwhile, claim counts continue to drop, making future growth in case management dependent on taking share from Genex, Corvel, and smaller CM firms. (note there are aberrations from time to time and place to place)

My guess is owner Omers  – a very patient owner indeed (it is the private equity arm of the municipal employees’ pension plan in Ontario, Canada) will stay invested until they think they can sell it for twice what they paid…or perhaps be happy with the $125 million+ of cash flow Paradigm throws off every years.

On the positive side, Paradigm was smart enough to hire Kaye Lewis to handle customer implementations. Kaye is one of – if not THE – best client management pros in the business. Her departure was a big loss for CadenceRx, her arrival is a big plus for Paradigm.

What does this mean for you?

A solution in search of a problem only works when those with the “problem” KNOW they have a problem.

Oh, and branding is super important.

And workers’ comp is NOT a growth industry.

 


Aug
30

Help me understand…

Why some people refuse to get vaccinated, but are fine with taking large doses of drugs commonly used for horse de-worming.

Out of 163,000,000 people fully vaccinated, there have been 1,263 COVID deaths…yet anti-vaxxers still refuse to do the easy, safe, and smart thing.

Yep, in just one state, Missouri, there’s been a big jump in calls to the poison control center due to people in distress from taking ivermectin; at least two Mississippians have been hospitalized due to overdosing on the drug…. and 7 out of 10 calls to the center have been for ivermectin.

Ivermectin is also a big problem in Texas…

Ivermectin “tablets are approved by the FDA to treat people with intestinal strongyloidiasis and onchocerciasis, two conditions caused by parasitic worms.”

News flash – COVID is NOT transmitted by parasitic worms. Nor is there ANY credible evidence it protects against COVID or has any meaningful effects.

Yes, there is a research paper based on a meta-analysis authored by several scientists but these “scientists”:

  • didn’t disclose they are members of a group promoting ivermectin;
  • ignored the fact that most of the studies cited had “incomplete information and significant methodological limitations, which make it difficult to exclude common causes of bias,”
  • views were rejected by the leading scientific society focused on infectious diseases; and
  • another meta-analysis rejected the ivermectin-supporters’ “conclusions.”

Oh, and “The few existing higher quality clinical trials testing ivermectin against the disease uniformly have failed to find a positive result. It’s only the smaller, lower-quality trials that have been positive. This is a good indication that the drug probably doesn’t work.”

Double Oh, and the rest of the scientific world isn’t having their BS.

Triple Oh... after internet sleuths raised concerns about plagiarism and data manipulation, the preprint server Research Square withdrew the paper because of ‘ethical concerns’.”

And one more Oh…

Not only is ivermectin very much unproven, it is also dangerous when taken in large doses. From the FDA:

You can also overdose on ivermectin, which can cause nausea, vomiting, diarrhea, hypotension (low blood pressure), allergic reactions (itching and hives), dizziness, ataxia (problems with balance), seizures, coma and even death.

There are multiple reports of people taking horse-level doses of ivermectin;

Again the FDA:

animal drugs are often highly concentrated because they are used for large animals like horses and cows, which can weigh a lot more than we do—a ton or more. Such high doses can be highly toxic in humans.

Moreover, FDA reviews drugs not just for safety and effectiveness of the active ingredients, but also for the inactive ingredients. Many inactive ingredients found in animal products aren’t evaluated for use in people.

Meanwhile, reality is “less than 0.004% of fully vaccinated people had a breakthrough case that led to hospitalization and less than 0.001% of fully vaccinated people died from a breakthrough Covid-19 case…”

So we have knuckleheads overdosing on horse de-worming drug while they refuse to get vaccinated because…why?

They’re suicidal?

No – it’s actually because their “tribe”/”clan’s” views are more important to those individuals than ANYTHING else – including their lives and the lives of their loved ones, babies, grandmothers and spouses.

What does this mean for you?

Belonging to the tribe, and being accepted by the tribe, is the dominant force in the life of anti-vaxxing ivermectin-takers – and no amount of science, marketing, education, compassion or reason is going to get most of them to change.


