Category Archives: Outcomes

No Paradox

Sometimes, the solution to a problem is staring you right in the face, but you refuse to see it because you are blinded by your perceptions, your beliefs, or the distortions others have placed in your mind by lies and falsehoods spread about the real benefits of the solution, or the downsides.

Case in point, the question of single-payer health care in the US. The health insurance industry and their lobbyists and defenders in Congress have done a great job poisoning the minds of many Americans against the idea of single-payer, whether on ideological or economic grounds.

Yet, many of these same Americans are getting some form of government-sponsored health care, either Medicare, Medicaid, Tricare, or health care through the Veterans Administration. So, it was striking that before the enactment of the ACA, many Tea Party protesters shouted or carried signs that read, “Keep your hands off of MY Medicare!”

What they did not know or realize, was that it wasn’t THEIR Medicare, but the government’s Medicare. They were ones receiving the benefits.

So, it struck me this morning when I read an article by Tom Lynch of the Lynch Ryan blog, Workers’ Comp Insider.com.

The article, The American Health Care Paradox: A Lot Of Money For Poor Results, compares the US health care system with the health care systems of the OECD nations (Organization for Economic Cooperation and Development).

The OECD has 35 members, of which the US is one, and was formed in Paris in 1961. They promote policies that will improve the economic and social well-being of people around the world. It also performs annual comparative analyses of issues affecting its members.

Health care is one such issue, as is life expectancy, infant mortality, obesity, and death rates from cancer, among other health care-related topics.

But regarding health care, as Tom reports, on a per capita basis, we spend 41% more on health care than our wealthy nation peers in the OECD, and 81% more than the entire OECD average.

The following graph indicates amount of public versus private funding of health care among the OECD nations, as well as the OECD average. The light blue bars indicate private funding; the dark blue bars indicate public funding.

OECD Health Care Funding — 2015

According to Tom, while our public funding (Medicare, Medicaid, etc.) is comparable to many of the other countries in the OECD, private funding in the US is more than 100% greater tham Switzerland, and 300% greater than the OECD average.

Life expectancy:            US: 78.8 years (76.3 men, 81.2 women)
UK: 81 years (79.2 men; 82.8 women)
Japan: 83.9 years (80.8 men; 87.1 women)

Infant mortality:          US: 6.1% (per 1000 live births) 45% higher than UK at 4.2%, and 265%                                                higher than Japan’s at 2.3%.

Obesity and overweight rate is exceeded only by New Zealand. Finally, the rate of death from cancer per 100,000 people is 188, Mexico’s is 115, Japan’s is 177. But we lead the world in smoking cessation (whoopee!). So, I guess we can all breathe easier now than the rest of the world, especially the third world where so many start smoking at a very young age.

Into this discussion, Tom throws the current Republican tax plan, which he rightly says will throw 13 million people off of health care, and see $25 billion cut from Medicare.

Tom says that fixing health care will take time and a lot more money, and he is skeptical that the GOP tax scam will do that.

Duh! Of course it won’t. That’s the whole point of the tax scam and the umpteenth attempts to scuttle the ACA. They don’t believe in health care as a right for all Americans. It is in their DNA as Libertarian Conservatives. They are not Republicans, at least not like the two Republican presidents who tried to get health care passed, Theodore Roosevelt and Richard Nixon.

No, they want the money for their fat cat donors. They even said so publicly and bragged about it. And if all those votes to repeal and replace ACA didn’t convince you that they are fundamentally opposed to any government-sponsored health care, except their own, then you are blind.

The solution is staring you in the face on the above chart, Every other OECD member nation spends more publicly for health care than we do privately, and we are getting bad outcomes. Why is that? It is because health care is not like other consumer goods, and therefore should not be funded or marketed by private companies.

It is long past the time we should follow suit and do what every other OECD country has done, create a single-payer, improved Medicare for All system and stop fooling ourselves that the private market works. It does not, and the proof is in the metrics on cost, life expectancy, infant mortality, obesity and cancer deaths, etc.

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Illogical!

