Insight, analysis & opinion from Joe Paduda

Apr
3

Don’t obsess.

Obsessing over stuff we don’t know and can’t control will make us nuts.

Instead, focus on what you can do to protect yourself and your loved ones, and help others any and every way you can.

Why you should ignore a lot of the “experts” and their models.

Just two days ago I said: Ignore anyone who says we’ll be back to normal by this date or that.

I’ll add – Ignore anyone who says there will be this many infections and this many deaths – their “models” are based on data that is likely wildly inaccurate and make assumptions that differ wildly.

(the model used in White House press briefings assumes all states impose lockdowns similar to China’s and keep them in place for months. Meanwhile, the President is talking about a lockdown that ends in a few weeks and many states were late imposing lockdowns – or haven’t yet.)

A basic rule of statistical analysis is “when different studies of the same thing don’t agree it’s probably because they aren’t counting the same stuff the same way.” (OK, I sort of made that up – but it’s entirely true.)

A percentage is based on a numerator (the top number), which in this case is the number of people who died “of COVID”, divided by the denominator – the number of people “infected”.

First, the numerator – deaths due to COVID.

The “death rate” in Germany is 1%, Italy’s is 10%, China’s 4 percent, and Israel a tenth of that at 0.4%.

What?? How can this be? Is it because Italians are older? no…Germany’s population is older than Italy’s. Are Israelis healthier? Well…

From the BBC – “it might seem simple enough: if a patient dies while infected with Covid-19, they died of Covid-19.” Perhaps – but they may have died from a car accident, or might have an underlying health condition such as COPD or asthma or heart disease. The UK counts ANYONE who dies and has tested positive for COVID as a COVID death. Even if they died in a car accident.

Here in the US, physicians have discretion; they report whether the patient died “as a result of this illness.” So, it’s not surprising that the UK would have a higher death rate than the US.

A related issue – reports from Italy indicate there are a lot more people dying of all causes than usual, and many of those “extra” deaths aren’t attributed to COVID. “Only 12 per cent of death certificates have shown a direct causality from coronavirus,” said the scientific adviser to Italy’s minister of health last week. [source here]

So, we do not know the actual number of people who have died “as a result of COVID.”

Now, the denominator – the number of people  “who have COVID.”

Different countries also report different “infection rates”;

  • China may not report people who test positive but don’t show symptoms (are “asymptomatic”). As a substantial percentage of people who get infected don’t show symptoms, that makes China’s “infection rate” seem a lot lower than it really is.
  • The number of tests isn’t as useful as the percentage of people tested. Reality is, if we aren’t testing everyone, we don’t know the real percentage of people with COVID.
  • Here in the US we are STILL way behind testing; we’re only testing about a hundred thousand people a day – about the same number we tested 9 days ago.

Oh, and there are two different “fatality rates.”

Again the BBC:

There are, in fact, two kinds of fatality rate. The first is the proportion of people who die who have tested positive for the disease. This is called the “case fatality rate”. The second kind is the proportion of people who die after having the infection overall; as many of these will never be picked up, this figure has to be an estimate. This is the “infection fatality rate”.

Head swimming yet?  Yeah, mine too.  Net is no one knows how many of us are infected and we don’t know the number of people who die of COVID-related conditions.

We DO KNOW:

  • social isolation will help keep you safe;
  • sanitizing everything will help keep you safe;
  • helping others will help keep you sane.

What does this mean for you?

Obsessing over stuff we a) don’t know and b) can’t control will just make you nuts. Focus on what you can control.

And be nice.

 


Apr
2

Life after COVID – desperate times, desperate measures

Things that are keeping me awake at night (besides the normal problems associated with being a 61 year old guy)

The number of people without health insurance will increase – a lot, driven by:

Note – in yesterday’s press conference, President Trump did make some vague comments about possibly using Medicare and/or Medicaid to pay for COVID treatment. Here’s the quote:

“I’m not committing,” said Trump. “I have to get approval. I’ve got a thing called Congress. It’s something to look at and we have been looking. “

This would require a massive change to Medicare and/or Medicaid laws, followed by an equally massive change in lots of regulations, followed by…who knows what.  Reality is, there are way better ways to address this.

