Insight, analysis & opinion from Joe Paduda

Feb
27

First Health still without WC exec

Industry sources indicate that Coventry Health’s year long effort to find a leader for its’ First Health workers comp managed care entity has hit another snag.
Evidently the last candidate rejected an offer from Coventry within the last few days, leaving Coventry with an empty pipeline. The job has been open for about a year, and search firm Spencer Stuart has had the engagement for a few months.
Faithful readers will note that I reported Coventry was close to naming an exec a few weeks ago. For unknown reasons the deal could not get done. My take (based on nothing but idle speculation) is the workers comp business may well be more competitive and tougher than Coventry either knows or admits. Aetna’s Work Comp Access program appears to be gathering momentum; Concentra has not stumbled recently; and specialty managed care vendors such as MedRisk and CHOICE Medical Management are “hollowing out” First Health’s network business by taking out pieces of the network (PT and Florida respectively). First Health will be losing big chunks of business from two of its largest network customers this year.
Perhaps the candidates know they are not being asked to take over a thriving market dominator, but rather right the ship of a firm that has grown stagnant and stale.
What does this mean for you?
The right leader could return First Health to prominence in this sector. The longer this goes on, the more important it is to select – and sign – the right candidate.


Feb
26

Ohio’s BWC coingate gets even better

It isn’t often that international auction house Sotheby’s gets involved in workers compensation cases, so the news that two of their numismatic experts pulled an all-nighter looking for coins missing from the Ohio Bureau of Workers’ Compensation is “top of the fold” stuff.
According to a report in the Akron Beacon Journal, Sotheby’s was contracted to track down and value the rare coins that were part of the BWC’s investment “strategy”. This highly unusual investment was made possible by the work of Tom Noe, a now-indicted political crony of Ohio Gov Bob Taft (R). .
Noe, who faces criminal charges for his allegedly illegal campaign contributions and other acts, had been storing the coins at several of his shops around the country, including ones in Sarasota, Maumee Ohio, and Colorado. Unfortunately, the Sotheby audit indicates that the coins they were able to locate are worth between $21 and $27 million; about half of the advertised value of BWC’s investment.
Highlights of the audit included the appearance of an Ohio State Trooper complete with badge and gun at one of Noe’s shops during the on-site audit. Evidently the Sotheby’s people were getting nowhere until the Law arrived, after which they stayed up all night looking at doubloons and double eagles (I’m guessing’).
So, the scandal that won’t fade away (much to the delight of this blogger) gets even better. Somewhat like a rare coin, it continues to appreciate the longer it is around.


Feb
24

UPDATE – Health Wonk Review

This is the premiere edition of Health Wonk Review, a biweekly (or so) compendium of the best of the health policy blogs. We’ve asked over two dozen health policy, infrastructure, insurance, technology and managed care bloggers to send in their best, provided to you in Cliff Notes style. We’ll do this every couple of weeks or more often if the host wants to.
Why? Bunches of reasons.
First, the last two months have seen a renewed interest in the health care policy arena, triggered by Pres. Bush’s State of the Union address, the financial difficulties of GM et al, the emergence of consumer-directed health plans, and the Part D mess.
Second, there are so many excellent policy blogs in the ether that it is impossible for anyone to keep abreast of them all.
Third, Nick Genes’ Grand Rounds has done such an excellent job covering the medical blogger community it inspired us to try to do the same on the policy side (plus Nick has already done most of the heavy lifting figuring out this type of thing so we didn’t have to do too much work).
And as you’ll read, we’re off to a pretty good start.
UPDATE – for a couple of late entries, click below…

Continue reading UPDATE – Health Wonk Review


Feb
22

PBM win over third party biller

For the dozen or so people in the workers comp business who follow these things, the recent win by ScripNet in its ongoing legal battle with third party biller (TPB) WorkingRx was excellent news – at least for the payers.. The court threw out WorkingRx’s lawsuit, noting that it had “no greater right to reimbursement from ScripNet than a pharmacy would have.”
WorkingRx and its competitor Third Party Solutions have been working two fronts in their effort to stabilize their businesses; suing payers who refuse to pay their bills in full, while attempting to sign deals with pharmacy benefit managers and payers in return for a “discount” off the TPB’s (inflated) charges.
The court win is by no means the final word; TPBs have proven to be remarkably resilient and are proof that businesses that can evolve quickly can survive.
What does this mean for you?
More clarity from the courts re the legal position of TPBs.


Feb
21

Health care quality measures, politics, and dollars

There are lots of moving parts, political agendae, and battling priorities in the pay for performance movement, and it is getting even complicated-er. Today’s announcement by the AMA that it will produce metrics for assessment of physician quality (registration required) is a clear indicator that financial motivations have, at least temporarily, outweighed physicians’ measurement phobia.
There are two distinct but closely related and very powerful forces at work here – one financial and the other political. Financially, the key issue is concern among docs that these “quality indicators” will be used to reduce reimbursement. And that fear is not unfounded. One has to look no further than the latest Federal budget proposal and the annual battle over the mandatory reduction in Medicare physician fees to understand that the phobia has a solid foundation in reality.
Politically, Bush’s pronouncements in favor of consumerism as the solution to the health care cost crisis have painted him into a corner. Critics (myself among them) have noted many problems and challenges (read near insurmountable obstacles) with this approach, chief among them its breathtakingly na


