Insight, analysis & opinion from Joe Paduda

Mar
15

Medicaid

Checking in on Medicaid…41 states have expanded Medicaid, and by dribs and drabs some of the holdouts are moving to do the same.

Georgia may well be the next state to follow suit; a court recently ruled in favor of the Peach State’s approach.

Medicaid is one of those rare programs that delivers way more than it costs – economic impact is strongly positive, beneficiaries are much more likely to be healthy enough to work, clinical outcomes improve…

Oh, and uncompensated care costs drop – a LOT…so health systems and hospitals have less incentive to hoover dollars out of employers’ pockets.

Infrastructure investment – Billions of dollars will be invested to  improve infrastructure in places that need it most. From WaPo:

Earlier this week the White House unveiled $3.3 billion in federal grants to remove or retrofit highways that separate minority neighborhoods in many cities from jobs, entertainment centers, hospitals and other services.

In one of my adopted hometowns – Syracuse – the process is well underway. This rights a wrong done decades ago when politicians steamrolled poor folks in poor neighborhoods to build highways to suburbs.

Employment and long-term care

Yes, healthcare worker staffing is a big issue...the good news is much of the potential shortfall can be addressed by immigrants. 

Longterm care is particularly affected…three out of ten workers in long term care are adult immigrants.

What does this mean for you?

More opportunities, improved health, and more healthcare workers = a better place to live and work and raise a family.


Mar
13

Hackers disable nation’s largest healthcare data interchange

A major cyber attack has crippled the nation’s largest healthcare authorization and payment system, leading to weeks of missed payments.

From WaPo:

The hackers stole data about patients, encrypted company files and demanded money to unlock them. Change Healthcare subsequently shut down most of its network as it tried to recover.

The system owned by Change Healthcare, a subsidiary of United Healthcare, has been down since February 21; reports indicate BlackCat, a shadowy hacking group is responsible. BlackCat and/or a closely related entity reportedly received what appears to be a ransom payment of $22 million

UHC reported Change’s pharmacy processing functionality had been restored last week, and its

electronic payment platform would be reestablished beginning March 15, and that it expected to start testing and establishing claims network connectivity on March 18, with service restored through the week.

Don’t expect a full recovery then; that’s the date UHC will start testing a rebuilt system.

Change’s electronic communications, billing and payment system handles everything from utilization review to bill submission to validation to payment and reconciliation for hospitals, health systems, provider groups, clinics, specialty providers, pharmacies and Pharmacy Benefit Managers.

According to Change, the system handles about 15 billion transactions a year, or about half of all medical claims.

What does this mean for you?

P&C insurance execs and Boards should re-think  their chronic under-investment in all things IT.

note: HSA consulted for Change prior to its acquisition by UHG in 2022.


Mar
12

It’s a stutter.

I had a bad stutter for years,

From mid-seventh grade up thru high school I struggled mightily to get the words out, to avoid humiliation, laughter, scorn and – worst of all – pity.

As a formerly eloquent speaker and school play actor I had no idea what happened, why, how to fix it, and whether I’d ever be able to stand up in front of people and just…say   my   name.

It came and went for years after high school…I have a very painful recollection of  stuttering badly while giving a talk about exercise physiology during graduate school, watching the group suffer along with me.

Over the years I forced myself into situations again and again as I tried to overcome stuttering…for reasons unknown my stutter eventually faded into a distant if very painful memory.

I relate this because I am appalled by the media’s laziness, stupidity, crassness, and total lack of empathy all on full display when discussing President Biden’s occasional word stumbles. He’s not going thru dementia, nor does he have Alzheimer’s, and he’s not suffering the after-effects of a stroke.

Nope, he’s got a stutter.

Unlike me, the President has not fully conquered his stutter, yet he puts himself out there every day, knowing all too well he’s going to be laughed at, mocked, and demeaned because he stutters.

The meme-makers, mockers and insulters are pathetic indeed, seeking to drag down a person because of a sometimes-disabling condition, to use Biden’s condition to make them feel better about themselves, to get a cheap laugh from equally-pathetic barroom morons.

