Insight, analysis & opinion from Joe Paduda

Jun
2

National health care is coming.

National health care will be reality within five years. All the theory, intellectual debate, politicking, lobbying, trips to Scottish golf resorts and campaign contributions funded by lobbyists, insurers, providers, and big pharma will come up against two overwhelming forces – demographics and the weight of bad decisions in the past.
As of the last Medicare trustee report, Medicare’s long term debt is $32.4 trillion. Part D alone is responsible for a quarter of that amount, or $8 billion. In comparison, the entire Social Security debt is $4 trillion.
In the face of that incomprehensibly huge figure, we have a Congress that is incapable of doing anything that might alienate seniors, doctors, pharmaceutical manufacturers or hospitals. We have an administration seeking to cut provider reimbursement and increase seniors’ costs by $36 billion over 4 years. That’s about 1% of the total medicare deficit. And we have the Bush tax cuts set to expire by 2011, which just happens to be the same time the Medicare trust fund cash flow turns from black to red as the Baby Boomer generation starts cashing in.
This will force change. The only question is will there be a single payer system, universal coverage via private insurers, some form of hybrid, or a new and as-yet unformed model. Given the recent transgressions of the major national health plans, I wouldn’t go too long on Aetna, United Healthcare, or CIGNA stock.
If you are looking for what it may look like and the features thereof, see here and here.
What does this mean for you?
Your decision – part of the solution or part of the problem?


Jun
1

Part D results are…

Part D’s enrollment deadline came and went, and along with it the orgy of claims, counter claims, blames and counter blames. So now that at least a bit of the dust has settled, where are we?
Confused.
Depending on whom you read or watch or listen to, the program has either been a success or a failure, is working or is not, is profitable or a loser, has enrolled “enough” people or has fallen well short.
The reality is as confusing as the perceptions appear to be. In any effort to cut through the spin, I checked in with Bob Laszewski of Health Policy and Strategy Associates. His take is it is too early to tell how things are going, and in the absence of truly meaningful metrics, we’re just going to have to wait and see.
Here’s why there is so much confusion.
There is no consensus on how many seniors have signed up for Part D or have alternate drug coverage under other plans. For starters, health plans and the Feds can’t agree on who is signed up by whom. Some health plans have been told they have thousands more members than they can account for, while others are being told large numbers of their “enrollees” actually signed up for Part D when they already had coverage under Medicare Advantage or another plan.
As near as I can figure it, there are between 8 million and 4.5 million seniors still without coverage. More details to follow…
Meanwhile, Humana, one of the more “successful” health plans in terms of signing up seniors for its Part D programs, recently saw its debt ratings outlook downgraded by AM Best from ‘stable” to “negative” in part due to large Part D enrollment and associated reliance on government contracts and increased capital requirements.
And AM Best may be on to something. The Medicare Trustees recently projected that the Part D program’s costs would increase by 11.5% annually over the next ten years. If those projections hold true, early claims about the currently “favorable” loss ratios may be short-lived.
We’ll have to wait until at least mid-July for reasonably accurate enrollment figures, and accurate financials will take another five months or so. If someone provides numbers in either category before those dates, be skeptical.


