Insight, analysis & opinion from Joe Paduda


What happened while some of us were in Las Vegas

WCRI posted lots of excellent research, and topped it off with a webinar…I’ll be diving into these later this week, but for those chomping at the bit, here’s a brief summary.

The research included a:

…and an excellent webinar o the effects of Opioid-related Policies on Opioid Utilization after Work-related Injuries – you can watch the webinar here – no charge!

PhRMA appears to be holding off efforts to enable the government to negotiate drug prices for Medicare and Medicaid members; the $22.4 million it spent on lobbying is a pittance compared to the profits the industry is generating. Three Democrats in states with lots of Pharma companies appear to be holding things up, soaking up big bucks in campaign donations in the process.

And then there’s COVID

New research indicates “natural immunity from a COVID-19 infection fades quickly, leaving individuals susceptible to reinfection.” Published in The Lancet, the study found a previous COVID infection does not provide much protection against re0infection.

Research published by the Kaiser Family Foundation indicates 90,000 of our family members, dear friends, colleagues and co-workers didn’t have to die of COVID.  That’s the estimated number of additional deaths due to failures to be vaccinated.

Oh, and the number of vaccinated people who died of COVID was tiny by comparison, so don’t believe that BS about Colin Powell.

Health systems are ramping up terminations of  workers who refuse to get vaccinated  – but the number of employees fired remains pretty low.

What does this mean for you?

WCRI does great work.

Get vaccinated and wear a mask.


National Work Comp – general impressions

Yes, attendance was way down.

Yes, the exhibit hall was pretty quiet.

Yes, it was really good to see old friends and colleagues, to re-connect and just smile at each other live, in person, and not in 2D.

Yes, it was a bit hard to connect names to faces when those faces haven’t been seen live in a too long and were mostly covered by masks…and

Yes, dealing with reading glasses, hearing aids (yep, that’s me) and masks can be pretty challenging.

What’s new.

Mental Health/behavioral health were big topics – and that is excellent/terrific/welcome indeed. Carisk announced a partnership with Tower MSA and Ametros to help resolve and settle claims; behavioral health issues are often the primary reason claimants are reluctant to settle. (Carisk is an HSA consulting client)

AI. Lots of AI. Tons of AI. Fraud detection AI. Claim processing AI. Voice Response AI. Chatbot AI. My bet is we’ll be seeing even more of it, as the biggest challenge most payers have these days is staff.

Catching up with colleagues in the payer world, every one noted adjusting talent is:

  • getting older,
  • getting crankier (well, this is a bit unfair, but adjuster dissatisfaction was definitely a topic),
  • leaving for better pay,
  • leaving for better conditions (be careful, the grass may well be greener because there is more fertilizer on it…)
  • and really hard to find.

So, here comes AI to hopefully increase job satisfaction and reduce the number of low-value clerical-type tasks so adjusters can actually, you know, manage claims.

And, adding behavioral health expertise to the claims management process will help reduce claim inventory, further reducing adjusters’ work load.

Enlyte is the new name for the Mitchell/Genex/Coventry business...personally I’m not a fan – I would have preferred Magic as that’s way cooler and kind of ties back to the MGC thing.  Also not a fan of the consolidation of all customer facing stuff into a central entity. In a past life I sold group insurance for Liberty Mutual; While I was really good at selling group health and disability, I was way less than any good at selling retirement plans  – which I had to do if iIwas going to get the commission multiplier.

No one else was any good at it either, so much so that Liberty dropped the requirement that we sell retirement plans.

Nina Smith has the unenviable task of trying to get Mitchell bill review people to sell Genex stuff, Coventry’s network experts to sell Genex stuff… you get the picture. Ok, you say, Mitchell has been “selling” networks for a long time, Coventry used to sell bill review, Genex has been doing both. While this seems pretty straightforward, it is not. I can assure you it will take a lot of time, a lot of handholding, and a lot of patience.

Masks were required, but I saw too many people, including some I know well who didn’t wear them. That is disrespectful at best and just not smart. The reason:

  • attendance was way down,
  • many companies didn’t attend, and
  • this country hasn’t gotten back to “normal”,
  • which means claims counts are still low
  • and premiums are too

is because too many people have listened to claptrap and nonsense (I know, I really want to swear…) and for whatever dumb and completely unfounded reason won’t wear a mask to protect the rest of us – and themselves.

I feel for the event planners and folks behind this; while I don’t have official attendance numbers, this place is nowhere near as busy as it has been at past events. No taxi line, no problem getting a table for breakfast, fewer folks walking around in business casual.