As for the media, I am furious with TV anchors, pundits, reporters, and editors for failing to address this consistently, fairly and completely. No, these superficial “personalities” would much rather parrot the “he’s old, see he can’t finish a sentence, mixes up his words, mumbles at times, and veers off track…” idiocy.

Well, you idiots masquerading as media those are ALL STRATEGIES STUTTERERS USE TO TRY TO GET THE WORDS OUT.

Mumbling hides stutters.

Mixing up words happens when you are desperately trying to find a word to use instead of the word that’s stuck in your throat.

Not finishing a sentence is because you can’t get the last words out without stuttering.

Going off track – same..

What does this mean for you?

How would you feel if you stuttered? Couldn’t communicate verbally? Got laughed at for something you can’t control?

I thought so.    So don’t be a jerk.

 


Mar
11

WCRI – the heat is on.

Kudos to WCRI – it is the first workers’ comp research organization to give center stage to the impact of climate change – primarily heat – on workers’ comp claims.

Dr David Bonauto of Washington’s Labor & Industry (state WC fund) led a session on Washington’s analysis of climate change’s affects on workers. A few quick takeaways…

There have been three studies re Heat Related Illness (HRI) in WA based on 16 years of data.  There were only about 850 accepted HRI claims out of 1.7 million…but the hidden impacts of heat are just beginning to be understood.

  • Heat increases absorption of chemicals thru the skin and potentially increases toxicity, a major concern for ag workers working with insecticides and fertilizers
  • Heat and wildfire smoke increases cardiovascular disease; it appears the mechanism is chronic inflammation.
  • Excessive heat leads to “incredibly diminished productivity”
  • There is a much higher [67%] risk of injury when temperatures are above 82-86 degrees compared to a baseline of 76 degrees.
  • The most vulnerable industry?   Public administration…my guess is this is driven by first responders and fire fighters.

thanks to MTI America’s Nikki Jackson for the slide pic

WA L&I isn’t the only organization doing credible research – WCRI research found 14% more claims occurred at times of high heat – think of these as indirectly related injuries. Falls off ladders are an example.  Great to see WCRI dig into this, although it would have been even better if we had this information several years ago.

The second employer session provided much-needed perspective from executives dating with the fallout from climate change.

Joann Moynihan from Travelers said the industry needs to broaden this dicsussion…it’s not heat claims specifically, but heat-related claims…Ms Moynihan’s words to the effect of “this is an indication of where the. industry is headed” should be a wake-up call to stakeholders who are mostly sleepwalking through massive changes to the work environment. 

Chrissy Lynch of the Massachusetts AFL/CIO described how workers in Mass are now dealing with forest fires…”we never thought we would”…that and it “doesn’t really snow here any more…we are trying to figure things out on the fly.

What does this mean for you.

Wake the *&^%** up. 


Mar
8

Good news Friday!…jobs and pay are both up!

275,000 new jobs last month – VERY good news indeed!

Since the beginning of 2021, over 10 million jobs have been created.

Yesterday’s jobs report showed strong employment growth across multiple industries;

 

Over the last 3+ years, 800,000 manufacturing jobs have been created..

Along with big job increases, wages are up too.

Last month average hourly earnings rose to $34.57 – a 4.3% increase YoY. (that’s about $69,000 a year)

From USAToday:

“Since the spring of last year, pay increases have outpaced inflation, giving consumers more purchasing power.”

What does this mean for you?

More jobs + higher wages = more payroll + more consumers buying more stuff.

Note – thanks very much to several folks at WCRI who thanked me for doing the Good News Friday posts – I appreciate you.

J.  – thanks for sharing that even though we may have different political views, you appreciate the posts.

Have a most excellent weekend!


Mar
6

To know why some think the US healthcare system is going to get better and cheaper – and why I strongly disagree, read on.

David Cutler PhD led off the WCRI’s confab with a discussion of the future of healthcare. It was GREAT that a conference has finally tried to educate work comp people about healthcare – after all that is the biggest driver of workers’ comp.  Sorely needed.

But…(more on that in a minute)

Dr Cutler noted that US healthcare is about as unstable as it has been for some time. And there is much more uncertainty to come.

He then asked the audience to vote on whether healthcare will get better and cheaper, stay the same, or collapse.

I voted collapse.