Back to the growth in the uninsured and implications for COVID:

  • some/many will not get tested for COVID as they can’t afford treatment and are terrified of debt.  Some of these folks will continue to work because they have to, which increases the likelihood they’ll spread the disease.
  • hospitals and other healthcare providers – which are already struggling financially because they aren’t doing profitable surgeries for privately insured patients – are going to be delivering a lot of care to people who can’t pay for it.

Net – fewer people with decent health insurance will mean more people will get infected, and the healthcare delivery system is going to have serious financial problems.

A modest proposal.

Here’s a fix.  The federal government makes COVID testing and treatment a federal benefit for all residents (yes undocumented people too) and reimburses providers at Medicare rates.

This would:

a) alleviate the huge financial pressure on hospitals, EMS, and all healthcare providers;

b) increase the number of people tested; and

c) get us back on track sooner than if we do nothing.


Apr
1

The not-April Fool’s post

Well, the WORST thing about this damn pandemic is I can’t do my annual April Fool’s post.  So, instead of actually working, I’ve been trolling twitter for the best COVID tweets and the inter-webs for great stories.

This story wins the prize

 

Ok, now the twitter-verse’s take on Covid!

 

 

Dad joke alert…

Sports fans…

A new sport!

 

 

Zoom meetings ain’t new after all…

Snark alert

The COVID shutdown’s impact on nature

Hoarding alert!

 

 

Sorry!

 

regular COVID jokes…

People with a cold – “I just want to stay in bed and do nothing, I feel terrible”  People with Corona Virus – “I feel terrible, I think I will go skiing in Austria, visit the Eiffel Tower and maybe do some white water rafting in Camino de Santiago”

– To the people who bought 20 bottles of soap leaving none of the shelves for others, you do realise that to stop getting Coronavirus, you need other people washing their hands too.

– During self isolation.. Dogs: “Oh My god, you’re here all day and this is the best as I can love you, see you, be with you and follow you! I am so excited because you are the greatest and I love you being here so much!

Cats: “What the hell are you still doing here?”

– Mexico is asking Trump to hurry up and build the wall NOW!

 

Tomorrow back to our regular broadcast…

 

 

 


Mar
31

COVID19 – the latest data and the cost of ignoring reality

Ignore anyone who says we’ll be back to normal by this date or that.

The problem is straightforward –

  • we don’t have enough data,
  • far too many people are still doing stupid stuff, and
  • there’s still way too much happy talk from people who should know better.

Testing is only now ramping up – six weeks+ into the COVID era there have been less than a million tests in the US; we lag well behind other developed countries in the percentage of residents tested.

The painful reality is the government’s repeated missteps and screwups have left us in the dark about the real dimensions of the spread of COVID19.

Where are we today

We don’t have current, accurate data from an official governmental source on the actual number of COVID19 tests that have been conducted. The CDC’s own database reports a drop in the average daily number of tests since March 17 – but that doesn’t include all tests.

Fortunately, there’s a volunteer project documenting the test count and other key statistics; you can keep updated here. Pretty impressive effort, with data quality ratings as well so you can determine for yourself your level of comfort with the accuracy of the count.

As of 6:42 am eastern yesterday, there were 851,578 tests reported in the US, with 141,232 positive.

As of 6:42 am eastern today, Tuesday March 31, the Covid Tracking project reported 956,481 tests, with 162,399 positive.

Again according to the Covid tracking project, as of 7 am eastern yesterday March 30, 19,839 patients were hospitalized and 2,447 died.

The hospitalization count increased to 22,490 (13%), and the death count increased 21% to 2,981.

Another leading source is Johns Hopkins University; it’s numbers are slightly different than the Covid Project (143,055 positives and 2,513 deaths as of 6:11 am eastern yesterday March 30).

I’ll let you ponder why a group of volunteers and a university are able to do a better job tracking these data than the nation’s disease tracking institution. (fortunately the Trump Administration, which just three weeks ago had sought a $1.2 billion cut to CDC ‘s budget – and an additional $452 million cut to National Institute of Allergy and Infectious Diseases (NIAID)’s budget – changed it’s mind.