Putting on a conference is a shipload of work, especially these days. While I lament the very real issue of pay-to-play, the conference owners need to make a buck, something they haven’t for far too long.

What does this mean for you?

Until and unless we all get vaccinated and wear masks we will not put COVID in the rear view mirror.

I thanked Denise Algire and Michelle Kerr for all the work that went into this – and you should too.




National Work Comp Conference – last minute advice

The annual gathering of the work comp tribes begins today – I’m reprising a post from a couple years ago on lessons I’ve learned

1.  Realize you can’t be everywhere and do everything. Prioritize.

2.  Leave time for last-minute meetings and the inevitable chance encounters with old friends and colleagues.

3.  Unless you have a photographic memory, use your smartphone to take voice notes from each meeting – right after you’re done – or write down key points immediately.  Otherwise they’ll all run together and you’ll never remember what you committed to.

4.  Introduce yourself to a dozen people you’ve never met.  This business is all about relationships and networking, and no better place to do that than this conference.

5.  Wear comfortable shoes, get your exercise in, and be professional and polished.  It’s a long three days, and you’re always ‘on’.

Finally, in these day of YouTube, phone cameras, Twitter, Instachat and SnapGram, what you do is public knowledge.  That slick dance move or intense conversation with a private equity exec just might re-appear – to your dismay.

And beware the white man’s overbite!!!


Prepping for the National Comp Conference

Looking forward to next week’s National Comp Conference, sort of old home week for the WC industry.

A few sessions caught my eye…

Ceil Jung and Sylvia Sacalis will be discussing infectious diseases in the workplace Wednesday at 11 am local time.

Erica Fichter, Teresa Williams, and Dawn Soleta will dive into protecting employee mental health and well-being. This is one of those sessions we all wish we’d had before things got so…weird.  2:30 Wednesday is the time slot,

which unfortunately is the same time John Hanna, former Pharmacy Director at Ohio’s Bureau of Workers’ Compensation and I will be digging into the details of PBM program leakage. Join us Wednesday at 2:30.

Legendary pharmacy expert Phil Walls RPh and the very knowledgeable Adam Seidner MD are going to unpack issues related to the use of antidepressants Thursday at 10:45. Kudos to the duo for encouraging non-medication approaches to helping workers recover their mental health.

A note of appreciation to the conference planners – this year there is a lot of focus on mental health and related matters, a topic that has long been neglected.

One session that grabbed my attention is focusing on the cost and impact of mental health issues for both disability and workers’ comp. Michael Lacroix, the Hartford’s Medical Director and Pamela Bloom-Pugliese are the speakers – alas this is also scheduled for 10:45 on Thursday…

Cliff Belliveau is brilliant – his Thursday afternoon session will offer a brief guide to interpreting data to help you understand the importance of clinical interventions, drivers and solutions to specific pharmacy issues.

Make sure to stick around for Stuart Colburn and Mark Pew’s session focusing on defusing distrust Thursday at 4:45. With trust comes rapid progress…Stuart is also leading a 60 tips in 60 minutes session Friday am – also focused on mental health related issues.

Travel smart and safe, don’t shake hands, and let’s all learn a lot and care for each other.



Sticks, carrots, and vaccinations

Delta (my favorite airline) isn’t forcing employees to get vaccinated.  It is charging the unvaxxed more for health insurance.

Ochsner Health system in Louisiana is following suit, adding the same surcharge for spouses or partners that are not vaxxed in an effort to help cover the $9 million in costs the system spent on caring for workers infected with COVID – and pay for future expenses. The unvaxxed will have to pay $200 more per month and comply with strict testing requirements.

Financial giant JPMorgan will charge unvaxxed employees more for health insurance as of January 1 2022.

Those who come down with COVID are also going to see higher out-of-pocket costs as more insurers pull back on the first-dollar coverage they were providing for COVID care. Average out-of-pocket costs around $3,800 are expected for unvaxxed patients hospitalized for COVID treatment.

While a lawsuit has been filed by some Ochsner employees seeking to overturn the surcharge, legal experts dismiss any chance of success. CMS has told self-insured employers they cannot refuse to provide coverage for unvaxxed patients’ COVID care, but they can charge those members more. This is consistent with regulations regarding tobacco use, which can result in insurance surcharges.

Meanwhile, many of Delta’s competitors are mandating vaccines, perhaps in part because unvaxxed workers mostly comply with mandates. And all the data to date indicates the vast majority of workers are getting the shot rather than the heave-ho.