Aug
27

Friday update

Sorry loyal readers – been swamped w a big project; auditing the Federal work comp program’s pharmacy program.

Here’s what happened this week while I was immersed in data, workflows, job descriptions, reports and contract terms.

COVID

Florida – from colleague, master fisherman and good friend David Deitz MD PhD came thisanticipating more deaths among the unvaccinated, Florida hospitals are renting refrigerated trucks for temporary morgues.

The Sunshine State isn’t the only state with hospitals anticipating more deaths due to vaccine stupidity. Texas and Kentucky hospitals are also lining up rental trucks…

Most insurers are ending waivers for patient copays/coinsurance for COVID treatment. This means those who do have to get care  – or their heirs if that care doesn’t save their lives – may well face ginormous bills for treatment.  From Kaiser Health News:

 there’s logic behind insurers’ waiver rollback: Why should patients be kept financially unharmed from what is now a preventable hospitalization, thanks to a vaccine that the government paid for and made available free of charge?…

A harsher society might impose tough penalties on people who refuse vaccinations and contract the virus. Recently, the National Football League decreed that teams will forfeit a game canceled because of a covid outbreak among unvaccinated players — and neither team’s players will be paid.

But insurers could try to do more, like penalizing the unvaccinated. And there is precedent. Already, some policies won’t cover treatment necessitated by what insurance companies deem risky behavior…

I’m all in favor of personal responsibility – and no COVID isn’t the same as addiction treatment or lifestyle issues.

Those damn topicals

Topicals and compounds just won’t go away…Mostly because profiteering fraudsters are adept at figuring ways around regulations, insurers’ prior authorization requirements, network contract language, and system edits.

WCRI’s has just published a very useful report on the issue; this data point really got my attention:

payment share for topicals in the typical state increased from 9 percent in the first quarter of 2015 to 19 percent in the first quarter of 2020.

And don’t miss WCRI’s Dr Vennela Thumula and Te-Chun Liu research on off-label use of gabapentinoids, one of the other fast-growing and highly-questionable prescribing practices so damn common in work comp.

What does this mean for you?

Get vaccinated, and be very careful if you live in an area with a low vaccination rate.

And check your drug spend reports for topicals and gabapentinoid utilization. If your PBM can’t help you, get another PBM. 


Aug
25

Consolidation in work comp services – speculating on Mitchell’s future

Considering the landscape of service providers, one might think it easy to identify the acquirers and targets.

Reminder – the companies we are considering are Mitchell/Genex/Coventry (MGC), Paradigm, Conduent, Optum Workers’ Comp, OneCall, ExamWorks and one step down, MedRisk (HSA consulting client).

To date, ExamWorks, MGC and Paradigm have been buyers; acquisition activity has slowed appreciably as there are fewer targets and prices are at an all-time high. That said, sources indicate Paradigm continues to focus on growth through acquisition (we’ll dig into that later). I’d expect Exam to keep acquiring IME and related companies as it solidifies its dominant position in that space.

MGC is a different story; a few years ago it was an auto casualty and work comp bill review company, today it is in every work comp medical management area, with large holdings in pharmacy management, a big work comp PPO, and the largest case management/UR operation in the business.

Word is MGC is using those assets aggressively, leveraging Coventry’s network to strongly encourage/require customers use Apricus, its specialty network services. While that tactic will certainly work with some buyers, others – with long memories of Coventry’s previous owners’ heavy-handed treatment of customers. – may well rebel.

Historical diversion – after Coventry bought Concentra’s WC PPO network, Coventry used its overwhelmingly-dominant position in WC networks to get price increases and more favorable terms from most customers. This enraged buyers long used to getting their way, buyers who had pitted Coventry against Concentra in negotiations…many vowed to never again allow a “vendor” that amount of power.