Then there’s the report from Wuhan China (the apparent originating location for coronavirus that 5% – 10% of people who a) tested positive, and b) recovered, have now tested positive again.

Communities and institutions that aren’t taking tough measures to control exposure are getting hammered.

Elected officials and many citizens of Fort Myers, FL listened to politicians, not scientists, keeping beaches, restaurants, and a casino open despite warnings. In a county where 30% of residents are over 60, only about 4 out of 10 residents complied with isolation guidelines last week. This may well have devastating consequences – so far there are 171 confirmed cases and 6 deaths in Lee County. with 40 hospitalized.

Those totals will certainly increase.

Many residents of The Villages, a retirement community in central Florida, ignored pleas to avoid socializing; 29 have tested positive as of last Friday.

Liberty University was one of the very few colleges that invited students back to campus after spring break; not surprisingly some showed COVID19-type symptoms, and at least one has tested positive. Yesterday Liberty President Jerry Falwell disputed some of the Times’ reporting; note earlier Falwell dismissed COVID19, comparing it to swine flu and inferring it was a North Korean plot or an effort to harm President Trump.

What does this mean for you?

I bring these to your attention to note that coronavirus doesn’t care about ideology; social distancing reduces infections and saves lives; not enforcing social distancing increases infections and kills people. Places like Ft Myers and Lynchburg VA (Liberty University’s location) – and the people who live there – will suffer from COVID deniers’ decisions.


Mar
30

COVID19 and Workers’ Comp – top 10 takeaways

I’m in the midst of a survey of workers’ comp payers re the impact of COVID19; will update you as we get more information from more participants.

As always, responses are completely confidential and respondents receive a detailed survey report; a public version is also produced which is much less informative.

If you want to participate, please email HelenAtKingKnightDotCom.

I’ve spoken with a number of payers, vendors, and other stakeholders…for now, there are a lot more questions than answers. Here’s what I’m hearing:

  1. Frequency and claims numbers are way down – as in 20-40%. That’s not surprising as far fewer people are working, and those that are don’t want to go out on work comp as they want to keep their earnings coming.
  2. Companies with large offshore workforces – think India – are scrambling to get things working after widespread shutdowns and mandatory workplace closures. This is particularly problematic in document management, scanning and Key-From-Image operations as well as off-shored UR and case management (think Philippines)
  3. COVID claims are starting to come in, mostly from nursing home, medical and first-responder entities.
  4. Disability duration for current claims will likely increase as a) patients don’t want to or can’t access medical treatment; b) some treating physicians are postponing non-essential care and won’t see patients to give them RTW approval; and c; there aren’t jobs to go back to.
  5. On a closely related issue, some payers are (finally) fully embracing tele-services; PT, triage, medical visits, etc. Unfortunately, many slow-walked tele-services for years so they are not prepared to shift patients from on-site services to tele-services, thus contributing to longer disability duration and higher indemnity expense.
  6. Cash is king. Suppliers/service entities in tight cash positions and/or with significant leverage (lots of debt) are in a very tough place. These firms have been paying their debt expense with cash flow from ongoing operations; with new claims counts falling off a cliff cash flow is also way down.
  7. Conversely those companies with little to no debt are in relatively strong positions.  Look for these firms to snap up debt-heavy competitors.
  8. Sectors including PT, home health, transportation and translation are among those feeling the pressure.
  9. Individual industries – think energy, hospitality, healthcare, are showing markedly different impacts from COVID19 and other drivers. While premiums are holding steady for now (from a very small sample set), there will be a big drop in payroll for April which will reduce future premiums.
  10. Generally speaking, US P&C insurers’ statutory surplus is high (about $850 billion) and investment income is in good shape, altho as 23% of US P&C investments are in equities that could change.  Conversely, as most assets are in very secure bonds, the appreciation in bond prices – particularly for high quality bonds – will have a positive effect on surplus.

The key questions are:

How long will this last?  I’ll be posting on this tomorrow – or more accurately posting on why we don’t know and won’t for some time.

How much will COVID claims cost?

