Insight, analysis & opinion from Joe Paduda


More on cheating docs

Gary Schwitzer has posted a quick item in his blog providing more detail about the financial benefits to physicians of “leasing” imaging services. For those who missed the article in the Wall Street Journal, Schwitzer’s blog has a link and excerpts.
The net – a physician referring two MRIs per day would net over $120,00 annually.
What does this mean to you?
Hmmmmm, some perverse incentives to increase imaging utilization, perhaps? A more subtle way to cost-shift, to capture more income to offset lost income due to reduced Medicare reimbursement? Outright fraud? or all of the above?


GM, WalMart, and health care reform

Two articles in today’s press highlight the growing impact of health care costs on US business. One, an opinion piece by Paul Krugman in the New York Times (subscription required) , compares the workforce compensation of GM and WalMart, noting WalMart’s significantly lower per-employee wages and level of health benefits programs. The other appears in the Economist, a publication with a more conservative bent, and notes the impact of health care and pension expenses on the Big Three (well, now that Toyota is one and Chrysler is not, perhaps the Big Two and Number Four) automakers.
Krugman’s comparison of WalMart and GM is illuminating. Here are his main points.
1. GM pays about $1500 per car for health benefits.
2. GM has about 2.5 retirees for each working employee
3. GM used to be the largest employer in the nation. Now, WalMart is.
4. When GM was the largest employer, average wages were equivalent to $29,000 annually in today’s dollars. WalMart employees average $17,000.
5. Essentially all of GM’s workers have incredibly generous health coverage. About half of WalMart’s have any company-paid health coverage.
6. This is not to praise or denigrate either company, just to illustrate how the US economy is changing and the impact on the “average” worker is a reduction in income and health benefits coverage.
The Economist (perhaps the best newsmagazine in existence) has an equally interesting perspective on the US auto manufacturers. Here are the main points from their article on GM and Ford, subtitled Detroit’s car industry and its unions now have to reduce legacy employment costs (available by subscription or free to print subscribers).
1. “GM’s 30-year slide from 60% of the American market has now taken it to 25%; Ford’s share is under 20%: neither shows any sign of arresting this trend, which looks dangerously close to tilting into precipitous decline, at least in their home market (both are now faring better abroad).”
2. “the American transplant factories of their Asian and European competitors have none of these (health care and pension) costs, and have young, non-unionised workforces.”
3. “the really big challenge for GM and Ford is attacking those legacy costs. That boils down to one thing: Detroit must persuade the unions to give some ground on pensions and health-care.”
4. the article goes on to point out that big steel, textiles, and heavy equipment have all weathered this storm and come out stronger, but the storm may well be hurricane-strength.
My conclusion? Health care costs and their attendant drag on American business have become an issue of survival. At long last, big business is recognizing that they cannot compete in the global economy without major reform of the US health care system.
What does this mean for you?
Health care reform is going to happen, and will be driven by both sides of the political aisle (Krugman representing the liberal and big business and the Economist the intelligent conservative). There will be a major effort at health care reform in the next two years. Pay close attention, and seek to understand the underlying motivations, for therein lies the impact on your organization.


Medicare cuts in MD reimbursement

California HealthLine has an excellent roundup of Medicare news. Most significant is their take on physician reimbursement, which is slated to be cut by 4% on 1/1/2006. Lawmakers appear to be interested in rescinding the cut, which would be consistent with their actions the last time Medicare physician reimbursement cuts were slated to take place.
Expect changes late in the year or early next – I know, early next year would be after the cuts are scheduled to take effect. The political winds are moving in that direction, with the AMA and AARP staking out positions (no surprises there)
What does this mean for you?
1. With most state WC and other fee schedules tied to Medicare rates, cuts in physician reimbursement will directly affect payouts in these lines of insurance.
2. If Congress does not act until early next year, companies tasked with implementing fee schedule changes will find themselves burning the midnight oil to build fee schedule tables that can meet either eventuality -cut or no cut.
3. PPO discounts are often pegged to Medicare, so their revenues will either increase or stay the same, depending on what Congress does.
4. And most important, a decrease in reimbursement will lead to more physicians dropping out of Medicare, Medicaid, and any reimbursement program tied directly to Medicare. Today physicians ask for, and receive, reimbursement higher than the state fee schedule in WC in Massachusetts. Florida raised its fee schedule from 87% of Medicare (on average) to 114% in large part due to physicians refusing to take the lower reimbursement. Early evidence is physicians are returning to the system, and utilization has not increased.
Editorial statement – price controls simply do not work. When will the politicians, managed care “experts” and PPO companies learn this?