He also differentiated between “Trend” and “Wiggle”, noting it is important to consider what is actually a trend vs what is more likely slight ups and downs – need to differentiate between one-time factors and overall structural issues with long-lasting implications.

Cutler attributes consolidation among small providers to the drop off in patient service demand; that is, demand for providers’ services declined and therefore the smaller providers needed to merge or be acquired. I’d note that Cutler did not mention other factors driving consolidation, namely:

  • Interoperability (CMS IT requirements that can be a big lift)
  • small office staffing woes,
  • office operational expense increases, and
  • PE buyouts that make owners wealthy overnight.

Why Cutler is positive about the future of the US healthcare system

  • Delivery of medical care (number of services rendered) fell off during covid and really hasn’t fully recovered, which implies there are fewer unnecessary procedures/visits/treatments these days. (assumes the decline was mostly in unneeded services)
  • Elective stuff didn’t come back – such as hip replacements, shoulder surgery, etc.
  • Staff shortages are less of an issue of late

Dr Cutler also noted that in his view, medical staff burnout and labor force withdrawal from healthcare delivery roles will be temporary…Employment is coming back.

Very briefly, Dr Cutler’s thinking is that hospitals have too many beds; a lot of care has moved to outpatient facilities and ambulatory surgical centers (ASCs)…as a result hospitals will close floors, other hospitals will close, and the need for nurses in hospitals will thus decline.

Notably, Dr Cutler provided data from CMS to build a case that healthcare itself is better controlled – Medicare growth has been relatively flat over the last few years, and some analysts believe this has reduced total spend by several trillion dollars.

Finally, Dr Cutler also discussed value-based care and the move to bundled care, I suppose as evidence that healthcare is getting more efficient.

So here’s the “But…” in which I respectfully disagreed – and and still do disagree – with Cutler’s optimistic outlook.

Cutler – Shift of care away from and hospital closures will reduce costs and staffing needs

MCM – I don’t have the data, and I’m sure Dr Cutler does, but there’s both anecdotal “evidence” (family members have left patient care for other jobs in healthcare) and actual research that clinical staff shortages are NOT moderating.

Here’s rather compelling evidence that the shortage is NOT going away.

According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country through 2030. In this state-by-state analysis, the authors forecast a significant RN shortage in 30 states with the most intense shortage in the Western region of the U.S.

Perhaps Dr Cutler is talking over the very long term – and perhaps the Journal’s authors are not accounting for the shift in care to outpatient facilities.

Perhaps. On the other hand, change is very, very slow in healthcare.

Also, hospitals are major assets, assets which are providing a ton of revenue to the health system or hospital’s owners. Sure, many owners might like to walk away…but they can’t – not without huge pressure from unions, workers, communities and politicians. So, they’ll do anything they can to keep the patients coming, to keep the hospital open – if they don’t they will go belly up – oh and some of the hospital’s execs will not have jobs.

Cutler – Value-based care is saving money…

MCM – There is very little evidence that VBC actually saves money, and a lot of evidence that it doesn’t. In fact, a CBO study indicates that overall, well-funded, well-designed and well-run VBC initiatives actually resulted in higher costs. I’d note that some disagree with CBO’s results. – however those disagreements generally focus around better outcomes, health indicators and the like – NOT on cost reductions.

Cutler – Medicare spending is below predictions thus healthcare is less costly

MCM – But other payer spend has not.

Yes, Medicare’s costs have been below predictions…but that’s NOT the case for individual insurance, group health and Medicaid spend – which has has increased.

To be fair, Cutler agreed with my comment (which I made after his talk), but noted Medicaid spend per enrollee has declined.

He is correct…however in my view but likely because the expansion of Medicaid involved more healthier people being signed up before and during the COVID emergency.  And, their costs prior to enrollment were likely uncompensated care…so my take is overall medical costs weren’t reduced, just shifted to a different payer.

At least for the next few years – and likely longer – the “shiftee”, dear reader, is often workers’ comp.

Finally, good friend and colleague Gary Anderberg PhD of Gallagher Bassett commented that all of us are getting older and sicker and how does that factor into predictions re cost. Cutler indicated he sees it as a mixed picture as cognitive and CV health are improving while others – obesity-related such as diabetes in particular – are declining.