Will work comp end up with a large COVID19 exposure?

 


Mar
27

COVID19 and Chloroquine – what does the science say?

The President and the Governor of my home state (New York) are all in on chloroquine and variations thereof.

Spoiler alert – there is no credible evidence that chloroquine is effective in treating COVID19.

And lots of evidence that the drug can be quite harmful.

Let’s unpack the “science”.

First, it’s important to note that this drug has been tried on numerous viral diseases; “Researchers have tried this drug on virus after virus, and it never works out in humans. The dose needed is just too high,” says Susanne Herold, an expert on pulmonary infections at the University of Giessen. source here

There appear to be two sources of “information” that chloroquine advocates cite as justification for using the drug.

Neither meets basic standards of credibility.

One is s tiny “survey” from France; you can read it here. The study’s authors concluded:

our survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin.

Well…no.  The “survey” has many flaws, which combine to make it impossible to draw any meaningful conclusions.

(The primary author, one Didier Raoult has been widely criticized for various misdeeds…this is a detailed and quite damning profile)

  • the study was tiny – 42 patients in total at the outset, of which 26 received the drug and 16 did not (these were the controls)
  • out of the 26 who got the drug, 6 were excluded from the reported results, and 4 of those 6 did not do well:
    • 1 died
    • 3 were transferred to the ICU
    • 1 stopped taking the drug due to nausea
    • and 1 left the hospital
    • “As several people wrote sarcastically on Twitter: My results always look amazing if I leave out the patients who died, or the experiments that did not work.” source here
  • the survey’s authors claimed it was a 14 day study but that doesn’t fit between the 12 days from when the study was approved till the day it was concluded
  • the study was not randomized; that is, the separation of study patients wasn’t statistically random which could lead to selection biases (for example, the control group was much younger than the study group, which reflects non-random sampling
  • the “outcome” wasn’t consistently identified or measured;
    • many control patient outcomes are presented as Positive vs Negative, rather than a count (of the actual virus load) vs Negative, as they are for patients in the active treatment group
    • instead of a typical result e.g. 28 day post-treatment mortality (death) rate, for some patients it was the presence or absence of the virus in a nose-swab test.
    • most problematic, some patients tested “negative” one day then “positive” the next; others showed the opposite results...since the final test was a single snapshot and no follow-up was done, we don’t know if the patients that were “negative” at the end of the survey didn’t subsequently become “positive”…or vice versa
    • the outcome also wasn’t specific as it didn’t indicate how much of a “viral load” existed, only if it was present or absent (defined as viral load under a certain threshold)
    • so, “negative” patients could have had the virus, just not enough to trigger a “positive” test result
    • “It would have been better if the authors would use clinical improvement (e.g. fever, lung function) as the outcome, not a throat PCR. The virus could still be rampantly present in the lungs, and the patient could still be very sick, while the virus is already cleared out of the throat. If PCR is an outcome, it would be better measured as e.g. at least 2 or three consecutive days of PCR negativity.” source here
  • There’s a lot more to this – you can read a critique here.

Next – reports from China, which were cited by the French study’s authors as a reason to consider using versions of chloroquine.

The reports included

a) opinions from Chinese physicians that were based on their personal observations, not on actual studies.  A key source for this was a letter published that did not provide any details, data, or credible evidence as to the efficacy or safety profile of chloroquine and related drugs.

Remember…a letter – often cited by opioid promoters as evidence of the drug’s safety and efficacy – helped spark the opioid epidemic, I’d be careful relying on the Chinese letter as a rationale for using chloroquine.

b) many of the clinical trials that were started some time ago were canceled or suspended, leaving no data or substantive conclusions

Fortunately the WHO has begun several major scientific studies to evaluate various drugs’ efficacy and safety…we can be hopeful that they will yield actual credible information that will help us defeat COVID19.

Here’s a handy cheatsheet you can use to evaluate news reports and Facebook posts about COVID19 “cures”,

DANGER!

Finally, this stuff can be dangerous if not deadly. Doses of chloroquine and related drugs just slightly above recommended levels can kill. The drug can damage vision, appears to be dangerous for anyone with cardiac arrhythmia, and has a host of other nasty side effects, many of which occur even when patients are taking doses far lower than “recommended” by French and Chinese doctors.

