Insight, analysis & opinion from Joe Paduda

Dec
14

Work comp payers – watch out for facility costs

Pharmacy costs are dropping, imaging is not an issue, physician expenses are growing modestly, and while PT payments are going up a bit, much of that is fee-schedule driven.

The problem area – and it is a big one – is facility cost. (There’s another, more insidious problem we’ll get to next week.)

A recent HealthAffairs article highlighted the facility problem; the median price paid by auto insurers and other non-conventional commercial insurers was 2.8 times Medicare reimbursement in 2010, and 3.8 times Medicare six years later.

First, what are the factors driving this?

  • The hospital/health system industry is massively consolidating, and consolidated markets are higher cost markets. Simply put, market share = pricing power for hospitals.
  • Medicare reimbursement is not increasing, and neither is Medicaid. Governmental payers account for more than half of most hospital’s patient loads, so facilities need to find other revenue sources that pay more.
  • Not-for-profit hospitals are not doing well financially – so they are looking for nickels in the couch cushions.
  • Niche payers – like auto and workers comp – are the softest of targets due to a) little buying power and b) inconsistent ability to direct and/or “manage” care.
  • Many facilities are investing heavily in outpatient facilities, places where a lot of work comp patients seek treatment.
  • Fee schedules in some states – we’re talking about you, Florida – can be highly lucrative and/or are easily gamed
  • Health systems are buying up physician practices, so the care delivered in those practices now comes with a facility bill as well as a procedure cost.

It’s refreshing to see this problem hit the real media, but many payers have been quietly alarmed about facility pricing issues.

Unpacking the HealthAffairs article, there are a few key takeaways.

  1. The study focused on Florida, which is hugely problematic. It reminds us that when you’ve seen one state, you’ve seen one state. So, payers need solutions targeted specifically to each jurisdiction.
  2. That said, for-profit systems are way more costly than not-for-profits.
  3. This is a price issue.
  4. Network direction is hugely important. There are plenty of sources to identify lower-cost facilities, sources that most work comp payers don’t seem to be using.

What does this mean for you?


Dec
13

Holiday for Health Wonks

The end of the year is fast approaching, and with it the end of the year for Health Wonk Review.

Thanks to Peggy Salvatore for bringing the holiday spirit to all things healthcare; her edition is up and ready for opening.

Folks with chronic conditions are hoping for something other than the coal pharma’s been shoving at them – colleague Tom Lynch talks about a chronic disease requiring medication, which, if not taken every day, guarantees death within two weeks… over the past 20 years prices for that medication have risen more than 800%.

Hank Stern talks up the Zero Card which may help with that – even just a bit would be great.

And Roy Poses darkens the halls with his report on a Russian’s donation of $200 million to Harvard’s Medical School. Some possibly seamy ties here, and ones that will make you wish for a bit more transparency.

That’s it for this year’s HWR – thanks for reading, and Happy and Merry to all!


Dec
12

OneCall’s latest numbers

Two faulty assumptions and a big change in fee schedules have combined with management missteps to make OneCall Care Management’s brief history a painful one.

The latest financials indicate things have deteriorated significantly over the last few years.

How did OneCall get here?

The original One Call was focused solely on the WC imaging space. Under Kent Spafford’s able leadership, the company was highly profitable, very creative, and pretty much without any significant competition. One Call was purchased by Apax, then merged with other companies in transactions valued at around $3 billion (some equity and a lot of debt financed the transactions).

The fee schedule change noted above was California’s switch to the CMS fee schedule in 2014, which occurred simultaneously with CMS’ significant cut in reimbursement for imaging. The result was a dramatic drop in margins in California; other states followed suit and the result was a significant decline in earnings.

Faulty assumptions

While the fee schedule change was an unpredictable event, other problems have been self-induced.

Founded in its present form 2013, OCCM struggled since its inception to validate investors’ belief that A) the whole is greater than the sum of the parts, and B) there is lots of “whitespace” open to service providers (not so much).

(I’ve written extensively about these challenges; previous posts are here.)

Fact is most payers don’t see added value in buying everything from one entity – unless each service line is itself best-in-class. Rather, most buyers want to be able to pick and choose the networks, specialty networks, UR and CM providers they work with – and change them when they find better options.

Financials

At its height, OCCM’s earnings were reported to be around $280 million. Those days are long past: sources indicate EBITDA has dropped by almost a third, and my take is it will continue to decline.