May
31

UHC fighting the wrong battles

The latest health care plan to enter into a very public battle with a large provider is Oxford Health, a subsidiary of United Healthcare. And their opponent, Jamaica Hospital of Queens, New York, appears to be on the losing end of an unfair battle. Evidently (free registration required) Oxford and Jamaica Hospital completed negotiating a new contract about 18 months ago that increased reimbursement rates significantly. Jamaica signed the deal, sent it on to Oxford, and went on about its business.
Jamaica’s business is providing health care, which it does for many poor, uninsured, and underinsured folks in and around Queens. The hospital was counting on the new deal with Oxford to help it continue to provide these services to this population.
A few months later, Jamaica figured out Oxford had not changed its reimbursement amounts, and complained to the payer. After a bit of wrangling, Oxford told Jamaica that it would not honor the contract (which it had yet to sign) until the hospital helped Oxford negotiate a deal with an anesthesiology group at another hospital in the same system. Jamaica said no, and after more wrangling, Oxford threatened to terminate the contract.
A termination would have jeopardized Jamaica’s ability to provide a broad range of health care services to the uninsured and underinsured.
As a for-profit health plan, United Healthcare is one of the three remaining dominant national health plans (with apologies to Coventry and CIGNA). United is tough, very aggressive, and not afraid of a fight. While one can take issue with its negotiating tactics, my real objection is to the company’s bad battle selection. Instead of strong-arming a hospital system to force a group of docs to kowtow to its demands, United should be screaming about the unfair nature of the health care system that requires its contracted providers to shift costs to United to make up for revenue lost by caring for people without insurance.
United Healthcare’s obligation is to its customers, patients, and shareholders. It is not United Healthcare’s responsibility to pay for care for those people it does not insure. By using childish tactics in its fight with Jamaica over what are really petty issues, United is ignoring a much larger problem, and one it could, and should, actually win.
While I’m no apologist for United or its management, they are getting a raw deal. Too bad they haven’t figured out they are doing it to themselves.


May
30

Physician income, priorities, and the free market

It is axiomatic that one’s income is based on one’s value. If recent studies on physician income are any indicator, society still places a lot more value on doing procedures than on keeping people healthy.
According to physician recruiting firm Merritt, Hawkins & Associates, job offers for internists and family practice docs came with average salaries of $162,000 and $145,000 respectively. In contrast, cardiologists and radiologists were offered $$342k and $351k. The first group of docs provide primary care; diagnosing conditions, encouraging healthy behaviors, finding early indicators of life-threatening disease. They get paid for their time. Yes, they do procedures (excisions, tests, x-rays and the like) but their time is spent not doing things but figuring out what’s wrong with patients and making recommendations to fix the problems.
The second group of docs do procedures – yes, they diagnose, albeit on a patient that arrives with records in hand, preliminary work-up completed, and some indicators of a problem that falls into the specialist’s area of expertise – but they get paid to do things – analyze images, perform surgeries and invasive procedures, apply radiation to attack cancers and the like.
And primary care physicians are not (Lowes R. Earnings: Primary care tries to hang on. Medical Economics. September 17, 2004) seeing their incomes increase, while invasive cardiologists enjoyed an 11% jump in income from 2002 to 2003. Internists who are looking to generate more income are encouraged to sub-specialize in gastroenterology, cardiology, and other more lucrative areas.
The Lowes article provides an excellent perspective on the causes and results of the rise of “proceduralists”.
“The proceduralists have benefited from the waning of the gatekeeper model, since they’re now more accessible to patients. And they’re kept busy by graying baby-boomers anxious to preserve their hearts, knees, and various organs. Specialists also have managed to make up for meager third-party reimbursement by generating income from ancillary services such as diagnostic imaging, outpatient surgery centers, and even specialty hospitals.”
What does this mean for you?
The free market in healthcare is working. For specialists. It is most definitely not working for payers, taxpayers, and patients. And it is continuing to drag down our nation’s commercial and industrial competitiveness.


May
26

Concentra to announce major deal in Q3

Several sources indicate Concentra will announce a major acquisition in Q3 2006. Speculation is that the deal will involve adding a significant number of occupational medicine clinics to Concentra’s present 300 or so.
The next question is likely to be who/what clinics would be acquired. Here’s where the speculation turns to outright guessing.
One candidate may be HealthSouth. The troubled chain needs cash, has a lot of clinics, some of which actually generate decent patient volumes, and does a fair job of marketing itself to doctors and employers. However, HealthSouth sold its occ med clinics to another potential target several years ago.
The acquirer was USHealthWorks, a much smaller company company with strong traction in markets that are complementary to Concentra, including 56 occ med clinics in California alone. USHW is privately held, making a transaction smoother and likely faster than a deal with a publicly-traded firm. Concentra is owned by private equity firm Welsh Carson Anderson Stowe, which apparently remains enamored with the company’s potential.
Headquartered in Alpharetta GA, USHW has more than 160 clinics, 450 docs, and treats over 10,000 patients per day.
Adding USHW to the Concentra operation would result in one company with over 450 clinics touching over 13% of all workers comp injuries.
What does this mean for you?
More consolidation in the health care industry is quite consistent with recent developments, and while it may help streamline operations and reduce some overhead while improving claims and medical record document flow, my guess is some of the larger payers will be concerned about the growing market power of Concentra as the “initial treater” of WC injuries.