What does this mean for you?

To quote Karen Masterson, author of THE MALARIA PROJECT;

We should learn from past mistakes. Federal officials after World War II failed to listen to public health experts about the limitations of chloroquine. Our top political leaders today should avoid the same error.


Mar
26

A COVID-free post!

By now you’re as sick tired of COVID as anyone, so today we’re not mentioning the thing that shall not be mentioned.

A few things of note that crossed my desk here at the Intergalactic HQ in Skaneateles NY…

The fine folks at IAIABC have developed a super helpful app that tells you what state workers comp departments/agencies are up and running, doing what things/delivering what services. Way to step up fast, Jen and team!

Also, members can download an issue brief on telemedicine here. Of note several states have emergency regs in place addressing telemedicine and related issues.

WCRI is reminding us that their 2010 study entitled “Recession, Fear of Job Loss, and Return to Work” by Richard A. Victor PhD and Bogdan Savych PhD is available here. Timely reading for these days when unemployment filings hit 3.3 million, 4.5 times higher than the previous record.

The issue voted “most likely to make workers’ comp adjusters go ballistic” is…air ambulance! Good news – MTI America’s Melissa Galea is leading a webinar on that topic; you can sign up at no cost here.   (MTI America is an HSA client)

Finally, for those concerned about supplies of mission-critical commodities, here’s an excellent way to ensure those commodities are only used when absolutely necessary.

 


Mar
25

COVID-19 quick hits

First – reminder that every April 1 I do my annual April Fool’s post. It usually catches a few folks…you’ve been warned!

Now, a few things of note that crossed my virtual desk.

Chloroquine as a treatment for COVID-19

You may have seen President Trump talking about a malaria medication…

Two news items hit this morning, one noting that a patient just died after taking a version of the chemical.

A very small study found outcomes for patients that took chloroquine were not different than outcomes for patients that received a placebo. Out of  30 patients, 15 patients got the malaria drug and 13 tested negative for the coronavirus after a week of treatment. 15 patients didn’t get hydroxychloroquine; 14 tested negative for the virus.

Last week the drug was touted extensively on Fox and the Glenn Beck Show, with that “science” based on an unpublished paper describing what happened to a handful of patients treated with the medication.

Read the link if you want to understand why the “science” was crap and the “conclusions” total bullshit.

Takeaway – this drug can be very dangerous, is far from proven effective, and current studies are too small and have other limitations that make it impossible to draw any firm conclusions regarding its efficacy and dangers.

US Infection trend

As of 9:35 am eastern March 25, there are 55,238 confirmed cases in the US and 802 COVID-19 related deaths. Caveat – the number of cases is almost certainly significantly higher (not enough tests available) as is the actual number of deaths.

Takeaway – we are nowhere near the peak of this pandemic…here in New York we have over 25,000 confirmed cases…3 in our town of 4,800 people.

Conferences

are pretty much not going to happen.  NCCI’s annual confab will go virtual; more details on the free web-based event here. The date is May 12, 2020, and it kicks off at 1 pm ET.

Work-at-Home

Briotix Health has developed a free app to help we work-at-home folks prevent injuries and other nasty stuff. Info is here.

A link to the Virtual Office is here.


Mar
24

Workers’ comp and COVID-19, part 2

Workers’ comp is singularly ill-equipped to handle COVID-19…but some organizations are making solid progress

The industry’s antipathy towards change, resistance to anything smacking of risk, and rejection of most anything remotely “innovative” ensures many payers, vendors, regulators and other stakeholders won’t be able to handle the fallout from COVID-19.  Industry veterans know that any change is brutally hard, slow, and fulls of fits and starts; if there’s a business that struggles mightily to innovate its workers’ comp.

Few WC organizations will adapt quickly enough to keep pace. Executives get promoted for not making mistakes, for squeezing vendors, for cutting administrative expenses – not for innovating, taking risks, being creative. These “attributes” are exactly what organizations don’t need if they are to survive the next few months.  Example – many payers are viewing COVID-19 thru the lens of yesteryear, acting as if the future will be the same as the past.