2018 has been a tough year; an investment industry source indicated Q3 EBITDA was down 15% from the prior year’s quarter, while revenues actually increased 3%. Annual EBITDA saw a smaller decrease of about 10% for the 12 months ending 9/30/18.

Reports indicate total debt is just shy of $2 billion, and debt service (the interest OCCM pays to its creditors) is about $160 million annually.

Here’s the important stat – with Pro Forma EBITDA (EBITDA increased by management adding stuff that isn’t normally accepted by accountants) of $190 million, there’s not a ton of free cash (about $30 million) available for investments in staff, marketing, and other expenses.

Reportedly total leverage is 10.3x based on total debt just shy of $2 billion.

A big chunk of expense is for Polaris, the much-anticipated platform solution that saw an initial “rollout” of what was described to me as an abbreviated version a couple months ago. Evidently, full rollout is scheduled for 2020, when the company will realize the majority of the costs of the project.

While the company is looking to Polaris to improve efficiencies and reduce costs, my opinion is Polaris is intended to address investors’ problems – not customers’.

This from a post on MedRisk’s resurgence a couple years back [MedRisk is a consulting client}:

One Call is all-in on a technology solution, investing millions in a customized application intended to deliver on the “One Call” promise (currently the seven different services offered by OCCM have separate systems and processes). “Polaris” is slated to be “fully implemented” in Q1 2018, although it’s not clear what “fully implemented” means.

don’t believe “automating” and off-shoring key customer-facing functions is the right answer, not in a high-touch business where adjusters, therapists, physicians, and patients all are key parts of the rehabilitation process.

Cost cutting is a necessity if the firm is going to continue to invest in technology and other critical areas; a staff reduction in 2016 significantly reduced client-facing staff.  Four sales reps were let go last week, a move company representative said was in keeping with OneCall’s intention to shift account management and related functions from the field to internal staff.

So, getting more efficient may be at the cost of improved customer service. If it is, that’s the recipe for further trouble.

Investors may take heart from one very successful turnaround. PMSI was teetering on the edge of the abyss when Eileen Auen took over. Several years later it sold for about ten times what it was worth when Ms Auen started. The company then became the core of what is now OptumRx’s work comp PBM.

That said, the situations are quite different, the changes needed even more dramatic, and executives with Eileen’s talent and abilities are rare indeed.

What does this mean for you?

For investors, listen to people who actually understand the business before spending your gazillions. Many saw this coming.

This also brings to the fore the issues inherent in private equity investors’ fascination with work comp services over the last decade, chiefly what happens when things don’t go perfectly. High debt loads can choke off critical investment in customer service and product development, especially when revenues start to decline.


Dec
7

Vegas Day Three – Yin and Yang

With sore feet, a pocket full of business cards, and an envelope stuffed with receipts, the work comp world is headed home.

My main takeaway from the NWCDC conference – Yin and Yang, black and white.

Serving patients and employees.

Congratulations to Starbucks and Noreen Olson, Claims and Risk Management for winning a Teddy Award. I met Noreen for the first time yesterday, and her passion for doing the right thing by her “partners” (that’s what Starbucks calls employees) came across loud and clear.

This from Risk and Insurance’ Autumn Heisler article on the award, quoting Steve Legg, director of risk management, Starbucks:

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” [emphasis added]

As a big Starbucks coffee fan, I like it even more now.

There was an entire track devoted to the advocacy model – which is terrific. But, we’ve got so far to go.

Let me explain…

The hall had too many vendors focused on how to reject claims, surveil patients, use tech to deny work comp benefits.  I spoke with one that touted their tech’s ability to help payers use AI to show a worker couldn’t possibly have gotten hurt at work.

Yes there are cheaters, but they represent a small fraction of patients.

Several sessions involved InsurTech/data analytics/Artificial Intelligence. Kudos to the session selection folks (I am peripherally involved, but don’t have any role in those decisions) for helping educate all of us non-techies on this.

Sedgwick’s George Furlong and Stephany Rockwell of JBS talked about using tech to improve decision making; their session provided real world examples while pointing out the dangers of relying solely on machines to assess data and come up with recommendations.

But much of this great tech isn’t focused where it should be – the customer interface. Reality is, dealing with insurance and insurers is a pain in the butt. Claimants are treated with suspicion, made to jump thru hoops, and generally not served well.

