Insight, analysis & opinion from Joe Paduda

Dec
15

Vioxx and Workers’ Comp liability

The recent disclosures related to Vioxx’ impact on cardiovascular disease should be raising some big concerns amongst financial folk at WC payers. Here’s why.
Vioxx was commonly used to treat musculoskeletal injuries – sprains, strains, and the like. These happen to be very common WC injuries, and thus lots of WC claimants received scripts for Vioxx.
The law in most states holds that WC is liable for treatments for conditions arising from occupational illness or injury. This has been consistently intrepreted to include liability for conditions arising from the treatment itself – whether that be pain meds after surgery, PT after surgery, Viagra to combat the ill effects of other meds, etc.
The implications of Vioxx for WC are thus obvious. WC payers are potentially liable for cardiovascular conditions for WC claimants who have incurred cardiovascular conditions, and especially those claimants who had CVD prior to receiving Vioxx.
While WC payers have the right to subrogate those claims back against Merck (manufacturer of Vioxx), this will be a long, messy, and expensive process.


Dec
9

Hospitals and purchasers

A very good discussion of the contentious relationship between (and among) hospitals, employers, and insurers can be found on healthsignals new york.
The article refers to recent developments in the Denver market that are worth reflecting upon.


Dec
9

Insurance Industry Profit Margins

Weiss Ratings has recently released their report on insurance industry profitability, and the news is both good and bad. Good if you compare it to past year’s reports, bad if you are expecting robust returns.
The report notes: “Of the 544 insurers studied by Weiss for the year ending 2003, 69 percent experienced either negative margins or profit margins of less than five percent.”
Makes the grocery business look like a great investment.
Breaking down the numbers further by category, here are the individual industry sector results:
HMO – 3.8%
Life Insurance – 8.2 percent
Health Insurance – 5.5 percent

and the overall winner for most profitable insurance sector is…
P&C at 8.3 percent
Not surprisingly for those who have been reading our blog, the culprit appears to be the industry’s inability to contain rising health care costs.
Melissa Gannon, Weiss VP, notes: “”Although the industry has enjoyed an increase in revenues by raising premiums, insurers have also had to deal with the rising cost of medical care as a result of more open networks, an aging population, expensive medical advances, and an inefficient healthcare system.”
While some in the media believe we are all wintering in St Bart’s except for those brief holidays in the Alps, the truth is we continue to work very hard to combat health care costs, and do not appear to be making much progress.
Note – For those unfamiliar with Weiss, they are perhaps one of the more critical rating agencies, but their tough standards have been validated time and again as the more recognized entities have missed such debacles as Kemper Insurance’s sudden demise.


Dec
6

Health care in the EU

The Global Medical Forum held their 2004 US Summit in Washington DC last week, focusing on the different systems’ approaches to health technology. Building on the 2003 Summit’s focus on Pharmaceuticals, the presentations provided compelling insights into the ways technology is reviewed, adopted, and reimbursed in the EU.
Some of the more intriguing points included:
—the evaluation process tends to be much longer in the EU than in the US, and involves stakeholders from the patient, provider, hospital, and governmental communities
—in Germany, this process includes consideration of appropriate reimbursement amounts (contrast this w the US “we approve, you pay” methodology)
cost-effectiveness is absolutely a consideration when reviewing new technology for possible reimbursement
—in Germany, only 20% of new health care technology applications are accepted..
I left with several other impressions and “take-aways”. First, the EU relies, to a surprising degree, on US health care data when evaluating their own situation or projecting into the future. Second, the evaluation of the cost-effectiveness of a specific technology makes a lot of sense, and is done rather well by the Germans. Third, in Great Britain’s much-maligned National Health System, there is surprising (at least to me) willingness to consider new technology, and to pay for expensive evaluations of same.
We can learn quite a bit from our colleagues in the EU. Health care systems in the EU tend to deliver excellent care for a lot less money than we do here in the US.
Paradoxically, I heard from several European experts that they see real value in some of the components and attributes of our system. For example, we are much better at collecting, analyzing, and using data.


Dec
2

Health care costs back on the rise…

Health care cost increases, which appeared to be moderating last year, appear to be stepping on the accelerator again. The Center for Studying Health System Change’s recent analysis indicates that health care costs continue to grow much faster than either overall inflation rates, or, more importantly, worker incomes.
CSHC’s analysis indicates that hospital price increases are one of the key factors driving health cost inflation, with prescription drug costs continuing to accelerate as well.
CSHC’s analysis and review of the numbers forecasts the impact of continued inflation, noting :
“Health care costs likely will continue to grow faster than workers’ income for the foreseeable future, leading to greater numbers of uninsured Americans and raising the stakes for policy makers to initiate effective cost-containment policies or accept the current trend of rapidly growing health care costs and gradually shrinking health coverage.”
With the number of uninsured exceeding 45 million by most counts, 18% of the non-Medicare population is now uninsured. This compares to an uninsured rate of 0.1% in Germany, a country with health care costs as a percentage of GDP some 50% less than ours.