While many of those buyers have exited the space, the memory lives on.  That said, given the heavy-handed, dictatorial attitude many payers display towards “vendors” I can’t fault any “vendor” responding in kind…

OK, back to buyers – as anyone with any experience in M&A knows all too well, digesting one acquisition is tough enough. Mitchell has acquired multiple companies, and the integration has not always been smooth. Eight months into:

  • standing up and staffing a PPO division,
  • continuing to work on integrating multiple PBM operations,
  • building up a specialty network division to compete with OneCall, and
  • dealing with channel conflict issues (perhaps the biggest – a bill review company owns a big network used by other bill review companies),it would be challenging indeed to add even more work to management’s day.

It’s not the consumption that’s the problem, it’s the indigestion.

What does this mean for you?

While MGC might pursue other acquisitions, it is much more likely to focus on getting the highest possible value from the deals it has already made.


Aug
18

Consolidation in work comp services – multi-service vs single focus

Ed. note – got an email from a colleague asking “so why should I care about who owns who or what their strategy is?” Because your service providers – that you pay a shipload of dollars to and through – determine your medical and combined loss ratios. So you’d best figure out if your priorities are the same as their’s.

Okay, we’ve dug thru the differences between corporate- vs private-equity owned work comp service providers, today we focus on multi-service providers and single-service providers – and how they compare.

The first group is Mitchell Genex Coventry (MGC), Optum WC, and OneCall; the second Conduent, ExamWorks and MedRisk (HSA consulting client).

The good thing about being a multi-service entity is you’ve got flexibility, a diverse income stream, and several services/products that may interest prospects and keep customers tied down. You may also be able to leverage one line to get more business, and depending on what your services are, perhaps even apply enough pressure to force customers to use those other services.

The bad thing is your business lines are rarely all best in class; an under-performing service may de-value your other lines. The other bad thing is they can be pretty different, require different expertise, systems, processes, reporting, and network development.

Example – Imaging is one-and-done, customer value is mostly scheduling and price (yeah people talk “quality” of reads…but its almost always talk). Physical medicine is utilization-driven as price-per-service way less important than a scan that often costs 15-20x more than a PT service. PM also requires lots of data and information feeds, more clinical oversight, a different contracting strategy, and ongoing monitoring of attendance and progress. Transportation is different as well, and so is DME.

Net is it is difficult indeed to be really good at multiple services AND have scale where you can get competitive prices and deliver all services everywhere payers need them delivered.

Single-service suppliers get really really good at one thing; this affords them scale, reduces distractions, and builds a lot of corporate expertise – and if done well – a solid brand.

But – and it’s a darn big but – if a big state changes its fee schedule, or Medicare does the same, you could be screwed. Example – California adopted a Medicare-based fee schedule the same year Medicare slashed reimbursement for imaging. Imaging companies got hammered, as California has about 17% of the nation’s WC volume.

Okay, so here’s the net – Multi-line businesses are tougher to manage, but can insulate the owner from regulatory risk and provide leverage over customers.

Single-service suppliers are usually really good at what they do, but there’s that regulatory risk thing.

All that said, each of these companies is – in some very important ways – unique. with their own strengths and weaknesses, strategies and tactics.

What does this mean for you?

Are your suppliers’ priorities, successes, and growth strategies aligned with yours?


Aug
17

Consolidation in work comp services – PE vs Corporate owners

Yesterday’s intro to the coming consolidation in workers’ comp services identified 7 entities – Mitchell/Genex/Coventry (MGC), Paradigm, Conduent, Optum Workers’ Comp, OneCall, ExamWorks and MedRisk (HSA consulting client) that might will be the last one(s) – standing when the music stops.

I’ve written extensively (as in more than 60 posts) about what’s driving this, how individual companies are reacting, and potential implications for the industry. While the main themes remain accurate, my views on potential impacts are evolving.

While each of these companies is unique in its own way, they can be grouped into two broad categories – multi-service providers and single-service providers.

The first group is MGC, Optum WC, and OneCall; the second Conduent, ExamWorks and MedRisk.

Another way of grouping is by ownership; Optum and Conduent are owned by much bigger corporations while the other 4 are private equity owned.