What does this mean for you?

I still vote collapse.

 


Mar
5

WCRI – Employers weigh in…

Good decision to add three very different employers to the conference; Publix, Disney and Duke University.

[As a Syracuse alum, I thought WCRI could’ve made a better choice than Duke…]

Here’s my quick take…there was a ton of content with which your faithful reporter could not keep up…so apologies for the somewhat disjointed post.

None of the three are doing pre-employment drug testing (except as required by law)

Publix self-administers work compMichele Maffei has over a hundred employees managing the program. Michelle and her colleagues are very involved in the entire process, work diligently to engage with local operations, and focus tightly on return to work. They handle clinical management, claims, and bill review inhouse. RTW is a huge priority; they try to get everyone – even amputees – back to a job at Publix; during Covid a transitional job was checking in folks showing up for vaccination.

Publix identifies the medical providers they want to provide care to their associates and in some cases contracts directly with those providers; “we are very purposeful about what we do.” Oh, and consistent with earlier findings, telemedicine usage has dropped off post-Covid.

Sharon DelGuercio noted Disney can pay above fee schedule if they need to get specific specialties in central Florida to treat associates. Still it can be difficult to ensure ready access. Disney focuses on the full scope of recovery drivers, striving to keep them in their home location, a strong transitional program with over 400 job descriptions.  Disney’s focus is, quoting Sharon; “nobody goes home”

Duke University’s Charles Kyle weighed in on behavioral health, a main focus of the worker’s recovery program. Return to work is also key; as Duke is very de-centralized different units have their own priorities however costs are tracked back to those units.

A recent focus and rising concern among healthcare professionals [Duke has a major medical center as well] is violence, especially gun violence.  Other forms of physical violence seem to have increased as well across both the medical facilities and University operations. Duke has a task force assigned to this and is steadily improving prevention and recovery initiatives for workers injured by violence.

Panelists acknowledged that in general there’s a higher level of violence, a higher level of incivility, they are just meaner than they used to be.

Michele mentioned physician dispensing (PDD) as a key priority; with their operations in Florida this is NOT a surprise.  MDs should not be allowed to give patients drugs as they are not pharmacists.

 

 

 


Mar
5

Vennela Thumula PharmD and Randy Lea, MD doves into the presence and influence of psychosocial factors on recivery.

Dr Thumula led off by noting psychosocial barriers are the number one obstacle to recovery.

A variety of factors are barriers including:

  • Poor recovery expectations, fear of pain
  • Catastrophizing
  • Perceived injustice
  • Family system support issues, pre-ex psych factors
  • Job dissatisfaction

Multiple guidelines recommend early identification of psychosocial risk factors. WCRI looked into prevalence of psychosocial factors in LPB patients seeking PT. do they recover differently

These factors were common, strongly associated with functional recoveries after PT care, and WC patient had more psycho risk factors and these facts were more strongly associated with functional outcomes.

Dr Thumula laid out the various screening tools used in the research and described the variation between WC and other payer types

Key takeaways:

  • WC patients had high levels of fear avoidance and negative coping, both of which might impede return to work.
  • Workers with higher levels of psychosocial risk factors (PF) had smaller functional improvements than those with lower levels.
  • And, workers with elevated psychosocial risk factors were less likely to make meaningful improvements in function
  • And, they had a much higher likelihood of “very limited” function at discharge from PT.

Dr Randy Lea summarized the findings and provided attendees with what they can tell colleagues upon return from the Conference.

  • First, WCRI’s study is the most robust that focused on WC.
  • Prevalence of PF was high – 1/3 to ½ were high risk.
  • High risk factors result in 40% less improvement than workers without those factors.

So, stop, take a step back, and understand these are frequent, do occur, and are impactful.

Then, you may want to:

  • refer the patient to a mental health professional, and/or
  • make sure the treating clinician knows about the PF factors, and/or
  • use the research to predict those who are most likely to benefit from care.

Mar
4

CWCI’s annual conference is almost here

I connected with CWCI President Alex Swedlow  – and good friend and colleague – to find out what’s been going on in the Golden State and what the annual confab will feature.