Dec
2

The ongoing investigations into broker and insurer malfeasance continue to send shockwaves throughout the insurance industry. And, these investigations are causing those doing business outside the “broker-insurer-underwriter” world to revisit what have been long-established “ways of doing business.”
While Mr. Spitzer and colleagues have started their investigations at the sales end of things, they may well find themselves uncovering many other instances of inappropriate or unethical payments.
For example, managed care vendors often pay TPAs an “administrative fee” that is a percentage of the revenues they receive from the TPA’s clients. Typically these fees amount to 10-15% of total revenues, but fees in the 25% range are not unheard of. There is speculation in the WC industry that one large managed care firm pays one large TPA upwards of $10 million in “fees” annually.
These fees are rarely fully disclosed to the TPA’s clients, and when there is disclosure, it is obscured by legalese, buried in the depths of a lengthy contract, and often mistaken for innocuous boilerplate.
One very large WC TPA claims it has provided full disclosure by including language similar to the following.
“The TPA does not receive any payment from the managed care vendor, except it reserves the right to charge the vendor for administrative expenses related to implementing managed care programs.”
Clearly it is incumbent upon risk managers, TPAs, underwriters, and brokers to fully and completely disclose these arrangements. It is just as clear that until and unless the light of day is shone on a few of these deals, they will continue unabated.


Nov
16

Coventry and Workers’ Comp

Coventry’s acquisition of First Health represents a critical point for the WC managed care business.
As the market leader with some $190 million in annual revenues in WC bill review and network services, FH has long been a strong, and somewhat self-possessed, “vendor”. Carriers and TPAs have found FH to be inflexible, and in some cases dictatorial, regarding terms, conditions, pricing, and services. Some are hoping that the new management will adopt a more “customer-friendly” approach. Early reports from FH customers are that their FH contacts and account managers are saying the right things, but have no in-depth information about Coventry’s future plans for Workers Comp.
Coventry’s latest presentation may shed a little light on this issue. In it, Coventry notes the growth opportunities inherent in WC, the strong “bench strength” of FH WC management, strong growth opportunity in WC (mid teens to low twenty percent range), and potential for reform-driven growth.
I am highly skeptical. FH has, if not poisoned the waters with the market, at least rendered them highly distasteful. Their product offerings are primarily a large, deep discount network and a bill review system that they do not own nor effectively manage. Many payers, facing rising medical costs despite their long relationship with FH, are looking elsewhere for the next generation of managed care.
In the final analysis, Coventry’s future in WC will depend as much on the analysts’ opinions, and therefore the stock price, as anything. If analysts see no synergies, Coventry may decide to “pursue other options” with the WC assets.


Nov
16

More questions about Coventry-First Health deal

The analysts continue to question the acquisition of First Health by Coventry Healthcare.
Wachovia analysts are among those who appear to be reserving judgement in their latest pronouncements (as noted in Maryland’s “Business Gazette”):
“The deal “marks a turning point in Coventry’s evolution,” the Wachovia report said. Coventry has historically been a regional managed care company operating locally concentrated health plans in several markets, and its customers have largely been small employers with some municipalities and local divisions of larger employers.
“With the acquisition of First Health, Coventry will change the profile of the company dramatically,” the report said. “For investors, the combined company will look like another multimarket managed care company trying to compete.”
First Health has a national preferred provider organization and a workers’ compensation business and does some pharmacy benefit manager services, areas that require different management skills than Coventry is accustomed to, according to Wachovia. In addition, First Health has had difficulty competing with the largest managed care companies such as UnitedHealth, Aetna and BlueCross BlueShield plans. ”
The challenge of integration will be met by one of the stronger management teams in the industry. The Gazette’s article goes on to note:
“We have always been impressed by Coventry’s management and are confident that the company’s internal candidates will be strong,” according to the Wachovia report. The analysts cited McDonough’s previous stint as CEO of a division of UnitedHealth, which has similar products to First Health.
Thomas A. Carroll, an analyst with Legg Mason in Baltimore, called Coventry’s leadership “one of the best management teams in the business.”
So what are the issues facing Coventry?
— Coventry is a regional HMO firm, with particular strength in small group fully insured business; FH is a national firm with a very large customer (MailHandler’s program as well as other large self-insured customers, and is also a major player ($194 million in 2003) in a business (Workers Compensation) that is foriegn to Coventry.
–Further, FH deals primarily with large-self insured group health customers, a market segment that Coventry has not pursued aggressively.
–Weak management at FH. Statements in the analyst’s reports as well as by Coventry management during the investor telecon on the day the acquisition was announced lead me to believe Coventry does not view FH management as up to the task. This, coupled with the large payday for 16 FH executives (splitting over $20 million between them) leads me to speculate the senior level at FH will not be around much longer.
–There were also rumblings in the market that FH was looking for an acquirer for some time; the Gazette goes on to quote Wachovia’s report; “Even without the acquisition, we have doubts about First Health’s ability to grow or even maintain recent results,” the analysts wrote. While Coventry “has bought ‘fixer-upper’ plans in the past, the repair of [First Health] will require a different set of tools.”
Coventry’s management takes a markedly different view from these reports, a view that is best summarized as “the acquisition of First Health by Coventry = the whole is greater than the sum of the parts.” After the hit the stock has taken, Coventry responded with a detailed explanation/defense of the deal at an analysts’ meeting in early November. Again, the main point appears to be that the new markets and national scope will enhance Coventry’s future earnings potential.