One expert noted the surcharges are a powerful emotional tool, stating:

“There is this idea of loss aversion, that losses are weighed more heavily than gains, so a $200 incentive will not have as much influence as a $200 fine.”

What does this mean for you?

Unfortunately, sticks seem to be more effective than carrots, at least for the most committed of the vaccine holdouts.


COVID, care rationing, and consequences thereof

Hospitals in Idaho, Alaska, Alabama, Montana and other states are rationing care – a painful decision necessitated by unvaccinated patients suffering from severe COVID infections overwhelming available facilities.

In Idaho, the State Department of Health and Welfare now “allows hospitals to allot scarce resources like intensive care unit rooms to patients most likely to survive and make other dramatic changes to the way they treat patients.

  • In Kootenai Health’s ICU, one critical care nurse might be supervising up to six patients with the help of two other non-critical care nurses. The usual ratio is one ICU nurse for one ICU patient.
  • “nearly 92% of all of the COVID-19 patients in St. Luke’s hospitals were unvaccinated. Sixty-one of the hospital’s 78 ICU patients had COVID-19.”

A Montana hospital “was also forced to implement crisis standards of care amid a surge in COVID-19 patients” when all critical care beds were already occupied.

In Houston Texas, a military veteran died when no hospitals near him had space or staff to treat a sudden case of gallstone pancreatitis.

A 73 year old Alabama man died of a cardiac condition when the hospital in his hometown of Cullman, Ala., contacted 43 others in three states — and all were unable to give him the care he needed. Three weeks ago there were 60 more ICU patients than beds in ICUs.

There are many. many more examples.

This. Should. Never. Have. Happened.

And wouldn’t have if not for COVID deniers, anti-vaxxers, and the media channels that gave them a megaphone to spread their nonsense.

Getting anti-vaxxers to change their views is incredibly difficult; the media is replete with stories of COVID patients telling their doctors they don’t believe they have the virus (look them up).

Medical providers’s option is stark indeed – treat the patients with a self-inflicted disease, or send them home…and treat the heart attack, car crash, pancreatitis, stroke, burn, asthma attack and other patients.

It has come to this.

What does this mean for you?

With personal choice comes personal responsibility. 


Friday catch up

Let’s spend a minute on all things workers’ comp – and one COVID note.

First up, the fine folk at WCRI – in particular the eminent Bogdan Savych PhD – are putting on a free webinar on the

Effects of Opioid-Related Policies on Work-Related Injuries

– register here. This is particularly helpful for me; I’m helping out on a Federal research project comparing outcomes, impacts, and patient experiences from opioid programs and regulations in Washington and Ohio. Thanks to all taxpayers for helping fund this project – this is some really interesting work that I am quite sure will increase our understanding of opioid management.

NCCI just released their annual analysis of work comp industry reserves… And boy oh boy are there are a LOT of extra reserves sitting in payers’ coffers.

Key takeaway – NCCI-projected industry loss and LAE ratios continue to be below those reported by carriers.

Said another way, carriers are NOT releasing these excess reserves in the form of dividends or credits or whatever. My take – carriers are salting away dollars to protect their future profits from the inevitable – but much delayed – market turn.

While one may think this is a one-time difference between carriers and NCCI, the data clearly shows otherwise.  Over the last decade insurers have consistently over-estimated claims and admin costs  – especially from 2014 to 2017. (graph courtesy NCCI)

So here’s my take – carriers are over-reserving because their actuaries haven’t yet figured out the rapid decrease in opioid utilization is having a major impact on claim duration, indemnity expense and medical costs. Carriers were well behind the curve when opioid use exploded in the middle of the last decade, and they are repeating that error now on the downside.

As a long-time – as in 27 years – consultant, I’m always on the lookout for advice for clients about working with consultants. Great piece in Harvard Business Review on that topic…key takeaways are consistent with my experience:

  • first and most important, spend the time to define the problem(s) you are looking to solve for. That will save untold weeks – and thousands of dollars billed
  • all parties should be humble and very open-minded – including the consultant
  • don’t assume you know the solution; going to RFP should be an option, but not the first one to address a market need, performance issue or vendor problem

File this away and pull it out next time you look to engage a consultant – me or anyone else!

One COVID fact check…I’ve heard from a couple folks that migrants on the southern border are a major source of COVID infections – partially because they aren’t being tested. Well, all are being tested, and the test positivity rate is actually much lower than among residents of border counties.

