Author Archives: Transforming Workers' Comp

About Transforming Workers' Comp

Have worked in the Insurance and Risk Management industry for more than thirty years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. Have experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. Received my Master of Arts (MA) degree in American History from New York University, and received my Bachelor of Arts (BA) degree in Liberal Arts (Political Science/History/Social Sciences) from SUNY Brockport. I have studied World History, Global Politics, and have a strong interest in the future of human civilization in all aspects; economic, political and social. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. LinkedIn Profile: http://www.linkedin.com/in/richardkrasner Resume: https://www.box.com/s/z8rxcks6ix41m3ocvvep

Medicare Does Not Cover Retirees Overseas

A LinkedIn connection posted the following article yesterday from the Center for Economic and Policy Research (CEPR), and I thought that since it was a while since I wrote about medical travel issues, that this would be a good topic to discuss. In addition, it occurred to me that in all the talk of Medicare for All, there is no mention of retirees who retire outside of the US being covered by a MFA plan.

So the following article will have two functions: to stimulate interest in the medical travel industry for retirees who aren’t covered presently under Medicare as a new stream of revenue; and secondly, for those advocates of MFA to consider adding a provision in their plans to address this problem.

Here is the article in its’ entirety:

It’s Not an Accident Medicare Doesn’t Cover Retirees Overseas: No One in the Media Supports Free Trade!

Written by Dean Baker

Published: 18 July 2019

The New York Times ran a piece warning retirees thinking of moving overseas that Medicare will not cover their medical expenses in other countries. This is true, but the NYT piece never once pointed out that this is conscious policy, not something that just happened.

Readers of the paper may recall that it reports on trade agreements all the time. These trade agreements cover a wide range of issues, including things like enforcing patent and copyright monopolies and rules on Internet commerce and privacy.

If anyone in the United States in a position of power cared, then it would be possible to include transferring Medicare payments to other countries, to allow people to buy into other nations’ health care system on the list of topics being negotiated. This doesn’t happen because, unlike access to cheap labor for manufactured goods, there is no one in power who wants to make it easier for people in the United States to take advantage of lower cost and more efficient health care systems elsewhere.

While such a policy could potentially save the U.S. government an enormous amount of money on Medicare (costs in other rich countries average less than half as much per person), the health care industry would scream bloody murder if any politician attempted to implement free trade in health care services. “Free trade,” as it is conventionally used in U.S. policy debates, just means removing barriers that protect less educated workers from foreign competition.

The New York Times, like other mainstream publications will not even allow free trade to be discussed in its pages in contexts where it might hurt the interests of the wealthy.

http://cepr.net/blogs/beat-the-press/it-s-not-an-accident-medicare-doesn-t-cover-retirees-overseas-no-one-in-the-media-supports-free-trade?

Tracking Poll on Medicare for All

Last week, during the Democratic debates, the candidates were asked if they supported eliminating private insurance as part of their plan for single payer health care. Only four candidates raised their hands: Elizabeth Warren, Bill de Blasio, Bernie Sanders, and Kamala Harris.

The rest offered various alternative plans such as a public option to buy into Medicare, and Sen, Klobuchar said that she did not want to kick half of the country off of their insurance in four years.

Much has been made of the fact that many Americans say they like their private insurance, and thus are opposed to Medicare for All.

However, a tracking poll released yesterday, and posted by Don McCanne on his Quote of the Day newsletter, indicated that while support for Medicare for All drops if it means that private insurance is eliminated, once it is shown that patients would keep their doctors and hospitals, support for Medicare for All goes up, according to an article in Morning Consult by Yusra Murad.

Here is the tracking poll taken between June 29th and July 1st:

Morning Consult + Politico

National Tracking Poll #190675 June 29 – July 01, 2019

Do you support or oppose a ’Medicare for All’ health care system, where all Americans would get their health insurance from the government?

53%  Support

30%  Strongly support

23%  Somewhat support

36%  Oppose

13%  Somewhat oppose

23%  Strongly oppose

11%  Don’t know/No opinion

Do you support or oppose the public health insurance option, a system in which Americans can choose to purchase medical coverage either entirely from a federally-run health program, entirely from private insurers, or a combination of both?

68%  Support

33%  Strongly support

35%  Somewhat support

17%  Oppose

9%  Somewhat oppose

8%  Strongly oppose

16%  Don’t know/No opinion

Do you support or oppose the 2010 Affordable Care Act, sometimes referred to as Obamacare?

