Category Archives: Group Health Plans

Fam Tours for Self-Insured Employers

The subject of medical travel for self-insured employers is one that this blog has rarely discussed from the point of view of the medical travel facility.

Previous posts here have discussed a possible scenario for medical travel by self-insured employers under workers’ comp, the experience of one company that did so for its employees under their group health plan, and why self-insured employers are failing to adopt medical travel, as well as other posts that briefly mentioned self-insured employers.

Yet, at no time has this reviewer, in the position of content writer, ever discussed how the medical travel facilities can market their services to potential self-insured customers.

A new book by Maria Todd, her sixteenth in fact, does exactly that. Organizing Medical Tourism Site Inspections for Self-Insured Employers is a well-written manual for medical travel facilities seeking to highlight the services they offer by hosting site inspections, or more colloquially known as “fam tours,” or familiarizing tours.

Note: This writer had participated in only one fam tour to medical facilities when I spoke at a medical tourism conference in Mexico in 2014.

Knowing the Customer

Dr. Todd’s book focuses on the ways medical travel facilities can know their customers by knowing which self-insured employers are more likely to develop a medical travel program for their plan beneficiaries, and the criteria the Plan Administrators will look for to engage their services and the conditions under which such travel is possible.

One example given is if flying time to a medical tourism destination is less than three hours by plane. For American workers, who have US passports, longer distances would eliminate travel to parts of Asia, the Middle East, parts of South America, and Russia. Such locations would be possible if the employees were working there or nearby, and they were the closest facilities available.

She also discusses what will attract multinational employers who have workers around the world to select facilities that can handle industrial accidents, as well as general health and rehabilitative services. Some employers may be self-insured for their domestic employees, but purchase an insurance cover called an International Private Medical Insurance, or “IPMI.”

Selling Solutions

To educate hospital executives and managers on how to sell solutions to Plan Administrators, Dr. Todd includes a chapter on a topic she says executives and managers often do not consider important.

The chapter focuses on what not to say or do when conducting a site inspection. You, as the seller might consider certain areas of your facility important to highlight, or is one that you take pride in, but may not be something your guests are particularly interested in.

One such area is Accreditation. Not knowing abbreviations for accrediting organizations such as the Joint Commission International (JCI), or what the big deal is about accreditation, is something the executives and managers need to be aware of beforehand and to be prepared to explain why it is important.

Proper accreditation will go a long way to ease their minds over deciding to use that facility, and being presented with an unfamiliar or disreputable accreditor, or one whose certificates are not worth the paper they are printed on, is something to be aware of also.

Another area of concern when hosting a site inspection is scientific presentations. It is quite possible that some of your guests may be physicians and nurses who will benefit from seeing such presentations, but for those Plan Administrators who are not medical personnel, such tours maybe considerably boring, if not completely too technical for them to comprehend.

Technology Tours

A similar mistake made is taking business-focused guests to see the technology the facility has installed and uses. Dr. Todd recommends they create a spreadsheet of the expensive equipment they have and write a short blurb about each.

Her main point is this: Plan Administrators are seeking three things: transparency, good value, and superb, culturally-sensitive customer service.

Other areas to avoid on Fam tours

The Emergency Department, laboratory, radiology and imaging department, cardiac catheterization lab, and the PET/CT, and PACU’s are a waste of time, per Dr. Todd, and may even disturb the patient’s privacy and recovery.

Final five chapters

The final five chapters deal with developing relationships, the contracting and provider network criteria (where to get preliminary data, contract terms and payment agreements, and avoiding payment hassles with the right language), the basics of ERISA (ERISA fiduciary responsibilities, self-insurance plan sponsorship not limited to the US, and government employers pay for healthcare services outside of their countries), how to prepare for site inspections, and lastly, rate proposals.

Closing

Dr. Todd’s book is a must for any self-insured employer considering a medical travel program for their beneficiaries. For those employers who self-insure for general health care, this book provides them with the knowledge they need to have to explore doing so. For those self-insured employers who self-insure for workers’ comp, this too is an important book.

The likelihood that the Affordable Care Act will be repealed or replaced, with something worse, or with nothing at all, grows stronger every day now. Once that happens, premiums will rise, and alternatives such as medical travel will seem much more plausible and cost-effective.

