Insight, analysis & opinion from Joe Paduda

Aug
8

The Inflation Reduction Act’s biggest loser

For the first time in about forever, big pharma lost.

One can’t overstate the impact of the-about-to-become-law Inflation Reduction Act on pharma. The most powerful lobbying force in Washington got steamrolled – with one major exception.

Medicare will now be able to negotiate drug prices, a change that will lead to massive savings for seniors (a group I will join next year) and taxpayers alike. This didn’t come without a last-ditch effort by a horde of suits invading the Senate and House…but for once, the invasion was turned back.

Medicare part D was a huge taxpayer gift to big pharma as it covered seniors’ drugs while not allowing Medicare to negotiate prices. This was a giant boondoggle; Christmas, birthdays, anniversary and graduation presents all rolled into one 20 year giveaway. (historians will note this was entirely driven by Republicans – and added $9.4 trillion to the ultimate Federal deficit)

Imagine if you could a) add a huge new market for your services/products and b) set your own prices…why…you could buy that baseball team you always wanted!

Well, at least the insulin manufacturers won. Republican senators blocked a provision which would have capped diabetics’ monthly insulin costs at $35. 

1 out of 7 Americans that need insulin spend more than 40% of their income after food and housing on the drug.

What does this mean for you?

Just when you thought Washington couldn’t do anything – it does something really big and really important. 


Aug
5

Jobs…but…

Over half a million jobs were filled in July, far exceeding expectations.

We have now recovered every job lost during the pandemic – a darn impressive record given inflation, higher interest rates – the unemployment rate now matches its 50 year low. 

Things are looking pretty good, although people remain  concerned about inflation. The good news there is fuel prices have dropped appreciably over the last few weeks, with gas prices falling 50 days in a row.

The result is a very mixed economic picture, although things seem to be trending in a positive direction on the inflation front.

What does this mean for you?

More jobs -> more payroll.


Aug
1

Just the facts, ma’am…

Today we’re doing a very quick recap of stuff we learned over the last couple of weeks…no opinion here (yeah that was really hard for me…)

Extra credit for identifying the man in the picture…

But first, for those of us perennially mad at ourselves because, well, we screw up and aren’t perfect, read this. Short take – perfectionism…

“…makes for a thin life, lived for what it isn’t rather than what it is. If you’re forever trying to make your life what you want it to be, you’re not really living the life you have.”

Drug prices

Make for great politics…even when all the caterwauling is wrong. The issue is what we – the consumer – pay is NOT what insurers, PBMs, and other payers pay.

That’s due to the “gross-to-net bubble”, a term popularized by the estimable Adam Fein Ph.D.

When rebates and discounts were factored in, brand-name drug prices declined—or grew slowly—in 2021.

So…you getting those rebate checks?

COVID’s origins

Remember the theory that COVID came from a Chinese lab? It is looking increasingly sketchy.

comprehensive, detailed, and multi-factor analysis by scientists from four continents found

the emergence of SARS-CoV-2 occurred via the live wildlife trade in China, and show that the Huanan market was the epicenter of the COVID-19 pandemic.

The peer-reviewed research published in the journal Science covered molecular epidemiology and spatial and environmental analyses.

Investors and physician practices

Private equity investment in physician practices varies a lot by specialty and region. Quick takes…

  • about 5% of physicians were in private equity-acquired practices
  • The highest percentage was in D.C. (18.2%)
  • More than one in ten docs in AZ, CT, FL, MD, and FL were in PE-acquired practices

The researchers wrote…

“Because some private equity acquisitions consolidate physician practices into larger organizations, geographic concentration of private equity penetration may be associated with reduced physician competition, which could lead to increased prices, [emphasis added]

An interactive map and the research report are here.

Gun violence

Gun makers earned over 1 Billion (with a B) dollars from sales of military-style assault weapons over the last decade. A report to Congress found:

  • gun makers marketed to young men by claiming their weapons will put them “at the top of the testosterone food chain”…
  • the weapons were described as an “apex predator”
  • some ads for these weapons “mimic first-person shooter video games popular with children.”

source here

The AR-15 is the most common of these weapons…the NRA named it “American’s Rifle” back in 2016. (and here I always thought it was Davy Crockett’s flintlock rifle…)

(disclosure – I hunt and have several rifles – none are semi-auto like the AR-15)

Workers’ comp physician fee schedules

…are all over the place…Louise Esola at Business Insurance reported on a recent WCRI analysis that found:

About one-quarter of the fee schedule states established their rates for office visits near the Medicare level or below, while about the same number of states set their fees for major surgery at triple the Medicare rates or more in each state…

The study – authored by Olesya Fomenko and Te-Chun Liu and up to date as of this spring – is here. (sorry for misspelling of Dr Fomenko’s  name in  earlier version…darn spellcheck!)