48%  Support

24%  Strongly support

24%  Somewhat support

41%  Oppose

11%  Somewhat oppose

30%  Strongly oppose

10%  Don’t know/No opinion

As you may know, during the Democratic presidential primary debates some candidates advocated for installing a ’Medicare for All’ system that would diminish the role of private insurers. Would you support or oppose ’Medicare for All’ if it diminished the role of private insurers?

46%  Support

24%  Strongly support

22%  Somewhat support

35%  Oppose

9%  Somewhat oppose

26%  Strongly oppose

18%  Don’t know/No opinion

As you may know, during the Democratic presidential primary debates some candidates advocated for installing a ’Medicare for All’ that would diminish the role of private insurers but allow people to keep their preferred doctor and hospital. Would you support or oppose ’Medicare for All’ if it diminished the role of private insurers but allowed you to keep your preferred doctor and hospital?

55%  Support

31%  Strongly support

24%  Somewhat support

31%  Oppose

9%  Somewhat oppose

22%  Strongly oppose

14%  Don’t know/No opinion

https://morningconsult.com/wp-content/uploads/2019/07/190675_crosstabs_POLITICO_RVs_v2_BH.pdf

So, while a majority of Americans are opposed to Medicare for All if it means that they will lose their doctors and hospitals if private insurance is eliminated, a majority of Americans support Medicare for All if it means they can still go to the same doctors and use the same hospitals.

Candidates supporting Medicare for All must be careful to make that distinction, and to frame the discussion of single payer in such a way that it conveys the fact that it would not be government-run health care, but rather, government-financed or supported health care, etc.

 

Medicare for All and the Democratic Debates

See the source image

For those of you who did not watch the two nights Democratic debate, and those like me who did, one thing is clear. Medicare for All is very popular among the audiences who attended, judging by the applause garnered each time a candidate was asked about their plan for providing every American with health care.

On the first night, the moderator asked for a show of hands to the question as to who supported eliminating private insurance, only two candidates, Sen. Elizabeth Warren and New York mayor Bill de Blasio raised their hands.

The rest of the candidates on the first night supported keeping private insurance or giving people the choice of a public option, and de Blasio and former Congressman Beto O’Rourke sparring over the issue.

This is how some of the candidates responded to the issue:

“I’m with Bernie on Medicare for All,” said Elizabeth Warren

Amy Klobuchar said she preferred a “public option”, “I am just simply concerned about kicking half of America off of their health insurance in four years,”

Former Texas Rep. Beto O’Rourke allowed that the goal should be “guaranteed, high-quality, universal health care as quickly and surely as possible.” “Our plan says that if you’re uninsured, we enroll you in Medicare,” and called his plan Medicare for America.

On the second night, the same question about abolishing private insurance was asked, and again, only two raised their hands, Vermont Sen. Bernie Sanders and California Sen. Kamala Harris.

Former Vice President Joe Biden, who defended the ACA, said that Americans “need to have insurance that is covered, and that they can afford.”

Candidates Pete Buttigieg, mayor of South Bend, Ind., New York Sen. Kristen Gillibrand, and Colorado Sen. Michael Bennet all gave their views on universal coverage, noting the importance of a transition period, and suggesting that a public option would allow people to buy into Medicare.

While the rest of the candidates from both evenings’ debates were divided against their fellow candidates who supported Medicare for All, those who spoke up for it, Sanders, Warren, Harris and de Blasio, won over the audience in the hall. What remains to be seen is how their ideas are received in the primaries beginning early next year.

According to Bloomberg, (the publication, not the former New York mayor), Medicare for All enjoys broad support: 56% of Americans said they supported such a plan in a January survey by the Kaiser Family Foundation. However, when told Medicare for All would eliminate private health insurance, 37% said they favor it while 58% said they oppose the idea.

So, supporters of Medicare for All have their work cut out for them. They need to convince more Americans that sustaining the current system of private insurance, whether they get it from their employers, or they purchase it on their own, is a big part of the problem facing the US health care system.

Another point that is forgotten in the debate is the fact that what is being proposed is not a government takeover of health care, but rather a transition from a broken system to a government financed system of health care. Candidates who support this should explain the difference, and not be led into the trap set by debate moderators or interviews of calling Medicare for All, government-run health care.