(note that a recent report indicating 18-20% of migrants leaving Border Patrol custody tested positive specifically includes ONLY those migrants targeted for “expedited removal” and thus is not a complete sample of all migrants)

While those two data points don’t completely address the assertion that migrants are the cause of infections (and there’s no way to prove or disprove that assertion) – it is clear that COVID infections in those border counties would be a lot lower if more residents wore masks and were vaccinated.

What does this mean for you?

Always check your sources, be humble, and do your research.


Yesterday’s post

Did exactly what it was intended to do – engaged with a lot of people, bluntly stating what many are thinking.

Some of the willingly unvaccinated are very good friends, people I admire, respect, and care about. It grieves me to no end that we are so far apart on this issue, and that it has come to this.

The title and some of the language offended a few (out of 2567 subscribers, 21 unsubscribed). While I absolutely do not apologize for my language I do understand why you may have been offended. Long time readers know that I almost never curse on MCM (although I am more profane in person); I think I’ve used profanity fewer than 5 times in over 3500 posts.

On the other side, 8 new subscribers signed up and comments and private emails were overwhelmingly supportive.

What is apparent is this.  Anger with the willfully unvaccinated is growing, and for very good reason. Unless you are a Native or Black American or have a legitimate medical issue, you have no valid reason to put your family and friends and the rest of us at risk because you don’t want to get the vaccine.

(Native and Black Americans should absolutely get vaccinated; however knowing how we killed millions of Native Americans and infected Blacks in the name of science one can certainly understand vaccine fears, fears we must overcome.)

You have already been vaccinated to protect you from polio, mumps, measles, rubella, and many other childhood ailments. Many of us have vaccinations protecting us from the flu, tetanus, rabies, shingles and myriad other diseases.

You didn’t rebel, protest, or demonstrate when your kids had to get those vaccinations to attend school.

You didn’t scream and shout when you asked for a shingles vaccine to protect you from this painful and debilitating infection.

No one was outraged when we effectively ended small pox and polio infections through mass vaccinations.

So ask yourself – why are you so angry about COVID vaccines?  And be honest. Do not spout meaningless nonsense you read somewhere on Facebook about VAERS or breakthrough infection issues or other blather. We are done refuting arguments that don’t stand up to the most cursory examination.

And I will publicly call out commenters who spout such idiocy.

The reason is tribalism. You and your friends and family have been duped into making COVID a divisive issue, to separate us and push us apart. After 20 months of attempting to educate, inform, discuss and debate, the majority of Americans are fed up with your intransigence, your willful ignorance, your refusal to accept the science.

I have tried and tried and tried again, writing over 120 posts about COVID only to be met with the same tissue-thin arguments based on nothing but a Facebook post.

So, we are done with you.

If you refuse to get vaccinated, then you get to own the consequences of your decision. You tout personal responsibility, you teach your kids to be responsible, you demand it of your elected officials, then fine – you get to:

  • lose your job,
  • pay for all your COVID-related medical care, and
  • be sued for the care of others you infect.

What does this mean for you?

Your decisions have consequences. Own them.


Get a goddamn vaccination and wear a goddamn mask.

Warning – I am really pissed off.

We are very close to several clinicians that work in medical facilities. They are overwhelmed with COVID patients – almost all of whom are unvaccinated. It is devastating to talk with these medical professionals, to hear their pain and immense frustration and anger and fear.

There are no more beds in the Pediatric ICU, no more ecmo machines available for anyone – covid patients or not. Many procedures are being postponed indefinitely because unvaccinated COVID patients are occupying all the beds, Unvaccinated COVID patients are sucking up all the care, all the energy, all the will and desire and expertise and passion and patience and resilience.

All because many Americans allow themselves to be duped into believing somehow COVID isn’t a problem, that kids won’t be affected, that vaccinations are dangerous, that bullshit from right wing pundits is more believable than facts from scientists or pleas from physicians.

And this is just one hospital, albeit a very big one that serves a very large area. Hospital beds in eastern Washington are full to beyond capacity because idiots in Idaho aren’t vaccinated. Hospitals in Florida, Mississippi, Missouri, and many other states are also overwhelmed, all because total assholes who know better are lying to people.

Hospitals in several states are doing battle triage – meaning if you are in a horrendous car accident, have a stroke or an embolism or fall off a ladder, if your baby falls in a pool or your mother falls down the stairs you/them are gonna die because the facilities and doctors you need are too busy caring for fucking idiots who refused to get vaccinated and are now dying of COVID.