Here’s the registration info.

note highlights are mine.

MCM – Please briefly describe the workers’ compensation industry in California…frequency, disability duration, cost drivers, outcomes, market share of major payers.

AlexCalifornia has the biggest WC system in the county, bar none.  Whether it’s premium, frequency, medical care delivery volume, expenses.  We’re a high litigation state with significant friction costs. 

That said, our state has accomplished some remarkable changes and improvements through legislative reforms, regulations, and payer’s delivery systems that have significantly improved the efficiency and effectiveness of benefit delivery to CA injured work force.

MCM – I hear there are concerns about access to care in California for workers’ comp patients. What does the research say?

AlexAccess to care is a national crisis that is just now reaching full awareness.  We are all waiting longer for access to specialists whether you are hurt on the job or during a weekend softball game.

The concerns about access within WC has been a research topic for CWCI for 25 years.  Our most recent studies show that during the acute care phase (90 days) and the first year of treatment following the injury, the CA WC system delivers most services within a few days of the injury with little change in the mix or volume of professional services over the past 5 years.    Expensive, yes. But a remarkable and stable result.

Let’s remember that workers’ compensation represents less than 2 percent of the CA healthcare economy.

Also, the National Institutes of Health project CA will be short 35k physicians and 45k nurses by 2030 with almost 1 out of 3 physicians retiring within 5 years.  So right out of the gates, our system has very little leverage for addressing this problem.  This makes our current medical delivery systems all the more remarkable.

MCM – Thinking about the various sessions, which one will have the most long-term impact on workers compensation and why?  I noted a panel will explore the impact of exogenous influences on workers comp…can you give our readers a couple of examples and their impact?

Alex – The theme of our 60th Annual Meeting is “An Altered State”.  We will explore how our system has expanded well beyond the original “Grand Bargain” and into its current form and function.  We will also focus on key bread-and-butter issues including fresh research on claim development, medical service delivery and dispute resolution, the controversial medical legal fee schedule, COVID, and that great, unique to CA imponderable, Cumulative Trauma claims. These are all issues that originate within our system.

CWCI just published a study on this (free to all here); here’s a top takeaway:

In 2022, CT claims represented more than one out of three litigated claims. And, as Alex notes, CT is a “condition” unique to California. 

I smell something…and it isn’t a rose.

(back to Alex)

We will also explore exogenous influences, trends and issues that originate outside of our system that nonetheless have a significant influence on CA WC. We will preview the results of one of the first studies to use our state’s CURES system (California’s prescription drug management program) which captures all control substance prescriptions issued to all Californians across all payer groups.  The results show state-wide changes in opioid use over a 5-year trend.  The study also provides a look into simultaneous prescribing patterns across payer groups.

Other sessions will address our state’s economy, political climate, the looming $70B budget deficit, workforce migration, access to care, and some key interstate comparisons that show how much CA WC has changed over time.

Joining our staff, we have two great guest speakers from the Public Policy Institute of CA, Sarah Bohn and Eric McGhee, who will present new data on specific external forces that impact the vitality of our WC system.  In addition, our long-time colleague, Ramona Tanabe, President of WCRI will discuss interstate comparisons to show how CA WC has evolved relative to other states.

What does this mean for you?

If you want to know, you’ve got to go.

 

 

 


Mar
1

Good news Friday…a robust economy and optimistic consumers

In out continuing effort to keep a positive outlook, we once again bring you news to brighten the day.

today – the economy – which is doing quite well, thank you – driven by rising wages.

First up – the US economy is “very strong – last quarter it grew 3.2%, a very good rate indeed.

Consumer incomes jumped 1.0 percent…”in January, aided by higher dividend payments and the annual cost-of-living adjustment in Social Security.”

and…”consumers have also become more optimistic about the economy, surveys show

Those factors likely helped drive new home sales up almost 2 percent year-over-year. This helps the construction industry and employment of tradespeople, durable goods such as appliances and HVAC and home goods.

from MarketWatch core inflation dropped to 2.8% in the 12 months ended in January. (PCE is personal consumption expenditures) – graph from US BEA

What does this mean for you?

Better economy = more jobs + higher wages + lower inflation = more disposable income = more jobs…


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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