It must be made clear that the providing of care will remain private, but that paying for it will not. Sanders’ stump speech line about going to any doctor sounds reminiscent of President Obama’s promise that you can keep your doctor under the ACA, but the reality was far from that.

But the takeaway from the debates indicates that the campaign will be a long and hard fought one, and that Democrats must be very clear what it is they actually want to do on health care, know how to pay for it, and sell it as the best solution to our dysfunctional health care system, or as author Marianne Williamson called it, a sickness system.

Because already, the Orangutan has pounced on one issue raised in the debate, the support by all candidates for providing medical care to undocumented immigrants. In today’s charged political climate where racism has raised its ugly head, and nationalism is on the march, such ideas can be disastrous, especially if rejected by swing voters and independents.

Time and the primaries will tell.

Medicaid Work Requirements Are Detrimental

Previous posts in this blog about Medicaid work requirements, especially in the State of Arkansas, suggested that they would be harmful to recipients of Medicaid benefits. Arkansas was the first state to implement work requirements last June.

In an exhaustive article out today from the New England Journal of Medicine, the authors found that requiring Medicaid beneficiaries to work had a detrimental effect on health insurance coverage in the initial 6 months of the policy but no significant change in employment.

Lack of awareness and confusion, the report states, about the reporting requirements were common, which may explain why thousands of persons lost coverage even though more than 95% of the target population appeared to meet the requirements or qualified for an exemption.

The conclusion of the report found that in its first 6 months, work requirements in Arkansas were associated with a significant loss of Medicaid coverage and rise in the percentage of uninsured persons.

The authors found no significant changes in employment associated with the policy, and more than 95% of persons who were targeted by the policy already met the requirement or should have been exempt.

Since the article is quite long, I have summarized the results here, but the full report can be found by clicking here.

It would appear that the goal of forcing Medicaid beneficiaries to go back to work has more downsides than upsides, but since this is being implemented by a group of puritanical, work-obsessed, economic libertarian politicians, reality has overcome their ideological disgust at giving people social benefits without expecting something in return — namely requiring low-income people to find a job in order to be covered for health care.

Isn’t it time we leave the 17th century and its puritan ethics behind and provide every American, rich or poor, with universal health care, with no strings attached? After all, that is what every other Western democracy does.

ACOs Do Not Improve Spending or Quality

Thank to Dr. McCanne, I am re-posting the following article from the Annals of Internal Medicine that was published Tuesday. I have written before about MSSPs, so I thought it would be a respite from talking about single payer.

Here is the article in its entirety:

Annals of Internal Medicine
June 18, 2019
Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis
By Adam A. Markovitz, BS; John M. Hollingsworth, MD, MS; John Z. Ayanian, MD, MPP; Edward C. Norton, PhD; Phyllis L. Yan, MS; Andrew M. Ryan, PhD

Abstract

Background:
Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.

Objective:
To evaluate the effect of the MSSP on spending and quality while accounting for clinicians’ nonrandom exit.

Design:
Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.

Setting:
Fee-for-service Medicare, 2008 through 2014.

Patients:
A 20% sample (97 204 192 beneficiary-quarters).

Measurements:
Total spending, 4 quality indicators, and hospitalization for hip fracture.

Results:
In adjusted longitudinal models, the MSSP was associated with spending reductions (change, −$118 [95% CI, −$151 to −$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, −$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (−0.24 hospitalizations for hip fracture [CI, −0.32 to −0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, −0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).

Limitation:
The study used an observational design and administrative data.

Conclusion:
After adjustment for clinicians’ nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects — including exit of high-cost clinicians — may drive estimates of savings in the MSSP.

Primary Funding Source:
Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.

In addition, here is an article from The Incidental Economist of June 17th on the same subject:

The Incidental Economist
June 17, 2019
Spending Reductions in the Medicare Shared Savings Program: Selection or Savings?
By J. Michael McWilliams, MD, PhD, Alan M. Zaslavsky, PhD, Bruce E. Landon, MD, MBA, and Michael E. Chernew, PhD.

Prior studies suggest that accountable care organizations (ACOs) in the MSSP have achieved modest, growing savings. In a recent study in Annals of Internal Medicine, Markovitz et al. conclude that savings from the MSSP are illusory, an artifact of risk selection behaviors by ACOs such as “pruning” primary care physicians (PCPs) with high-cost patients. Their conclusions appear to contradict previous findings that characteristics of ACO patients changed minimally over time relative to local control groups.