While this book was written from the perspective of the seller of healthcare services, purchasers of such services, either domestically or internationally, can benefit from reading it. Not knowing what to look for will only cost you time and money and be harmful to the health of your plan and your employees. I highly recommend this book to you.

Interesting Article on PPO’s

Forbes.com has published an extensive article claiming that PPO’s have perpetrated a great heist [author’s words] on the American middle class.

According to the article,  trillions has been redistributed from the American workforce to the healthcare industry, creating an economic depression for the middle class.

The article consists of an interview conducted by author Dave Chase and Mike Dendy, Vice Chairman and CEO of Advanced Medical Pricing Solutions, Inc., a healthcare cost management company.

Here is the link to the full article:

http://www.forbes.com/sites/davechase/2016/09/05/have-ppo-networks-perpetrated-the-greatest-heist-in-american-history/#25489cd66d00

Is it any wonder why work comp is also so screwed up? Too many cooks (or is that crooks?) taking their “cut” out of the middle class.

But we keep insisting that we have the best health care system in the world, that our workers get the best care when they are injured and don’t need to have any alternatives explored to improve the care and treatment they get, and that the free market is the best way to provide health care. It’s free alright. Free for the greedy to become more greedy. But not for you and me.

“Florida, We Have a Problem”

Tuesday, Judge David Langham, Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings, wrote a rather lengthy post about the differences between cost-shifting and case-shifting in workers’ comp.

Much of what the Judge wrote were subjects that I already discussed in a number of previous posts about cost-shifting and case-shifting, so I won’t go into it here. I am only focusing on the parts that relate to Florida workers’ comp. You can read the entire article yourselves.

But what caught my attention was what he said about Florida and what the Workers’ Compensation Research Institute (WCRI) reported in some of their studies on these issues.

As Judge Langham wrote this week, he wrote a post two years ago that asked the question “Why Does Surgery Cost Double in Workers’ Compensation?”

Judge Langham noted in that post that Florida employers have been documented paying almost double for shoulder or knee surgery that is paid for under workers’ compensation, compared to group health costs.

The implication of case-shifting in Florida, he says, could arguably be a doubling of cost.

He cited a WCRI report released earlier this year that suggests however that case-shifting is perhaps not as likely in Florida.

According to the report, Judge Langham continues, “as of July 2011, six states had workers’ comp medical fee schedules with rates within 15% of Medicare rates. They were California, Massachusetts, Florida, North Carolina, New York and Hawaii.”

However, Judge Langham pointed out that the WCRI concluded that case-shifting is more likely in states where the workers’ compensation fee schedule is 20% or more above the group health rates, and not in Florida.

Judge Langham stated that this analysis of workers’ compensation fee schedules does not appear to include analysis of the reimbursement rates for hospitals, and that It also seems contradictory to the assertions that Florida workers’ compensation costs for various surgeries have been documented as roughly double the group health rates (100% higher, not 15% higher).

Injured workers who missed work in the Florida workers’ compensation system could be compensated in 2016 at a rate as high as $862.51 per week, the “maximum compensation rate.”

So, if recovery from such a “soft-tissue” injury required ten weeks off-work, he wrote, the case-shifting to workers’ compensation might add another four to nine thousand dollars to the already doubled cost of surgical repair under workers’ compensation.

This could be directly borne by the employer if the employer is self-insured for workers’ compensation; or, if the employer has purchased workers’ compensation insurance, the effect on the employer would be indirect in the form of potentially increased premium costs for workers’ compensation following such events and payments, Judge Langham states.

According to WCRI, the Judge quotes, “policymakers have always focused on the impact (workers’ compensation) fee schedules have on access to care as well as utilization of services.

This has been a two-part analysis, he says:

First, fee schedules have to be sufficient such that physicians are willing to provide care in the workers’ compensation system; and second, the reimbursement cannot be too high, or perhaps overutilization is encouraged.

Lastly, Judge Langham points out that the disparity between costs has also been noted in discussions of “medical tourism.”

The last question he posits is this, “might medical decision makers direct care to more efficient providers, across town, across state lines?”

What about national borders?


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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Fee Schedules May Increase Number of Work Comp Claims

The Workers’ Compensation Research Institute (WCRI) published a new study that examined whether fee schedules increase the number of workers’ compensation claims.

In previous reports, the WCRI found that in many states, workers’ compensation pays higher prices than group health.