It won’t be.

Covid-19 will change workers’ comp in ways that would have been incomprehensible just a week ago.

But some are moving quickly.

Two big insurers are suspending premium collection – a huge shout out to Chesapeake and BWC Ohio for leading the way. Kudos to the State Fund of California for suspending policy cancellations and penalties for late payments.

Others may follow…for good reason. Workers’ comp insurance has been very profitable of late and most insurers can afford to tap into cash reserves.

Tele-everything is exploding, albeit haphazardly. Regulators in many states are scrambling to enable/allow/legalize the use of telemedicine in its many forms. Vendors are struggling mightily to keep up with the patchwork of state-specific regulations which are different today than they were yesterday.  Payers that pooh-poohed the very idea of telemedicine, or slow-walked it, or had programs in name only are beating down vendors’ doors, demanding access to a service they gave short shrift to just a week ago.

Inevitably, mistakes will be made – what was OK yesterday isn’t going to be tomorrow, and program requirements, procedures, approval processes, and forms are all in a state of flux. This is where the IAIABC could be hugely helpful; The IA is uniquely positioned to bring regulators together to agree on a standard set of guidelines and regulations that should be adopted by each state. These should be fast-tracked because telemedicine will be critical to ensuring injured workers get the care they need.

Regulators and industry executives that ponder, debate, discuss, and dither will do harm to patients, providers, and policyholders alike. Of course there will be things they won’t like or that “won’t fit” – but now is not the time to argue, it is the time for action.

This does NOT mean employers and insurers shouldn’t embrace telemedicine and telerehab, just make sure you are working with vendors experienced in the space. Concentra is one, MedRisk (HSA consulting client) is another. Carisk (also HSA consulting client) is able to deliver services to their cat/complex patients via their proprietary application. The company is also providing access to behavioral health services via telepsych.

For those in the Independent Medical Exam space, you may be able to ply your trade remotely. Register for Chris Brigham’s webinar Working in the Virtual World – Practical Steps for the MedicoLegal Expert here.  It’s tomorrow, Wednesday March 25 at 3 pm eastern.

And for those of us in need of a refresher in coping skills – which includes pretty much all of us – register for David Vittoria’s terrific (and free) half-hour webinar Calm Amidst the Chaos: Taking Care of Ourselves & Others When Things are Stressful. Sign up here.


Mar
23

Working in the brave new world of DC

That’s “During Covid-19”; hopefully we’ll be “AC” soon (After Covid-19)

I’ve been spreading so much doom and sadness it’s time to make amends.

OK, here’s some tips and advice from a person that’s been working from home for 20 years.

  1.  You will get a LOT more done at home than you do at work – if you are disciplined.  Fewer people to chat with, run into in the hall, and engage in non-work conversations means more time – and more ability to focus.
  2. Keep your cell phone on the charger, and use a wireless headset.  That way you won’t run out of battery, and you can pace around while you are on the phone. You’ll find that is way better then sitting at a desk or table – and way healthier too. Put that headset on the charger whenever you aren’t using it.
  3. Turn the email off for several periods during the day so you can focus on the task at hand. Unless you’re waiting on a time-critical email, being off the grid for an hour or so at a time isn’t a problem.
  4. Prioritize your tasks – now that you have more control over your daily work, make very sure that you do the stuff that’s important first. As a former professor told me many times, “Do the important stuff, THEN the urgent.”  Best way I’ve found is to write a list, then number them in order of importance – and stick to it.
  5. Don’t worry about background noise from dogs, kids, partner or spouse. We are all in the same situation.
  6. Respect those directly affected by COVID-19 and preparations for same. They may not have time for idle chitchat, when they ask for something it’s probably important, and they are really stressed.

Finally, it’s entirely okay to call people and talk business, ask for things to get done, check on progress, and otherwise carry on. This will pass, and in the meantime life has to go on.

What does this mean for you?

There’s a lot to be said for getting back to “normal” even when that “normal” is different than it was last week. 

 


Joe Paduda is the principal of Health Strategy Associates

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