Conclusion

Monitoring ACOs will be essential, particularly as incentives for selection are strengthened as regional spending rates become increasingly important in determining benchmarks. Although there has likely been some gaming, the evidence to date — including the study by Markovitz et al. — provides no clear evidence of a costly problem and suggests that ACOs have achieved very small, but real, savings. Causal inference is hard but necessary to inform policy. When conclusions differ, opportunities arise to understand methodological differences and to clarify their implications for policy.

And finally, Don McCanne’s comment:

This important study in the highly reputable Annals of Internal Medicine concludes that accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) did not show any improvement in spending or quality when adjustments were made for selection effects, especially the non-random exit of high-cost clinicians (“I’m worth the extra money, and if you’re gonna cut my fees, I’m outta here.”)

The conclusions were immediately challenged by others in the policy community who have previously published studies indicating that “ACOs have achieved very small, but real, savings,” albeit admitting that “there has likely been some gaming.” And the savings were, indeed, very small. Others have suggested that the very small savings did not take into consideration the significant increase in provider administrative costs for technological equipment and personnel to run the ACOs, and certainly did not consider other unintended consequences such as the tragic increase in physician burnout.

Another problem with the infatuation for ACOs is that politicians and the policy community are insisting that we continue with this experiment in spite of the disappointing results to date. That simply postpones the adoption of truly effective policies, such as those in a single payer Medicare for All program, that would actually improve quality while greatly reducing administrative waste. The tragedy is that this also perpetuates uninsurance, underinsurance, and personal financial hardship from medical bills.

People are suffering and dying while the policy community continues to diddle with ACOs and other injudicious policy inventions. Enough! It’s long past time to reduce suffering and save lives! Single Payer Medicare for All!

(Yes, I’m angry, but even more I’m terribly anguished over the health care injustices that we continue to tolerate through our collective inaction.)

See, we can’t get away from Medicare for All after all.

 

From Monopolies to Monopsony

Axios yesterday reported that the US health care system is made up of mostly monopolies, and that the industry is dominated by a small number of companies, according to an article by Sam Baker. And this, critics say, drives up prices for everyone.

The following chart highlights the combined market share of the two largest companies in the selected health care sectors.

Da

Data: Open Markets Institute; Chart: Axios Visuals

Because the US spends more than any other industrialized nation for health care, because our prices are higher, the monopolies that support those high prices could undermine both the liberal and conservative dreams of a more efficient system, according to Baker.

Here is the big picture, according to Baker:

  • Hospital systems continue to merge with each other and gobble up doctors’ practices, which lets them charge more for the care they provide.
  • Insurers and pharmacy benefit managers are also merging, and are now on track to bring in more revenue than the tech industry;s biggest powerhouses.

The trend towards concentration, Baker wrote, extends throughout the system, even into sectors that most patients never directly interact with, according to the data from the Open Markets Institute and shared with Axios first.

Returning to the chart above, let’s look at the suppliers for hospitals:

  • One company controls 64% of the market for syringes. Just 3 companies control the market for IV solution, and two companies make 47% of the hospital beds.
  • The biggest sector is syringes, with $3.8 billion in annual revenue. In a system that is already not very competitive, OMI found, each step without competition feeds into the next one.

Open Markets policy director, Phil Longman stated that, “America’s health care crisis is brought to you by monopoly.”

A particular example, and one that I am familiar with, is Dialysis:

  • Dialysis clinics bring in about $25 billion per year in revenue, and two companies, Fresenius (my clinic) and DaVita — control 92% of the market.
  • Fresenius is the leader, with almost 50% market share.
  • The manufacture of dialysis supplies is also concentrated around two companies, one of which is Fresenius, as my delivery truck and boxes and other materials can attest to. In this, they control 33% of that market.

What then does this monopolization mean for both sides of the health care debate?

This level of concentration can pose a problem for both liberals and conservatives, argues Longman.

