Insight, analysis & opinion from Joe Paduda

Jun
20

Workers’ comp pharmacy – the latest

We are finishing up our Annual Survey of Pharmacy Benefit Management in Workers’ Comp…here’s three findings from the 15+ we’ve done so far.

1) 60% of respondents are reporting an increase in overall drug spend – with reasons varying from more claims to an uptick in catastrophic cases to jurisdictional impacts.

While we’re a long way from done and more respondent data is coming in, if the trend continues this would be the second year of “non-decrease” in spend, signaling that the years-long drop in spend has stopped – and may have reversed.

This from last year’s Survey…this year’s will include 2022 and 2023 data.

2) Conversely, 80% of respondents are reporting lower opioid spend year over year. If other respondents’ data is consistent, this marks the seventh consecutive year of a decrease – wonderful news indeed as patients and providers choose safer – and often more effective – solutions to pain.
This from last year’s survey

3) Most respondents see a future for AI in the PBM world… but the emphasis is definitely on the future. There seems to be significant hesitation around implementing AI-based tools at this point. Ultimately, respondents see a range of “futures” – ranging from 100% automation of the entire process driven by AI to those who see AI focusing largely on early trend identification and clinical management improvements.

If you woulds like to participate, leave your info in the comment box below.

Public versions of our Annual Survey report are available for download here at no cost and no registration – note respondents get a much more detailed version of the report. 

Thanks to HSA’s Jay Stith and Helen Knight of CompPharma for their work on this year’s Survey.


Jun
19

Facility cost does NOT equal quality – part 4

Back to Florida… the home of many workers comp payers’ nightmares.

This time in Miami – where we find Kendall Hospital.  A large teaching hospital, level 1 trauma center, and…the most costly facility within a 10-mile radius.

Combining scores for patient safety, clinical outcomes, patient engagement and cost, Kendall Hospital ranks 6th out of 7 local facilities with a score of NEGATIVE .17 – largely due to its high cost but also because of its unpopularity with patients and below average clinical outcomes.

Kendall earns the worst score possible of -10 for cost – and for years has been one of the most expensive facilities in the area. Of the facilities in the area receiving a grade for patient satisfaction, Kendall ranks last with just a .8 out of 10 and scores a 3 out of 10 in clinical outcomes.

There’s one nearby hospital that scores waaaaay better on Health Strategy Associate’ proprietary Facility Assessment Tool; Larkin Community Hospital.

Larkin Community Hospital, earns a 0 for relative price (the LOWER the score for price the better)– the top score for the metric. It also scores 7 out of 10 for clinical outcomes (more than twice Kendall) and has a high patient safety rating at 8.3 out of 10.

Put it all together, and Larkin comes in as one of the top-rated facilities in all of Florida.

What does this mean for you?

Two things…how many of your patients are going to a very costly hospital with poor scores on patient safety and clinical outcomes?

And what are you going to do about it?

This post penned by Jay Stith, the brains behind HSA”s Facility Assessment Tool (c).


Jun
14

Good news Friday…jobs and wages are up, inflation’s down.

Going to be a nice weekend in New York’s Finger Lakes…hope it’s just as nice wherever you are…

Here’s the good stuff that happened this week…

Jobs and increasing wages

The economy is boomingadding over a quarter million jobs in May, continuing 41 consecutive months of job gains.

Wages increased over 4% year over year, driven mostly by the service sector.

Inflation’s dropping

Fox news reported “inflation cools more than expected in May” yesterday…the producer price index fell 2/10ths of a point, the biggest drop since October. (Producer prices are inflation measures at the wholesale level – before it reaches consumers)

The biggest driver???

Gas prices plummeted 7.1%.

Medical debt

The Consumer Financial Protection Bureau (CFPB) proposed a rule that would remove as much as $49 billion of medical debts that unjustly lowers credit scores for 15 million Americans.

The rule will:

  • strip medical bills from most credit reports,
  • increase privacy protections,
  • help to increase credit scores and loan approvals, and
  • prevent debt collectors from using the credit reporting system to coerce people to pay.

The CFPB was created to help consumers, and it has been remarkably effective. Bookmark the site for help with bank issues, junk fees, mortgage problems, credit  card fees, auto loans…

What does this mean for you?

More dollars in families’ pockets and more jobs + better debt ratings = happier people.

 


Jun
13

Heat exposure – OSHA makes progress and a Simple Question.

In a key step to help protect workers from excessive heat, OSHA’s Advisory Committee on Construction Safety and Health (ACCSH) met to review a draft rule’s initial regulatory framework.

