Insight, analysis & opinion from Joe Paduda

Oct
7

The wild world of workers comp managed care

These are wild times for the workers comp managed care industry. With Aetna’s recent announcement that they are expanding their workers comp network into additional states, it appears the big health plan is becoming a serious competitor for network business. Sources indicate that the Hartford will be announcing expansion of their relationship with Aetna in the near future, with the business moving from First Health.
Liberty Mutual, the comp industry’s 800 pound gorilla, has yet to announce the results of their network selection process, an event that has many in the industry on the proverbial edge of their chair.
CorVel, which has been laying low, keeping under the radar after the adverse publicity from the Broward County School Board debacle is set to announce a major new business relationship; sources indicate it will pertain to provider networks. This announcement may come too late for one of their larger business relationships; the State of Florida is likely to go to bid for their managed care program in the near future.
Gallagher-Bassett has been revisiting their managed care vendor contracts, apparently (at least in part) to eliminate the referral, administrative, commission, and other fees that they have been receiving from the managed care vendors they work with.
First Health is still seeking a head for their workers comp unit; Aetna is as well. Meanwhile, Concentra’s takeover of Beech Street and Occupational Health and Rehab has made the company a more formidable competitor in the network and occ health clinic markets.
Changes to the Texas workers comp laws go into effect (realistically) on the first of the year, and national and regional players are scrambling to prepare. If California and Florida are any indicators, the first entities into the new programs will resemble pioneers – the settlers with the arrows in their backs. Kudos to them for their initiative, and credit to the “fast followers” for waiting a bit to watch how things shake out.
Meanwhile the private equity/venture capital world continues to buzz around managed care companies like bees around honey. There is a lot of attention being paid to these service providers; workers comp managed care is hot now among the investment community.
This is all playing out amidst the ongoing Spitzer/Blumenthal investigations into the insurance industry, sham bids, anti-competitive behavior, and outright fraud.
It all makes for a highly entertaining season.
What does this mean for you?
Significant change brings significant opportunity, along with big risks. Stay tuned; more changes are likely soon.


Oct
6

Case’s Revolution Health announces investments in health care firms

Steve Case’s Revolution Health has announced its first investments in the health care arena. They include a company that finds doctors and provides scheduling services; a health information firm; search firm targeting health issues; and two companies focused on insurance.
Case’s new company was announced three months ago to great fanfare, focusing on several areas:
–provide consumers with access to data on physician and hospital cost and quality
–lower health insurance costs by streamlining the purchasing process
–enable consumers to rapidly access their personal health care data at convenient locations
These initial investments appear to be somewhat in line with those priorities, although there are already many companies providing similar or identical services with significant revenue streams.
myDNA.com appears to be an advertising supported health information site, similar to others pervading the web. 1-800 Schedule is another web site that appears to be ad-supported. It does provide directories of providers, but there are no quality rankings, ratings, or profiles beyond basic info.
ExtendBenefits is an individual health insurance firm that also supports HSA administration. They claim 500,000 members and base their pitch on lower costs (claiming individual health benefit programs are 1/4 to 1/2 the cost of group programs (?)). ExtendBenefits is staffed by execs from eHealthInsurance and technology folk. There is an interesting article on their site quoting the CEO of Pitney Bowes on health insurance costs. One of the salient parts of the article follows:
“The same thinking has been applied to psychiatric and substance-abuse cases. The company set up an eight-session early-action program to make sure covered employees in these situations were seen early and often by professionals before they were released for more intensive treatment. Although this is more expensive in the short run, says Critelli, in the long term the program “saves money by getting better results from more data.”
Pitney Bowes has also found that substantially decreasing the cost of medications borne by employees results in fewer of them discontinuing their long-term treatments, which would invite more serious conditions and hospital visits. The company considers screening and diagnostic procedures a critical component of prevention strategies but found through data analysis that some diagnostic tools