Medicaid, Round Five

While state legislatures and governors are moving to make significant changes in Medicaid programs, a coalition including AARP, pharmaceutical manufacturers, labor unions, pediatricians and lobbying groups are preparing to do battle for their constituents. The impetus behind this nation-wide movement is the agreement between the Bush Administration and Congress on a $10 billion cut in Federal contributions to Medicaid programs (state governments pay somewhat less than half of the costs of Medicaid, with the Federal government picking up the rest). With that historical decision now law, states have to figure out how best to implement the cuts.
Perhaps most telling, there appears to be consensus from politicians of all stripes that something has to be done. And, given the influence that states have over Medicaid decisions, we will likely see a broad array of possible solutions advanced by legislators. Options include:
— requirements for beneficiaries to share in costs through co-pays and deductibles
— cuts in reimbursement for certain providers, notably nursing homes
— “stripped-down” benefit packages, with different benefits for children, the disabled, elderly poor, and working poor
— negotiations with pharmaceutical manufacturers to reduce drug costs
— change Federal funding for long-term care to a “block grant”, whereby states receive a set amount of money and can make their own decisions as to how to allocate those funds.
This is a good thing. There is no question the US needs to address the exploding costs of Medicaid, and states are excellent “labs” to test various approaches. There is also no question this will be painful for some, with recipients, pharmas, nursing homes, and hospitals among the likely victims. But, we have no choice. Medicaid has grown significantly in recent years, primarily driven by increases in enrollment. Many of the new enrollees are the working poor; individuals who work for employers that do not offer health insurance or cannot afford the employee contribution towards the premium.
What does this mean for you?
This is getting as tiresome for me as it is for you, but prepare for cost-shifting as pharmas and providers seek to recoup lost income by increasing charges and utilization for commercial payers. Especially vulnerable are liability and auto insurers, as their “managed care” programs are in the dark ages.


Merck detailing – crossing the line?

Back to the detailers v. doctors, if only just for a moment. Dr. Gary Schwitzer of the U. of Minnesota has posted an interesting piece on Rep Henry Waxman’s indictment (figurative, not literal) of Merck’s behavior related to misleading MDs about Vioxx.
Another blog has a highly entertaining review of some highly embarassing marketing training literature ostensibly used by Merck. Suffice it to say that they are using anatomy as well as physiology in their efforts to “reach” docs…
What does this mean to you?
The dollars pharmas have to spend on convincing MDs to order their drugs are much larger than the dollars managed care firms have to “counter-detail”. If managed care firms, insurers, and employers want to stand any chance in this battle, they need to figure out how to do a much better job of educating docs than they have to date.