Nov
13

WCRI Annual Conference

The Workers’ Compensation Research Institute is one of the leading research organizations focused on WC. Their annual conference in Cambridge MA just concluded, and once again WCRI produced some interesting and thought-provoking studies.
This year’s conference used a slightly different format, focusing on individual states rather than comparing several, or many, states in a single presentation. Stakeholders from TX, TN, and CA presented after summary data presentations by WCRI staff.
Here’s the highlights as I saw them.
1. Drs. Peter Barth and David Neumark discussed the impact of Provider Choice on Costs and Outcomes. Interesting findings included:
— Costs were lower, and outcomes better, when the employer chose the provider, than when the injured worker chose a provider they had not previously seen.
–When an injured worker chose to use a provider they had previously seen, costs and outcomes were equivalent to those delivered by the employer-selected provider.
–The “new provider”‘s outcomes and costs were significantly worse.
2. The CompScope 4th edition was previewed; this is a summary of medical costs, disability duration, benefit amounts and other outcomes for lost time claims (and others, but we’ll only discuss LT claims) in 12 states. Items of note include:
–Of late, medical costs have been growing rapidly; with costs in all but 3 of the 12 states increasing by more than 10% from 01/02 to 02/03. California saw the highest increase at about 17%. Considering that CA is the largest WC state, that is a truly frightening number.
–There appears to be a strong correlation between medical costs and medical cost containment expenses, with most states favored by low medical costs also enjoying low cost containment expense, and high cost states also burdened by high cost containment expenses. My take is this may be heavily influenced by the percentage of savings model used in PPO deals; the higher the medical costs, the greater the “discounts”; the greater the discounts, the larger the PPO fees; and thus the greater the “cost containment expense”.
So, the higher the medical expense, the more money the deep-discount, percentage-of-savings PPOs make. Interesting incentives…
3. Disability duration factors – Worker age, education level, part-time and/or seasonal workers, and employee-supervisor trust factor were all key factors influencing disability duration. Workers over 60 had much worse return-to-work results than younger workers. There was also wide variation among states, with Texas hampered by RTW rates substantially lower than the median. Regarding education, workers with high school diplomas returned to work much sooner than drop-outs.
The full CompScope 4th edition will be available from WCRI in 2005; while somewhat weighty, it is a “must-read” for managers and executives involved in WC.
Underwriters should also pay close attention to the report; there are a wealth of “indicators” that the insightful underwriter can use to better select, and de-select, risks.


Nov
10

Discounts and doctors

Why do doctors contract with large networks to provide care at a deep discount? Do they expect to get more business from those relationships? If so, does that additional business ever arrive at their examining room? How many other physicians in their area are also contracted with that network? If there are many, are they merely joining to maintain their patient base?
Have they actually done the math to determine the impact of the discount on their finances?
Here’s an admittedly simplistic analysis of the financial impact of a discounted patient visit.

  • The “non-discounted” price would be $100
  • The discount is 20%
  • The net profit on the average patient visit (non-discounted) is 30% (an unreasonably high number, but easier to work with for our purposes)

The doctor makes a profit of $10 per discounted patient visit, and therefore must see three times as many patients to justify that 20% discount. And that’s before one factors in the additional fixed costs associated with the larger patient load – more parking, more staff, a larger waiting room, more examining rooms, and more of his/her professional time.
Perhaps more physicians are “doing the math”, and that is why managed care firms are having a much tougher time getting discounts.
The network deep discount model has other fundamental flaws, flaws that are only now beginning to be fully appreciated.


Joe Paduda is the principal of Health Strategy Associates

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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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