While we wait for OSHA’s rule-making process to wend its way to fruition, inspections:

are happening under a National Emphasis Program intended to encourage “early interventions by employers to prevent illnesses and deaths among workers during high heat conditions…by adding an enforcement program targeting specific high-hazard industries or activities in workplaces where this hazard is prevalent during high heat conditions [emphasis added]

The OSHA instruction is here.

We all know increasing heat is endangering workers; more and more research demonstrates heat increases claims and can kill workers. While OSHA’s Rule will eventually be helpful it is unethical and immoral for us to wait on the Feds before we protect workers.

This is particularly timely as a massive heat wave slowly moves east…

Over the last couple of months I’ve made several attempts to get two of the industry’s better-known pundits – Bob Wilson and Mark Walls – to help encourage State and local government regulators and politicians to protect workers from increasing heat risks.

In the past Bob, Mark and I have worked together on issues including physician dispensing, TPA fee disclosure, opioid overuse, calling out politicians for really awful behavior, conference planning…lots of stuff.

Hoping Bob and Mark will lend their support to this effort – both are very influential and their advocacy would undoubtedly help save lives and prevent heat-related accidents.

In the meantime, local RIMS chapters and other industry groups should seriously consider adding heat to their agenda of work to be done.

What does this mean for you?

Depends…do we really want to protect workers and their families? 

Note – if you need proof this is bad and getting worse – there’s this.


Jun
10

Good news Monday…Government is working.

In Bentonville Arkansas last week for the boys’ annual mountain bike trip…30 years and counting…recovering from a long one Thursday meant no GNFriday.

So here we go…

Driving up I-81 last week I encountered LOTS of construction – bridge replacements, repaving, new guard rails, overpass improvements…got me wondering how much impact the Inflation Reduction Act is having on public roads.

A Shipload. As in almost $200 billion to do desperately needed maintenance in every state.

Plus new factories – and lots of high-paying jobs – in rural North Carolina, along with:

  • 13,000 bridge repair projects – including the notorious Brent Spence Bridge between Ohio and Kentucky
  • 257,000 miles of roads resurfaced and/or improved
  • more than 450 port and waterway projects
  • funding for more than 1,400 drinking water and wastewater treatment projects
  • $3 billion for replacing lead pipes.
  • 500 projects for water recycling, storage, conservation and desalination to improve resilience against drought in the Western U.S.

What’s different about the IRA and other new Federal funding is much has been driven by local governments – towns, cities and counties applying for grants to make big improvements.  This from TIME:

The Biden Administration and the 117th Congress did something radical: Together, they decided to invest in the ideas and aspirations coming from Main Streets across America, rather than from inside the Beltway.

What does this mean for you.

Safer roads and fewer accidents.

More construction jobs.

More demand for materials and equipment.

 


Jun
6

Heat and Virtue Signaling.

The single biggest risk to workers’ comp is heat.

Heat will have more impact on worker safety, injuries, and illness than any other single factor…a risk that will only increase as our planet heats up.

credit WCRI

Aside from a few very recent studies (kudos to WCRI and NCCI) and rare conference sessions the industry has ignored – and continues to ignore – heat.

Politicians have banned local governments from passing laws to protect workers.

Other pols have failed as well; with a very few exceptions states have neglected to pass and governors to sign legislation to protect workers.

Few “Thought leaders” have spoken out to warn their large audiences to protect workers and encourage politicians and regulators to legislate/promulgate regulations to protect workers, or even just to inform employers that claims will increase along with temperatures…kudos to Jeff Rush of CJPIA and LWCC’s Jill Leonard for their efforts.

Outside of WCRI and NCCI, conference planners (NWC’s Michelle Kerr comes to mind) may be the only stakeholder to make an effort – those efforts mostly rewarded with abysmally low attendance at sessions focused on climate change and heat’s impact on worker safety…

The industry has tried mightily to reform its image; Kids’ Chance, injured worker advocacy, behavioral health and addiction treatment support efforts have gone a long way to strengthen the brand…but all that good will melt away unless the industry’s thought leaders, regulators, employers and insurers do the right thing.

Hypocrisy is “Virtue signaling” while actively and purposely ignoring/discounting what heat will do to workers.

What does this mean for you?

Increasing heat means more kids will need a “chance”.

WCRI’s webinar discussing their research on heat is today

 


Jun
5

What’s up with Optum workers’ comp?

Yesterday’s non-announcement that ExamWorks bought Optum’s Settlement (MSA) business should not have been a surprise.