Another study they issued, found that in some states, workers’ compensation prices were two to four times higher than group health prices.

Moreover, in most states, WCRI found, the workers’ compensation systems rely heavily on the treating physician to determine whether a specific patient’s injury is work-related or not.

Dr. Olesya Fomenko, the author of the report and an economist at WCRI, said that, “Policymakers have always focused on the impact fee schedules have on access to care as well as utilization of services. This study shines a light on an issue that policymakers and other system stakeholders might not be thinking of, which is that physicians may call an injury work-related in order to receive a higher reimbursement for care he or she provides to the patient.”

Two of the findings from the study are as follows:

  • If the cause of injury is not straightforward (e.g., soft tissue conditions), case-shifting is more common in the states with higher workers’ compensation reimbursement rates. In particular, the study estimated that a 20 percent growth in workers’ compensation payments for physician services provided during an office visit increases the number of soft tissue injuries being called work-related by 6 percent.
  • There was no evidence of case-shifting from group health to workers’ compensation for patients with conditions for which causation is more certain (e.g., fractures, lacerations, and contusions).

What does this mean?

It means that physicians seeking higher reimbursements are classifying some injuries as work-related, and that there is no evidence of case-shifting from group health where the cause is more determinable.

What it also means is that no matter what the industry tries to do to lower medical costs, there is always a way for physicians and other stakeholders to do the opposite for their own benefit.

And given that, you have to wonder why the industry is deaf, dumb and blind to alternatives that apply basic economic laws to saving money. If you can get a good or service at the same or better quality, and at lower cost, no matter where that is, you go there.

It works that way when buying cars in one state, when the buyer lives in another state, and it should work that way with medical care, particularly regarding surgery.

The industry should not listen to certain individuals who dismiss this idea, and call the locations where better or equal care can be obtained at lower cost, “Turkishmaninacanstans“.

It demeans the hard work and dedication of medical professionals and business people who have spent years and money on building a business to provide health care that is affordable and of the highest quality.

It insults the education and training of doctors, nurses, and medical technicians in those countries who otherwise might not be working in such a highly respect profession as medicine.

It only proves that the author of that canard is a coward, a racist, and dead wrong.

 

Colorado Gets Real on Workers’ Comp and Health Care

A shout out today to David DePaolo of Workers’ Comp Central for publishing an article today about a subject I discussed about a year ago, the combining of the silos of workers’ comp and general health care.

Voters in Colorado, the first state to legalize pot (talk about a real ‘Rocky Mountain High’) will decide in November on a ballot initiative that would create ColoradoCare,  a state-run program that will would pay for medical treatment provided to all residents of the state, including those who are hurt on the job.

According to the initiative, “ColoradoCare shall assume responsibility for payment of all reasonable and necessary medical expenses incurred by workers who suffer injuries or illnesses arising out of and in the course of their employment after the date ColoradoCare assumes responsibility for health care payments,”

The law, David writes, will levy (must be Jewish?)  a 3.33% payroll tax on workers and a 6.67% payroll tax on employers, as well as a 10% health care premium tax on non-payroll income to raise $25 billion to pay for medical care.

A 21-person board of trustees would be created to oversee the program. And, employers would still have to carry workers’ comp insurance to cover indemnity benefits (lost wages).

This would be something left up to legislators to figure out, says DePaolo, because the law is only intended to consolidate health care and eliminate the myriad of silos that create delay, confusion and ultimately heath care consumer angst.

It is David’s opinion that the measure will pass, but that is up to the voters of Colorado to decide (are you listening, Maria?).

So what this will mean is this: should the measure pass in November, it is possible that injuries sustained on the job that requires surgery could be achieved through medical travel, since what is possible now under health care would also be possible in workers’ comp (see my post, “Medical Tourism and Workers’ Comp: What’s Good for the Goose is Good for the Gander“).

When it passes, the following warning should be issued to all potheads in Colorado:

Before going abroad for surgery under the provisions of ColoradoCare, should they allow you to do so, please leave all of your “medicine”, in whatever form you take it in, and the paraphernalia that goes with it home, or else you will end up like Billy Hayes in a Turkishmaninacanstan prison.

But the hospitals in Turkishmaninacanstan are much better, and that is one reason why you are going there in the first place. For world-class health care at a lower cost.