Clearly politics trumps policy…unless someone can tell us why it makes sense for Florida to pay docs below Medicare, while paying hospitals many times Medicare… I’ll stick to politics, campaign contributions, lazy legislators and hand-cuffed or ineffective regulators as the main driver of work comp fee schedules. (oops opinion inserted into post…just can’t stop myself)

Happy August!


Jul
26

Wildly off topic #7, do our part.

Time to check in on how our Ukrainian friends are doing…

Last time we focused on strategy vs tactics…today we’ll cover why the Russians continue to do stupid stuff while the Ukrainians take full advantage of technology.

How who follow this closely know that the Russians are relying almost entirely on massive artillery barrages to level towns, cities, and villages before trying to push troops in. That was working, and Ukrainian forces were hard-pressed to withstand the bombardment.

From the Kyiv Independent: “artillery dominance compensates for the weak performance of Russia’s infantry.” 

That was then.

It’s quite different now, mostly because A) NATO countries have sent hundreds of artillery tubes (think cannons) and dozens of rocket systems to Ukraine and B) Russian logistics are awful.

A – These NATO weapons are much more accurate and have greater range than most of the stuff the Russians are using.

This allows the Ukrainians to shoot from further away, reducing the risk from Russian “counter-battery fire” (radar can identify where the outgoing shells and rockets are coming from so the enemy can shoot back). The new weapons systems are also much more mobile; our HIMARS rocket systems can shoot and be gone in 2 minutes. (thank you American taxpayers!)

Since mid-June, Ukrainian artillery has become increasingly lethal and extremely effective. This from the Kyiv Independent.

On June 15, a massive explosion occurred near the city of Khrustalniy (formerly Krasniy Luch) in occupied Luhansk Oblast. Explosions continued for days. According to satellite images, the blasts created a destruction zone spanning some 500 meters around the epicenter. The site was one of Russia’s largest ammunition depots

July 2, Ukraine’s military published a video showing an enormous explosion at another large depot in the city of Popasna…Two days later, another devastating blast destroyed a large depot in the city of Snizhne. Three more depots were also hit in Donetsk.

Which leads us to B – Russian logistics.

Faithful readers will know Russian logistics – in English the process of supplying troops with fuel, munitions, water, spare parts, and equipment – is awful. They don’t use forklifts to move heavy stuff, but rely on manpower. They don’t have pallets, but rely on manpower. They don’t have enough trucks, so they rely on trains.

That’s why the Ukrainians have been able to destroy thousands of tons of Russian artillery shells and other munitions; the Russians move those munitions to giant storage depots, where people offload the shells and trucks transport the shells to the artillery locations.

It’s pretty easy to identify where trains are off-loading, and even easier to use a few artillery rounds to set off giant, days-long fireworks shows.

 

reportedly a large Russian ammo depot; actual video is here.

So, the Russians move the depots further from the front lines  – out of range of most artillery.

Enter HIMARS – which has a range of almost 50 miles with current rockets – can hit pretty much any target inside Ukraine.

From Igal Levin, a Ukraine-born Israeli defense expert.

“…if all those forwarded bases, depots, repair facilities, all of the logistics chains are destroyed — [Russians] will have to deal with the need to bring supplies from beyond the Ural Mountains, then be thinking how to store and distribute them, how to bring munitions to artillery.”

The takeaway.

Russia has a far larger army, exponentially more artillery weapons, and enough artillery rounds in storage to fight for decades.

They also have a wildly corrupt economy, where kleptocrats stole billions of rubles intended to feed, clothe, and equip soldiers.

Ukraine has a much smaller military – and had a history of corruption, albeit one that pales in comparison to Russia’s. Their troops – men and women – are way more motivated, fighting for their families and  land, and increasingly well-supplied.

They are also very well led by commanders who have years of experience fighting the Russians in Crimea and the Donbas and are taking full advantage of Russia’s limitations and NATO largesse.

What do we need to do.

Keep the faith, people.  Russia’s invasion of Ukraine is a major contributor to inflation, driving up fuel and food costs around the world. Yes this sucks, but our sacrifices are nothing compared to what Ukrainians are doing every minute of every day.

This too shall pass. When it does Putin and Russia will be far less dangerous, food and fuel prices will be much lower, and the world will be a way better place.

If you can, please help Ukrainians suffering from hunger, homelessness, injury and disease by donating to Care.


Jul
25

A creative way to generate work comp PBM revenue.