Word on the street is Optum’s been trying to off-load its PBM (pharmacy benefit management) and ancillary services businesses for some months now. That and – for those of us who’ve been in this business for a while – UnitedHealthcare’s history in workers comp make this almost inevitable.

Here’s what I wrote on this a few years ago:

…at various times, the company [UHC] owned:

  • a technology business focused on bill review (Power-Trak…later sold to Mitchell);
  • MetraComp, A WC PPO and managed care firm (and a former employer) and
  • Focus (this last of some interest to one reader in particular :)…also,
  • here is a brief note on UHC’s ill-fated entry into workers’ comp insurance back in the nineties. (spoiler alert – that damn tail will always get you.)
  • much more recently UHC’s Optum got into the work comp PBM business in a very big way, buying Catamaran.

So, this marks the sixth time (at least) UHC has gotten into-and-out-of workers’ comp and WC services.

VERY briefly, my educated view is:

UHC gets into WC as WC looks simple, is really inefficient, UHC likes to diversify (and in most instances does this quite successfully) and UHC is extremely self-confident.

And UHC gets out of WC because it is very complicated, has very limited upside, is a shrinking business, and distracts management from important stuff.

One data point...total national work comp medical spend is a bit over $30 billion. That is 1/12th of UHG’s total revenue.

What does this mean for you?

History predicts the future. 

 

 

 


Jun
3

ExamWorks acquires Optum’s Settlement Solutions business

The folks at ExamWorks reached out to me a while back about their MSP business, and specifically about a pending acquisition, namely Optum’s Settlement Solutions.

[Note there is no press release for this transaction; Optum requested ExamWorks not do a release.]

That has closed – today – so I can now publish my interview with Exam’s Christie Britt, President of ExamWorks Compliance Solutions… edited for clarity and brevity.

MCM – Why is Examworks focusing on the MSP space?

Britt – ECS has an established long history with MSP compliance, founded as Gould & Lamb in 2004 and merged with MedAllocators, and subsequently acquired by Examworks in 2014.  Medicare compliance has become increasingly complicated over the last fifteen years as the volume of liens has exploded and as CMS has taken steps to connect the dots to coordinate benefits.  MSP is very specialized, requiring expertise in claims systems, medical expertise, and Medicare compliance.  Payers are concerned about being compliant to avoid penalties and the risks must be addressed by specialists.

Our desire to be the leader in MSP compliance drives us to focus on this space.

MCM – How will this help ECS compete going forward?

Britt – ECS will bring to market the largest Section 111 Reporting program with the most file specifications to share data, the largest data aggregation engine, most configurable interfaces to accommodate the smallest to largest reporting clients and the most robust rules engine.

We will also have the largest team of MSP experts in the industry with the most tenured knowledge and experience to service the MSP industry.

MCM – Does ECS offer the full range of MSA/MSP services?

Britt – Yes, ECS will continue to offer the full suite of MSA / MSP Services for all customers.  Our core business is and will remain offering a fully integrated Section 111, MSA and conditional payment resolutions solution and tailored to our client’s risk appetite that fit seamlessly into any claim handling program.

MCM – The reporting issue is just one of the components of MSA/MSP services…how does this acquisition impact those other components?

Britt – Section 111 Reporting ties all aspects of MSP compliance together and can no longer be viewed as separate components. We are seeing CMS connect the last remaining “dots” by requiring Mandatory MSA reporting effective April 2025 (See more detail below). This changes the voluntary process of submitting an MSA to the WCRC for review and approval to a required reporting element that may generate a Civil Money Penalty if not handled appropriately.

This acquisition will impact the other areas of MSP compliance by providing a large portion of the industry with a solution that ties all aspects of MSP compliance together from the onset of the claim to its closure, designed to proactively identify claims that needs attention before they become a compliance issue and driving up the cost of the claim.

MCM – CMS continues to waffle around MSP and MSA requirements leading to confusion and uncertainty – and some strong disagreement among payers on core issues. What is ECS’ view on the importance/significance/utility of the MSA/MSP process?

Britt – Medicare has recently announced changes to Section 111 that will require payers to report an MSA amount on all reported workers’ comp settlements beginning with claims (including $0.00 settlements) that settle on or after April 4, 2025.

CMS promises to use this data to deny treatment at the point of sale, communicate with beneficiaries, and (if ignored) enforcement against the claims payer.