While there are multiple factors that will drive who consumes who, ownership type may well be the biggest single influence.  PE-owned firms tend to be much more focused on organic growth, cash flow, and identifying potential acquisitions; their owners are tightly focused on increasing the asset’s attractiveness to the next buyer. In sum, that is a business that:

  • shows consistent, strong growth;
  • has a stellar management team;
  • has strong cashflow; and
  • a viable plan for future growth.

In contrast, corporate-owned entities can suffer from:

  • lack of senior management attention (that is, management at the owning corporation) and
  • resource starvation (workers’ comp is often seen as a backwater and leaders can find it difficult to get the resources and attention needed).

Aetna’s bungled initial attempt to sell Coventry Work Comp is the best evidence of both problems. Optum’s continued focus on quarterly earnings  – and the attendant demand that all Optum entities deliver on their commitments regardless of market conditions – shows that corporate owners often talk a good game but when push (sure, add some staff) comes to shove (how are those quarterly profits looking?), shove wins.

We older types remember Aetna’s multiple “commitments” to growing/expanding/improving the Coventry network, commitments that were never fulfilled, and for good reason. With workers’ comp representing less than 1 percent of total US medical spend, a big healthcare company’s focus rightly should be on governmental and private health insurance.

OptumWC is a big player in worker’s comp pharmacy and also has offerings in specialty services; it is also building a network (and has been for some years). To date, Optum’s network development success has been modest at best, as has its ability to get payers to use that network. Sources indicate Optum is investing more in the PPO; if it does Coventry could have a viable competitor.

But “big” in WC is “pretty darn small” in the healthcare world.

WC is far less than one percent of UnitedHealth Care’s total revenue (UHG owns Optum); it can be difficult indeed for leaders of pretty small subsidiaries to get attention and resources from corporate overlords.

Conduent is another story. Built around Stratacare, the industry’s leading bill review company by market share seems to be caught in an endless cycle of management changes, delays in upgrades//updates/fixes, and consistently poor customer service. Conduent is – at its core – a document management business; WC bill review feeds that business.

I don’t see Conduent as an acquirer…if anything it is much more likely to spin off the WC BR business.

What does this mean for you?

Understanding owners’ motivations and priorities helps predict the future.

 

 

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Aug
16

Consolidation in work comp services – you ain’t seen nothing yet.

What’s coming is quite clear – there will be more consolidation in the work comp services industry, much of it likely in the next 12 months.

Cue Bachman-Turner Overdrive…

Workers’ comp is a shrinking industry; while there may well be occasional increases in premiums, claims counts, and spend, in general the long term trend is crystal clear – the only way to sure way to grow is to acquire other companies.

TPAs are growing in size and influence as many carriers pull back on investments and spending on technology, training, and physical assets. Many – but by no means all – carriers see significant potential benefits in moving claims services to TPAs:

  • the cost of claims becomes entirely variable, replacing much of carriers’ fixed costs;
  • flexibility – it is much easier to enter and exit states if you don’t have to stand up/shut down claims operations;
  • regulatory compliance – specifically staying up on and complying with claim-related requirements becomes the TPA’s responsibility (sure the carrier is ultimately responsible, but it can protect itself contractually)

In turn, TPA growth is affecting medical management, technology, and other services vendors…TPAs make big dollars from revenue sharing with those vendors, with obvious implications for claim closure, claim duration, and medical, indemnity ALAE expenses.

The big players in the service sector are Mitchell/Genex/Coventry (MGC), Paradigm, Conduent, Optum Workers’ Comp, OneCall, ExamWorks and one step down, MedRisk (HSA consulting client).

I’d add Sedgwick to the list albeit with an asterisk; as the largest payer in workers’ comp (outside of the Federal government) it has the market share and negotiating leverage to do what other payers can’t…BUT this power will diminish as the number of service providers shrinks and their leverage grows.

These players are snapping up smaller service providers, broadening the depth and breadth of their offerings while simultaneously strengthening their relations with payers. Buying companies with >$75 million in revenue is helpful strategically and financially, but the bigger these companies get, the less benefit they get from adding “tuck-in” acquisitions.