The work comp Pharmacy Benefit Management business has become hyper-competitive; total drug spend has dropped 6 of the last 7 years, there’s been massive consolidation of PBMs, margins are declining…all signs of a very mature industry.

Sounds like a not-very-attractive-business…right?

Well, due to accounting rules, PBMs are still wildly popular among work comp service companies.

They love PBMs because the companies get to count the cost of the drugs as well as their margins as top-line revenues – which makes those service companies look bigger than they really are.

The problem is…once you buy a PBM, you get a big one-time increase in revenue. But – and it’s a BIG but, unless you figure out how to grow that PBM revenue in a business that is declining, your top line flat-lines.

If you’re looking to sell your work comp service company, or otherwise tout strong financial performance, that is not a good look. Which brings me to a creative way a PBM is generating script volume without adding new payer customers.

Occ med clinic giant Concentra’s providers are writing scripts that direct the pharmacy filling the script to send it to Mitchell Pharmacy Solutions for administration.  (I looked for a company link, but couldn’t locate any mention of Concentra’s OccuScript program on their website)

According to Concentra, the OccuScript program:

  • has been in place for quite some time;
  • is mostly – but by no means exclusively – used in states where physician dispensing is not allowed (e.g. Texas);
  • appears to primarily address initial prescription fills which are mostly generics prescribed for a limited time;
  • about one of every nine scripts written in the company’s 520 clinics and 120 onsite centers flows through the program. Mitchell is the current administrator, providing network access and the claim adjudication platform. To be clear, Mitchell does not use its own pharmacy network…they contract with Script Care.

Injured workers treated at this clinic may be – or more likely are not – covered by a payer that contracts with Mitchell. (Mitchell is one of several work comp PBMs  – and far from the largest.) If it’s a Mitchell-contracted payer this form/process is helpful indeed.

In an email conversation with Concentra, the company noted “OccuScript supports medication compliance which is fundamental to evidence-based care delivery and positive patient outcomes.”  (note Concentra stated in an email “We have national employer customers whose injured workers are never processed through the OccuScript program…(some payers instruct Concentra on how to process scripts for their injured workers.))

Medication compliance is important indeed, but there are several potential issues/concerns/problems if the injured worker is NOT covered by a Mitchell-contracted payer.

  1. The payer gets a bill from a non-contracted billing entity which adds a lot of work for claims adjusters who have to figure out what to do with it.
  2. Unlike scripts processed by the PBM contracted by the injured worker’s employer/insurer/TPA, the payer finds out about the script AFTER it is dispensed. The drug(s) actually dispensed may – or may not – be:
    1. duplicates of other scripts,
    2. contra-indicated due to other drugs prescribed for the injured worker (while prescribers are supposed to ask about other meds, many patients aren’t able to recall drugs they are taking), and/or
    3. an expensive version of the prescribed drug (there are literally dozens of companies making ibuprofen, many at different prices for the same pill; contracted PBMs control for this with MAC lists.)
  3. The injured worker’s payer/employer/insurer is usually billed at a rate that is higher than their contracted PBM price – sometimes MUCH higher…driving up the employer’s/insurer’s/taxpayer’s work comp costs.
  4. Concentra’s OccuScript contracts with Mitchell who in turn contracts with Script Care…
    1. all of whom have to get paid,
    2. and adding communication challenges as issues have to pass through several entities.

So what to do?

Concentra avers it is ready and willing to work with payers and employers to route scripts to their PBM. It is also interested in working with PBMs. Sure, most “first fills” are “one and done”…but many are not. Getting on the claim as quickly as possible is an industry-wide best practice.

Note – Concentra execs were quite responsive to my queries about the program; kudos to CEO Keith Newton and Charles Bavier – who runs Concentra’s OccuScript program – for jumping on this.

What does this mean for you?

If you aren’t a Mitchell Pharmacy Solutions customer, get with Concentra ASAP to get those scripts routed to your PBM.

For those unfamiliar with this space…Insurers and TPAs hire Pharmacy Benefit Managers (PBMs) to ensure injured workers get the medications they need to recover and return to work. PBMs contract with pharmacies, operate call centers and employ pharmacists – all in an effort to deliver the right drug at the lowest possible price.


Jul
21

California’s Med-Legal Mess

In the esoteric world of workers’ comp, California’s “med-legal” issues rank near the top of issues bound to frustrate/infuriate.

Med-legal (analogous to physician review or independent medical exam) may have even moved up a notch or two, as expenses have zoomed after a change in the med-legal fee schedule that went into effect in April of 2021.