This from Gallagher Bassett SVP Jeff White’s presentation…

Contrast this with how Vegas treats visitors – everyone from cab drivers to housekeeping staff is welcoming, happy, courteous and out to make your stay a good one. The entire town knows its success – and each person’s livelihood – depends on you having a great time and telling everyone you know you did.

The contrast between the Vegas experience and how we treat “claimants” is a lesson in itself.

Opioids – progress – one patient at a time

I’m both very happy and deeply sad that opioids were the subject of several sessions. The solid attendance at these sessions speaks to the continued concern about opioids, and the focus on long-term chronic pain patients is critically important. The message – we CANNOT lose focus on this. We will be fighting this battle for years to come.

The good news is the growing recognition that we have to solve this one patient at a time. There are no general solutions, no silver bullets, but only a hard slog involving analyzing data, talking with each and every patient, designing a recovery plan specific to that patient, persisting when patients relapse.

One of the more realistic approaches is that developed by Carisk. I spoke at length with one of their customers, and came away heartened by the depth of understanding and focus on the patient.

Yes we are making real, meaningful progress; the work comp world has done so much more to reduce opioid use than every other payer system. We have much to be proud of – but there are still hundreds of thousands of patients taking way too many pills.

What does this mean for you?

Treat patients like Vegas treated you. And understand we are all individuals.

 

 


Dec
6

Vegas Day Two – Industry headwinds and poker

Yesterday’s top takeaway – the consolidation continues – and the impact can be seen on the exhibit hall floor.

Sure there were some new names on the floor, but there seemed to be fewer companies exhibiting this year than in the past.  Not surprising as work comp claims counts are down, premiums continue to drop, and there’s fewer dollars in the system to support service providers of all stripes.

Yet most companies are still planning to grow, and some of the biggest booths are from newcomers who don’t seem to know a lot about workers’ comp.

Investors talk about structural limits as “headwinds”, conditions that inherently limit growth opportunities.

Trade wars, full employment, declining frequency and employers that – for very good reasons – don’t care much about workers’ comp are combining to reduce growth in comp services.

Two possibilities.

Those headwinds may grow in velocity – or, a recession will increase claims and delay re-employment, which will help service companies while hurting payers’ combined ratios.

The companies planning to grow are hoping to draw to an inside straight.

A few – those with great customer service and a deep understanding of the business – have much better odds of success.

But most seem to be the chump at the table.


Dec
5

Vegas – Day One

Random takes from the first day of the National WC Conference.

myMatrixx landed the party spot of the Conference; SkyFall atop the Delano last night. First class event, lots of fun people, and great way to start the week.

The Vegas venue is excellent. Everything you need is here, located close to the hall, hotel, meeting spots, and restaurants. It makes doing business at the conference easy and efficient.

Damn expensive, but easy and efficient. I just paid $4.65 for a medium cup of dark roast – but got it at 5 am. The gym is pricey indeed. And dining here is just stupid expensive. Wah Wah Wah…I know, first world problem.

Conversations with several folks highly knowledgeable about work comp pharmacy. The industry continues to consolidate, drug spend continues to drop, led by double-digit reductions in opioid spend, and the revenue model will have to change.

Paradigm announced it is rebranding it’s subsidiaries; all will carry the Paradigm name. That makes a world of sense.

  • Paradigm has a strong brand name and is closely tied to catastrophic claims. When folks think cat claims, Paradigm is the name that comes to mind. Leveraging that brand awareness is just smart business.
  • The company hosted a media dinner last night – a very intelligent move and one other companies would do well to consider. All the key media outlets were there – and even a few minor ones like MCM.
  • Very few work comp services businesses understand the value of brand. As in almost none. Paradigm CEO John Watts does – and his company will be better off for it.

Paradigm paid very hefty prices for recent acquisitions, and itself sold for a billion dollars or so just a few months back. Watts et al will have to hit on all cylinders all the time to make that investment pay off. So far, so good. But the hard work is ahead of them.

Finally, among my many foibles is a terrible memory for names – I’m OK on faces, but can’t remember names at all. So, it’s not you – it’s me.


Dec
3

Preparing for Vegas

The annual gathering of the work comp tribes begins tomorrow – here’s a few thoughts from last year’s post.

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.  Get the NWCDC app for your Droid or iPhone – there’s a web-based version for tablets too.  It has the schedule, exhibit hall layout, local map, and a bunch of other handy information and tools.