Feb
20

Iraq’s impact on insurers

The continuing strife in Iraq and Afghanistan and its effect on the insurance and employer communities is the subject of an excellent monograph by Robert Hartwig of the Insurance Information Institute. Hartwig notes as the returning veterans are reintegrated into the working community, employers will face challenges addressing the needs of vets with physical and/or mental health problems resulting from the conflict.
The Americans with Disabilities Act requires employers to make reasonable accommodations for employees with disabilities. And, with over 15,000 servicemen and women injured to date, and about 30% of all troops serving in these areas citizen soldiers – either from the National Guard or Reserves – many will come back to employers who will need to address their unique circumstances.
The impact may well have a significant impact on workers compensation. According to Dr. Hartwig, workplace claims arising from injuries suffered during these conflicts will be covered by workers compensation insurance. Many of the states have shut down their Second Injury Funds, financial pools designed to cover injuries arising from previous claims. Now, with these funds disappearing, the financial liability for claims related to wartime injuries will be the responsibility of workers comp insurers and self-insured employers.
Taking into account the Pentagon’s plans through 2009, present troop levels and injury rates, Hartwig predicts more than 60,000 wounded troops will be returning from Iraq and Afghanistan.
What does this mean for you?
A “hidden tax” on insurers, adding to the total cost of these conflicts.


Feb
20

Repackagers’ margins

Physicians and clinics are finding that dispensing drugs to patients can be a very profitable venture. Advocates are claiming that the practice improves the quality of care and ensures the patient receives the necessary scripts.
Let’s take the quality of care issue first. No question – an obstacle to compliance is the requirement that the injured worker has to get the script filled. Therefore, the dispensing of meds by docs makes sense. The right drug gets into the patient’s hands quickly.
OK. That’s a good thing. But at what price?
An analysis by Alex Swedlow (data provided by Alex to me) et al at the California Workers Compensation Research Institute on 2004 data indicates the price for repackaged drugs is from two times higher than the fee schedule (for ibuprofen) to twelve times higher (generic Zantac). (CWCI will publish the full study in the near future)
And, repackaged drugs accounted for less than a third of all scripts, but over half of all dollars paid. This is especially troubling when one considers the overwhelming majority of the top 20 drugs are generic.
Sources indicate that the problem grew even worse last year, with some payers indicating a majority of scripts were for repackaged drugs.
What does this mean for you?
Higher costs for WC payers, businesses, and taxpayers in California.


Feb
17

apologies for the multiple notices

several recent posts have inadvertently been sent out multiple times to subscribers. No, I’m not that persistent – looks like a new software/IE glitch that I just figured out.
Changing over to a new version of the posting software shortly; manual fix in now and the new version should fix it.


Feb
17

FDA OK’s, Insurers Pay

When the (registration required) FDA approves new medical devices for specific conditions, insurers are almost always required to cover them. Even if the approval makes no sense, the device fails in clinical trials, and there is no conclusive evidence of its efficacy.
The cost per case for the device and surgery is about $25,000; over 500 implants have been performed to date (the majority during the so-called clinical study).
Dr. Daniel G. Schultz, director of the Center for Devices and Radiological Health, approved an electrical stimulator for the treatment of depression, despite the unanimous opinion of the Center’s clinical staff that the device had no discernable impact. A Senate committee investigating the FDA could find
no previous instance in which the director of the center had approved a device in the face of unanimous opposition from staff scientists and administrators beneath him. “(NYTimes)
In fact, in a study conducted by the device’s manufacturer, the device utterly failed to produce any measurable impact on depression in the study group.
Now that the device is approved for treatment of depression, expect manufacturer Cyberonics to put on a full-court press to get doctors to prescribe it. This over the concerns expressed on the floor of the Senate:
“I am greatly concerned the FDA standard for approval may not have been met here, and if that’s the case it raises further difficult questions about whether Medicare or Medicaid dollars should be used to pay for this device now,” Grassley, an Iowa Republican, said during a speech on the Senate floor.” (Reuters)
What does this mean for you?
More of your dollars spent on highly questionable and really expensive technology.


Feb
17

P&C Industry results

Wilma, Katrina, et al hammered insurer profits almost as badly as they hit the Gulf Coast, resulting in the insurance industry losing $2.8 billion during the first three quarters of 2005. There is actually good news in this, as the losses forced insurers to stop cutting prices, thereby starting a downward trend in industry financials.
According to “Insurance Journal”,
“Before Hurricane Katrina, rate decreases and competition on many lines began to emerge throughout the majority of 2005. However, following this event, the trend of rate declines reversed on some lines of business, particularly in those areas directly impacted by the hurricane, and stalled on others. While this rate environment will have a positive impact on future results, A.M. Best believes the retreat from rate decreases will be short-lived.
The insurance industry’s cycles are well-known and well-documented – it marches off the same cliff over and over again, each time promising itself that it won’t be that stupid again.
History predicts otherwise.
I’d expect rates to stay somewhat firm, as early forecasts are for a storm season every bit as fierce as the one just passed. And, it is coming up in a few short months.
What does this mean for you?
A chance to tell me what a lousy prognosticator I am if rates plummet.


Joe Paduda is the principal of Health Strategy Associates

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