This isn’t a short term problem.

Nurses doctors and other staff are running away from patient care because they cannot stomach treating yet another idiot for a dangerous disease because they were too lazy, too willfully ignorant, too willing to listen to some asshole on Facebook and not believe science, facts, nurses, doctors.

This is deeply personal for many. If your baby has a respiratory problem, good luck finding a facility with room and time and facilities needed to care for your baby – they are full with kids who got infected because assholes refused to get vaccinated.  Same thing with ICUs and CCUs, cath labs and operating rooms.

Republicans in many states are trying to pass laws allowing people to not get vaccinated, to not wear masks, in the name of “freedom.” I am done being politically correct when describing these pandering assholes.

They are the real baby-killers.

Through their willful ignorance, their calculating refusal to serve the people that elected them because they want more votes, their shameless pandering, more babies will die. more kids will be infected, more grandparents will be lost, more hospitals will close, more doctors and nurses will abandon their work.

The rightwing conspiracy-fomenting media decries the lack of “science” behind vaccinations, while touting a goddamn horse pill. These assholes recommend breathing in bleach – an incredibly stupid and dangerous idea with NO basis in science.

Personal freedom my ass.

We conquered polio, measles, chicken pox, small pox, mumps, diphtheria and countless other diseases by vaccinating people. You have had many vaccinations, and you are doing just fine.

If you don’t want a vaccine, fine.

You don’t get healthcare when you get COVID.

So goddamn confident in your beliefs and so committed to your “personal choice”? Fine.

You won’t need healthcare, and neither will your kids, mom, or grandparents, so the rest of us can get our heart bypasses, kidney transplants, cancer treatment, hip replacements, and emergency surgery.

Don’t be a goddamn hypocrite. Either get vaccinated and wear a mask, or stay the hell away from the rest of us, take your ivermectin, breathe in bleach, and bury your relatives by yourself.

Oh, and tell the mom with the sick baby who can’t find a Pediatric ICU bed that your personal freedom to be a complete idiot is more important than her baby’s life.

And I don’t want to hear any bullshit from COVID deniers and vaccine opponents. I am done trying to be polite, to explain, to use reason and facts and logic.






Consolidation in work comp services – comments on Conduent

As we march thru the list of big bigger and likely gonna-be-biggest WC services entities, we are now at the single service providers.

This won’t take much time.  Conduent is the leader in market share in workers’ comp bill review applications followed by Mitchell and Medata; the company claims 50% market share which sounds about right although the claimed “savings” of $16 billion is just nonsense (as it likely reflects reductions below billed charges, which we all know are not “savings”).

Back in the day there were lots more bill review applications and providers; PowerTrak, CompIQ, Smartadviser, Corporate Systems and CS Stars, (can’t remember their applications’ names). Strataware is Conduent’s application;  Stratacare – owners of Strataware – was acquired 7 years ago when Xerox bought ISG Holdings (ISG had previously acquired Stratacare)

Back in late 2018 we did a survey of bill review in workers’ compensation; (Conduent’s predecessor came out pretty well, Conduent not so much). I also conducted BR Surveys in 2009 and 2012).

There have been rumors aplenty about Conduent potentially selling its BR application. The company has suffered through staff departures, ditched the CompIQ platform, and gone thru too many senior staff of late. While still the largest player in the workers’ comp bill review application space, it is apparent Conduent has yet to figure out how to right the ship and set it on a steady and improving course. 

The problems extend beyond work comp bill review.

Overall, Conduent’s revenue declined rather precipitously from $5.4 billion in 2018 to $4.2 billion in 2020; work comp bill review is included in the “commercial healthcare solutions” category, which saw a smaller drop from $445 million to $431 million over that period (see p 73).

The CEO’s discussion of Conduent’s pretty poor results is a classic example of corporate speak…

Going forward, we will assess our diverse portfolio and apply a differentiated investment strategy to optimize, enhance and expand our solutions as necessary based on the needs of our clients. We are focused on positioning Conduent for long-term success and driving value for clients and shareholders.

Net is I don’t see Conduent adding to its workers’ comp portfolio; if anything Stratacare may be sold if/when Conduent’s Board decides it has had enough of poor results and restructures the company/changes leadership.

What does this mean for you?

Strataware’s future will be driven by larger issues – and hopefully resolution of those issues – at Conduent. 

If/when Stratacare is sold off, expect the other big players in workers’ comp services to be the likely buyers.


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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