This week I’ll share what I see coming, how each of these entities stacks up, and what this means for carriers such as Travelers and the Hartford that are staying the course.

What does this mean for you?

Change is coming; success, and survival, favors the prepared.


Aug
12

Hypocrisy and Hippocrates

A physician posting on MedPage blamed many of the problems in healthcare on private equity…and for-profit insurers.

That takes some…[insert anatomical reference here]. While his assault on Private Equity does have some merit, I can’t let his assertion that the profiteers are insurance companies stand.  What makes me nuts is Liu’s mindless and demonstrably false assertion, coupled with his complete inability to see that he is part of US healthcare’s cost problem.

Dr Mitchel Liu stated “For-profit insurance companies have long been regarded as the ultimate offenders in medical profiteering.”
Wow. Coming from a physician, who make more than docs in any other country, that is ballsy indeed.
Reality is physician compensation is a key driver of healthcare costs, and one of the reasons our healthcare costs are so much more expensive than other countries’. For-profit healthplans do make billions…but their margins are tiny compared to healthcare providers.
Liu also says:
“It’s time for medicine, including individuals and professional societies, to restore the integrity of the physician-patient relationship by taking a strong stand against all forms of corporate greed.”
Well, docs are often partners in Ambulatory Surgical Centers and hospital outpatient surgery centers.  Many docs belong to big multi-specialty groups that are quite profitable.  And, docs make a lot of money.
What does this mean for you, Dr Liu?
How about taking a stand against physician greed, Dr Liu?

Aug
10

Opioids, tapering, and risks – what you need to know

WorkCompCentral’s Mark Powell penned an excellent piece on just-released research on tapering long-term opioid patients.

One finding demands our attention; researchers found a statistically significant increase in overdoses and mental health crises in the 12 months after tapering was concluded. On average, these adverse events (science talk for bad stuff) happened 6 months after tapering concluded.

From the JAMA article:

In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering. These findings suggest that adverse events associated with tapering may be relatively common and support HHS recommendations for more gradual dose reductions when feasible and careful monitoring for withdrawal, substance use, and psychological distress. (emphasis added)

The study included 114,000 patients who had been on stable, higher doses (50+ morphine equivalents) of opioids over an 11-year period. It came on the heels of two chronic pain studies published earlier this year; one addressed opioid treatment for chronic pain and the other was a meta-analysis of 190 studies focused on non-opioid treatment. I wrote about both here.

Tapering is an opioid management approach involving a steady decrease in opioid dosage over a prescribed time. The decreases in dosage and how fast patients were tapered varied significantly among the patient population; patients who were on higher doses before tapering were at increased risk for adverse events.

There were some limitations in the study including; the population was Medicare Advantage and commercially insured; individual patient tapering may have varied after the initial decrease; and the data didn’t indicate if the prescriber or patient initiated the tapering.

A thoughtful and detailed discussion of tapering is here…in part the paper states:

The authors emphasize that any medical action taken should involve as much patient buy-in as possible and should not be driven by rigid opioid dose cutoff s and misinterpreted guidelines. The authors of this paper also support sustaining patients on their existing medication at its existing level if patients are continuing to benefit from use, are not experiencing significant side effects, and express the desire to remain on their current medication as opposed to pursuing a taper. In such cases, the risks of a taper would outweigh the potential benefits.

Regardless, this is a wake-up call to the industry. Yes, workers’ comp – once the addiction creation industry – has made great progress in reducing inappropriate opioid usage and some progress in helping long-term opioid patients reduce or eliminate opioids.

That said, there are a variety of opioid management approaches, and we should be considering – and open to – any and all.  Medication-assisted therapy involving methadone or buprenorphine, physical therapy, acupuncture, yoga, and talk therapy are among the approaches that have shown promise.

I’ll end quoting myself from a post back in 2019;

we need to make very sure we are doing the right thing for patients. In some instances this will involve telling patients what they don’t want to hear; we need to be prepared to do that and help them thru the process, while understanding that process is very difficult.


Joe Paduda is the principal of Health Strategy Associates

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