Oct
5

Employee paid health insurance on a large scale

Six large national employers have begun to offer employee-paid, low cost low coverage health insurance plans to part-time workers. The plans are provided by United HealthGroup, Cigna and Humana to employees without other health coverage. Plans range from a discount card providing lower cost prescriptions, medical and dental checkups to high-deductible programs with and without pre-existing condition limitations.
According to the New York Times,
“UnitedHealth Group is offering the discount card and four levels of limited coverage in all 50 states at monthly premiums ranging from $59 to $149. In 15 states, United will also offer high-deductible policies that cover major medical costs, under the same group rules with no add-on charges for people with preconditions.
The major medical premiums vary based on an enrollee’s age, sex and location. Humana will offer the high-deductible policies to individuals in 17 states and Cigna will offer them in Arizona only. Under these individual contracts, premiums may also be higher for those with preconditions.”
The program is offered to workers at Sears, Federal-Mogul, IBM, GE, and EMC as well as to independent contractors at Avon Products.
Credit goes to the employers and the not-for-profit group that is sponsoring the initiative, the HR Policy Association.
We’ll be following this closely to assess the results, market acceptance, and as time goes on, profitability of the program.
What does this mean for you?
An interesting experiment to watch and learn from. Possiblya way to stem the tide of uninsurance that is increasing costs for employers and employees as the uninsured population’s care is paid for by those with coverage.


Oct
4

GHI-HIP merger in NY

The mergers among health plans continued yesterday, with New York’s GHI and HIP announcing their intention to join forces to create the state’s largest single health plan. With four million members and $7 billion in revenues, the not-for-profits would dominate the New York metropolitan area, with especially strong market share in the municipal, blue- and pink-collar demographics.
HIP, the smaller of the two plans with 1.4 million members, also owns Vytra Health and Connecticare. The Connecticare acquisition was one of the more intriguing deals in recent years, as it combined two different models with distinct membership demographics, while adding broader geographic coverage to HIP. The company recently announced plans to acquire a high-deductible health insurance provider, PerfectHealth Insurance Co.
GHI covers 2.6 million members in the NYC, upstate, and northern New Jersey area, covering over 2/3 of City employees. GHI has extensive experience in administering governmental programs including state contract work on mental health, coordination of benefits, and Medicare + Choice.
We have been following this trend for quite a while, and with the two largest not for profit health plans in the nation’s most concentrated market merging, it is even more clear that consolidation will continue and likely accelerate. The merger sets up an interesting battle between the merged entity, the Oxford-United combination, and Wellpoint – Wellchoice for share in this key market.
What does this mean for you?
If you run a health plan or TPA in the NYC area, batten down the hatches; there will be a lot of collateral damage to smaller insurance and health coverage providers as these three giants go at each other.


Sep
30

Wellpoint’s acquisition of Empire Blue Cross

Wellpoint is continuing to consolidate its hold on the nation’s Blues plans with its recent announcement regarding the pending deal to acquire Wellchoice, the holding company that owns New York’s Empire Blue Cross and Blue Shield.
The transaction is valued at $6.5 billion in cash and stock, is scheduled to close in the first quarter of 2006, subject to regulatory approvals.
This continues the trend towards consolidation in the industry, following such notable deals as Coventry-First Health, United-Oxford, United-Pacificare, Anthem-Wellpoint and Aetna-HMS.
According to California HealthLine;
“The (Wall Street) Journal reports that slowed membership increases, large premium increases becoming less common and the fact that size helps insurers negotiate rates with providers has contributed to the trend of consolidation in the insurance industry (Martinez, Wall Street Journal, 9/28). Gary Claxton, a Kaiser Family Foundation vice president and director of the Health Care Marketplace Project, said, “If you want to grow, you have to look at new markets or consolidation.” He said that insurers have been unable to grow by adding new employers or members, so consolidation is their only option.”
Claxton’s comments echo earlier statements here. With Wall Street’s insatiable thirst for growth and continuously improving quarters, health plan execs are desparately seeking new business. There are now 13 remaining publicly traded health plans, and speculation is rampant that the smaller will continue to be acquired by the larger as health care Pac-Man continues. Coventry may be next on the list.
What does this mean for you?
Opportunities for speculation in stocks. Fewer choices in health plans. Confusion regarding who owns which health plan.