The change was intended to:

  • simplify the payment structure by replacing several variations with one flat-fee
  • increase the number of QMEs – Qualified Medical Examiners
  • and increase the number of oncologists and toxicologists,
  • reduce overuse of “supplemental” reports
  • do this all without more than a 25% increase in aggregate med-legal fees.

CWCI’s research indicated that results appear to be far less than intended…

  • the number of QMEs increased slightly – up 134 – with most ortho surgeons – NOT oncologists and toxicologists
  • there was no decrease in supplemental report services (e.g. billing for more pages reviewed)
  • and the average paid per month for comprehensive evaluations went up more than 50%.

Thanks to CWCI for sharing the details…need more details?

Sign up for CWCI’s webinar on Wednesday, July 27 at 10 a.m. (Pacific). Senior Research Associate Stacy Jones, who authored the study, and CWCI General Counsel Sara Widener-Brightwell, will review those changes and discuss the results of the study.  The program will be followed by a live Q&A session.

What does this mean for you?

As if we needed it, another entry in the Hall of Unintended Consequences tells us – YET AGAIN – regs have to be carefully thought through, responses anticipated and planned for, profiteer strategies gamed out, and then – AND ONLY THEN – finalized.


Jul
19

Healthcare costs are…

heading up.

First, a bit of background.

Big health insurers that sell insurance via the Exchanges have to file their rates with the Feds now. While they don’t insure a lot of people, their filings are detailed, public, and cover 13 states – Georgia, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, New York, Oregon, Rhode Island, Texas, Vermont, and Washington DC.

The fine folks at the Kaiser Family Foundation did a lot of analysis, here are the key takeaways.

  • many insurers are projecting a medical cost trend of 4-8%.
  • “A substantial share of the increase in premiums is from rising health prices and utilization of health care”
  • one insurer said “Medical Care Services CPI in March 2020 (pre-pandemic) was 5.5% and as of March 2022 is 2.9%. This data suggests a correction is imminent as labor and supply cost increases directly impact hospitals and physician offices.” [emphasis added]

Oh, and that COVID thing? “many insurers are projecting the pandemic will have a net neutral or only slight impact on health costs and premiums.”

So…what does this all mean?

My view.

  • for this year, increased utilization and prices will drive trend north of 5%
  • we’ll see a bump in Q3/Q4 as increased labor costs work their way thru the system
  • 2023 trend will likely settle around 5% as inflation in other sectors eases off.

The wild card is – brace yourself – politics.

Sen Manchin – the mercurial-I-can’t-make-up-my-mind-and-it-sure-is-fun-being-the-center-of-attention Senator from West Virginia will determine if 13 million Americans can no longer afford health insurance.

If legislation doesn’t pass, health systems will have to care for more people without health insurance; some systems and hospitals will raise prices to cover their losses.

What does this mean for you?

Higher healthcare costs for the privately insured, workers’ comp insurers, employers, and taxpayers.


Jul
18

(Perhaps) unintended consequences of abortion bans

With all the attention paid to abortion these days, I thought it worthwhile to dig into the financial and health impact of abortion and childbirth.

First, the cost.

Women who give birth incur about $19,000 in additional healthcare costs compared to women who don’t.

And that’s for women covered by large employers’ health plans.

Second, medical debt.

Lower-income adults in the South and/or in states that have not expanded Medicaid are much more likely to have medical debt than the rest of us.

Third, coverage.

About 13 million of us will see their health insurance premiums jump in January unless Congress acts. The issue is subsidies for lower-income folks who get their insurance via the Exchanges will expire at the end of this year unless they are extended. So far, the chances for an extension don’t look promising.

Fourth, societal costs.

  • Almost half of the women receiving abortions have incomes below the poverty line.
  • Lives will be hugely impacted, as “the expansion of abortion access … reduced teen motherhood by 34% and teen marriage by 20%”
  • Women who are denied abortions are three times more likely to be unemployed than women who were able to receive one, according to a 2018 study.
  • Women who were not allowed to access abortion services had nearly a four times greater chance of living below the federal poverty line.
  • And…”research shows that in 2010 the public paid just under $13,000 on “prenatal care, labor and delivery, postpartum care and 12 months of infant care.” per birth.”

Connecting the dots.

States that have or are likely to ban abortion are:

  • unlikely to have expanded Medicaid,
  • have much more restrictions on Medicaid coverage so far fewer people qualify for Medicaid, and
  • therefore many more poor women who are forced to have children will have higher medical debt,
  • will not escape living in poverty, and their child will grow up poor.

What does this mean for you?

If one is going to force people to do things, one should understand and be responsible for the consequences.