May
25

Solving legacy health care costs

GM’s health care costs are over $1500 per car. Chrysler’s are $1400, Ford $1100. Honda, Toyota, et al are a fraction of these figures. That disparity crystalizes the economic problem facing US industry (subscription required) competing in a world economy.
There are ample posts and many sources describing how GM got to this point, and all of them are interesting and serve as an excellent object lesson for executives and public policy folk. But the real question is what do we do about this now?
First, let’s stop the health care problem from getting any worse. To do that, we have to address the current health care delivery system, pricing, access, and eligibility.

Continue reading Solving legacy health care costs


May
24

P&C Predictions for 2006

2006 will be a good year for insurer profitability, according to Robert Hartwig of the Insurance Information Institute. If the storm season is not unduly harsh and if insurers can maintain some pricing discipline. Those are mighty big “ifs”, and while the weather may be unpredictable, the propensity for underwritering discipline to waver is well documented.
There are two components to profits – premiums and claims. And while the claims picture is cloudy, the revenue picture is pretty clear. Premium increases have leveled off to half of one percent, the lowest rate since the nineties. And in spots there has been evidence of rate decreases as insurers try to hold onto profitable business. If the discipline holds, insurers may be OK. If not, we’ll have problems.
While insurer profits look good (up 12% over 2004), that is misleading as the industry’s return on equity remains below that enjoyed by other, less risky businesses. An RoE of 10.5% is not adequate for an industry that is subject to huge unpredictable losses; investors will find better returns from less-risky investments in many sectors.
As unattractive as 10.5% may be, it is much better than the industry’s average results for the last ten years of 7.7%.
What does this mean for you?
Hold on to your hat. Predictions are for the hurricane season to be a bad one, and if a big storm makes landfall in a populated and/or industrialized area, losses will be big and so will rate increases.


May
19

The myth of the med mal crisis

The malpractice insurance crisis does not exist. Actually, it does, but only in the popular press and in the minds of the AMA, a few politicians and alarmists. In the real world, the cost of malpractice insurance as a percentage of total practice expenses changed little over the last 30 years, rising from 6% of expenses in 1970 to 7% in 2000.
The finding comes from a report based on data collected by the American Medical Association and published in the MarketWatch section of Health Affairs’ May/June 2006 issue.
While the overall percentage increased by just one point over that period, there were significant changes during the thirty years. From 1970 to 1986 malpractice expenses jumped from 6% to 11% of total practice expense before falling back to 6% in 1996. Premiums bumped back up by a point to 7% in 2000.
Notably, the cost of other practice expenses, including non-physician labor, utilities, rent and medical equipment and supplies, increased much more rapidly than med mal premiums.
Let’s contrast this reality with the hyperbole and outright misinformation generated by some; Ohio Rep. Deborah Price is a great example. She is one of the supporters of med mal reform who have cited some highly doubtful statistics, including one noting that “Four out of 10 Ohio physicians have retired or plan to retire in the next three years due to rising liability insurance premiums”.
If physicians are retiring because med mal premiums are now consuming a couple points more of their practice’s overall expenses, they are lousy business people and probably should join a large group practiice anyway.
NOTE – the AMA has published a comment on their website in an attempt to refute the original article claiming that the analysis stops in 2000 which makes it inaccurate (a possibly valid argument, although one that is refuted prospectively by the authors in their article) and arguing that the data used by the authors is misleading (although the authors make a solid case for their selection of data sources).
My take – the med mal “crisis” can affect pockets of physicians significantly while having relatively minimal effects on the overall population; and the inefficiencies in the insurance market are much greater contributors to the problem than are tort costs. And, most potential suits are never filed anyway.
What does this mean for you?
More wasted time arguing about non-factors when we could be trying to actually solve the real problems driving health care costs up and access down.


Joe Paduda is the principal of Health Strategy Associates

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