Sep
29

Spitzer subpeonas St Paul/Travelers

Eliot Spitzer, New York Attorney General and terror of the insurance industry, has just subpeona’d insurer St Paul Travelers for documents and information related to workers compensation. No further details were immediately available either from the AG or St Paul Travelers.
The company is one of the largest WC insurers and administrators in the nation, ranked #4 or 5, depending on criteria used.


Sep
28

Senate moves to allow negotiation for pharma prices

Sen Wyden (D-OR) claims he has enough votes in the Senate to pass legislation authorizing the Secretary of Health and Human Services to negotiate for Medicare drug prices with pharmaceutical companies. Critics were quick to decry the move, with the pharma industry claiming such a move would not reduce prices, would be counter-productive, and unfair.
Which begs the question, if it would not reduce prices, why are they so concerned?
In any event, despite the present budget crunch and moves by the HHS Secretary to reject providing access to Medicaid for victims of Katrina and Rita due to the increased expense, pundits claim the measure is not likely to pass because “it faces strong opposition from the Bush administration, Republican leaders and the pharmaceutical industry” (Las Vegas Sun)
In a related development, a study was released that compared pricing under the Veteran’s Administration’s negotiated pharma arrangement to the new Medicare Part D card. The net –
– prices for 49 out of the 50 most common drugs were higher under the Medicare program than the VA; and
– the average annual cost of drugs would be $220 higher under Medicare than the VA.
The VA is the only Federal governmental unit that is permitted to negotiate directly wtih pharma firms. The study was conducted by Families USA.
What does this mean for you?
Higher taxes to pay higher prices for drugs, but perhaps that is better than the cost-shifting that would occur if the Feds got tough with pharma and squeexed them for lower prices.


Sep
27

Concentra’s investor briefing

Concentra Inc.’s presentation at the Bank of America Investor Conference earlier this month focused on their continued growth, focus on workers comp, and impact of the acquisitions of Beech Street and Occupational Health and Rehab.
Here are some of the highligts from the presentation and comments on same.
Revenues for 2005 are projected to be $1.1 billion, with EBITDA of $156 million and operating cash flow of $101 million. Revenues are growing organically about 5% per year, while operating cash flow is down from $114 million in 2003 to $98 in 2004 to $101 in 2005.
Workers comp is by far their largest market, driving 70% of revenues. The Beech deal will certainly help diversify Concentra’s revenue base, as Beech is a strong mid-tier group health PPO. Beech’s provider contracts will also be compared to the Concentra contracts to identify the ones with the best rates. This, coupled with the greater buying power brought by Beech, may help Concentra drive better deals with some providers.
Of Concentra’s three distinct business units, by far the highest margin business is network services, with a margin of 31%, followed by the clinic business’ 14% margin. The care management sector, which is primarily field and telephonic case management, was hurt by declining revenues and price compression and returned 6%.
Of note, the clinics saw same store revenues up 6.6% on a 5% increase in visits. This at a time when the WC injury rate has been declining by about 4%.
Thomas made the point several times that after the completion of the OH+R deal, Concentra’s clinics will see one of of every ten workers’ comp injuries for initial care. While that sounds impressive, and is impressive, it is important to note that the clinics only see the routine injuries, and most of the dollars that are spent on WC medical go to the more complex cases that are treated by specialists.
The Beech Street and OH+R acquisitions were expensive at $210 million +. The Beech deal adds significantly to Concentra’s group health product offering. while OH+R will add 26 clinics after 8 existing clinics are closed.
Both Thomas and Kiraly repeated their assertion that Concentra is the industry leader in the WC managed care business, and is a full service integrated services provider. From a sheer numbers perspective, they are correct. However, other entities are leaders in segments of the WC business. For example, Coventry’s First Health is by far the leader in the WC PPO sector. MedRisk is the industry leader in management of physical medicine; and PMSI in pharmacy management.
Thomas noted that because Concentra manages all aspects of the claim, it therefore impacts more claims dollars than other competitors. Not exactly. Intracorp has case management, networks, bill review, peer review, and access to specialty managed care. So do Genex and CorVel. Concentra’s out of network bill negotiation entity (Concentra Payment Services) may well be the industry leader in non-network bill processing, but a host of competitors are now in this space.
While Concentra is not a public company, rumors have been rampant for years of their desire to become one. That, coupled with the large amount of debt outstanding, is evidently the reason for their continued participation in these road shows.