Jul
11

Healthcare Sharing Ministries and the brutal reality of medical debt

Last week I posted on Health Care Sharing Ministries, noting I’d been reaching out to the PR firm that works with theAlliance of Health Care Sharing Ministries, the PR people put out a release touting their new accreditation standards.

As I noted last week the accreditation process/requirements don’t appear to require minimum cash reserves, specific expense ratios or meet other financial adequacy minimums and the accreditation board doesn’t include individuals with actuarial or financial credentials.

In English, this is a very big deal. Unlike real health insurers, HCSMs aren’t required to have enough cash to pay your medical bills. Also unlike health insurers, members don’t have any recourse if their “ministry” decides your care isn’t worthy of their support.

This comes on the heels of a recent study that found almost a third of all Americans have medical debt; in their efforts to pay off debt respondents made a number of sacrifices and suffered substantial financial consequences: (actual study and responses from KFF)

  • cutting back on household spending
  • more than four in ten say they or a household member have used up all or most of their savings
  • respondents reported skipping payment on other bills,
  • and delaying college or buying a home, or changing their housing situation, while
  • half of adults with health care debt say they have made what they feel to be a difficult sacrifice in order to pay down their debt
  • One in seven adults with health care debt say they have been denied care by a provider due to unpaid bills

Here’s the truly awful thing…the least fortunate among us are in the worst shape.

I get that some people have had good experiences with HCSMs. I also know others have not, and are now among those with crippling, life-changing medical debt.

What does this mean for you?

HCSMs are no silver bullet…rather they are a “send the check in and hope you are covered if you get hurt or sick” non-solution.

It’s a measure of just how dysfunctional our healthcare system is that HCSMs even exist.

Ed note – I’ve been holding off on this post for days, hoping to hear something from AHCSM. I’ve repeatedly asked the PR firm for more details; evidently the right folks haven’t been able to respond.

I first reached out to the PR contact on June 21, 2022…three weeks ago.

 


Jul
6

Healthcare Sharing Ministries – the latest

Healthcare costs are about to jump again, driven by exploding staffing expenses, continued healthcare provider consolidation, and the brilliant profiteering by some of the largest (mostly for-profit) healthcare systems.

So, what’s a family to do?

A few have turned to Healthcare Sharing Ministries, a thing that looks like health insurance but isn’t. HCSMs purport to “share” health care costs among members in what might best be described as a risk-pooling framework. Almost all claim to be “Christian”, they are largely unregulated (except as charities), don’t comply with insurance regulations or laws in most states, and most have requirements that members:

  • are in good health,
  • make a statement of Christian belief, attend church regularly, don’t use tobacco or have sex outside of marriage and
  • commit to taking care of their own health.

note there are ministries focused on other religious denominations.

So…sounds good right? cheaper healthcare is better…well, HCSMs also:

  • are not legally required to pay your medical bills,
  • require enrollees to do much of the groundwork to get bills paid (negotiate upfront with the provider, get all the paperwork and documentation, pay upfront then seek reimbursement)
  • medically underwrite – meaning they require disclosures of pre-existing conditions and can reject applicants for medical reasons,
  • can refuse coverage to anyone for any reason,
  • have limits on what they’ll pay for healthcare,
  • can’t guarantee healthcare providers will accept sharing ministry coverage, and
  • have appeals processes that aren’t subject to regulatory oversight.

Enrollment is a bit hard to nail down; the Alliance of Health Care Sharing Ministries claims 1.5 million enrollees although it doesn’t specify the year. Other reports indicate AHCSM reported membership was “over 1 million” in February of 2019. Other sources report membership closer to that 1 million figure.

HCSMs tend to be significantly cheaper than health insurance plans, making them increasingly attractive. However, most families that buy health insurance through the exchanges get major subsidies that significantly reduce their premiums.

There have been multiple reports of individuals and families stuck with huge bills after their “Ministry” refused to pay for care. Aliera Healthcare Inc. and Trinity Healthshares, Inc are the most visible example of what can happen without tight regulation. Regulators in multiple states issued cease and desist orders after concluding the companies violated laws; Aliera was found guilty of fraud and filed for bankruptcy late last year.

Tops among concerns is this – HCSMs are NOT required to have enough cash on hand to pay medical bills. Even more concerning, they don’t have to report their finances, cash reserves, expense ratios or other data.

There’s an effort underway to “accredit” HCSMs; the process/requirements don’t appear to address this critical issue and the accreditation board doesn’t include individuals with actuarial or financial credentials.

I’ve asked the lobbying outfit that purports to represent HCSMs for details on the financial portion of that accreditation process. So far they’ve been less than forthcoming.

What does this mean for you?

be very careful.

 


Joe Paduda is the principal of Health Strategy Associates

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