Coventry call

More from the “group health” side of the Coventry call…
In general, a very strong quarter for one of the mid-tier players in managed care. Loss ratios were down, medical trend slightly decreased, and efforts are underway to address some of the key components of medical inflation, notably imaging.
There was some talk about increasing copays and deductibles, a “cost containment” mechanism from the early days of health insurance. These are now called “benefit buydowns”…
Details –
In line with other managed care players, medical cost pmpm trends were at 8.1% for the first quarter, which was mirrored by their Medicaid and medicare business. This was driven by better utilization (volume of services delivered), with inpatient utilization and pharmacy trending well. For pharmacy trend, Coventry also saw “more favorable unit cost and utilization.”
Medical Loss Ratios improved significantly; my sense is this was likely driven by the improvements in utilization coupled with premium rate increases.
Coventry execs talked about the components of medical expense in some detail, paying especial attention to diagnostic imaging. Evidently they are working hard on this area as costs are increasing. Specifically, Coventry is looking to cut unit prices. They are also trying a somewhat unique approach which will bear watching, purchasing imaging on a capitated basis from a vendor for imaging. In addition, they are using precert on all significant imaging in most markets.
On the benefit design side, Coventry is selling more higher deductibles and copay programs, referred to as “benefit buydowns.” For those of us old enough to remember, these appear to be nothing more than cost shifting of initial expenses to the plan member. This has been extended to specific service lines, including “benefit buydowns” in pharmacy.
Consumer Directed Health Planss – they have one, it is in the market place, although they have not seen huge demand due to their smaller size market – have 10k members in some form of that, expect it will grow but “unlikely to be exponential”.
Want to write a few large accounts and keep the “small group engine” going.
What does this mean for you?
Medical inflation is not tamed, but more under control than in prior quarters – this is consistent with other managed care firm results, so if you are not seeing a leveling off of the “rate of increase”, you’re doing something wrong.
Attention to the drivers of trend, notably imaging, is growing, and reflects a deeper understanding of the nuances of health care. Simply put, you cannot manage imaging like you manage hospital expenses. If you haven’t figured this out yet, get with the program.



Interesting notes from their analyst’s call, focusing on their First Health acquisition…
They are “achieving synergies” by reducing headcount and consolidating purchasing. On the pink-slip front, the combined First Health-Coventry operations will shrink by about 450 positions by year end. In total, they expect to exceed $25 million in synergies.
They are also successfully renegotiating vendor contracts; examples include telecom where expenses were $21 million between FH and Coventry. They have renegotiated deals to achieve savings of over $5 million, with no operational change.
In April, they completed conversion to FH for OON emergencies from an outside vendor who supplied that OON service.
During the call, Coventry’s CEO, Dale Wolf, was quick to note the value of FH, and specifically their workers’ comp products which are generating slightly more than $210 million in revenue per year (about 3% of Coventry’s total), but a surprising 11% of their margin. A profitable product line indeed. In total FH revenue was under $142 million in Q1 which was less than expected but not materially so.
Wolf stated that Coventry wants growth in their 3 areas at FH (WC, network rental, and the Federal Employee Health Benefit Program (FEHPB)), and noted that the equity markets appear to have confirmed their belief in FH.
Wins for FH for the unit include an expanded relationship with AIG, a new customer in Fireman’s Fund (which had been in the works for some time), (both in workers comp) and selling (non WC) services to a Fortune 100 employer. Wolf also cited new business wins in rental network. Coventry expects FH will continue to grow modestly in 2005 but more in 2006
On the network side, it sounded like Coventry is working to renegotiate facility deals to drive better discounts, although this was somewhat unclear.
Looks like FEHBP is a potential problem with declining enrollment, but high premium increases appear to have moderated somewhat and Coventry sounds hopeful.
The company has added one more position at senior level, one more to go. Wolf says they have assimilated FH and are in execution mode. Sources indicate the slot that is still open is for the leader of the Workers Comp unit; they continue to look outside the combined company (search has been going on for about two months to date).
While I have every confidence in Coventry’s ability to maximize the return from the FEHBP and network rental business (this is fairly similar to their core group health business), my sense is the optimism about FH’s WC business may be somewhat misplaced. Here’s why:
1. FH’s largest customer is Liberty Mutual, which accounts for about a fifth of their business in WC. Liberty has their network contract out to bid, and I would be quite surprised if First Health retains all of their present business. Expect them to lose several states to competitors.
2. The Hartford’s recently announced deal with Aetna to access their WC network in PA noted that they plan to expand their relationship into other states. Sources indicate this is not a hollow promise, so I would expect the Hartford to move other FH states to Aetna over the next 9-12 months.
3. FH’s WC network continues to suffer from “hollowing out”, as payers hire specialty managed care vendors such as OneCallMedical and MedRisk to provide imaging and physical medicine networks respectively. (note MedRisk is an HSA client). WIth imaging at slightly less than 10% and PM at about 20%, the loss of network access revenue for FH will grow as more payers adopt this strategy.
4. EDS manages FH’s medical repricing technology, and their ongoing struggles with the FH medical bill repricing system are well known, and are not helping the company solidify relationships with existing customers. This has always been a “loss leader”, strategically identified by the ex-FH leadership as a way to “lock in” customers for the FH network. It remains to be seen if the new bosses continue to support that strategy.
What does this mean to you?
Coventry management is quite strong, and has made signficant progress in fixing some of FH’s problems
. If you are working with FH, patience may be the watchword, but additional progress, in the form of a defined IT strategy, an increased willingness to partner with specialty networks, and a demonstrated understanding of the huge asset that is their medical bill database will be a requirement for success.