  • Conservatives, for example, wanted to shift dialysis away from VA facilities and let veterans use private care instead.
  • Especially in sparsely populated areas, there’s an argument that such an arrangement would be more efficient, Longman said — but without actual competition in the private market, the VA just ends up paying more.
  • But by the same token, large hospital systems dominate some regions entirely. They’re not only the only source of care for miles, but also the largest employer and thus an important political constituency.
  • And that could make it hard for Democrats to follow through on big payment cuts in an expanded public program or “Medicare for All.”
  • “What are the chances the taxpayers get a good price if we don’t fix the monopoly problem?

Here’s a thought. Let there be more competition, but let the financing and paying be done by one entity — the government. In other words, let the providing of care be carried out by many companies, hospitals, etc., but make the financing of health care and the payments for it the responsibility of the government through an improved Medicare for All.

Medicare already pays out to the existing hospitals and providers, irregardless if they are concentrated, and has for some time, so expanding Medicare to all should be the same.

Yet, until the monopoly problem is solved, nothing will change.

Immigrant Labor to Impact Care for America’s Elderly and Disabled

For all of those who support the efforts of the current fascist regime to stem the tide of immigration into this country, the following abstract and article from Health Affairs  from Zalman, Finnegan, Himmelstein, Touw, and Woolhandler, suggests that such policies will be detrimental to the care elderly and disabled Americans will receive in the future.

It is another example of the racist, wrong-headed, and neanderthal thinking on the right that will hurt millions of Americans who otherwise will not be able to care for their personal needs as they age, or should suffer a life-altering disability.

ABSTRACT As the US wrestles with immigration policy and caring for an
aging population, data on immigrants’ role as health care and long-term
care workers can inform both debates. Previous studies have examined
immigrants’ role as health care and direct care workers (nursing, home
health, and personal care aides) but not that of immigrants hired by
private households or nonmedical facilities such as senior housing to
assist elderly and disabled people or unauthorized immigrants’ role in
providing these services. Using nationally representative data, we found
that in 2017 immigrants accounted for 18.2 percent of health care
workers and 23.5 percent of formal and nonformal long-term care sector
workers. More than one-quarter (27.5 percent) of direct care workers and
30.3 percent of nursing home housekeeping and maintenance workers
were immigrants. Although legal noncitizen immigrants accounted for
5.2 percent of the US population, they made up 9.0 percent of direct care
workers. Naturalized citizens, 6.8 percent of the US population,
accounted for 13.9 percent of direct care workers. In light of the current
and projected shortage of health care and direct care workers, our
finding that immigrants fill a disproportionate share of such jobs
suggests that policies curtailing immigration will likely compromise the
availability of care for elderly and disabled Americans.

According to the article, the Institute of Medicine projects that 3.5 million additional health care
workers will be needed by 2030.

Currently, the authors state, immigrants fill health care workforce shortages, providing disproportionate amounts of care overall and particularly for key shortage roles such as rural physicians.

In addition, they report, Immigrant health care workers are, on average, more educated than US-born workers, and they often work at lower professional levels in the US because of lack of certification or licensure.

Finally, they work nontraditional shifts that are hard to fill (such as nights and weekends),6 and they bring linguistic and cultural diversity to address the needs of patients of varied ethnic backgrounds.

Along with the role immigrants play in the health care space, the size of the elderly population is expected to double by 2050, raising concern that long-term care workers will be in particularly short supply, according to the article.

Direct care workers—nursing, psychiatric, home health, and personal care aides—are
the primary providers of paid hands-on care for more than thirteen million elderly and disabled
Americans, the authors contend, and these workers help elderly and disabled people live at home, which is the preferred setting for most people, by providing assistance
with daily tasks such as bathing, dressing, and eating.

They also help elderly and disabled people in nursing or psychiatric facilities when living at home is not possible and during transitions home after hospitalization.

These workers are already in short supply, and the authors state that the Health Resources and Services Administration projects a 34 percent rise in the demand for direct care workers over
the next decade, equivalent to a need for 650,000 additional workers.

The projected shortages are compounded by high turnover and retention challenges, creating ongoing challenges to maintain a sufficient labor supply for-long-term care.

The rest of the article is divided into three main sections: Study Data & Methods, Study Results, and Discussion. Throughout the article are exhibits, and each section is further broken down into sub-sections.

The authors have done a serious effort to examine the impact current immigration policies will have on the future health care of the American people, but knowing this regime and their base of xenophobic, racist, paranoiac extremists, the American people will be the ones who will suffer, and many of them are the very people agreeing with these policies.