5.  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.

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

A few sessions you may want to consider:

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!!!

 


Nov
30

Bill Review Survey, Takeaway #3

Our last Bill Review Survey was in 2012; things have changed a lot since then – and mostly for the better.

Overall Industry rating

Six years ago we asked the 24 respondents to rate their overall impression of vendors on our standard 1 – 5 scale: the result as reported in 2012:

In what might be best described as a wake-up call for vendors and application providers, there were no ratings higher than a 3.4, with the average a 3.07 on the 1-5 scale (among respondents who knew of the specific vendor).

Put another way, the people who use BR services view BR providers as generally mediocre/adequate/acceptable.

Today, the average rating was just under 3.3, a small but significant improvement.

However, there were significant shifts for individual companies.

In 2012 the three top vendors – Medata, Mitchell, and StrataCare were all in a statistical dead heat, with Xerox/ACS rated a full point lower. (Xerox/ACS bought Stratacare, converted most/all of its users to the Strataware platform, and now operates under the Conduent brand.)

No longer.

This year, we asked the 30 respondents to provide ratings of ten bill review vendors on four different metrics;

  • overall perception
  • handling the basics of bill review
  • customer service and implementation
  • innovation and forward thinking

(All respondents did not give ratings for all categories or companies; the findings below are averages across those respondents who gave a rating for that specific company).

Mitchell (3.75) and Medata (3.71) were in a statistical dead heat for top honors in Handling the basics.

For Customer service and implementation, Medata (3.94) was the clear leader with Mitchell second (3.54).

Medata held serve for Innovation (3.91) and Mitchell (3.5) again took second place honors.

Here’s where it gets interesting. Medata and Mitchell were essentially tied for Overall perception by respondents who rated them.

But across ALL respondents, Medata’s Overall perception rating was 3.4, with Mitchell at 3.08. While Medata has the lowest market share of the top three application providers, it was tied for highest name recognition among our 30 respondents, and thus garnered the top spot in Overall perception amongst ALL respondents.

Here’s where we link back to last week’s posts on the critical importance of customer service;  the data shows Customer Service has the highest statistical correlation with overall perception.

Note – Corvel shared the top spot in name recognition, but got the lowest rating for customer service – and was essentially tied for the lowest score for Overall perception.

What does this mean for you?

Customer service wins.

Note – I’ve received several anonymous comments/emails lately.  I’d remind commenters that anonymous comments on MCM posts are ignored, as are comments with fictitious email addresses.

You know who I am. I and my readers need to know who you are.

 

 

 

 

 


Nov
28

Bill Review Survey – Takeaway #2

One of the more intriguing findings from our third Survey of Bill Review in Work Comp and Auto pertains to data analytics.

Multiple questions probed into respondents’ utilization of data analytics. The questions ranged from the state of their data management program through the relationship between the future of BR and data analytics. In our 2012 Survey, numerous respondents stressed the importance of data analytics, data quality, data management, etc. But despite that emphasis six years ago, respondents seemed to have made little progress employing data analytics packages and integrating data analytics into BR and vice versa.

From the Survey Report (to be released in early December):

A surprisingly low number of organizations have invested significant resources into data analytics.  Only a handful of respondents report that their organization has acquired, sorted, and leveraged data sufficiently enough to begin building predictive modeling or provider profiles.

That’s not to say payers haven’t built data warehouses or aren’t developing analytics capabilities. In fact, “Every large and medium sized respondent said their organization aggregated and transferred bill review data to a data warehouse for analysis.” Rather, most are still in that data modeling development and construction phase; using that data to build models, profiles, and gain deeper understanding is still a ways off.

More narrowly, half of respondents who process their own bills internally tied a data analytics package to their BR product (a more limited approach than combining BR data with data from other sources such as pharmacy, claims, medical management, first notice, and external data sources) while only 6% of those who outsource bill processing used a data package with their BR.

This dichotomy isn’t surprising as external users are generally much smaller organizations.

To get even more specific, fewer than 20% of respondents mentioned building predictive models and in most cases respondents said data was compartmentalized and only used for particular departments such as finance.

We asked what was the greatest unmet opportunity in bill review; Only 10% of respondents specifically noted the importance of data analytics going forward. And, just 20% of respondents said that a higher level of data analytics would be the future of BR.