Sep
27

California’s kids and health insurance

As the number of employers offering health insurance declines and Medicaid enrollment increases, the people left without health insurance coverage tend to be members of families where the parent(s) have jobs without coverage.
A new study released by the University of California – Berkeley indicates that less than half of the state’s children will be covered by employer-sponsored plans within five years if premium costs continue to escalate at double digit rates. Of the rest, 14% would have no coverage at all, and the rest would be insured by tax-payer funded governmental programs.
What does this mean for you?
Higher taxes, larger deficits, and increased cost-shifting from providers to insured patients will accelerate the death spiral of the US health care system.


Sep
26

Marsh hammered again

The investigations into broker/insurer malfeasance continued to make their presence felt last week, as Conn. Attorney General Richard Blumenthal announced the expansion of the state’s charges against Marsh. Blumenthal, never one to avoid the limelight, said
“We have uncovered powerful evidence of a systematic scheme to raise insurance prices,” Blumenthal said. “We also have strong evidence of bid rigging, victimizing specific Connecticut consumers and companies. In essence, Marsh established a toll both between insurers and consumers, and the toll exacted was heavy. Creating the illusion of free and open competition, insurers agreed to provide Marsh with rigged or fictitious quotes in exchange for the prospect of submitting winning bids on future placements. Marsh threatened retaliation against non-players.”
According to Insurance Journal;
One insurer wrote about a Marsh “broking plan“: “This is another protection job… Our rating has risk at $890,000 and I advised (Marsh) that we could get to $850,000 if needed. (A Marsh broker) gave me song & dance that game plan is for AIG at $850,000 and not to commit our ability in writing!”
The amended complaint identifies several major Connecticut businesses that were harmed by Marsh’s bid-rigging and price-fixing plan, including Hubbell Inc., Kaman Corp., Hexcel Corp., and Bridgeport Hospital.
Marsh has about 2,800 policyholder clients in Connecticut – 300 of them large businesses or government entities. Its corporate clients in the state also include Bic Corporation, United Technologies Corporation, Carvel Corporation, Ethan Allen Furniture, Timex Corporation, Xerox Corporation and General Electric Company.
The company’s state and municipal clients include the Connecticut Department of Administrative Services (DAS), and the cities and towns of Hartford, New Haven, Stamford, Manchester, West Hartford, and West Haven. Marsh was also the insurance broker for several large, publicly supported state construction projects, including Adriaen’s Landing. Marsh’s nonprofit clients include Yale University, Mystic Seaport and the Save the Children Federation.
The announcement of the expanded charges against Marsh came the same day Blumenthal announced that insurer ACE Financial Solutions Inc. had agreed to pay $40,000 to the state to settle allegations for a scheme in which ACE paid Marsh a secret $50,000 commission to steer an $80 million state contract to the company.”
The scandal that will not go away lives on.
What does this mean for you?
Yet more evidence that crime doesn’t pay, and practices that were once accepted with a wink and a nod can get you in serious trouble.


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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