Center for Medicare/Medicaid Services’ impact on private payers

There has been lots of news about Medicare lately; a good round-up is available at California HealthLine. News includes:
Physician reimbursement – the current fee schedule expires in 2006, after which reimbursement is scheduled to decline by 5% annually from 2006 to 2012. While some are predicting, with apparent confidence, that the cuts will be eliminated, it appears that others on Capitol Hill, searching for ways to deliver on Bush’s commitment to cut the Federal deficit, are turning their attention to Medicare.
 Medicare will be covering more services performed at Ambulatory Service Centers. Most of these are minimally invasive surgeries, and many have been performed at ASCs for years. It looks like CMS is just catching up with normal practice. However, some procedures, such as laparoscopic cholecystectomies, which are routinely done in ASCs, will not be covered in this setting by CMS.
 CMS will increase payment for stays in long term care hospitals by 3.4% on July 1 of this year and make it easier for LTC facilities to receive payment for “outlier” cases (those patients that consume significantly more resources).
 Drugs – under pressure from the retail pharmacy industry, CMS will require health plans to cover 90 days of drugs whether they are obtained at a retail or mail order pharmacy.
What does this mean for you?
As goes CMS, so follows commercial insurance. Here are the potential effects.
1. Physician fee cuts – physicians will seek to recover lost income from other payers, and those other payers tend to be their group health, auto, and workers’ comp patients. Watch for cost-shifting


workers comp and uninsurance

Workers’ Comp Insider is published by LynchRyan Associates, a company with a long-standing, and well-deserved, reputation for excellence in injury prevention and return to work. Disclaimer – the folks at LynchRyan are also friends, and we follow each others’ blogs religiously.
At the risk of appearing incredibly incestuous, there is an excellent posting on their blog of a real life example of the impact of the lack of health insurance on an employee, employer, and the financial situation of both. I tend to be somewhat abstract in my posts about the impact of uninsurance on other lines of coverage; their posting makes this problem real.


Cheating docs

One of the more distasteful practices in the medical profession is the subject of an article in today’s Wall Street Journal. The practice is so-called self-referral of patients by a physician to an imaging facility where they stand to gain financially. Yes, there are laws against this. Yes, physicians and business folks make lots of money thinking up creative ways to circumvent these practices.
This is one of the more creative I have heard of. To quote the Journal;
Imaging centers “structure referral deals as leases, under which physicians, each time they send over a patient, are renting the scan center’s facilities and employees.” The physician then bills the insurance company whatever rate they deem appropriate, and receives payment directly.
Imagine what they could accomplish if they worked to create value and better health, instead of thinking up ethically-challenged ways to generate even more physician income.
What does this mean for you?
If you are contracting with physicians, be very careful about the language re self-referrals; although many tend to turn up their noses at the mention of contract law, this is a great example of why the details are critical.
If you are evaluating an upsurge in diagnostic imaging, tie the referrals back to referring physicians, and look for any sudden increases. Then, have a talk with the doc.

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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