Considering the value added that accurate data analytics can provide on virtually all BR functions – not to mention the entire claims function, loss ratios, and financial results – and that a vast majority of respondents are not fully linking BR and data analytics, these results indicate significant opportunity.

Thanks to the 30 professionals who participated in the Survey, we have a clear picture of where the industry is today, and what they are looking for from vendors/partners tomorrow.

The respondents hail from all around the country, from insurers, state funds, TPAs, and large employers. Very large to very small, from national in scope to a single-state focus, these experts gave freely of their time and expertise and for that we are grateful indeed.

What does this mean for you?

The opportunity is clear.

Note – I’ve received several anonymous comments/emails lately.  I’d remind commenters that anonymous comments on MCM posts are ignored, as are comments with fictitious email addresses.

You know who I am. I and my readers need to know who you are.

 

 


Nov
27

Work comp services: Specialize or Generalize?

WorkCompWire’s Leaders’ Speak column features a two-parter from Jack Bailey of Bailey Southwell.  He has worked on a lot of transactions in our space and knows a lot about deal-making.

Bailey’s point about the growing importance of technology, and specifically the need for accreditation around cyber-security is dead on. His other thoughts on the importance of execution and customer service are as well.

I do have a different perspective on one of his statements.

From WorkCompWire:

Trend Away from Monoline Vendors to Integrated Service Offerings: While this isn’t necessarily a new concept in the industry, payers increasingly emphasize the benefits of having multiple service lines handled by a single vendor in their contract decisions. As an example, see the below quote from the recent quarterly earnings call of publicly-traded industry vendor:

…singularly focused vendors are quickly becoming obsolete while payers recognize a greater efficiency and effectiveness of integrated services.

Two points here.

First, outside of the quote – which I’ll get to in a minute – I don’t see any supporting evidence for this assertion. OneCall is the best example of a diversified service provider, and we all know how that experiment has worked out.

It hasn’t.

In contrast, single-focused vendors such as bill review firm Conduent, physical medicine management company MedRisk (HSA consulting client), DME/Home Health provider HomeCare Connect, and PBMs (most of which focus almost entirely on pharmacy) are doing well. Conduent and MedRisk are the largest providers in their business sectors, HomeCare Connect is growing rapidly, and PBMs myMatrixx (HSA consulting client) and Optum now dominate the work comp pharmacy business.

There are many reasons for this – which I’ve explored in past posts in mind-numbing detail – but the core issue is the same as in any other industry – doing one thing really, really well is hard enough. Doing several things really well is damn near impossible.

As Bailey noted, payers are demanding excellence in execution and customer service, demands that have (with rare exceptions) not been met by diversified service providers.

Point two.  The quote in Bailey’s piece comes from CorVel’s CEO. 

Of course Clemons would say that integrated services are the bee’s knees;  CorVel’s business model is predicated on getting as many dollars from its customers as possible.

Supporting evidence for my contention that single-focus companies are doing well, and are very attractive to investors is everywhere.

For example, SUNZ’ purchase of case management company Ascential Care and Mitchell’s acquisition of physician adviser/peer review/IME firm MCN. Both Ascential and MCN were founder-owned and had narrowly-focused businesses; they weren’t diversified.

Then there’s Paradigm’s acquisition of Adva-Net for about $110 million, a transaction completed in the last month or so. Adva-Net was also founder-owned (with some venture capital as well) and narrowly-focused; it brings a network of pain management providers and facilities to the table.

This follows Paradigm’s purchase of Foresight Medical last year. As I said last September, “Foresight’s niche is narrow but important – the company’s core business is negotiating prices for implantable surgical devices.”

Finally, in all my conversations with larger work comp payers, the vast majority of buyers want best-in-class services – because their customers expect and demand it. SVPs of Claims, VPs of Medical Management, Chief Medical Officers – I’ve never heard one say “I’ll take mediocre service levels and results because working with one vendor makes my life easier and is less burden on my department.”

Yes, there are exceptions, primarily for smaller payers who don’t have the staff or resources to handle multiple relationships. In that case, the “multi-offering supplier” approach makes sense, and this can be an attractive niche, with vendors building attractive businesses around wide service offerings.

What does this mean for you?

Market segmentation is key; understand what your buyers’ problem is, and solve it. Larger payers want best-in-class, and many smaller payers are looking for simplicity.

 

 


Joe Paduda is the principal of Health Strategy Associates

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