WCRI – Day One, Part One

Day One of the WCRI’s annual conference began with WCRI’s Chairman, Vincent Armentano, of The Travelers Companies, introducing new President and CEO John Ruser. He presented the first s…

Source: WCRI – Day One, Part One

Cross-border Health Care and the ACA

From the ‘before you go to the WCRI conference’ department is an article about a subject not on the agenda in Boston this week, and since I convinced the WCRI that crossing the Hudson river is not medical travel, nonetheless, people are leaving the country and one US state for medical care, and not just for work-related issues.

Jim Arriola, COO of MediExcel Health in California, and Caitlin Gadel, an attorney at Seaton, Peters & Revnew, wrote an article this month in California Broker magazine (pg. 20-22), outlining how cross-border health plans in California are complying with many of the provisions of the Affordable Care Act (ACA).

You may recall that I wrote about cross-border health care, especially for workers’ comp, in my article, “Cross-border Workers’ Compensation a Reality in California“, as well as these two articles, “NAFTA, Work Comp and Cross-Border Medical Care: A Legal View” and “NAFTA, Work Comp and Cross-Border Medical Care: A Legal View: Update“.

According to the article, almost twenty years ago, the California Department of Managed Health Care (DMHC), began regulating a consumer driven phenomena for receiving employer-sponsored health coverage south of the border.

As stated in the article, on a daily basis, up to 40,000 workers cross the border from Mexico to work in California. These workers and their families live in Mexico, and prefer to get their medical care in Mexico.

Changes to the Knox-Keen HMO Act allowed US and Mexican health plans to establish cross-border coverage. Much of this is occurring in the San Diego and Imperial county area, as discussed in “Cross-border Workers’ Compensation a Reality in California” with the Mexican HMO, SIMNSA, as well as others such as Blue Shield of CA, Health Net, Cigna, Aetna, and MediExcel Health Plan.

Depending upon the benefits of the plan, some cross-border coverage plans have premiums that are 40% to 50% lower than those in California.

There are an estimated 60,000 enrollees in various health coverage plans in California, and some experts predict the total number will increase to over 100,000 as more employers offer coverage as a result of the ACA rules and regulations, according to Gadel and Arriola.

Gadel and Arriola report that many ACA provisions (as well as the thousands of pages of regulations), apply to cross-border coverage, especially if the coverage is not a qualified expatriate plan.

Gadel and Arriola advanced the idea that some brokers may be concerned whether a cross-border plan satisfies the ACA definition of a minimu-essential coverage (MEC) when the provider network is in Mexico.

They also said that legal experts have noted that under federal regulations, employer-sponsored plans approved by state regulators are MEC plans.

In order to receive approval from the DMHC, such plans must submit evidence of their compliance with ACA regulations.

Brokers, it is suggested by the authors should not offer cross-border plans exclusively because of the differences between cross-border plans and expatriate plans.

However, the authors note, because of the complexity of the ACA’s conflicting interpretations, some cross-border plans may have been erroneously classified themselves as group expatriate coverage.

The reality, they say, is that the vast majority of cross-border plans and their enrollees do not meet the federal criteria for expatriate classification.

My last post, “Borderless Healthcare: A Model for the Future of Medical Care in Workers’ Comp” was based upon a presentation given last Thursday about medical tourism to Mexico. So if there are health care plans in California providing cross-border health care into Mexico, and there is also cross-border workers’ comp occurring between California and Mexico, and in both of these cases, the mode of transporatation is generally automotive, and the presentation by Manatt, Phelps & Phillips requires airfare to Mexico, why is it that workers’ comp cannot do the same?

I don’t want to hear excuses, I want to hear why this industry refuses to join the 21st century, why it points to laws and statutes nearly a hundred years old that restrict injured workers to their own states or to the US for medical care requiring expensive orthopedic surgery, when there are less expensive and better alternatives a short flight away?

A fellow blogger wrote today about this industry’s failure to fully embrace technology, and the answer to his questions, and to mine were right there…if this industry were to change, the status quo would be undone and many companies would be forced to go out of business and their profits with them.

Our workers’ comp “system” mirrors the general health care system in many ways, as per this quote from Uncle Walter:

“America’s health care system is neither healthy, caring, nor a system.”

Walter Cronkite

It is a profit-making endevour that preys upon the sick and injured and lines the pockets of lawyers and vendors. That is why no one in this industry is listening to us…greed.