In addition, CMS has made a number of technical changes to tie section 111 data with the common working file to better coordinate benefits and pursue recovery for past Medicare payments.  Section 111 reporting is an important obligation required under federal law, and because CMS continues to build enforcement activities around it, MSP issues have more claims impacts today than really at any point in the past.  Take, for example, Medicare conditional payments (aka liens).  CMS continues to misapply Section 111 reporting data and attempt to recover from workers’ comp claims payers for dormant / closed claims and – even if the claim is open and active – for unrelated medical care.  For this reason, and many more, conditional payments are a major area of compliance that requires payers to be cognizant of the claims impact of Section 111 reporting.

What does this mean for you?

ExamWorks continues to grow.

Next – what’s up with Optum?


Jun
3

Good news Monday…Rowing!, Obamacare, Ukraine and EV sales

Friday was opening day of the Intercollegiate Rowing national championships, so I was all in on watching my beloved Syracuse Orange race in the heats…

Great result – 6th in the nation for the Varsity 8…

So, that’s the reason for today’s Good News Monday.

First up…Obamacare saved my life” – showing once again that government CAN do great stuff.

And Ms. Will’s story is hardly unique.

Inflation…the real story

Turns out a major driver of food prices has been price gouging by retailers.

As more light is shed on big food, we are learning the extent of the profiteering…

  • During its Q1 FY 2025, ending April 30, 2024, Walmart saw its “consolidated net income” climb to over $5.1 billion, a 205.1% increase YoY, as the grocery giant spent $1.6 billion on cash dividends and $1.1 billion on stock buybacks.
  • During its Q2 2024, Costco Wholesale reported an almost 19% increase in net income YoY, from $1.4 billion to more than $1.7 billion, as it spent $8 billion on cash dividends and $322 million on stock buybacks during the first half of its FY 2024.
  • In Q4 2023, Target saw its net earnings top $1.3 billion, a 57.8% increase YoY, as it spent $508 million on cash dividends.

The Senate held hearings upon this last week, shining a very bright light on the real cause of inflation.

Note – we live next to several farms…suffice it to say our neighbors aren’t seeing the big jump in profits the big corporations are…

Ukraine

At LONG LAST Ukraine is able to use US weapons to attack Russia. This long-overdue policy change has already led to major setbacks for Russia.

The also-long-overdue arms package for Ukraine is heavily involved…with just one attack taking out a major oil refinery while drones sank 7 Russian ships.

EV Sales

You’ve heard a lot about lagging sales of electric vehicles…well, reality is Tesla sales have cratered while others – Ford, Rivian, Mercedes, BMW, Hyundai, Kia are surging.

Ford’s sales of the Lightning and Mach-E are booming  – good news for American jobs and the environment. 

Gotta wonder if Tesla’s problems are due to its shoddy quality control and/or CEO Elon Musk’s declining popularity.

What does this mean for you…

Government can do good stuff – if politicians let it!


May
29

Cost Doesn’t Equal Quality – Same Health System Edition

Even when dealing with the same health system it is important to monitor the facilities you are directing care to.

In parts 1 and 2 of this series, we looked at two Florida facilities and showed the complete lack of correlation between the facility’s cost and the quality output.

Today, we look at three facilities ALL IN THE SAME HEALTH SYSTEM… IN THE SAME CITY… with differing costs and outputs.

Three HCA facilities: HCA Houston Healthcare Medical Center, HCA Houston Healthcare West, and HCA Houston Healthcare Northwest – all within 40 minutes of each other.

Based on data from Health Strategy Associate’s Facility Assessment Tool, HCA Houston Healthcare Medical Center is superior across the board when compared to HCA Houston Healthcare Northwest and equal to or better than HCA Houston Healthcare West.

Versus West and Northwest, the clinical outcomes from HCA Houston Healthcare Medical Center are more than 2x the other two. The patients… AKA your clients… are more than 2x as content with HCA Houston Healthcare Medical Center and you/your boss/your board/your shareholders will be too when you pay less for higher quality care.

Again, higher quality facility at a lower price.

Shop Around! This dynamic occurs all over the country – check your utilization and your network to make sure you know just what facilities you are using. 


Joe Paduda is the principal of Health Strategy Associates

SUBSCRIBE BY EMAIL

SEARCH THIS SITE

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.

 

DISCLAIMER

© Joe Paduda 2024. We encourage links to any material on this page. Fair use excerpts of material written by Joe Paduda may be used with attribution to Joe Paduda, Managed Care Matters.

Note: Some material on this page may be excerpted from other sources. In such cases, copyright is retained by the respective authors of those sources.

ARCHIVES

Archives