Picking up where I left off last week with my post, Regulation Strangulation, regarding too much regulation, a series of articles from earlier this week, published in various health care journals and magazines, discussed a new scheme the good folks at CMS have cooked up to make our health care “system” better. (Or worse, depending on whether you have drunk the kool-aid yet)

You may recall my post from late last year, Models, Models, Have We Got Models!, that reported that CMS was launching three new policies to continue the push toward value-based care, rewarding hospitals that work with physicians and other providers to avoid complications, prevent readmissions and speed recovery.

In that article, I mentioned the various models CMS was implementing. My view then, as it remains today, is that these models have not worked, and have only made matters worse, not better.

So when CMS unveiled their latest scheme recently when Administrator Seema Verma spoke at the Health Care Payment Learning and Action Network (LAN) Fall Summit, this is what she said:

The LAN offers a unique and important opportunity for payors, providers, and other stakeholders to work with CMS , in partnership, to develop innovative approaches to improving our health care system. Since 2015, the LAN has focused on working to shift away from a fee-for-service system that rewards volume instead of quality…We all agree that quality measures are a critical component of paying for value. But we also understand that there is a financial cost as well as an opportunity cost to reporting measures…That’s why we’re revising current quality measures across all programs to ensure that measure sets are streamlined, outcomes-based, and meaningful to doctors and patients…And, we’re announcing today our new comprehensive initiative, “Meaningful Measures.”

Let’s dissect her comments so we can understand just how complicated this so-called system has become.

  1. Develop innovative approaches? How’s that working for you?
  2. Improving our health care system? Really? What planet are you living on?
  3. Financial cost? Yeah, for those who can afford it.
  4. Revising current quality measures? Haven’t you done that already after all these years?
  5. “Meaningful Measures”. Now there’s a catchy phrase if I ever heard one. You mean they weren’t meaningful before?

You have to wonder what they are doing in Washington if this is the level of insanity and inanity coming out of the bureaucracy on top of our health care system.

In an article in Health Data Management, Jeff Smith, vice president of public policy for the American Medical Informatics Association stated the following regarding the new CMS initiative.

According to Smith, “the goals are laudable, but the talking points have been with us for several years’ now…measurement depends on agreed-upon definitions of quality, and in an electronic environment, it requires access to and use of computable data. If CMS is going to turn these talking points into reality, it will need to put forth far more resources and commit additional experts to a complete overhaul of electronic quality measures for value-based payments.”

Mr. Smith’s comments are at least an indication that not everyone goes along with CMS every time they unveil some new initiative, model, or program, but again we see the words associated with the consuming of health care being used in discussing the current state of affairs. Terms like “value-based payments”, and “quality measures”, and “financial/opportunity cost”, etc., only obscure the real problem with our health care system. It is a profit-driven system and not a patient-driven system.

Let’s push on.

A report mentioned Monday in Markets Insider showed that 29% of total US health care payments were tied to alternative payment models (APMs) in 2016, compared to 23% in 2015, an increase of six percentage points. These APMs were discussed previously in Models, Models, Have We Got Models!,

The report was issued by the LAN, and is the second year of the LAN APM Measurement Effort (try saying that three times fast). They captured actual health care spending in 2016 from four data sources, the LAN, America’s Health Insurance Plans (AHIP), the Blue Cross Blue Shield Association (BCBSA), and CMS across all segments, and categorized them to four categories of the original LAN APM Framework. (Boy, you must be tired trying to remember all these acronyms and titles!)

Here are their results:

  • 43% of health care dollars in Category 1 (traditional FFS or other legacy payments)
  • 28 % of health care dollars in Category 2 (pay-for-performance or care coordination fees)
  • 29% of health care dollars in a composite of Categories 3 and 4 (shared savings, shared risk, bundled payments, or population-based)

Speaking of shared savings, an article in Modern Healthcare reported that CMS’ Medicare shared savings program paid out more in bonuses to ACO’s than the savings those participants generated.

As per the report, about 56% of the 432 Medicare ACOs generated a total of $652 million in savings in 2016. CMS paid $691 million in bonuses to ACOs, resulting in a loss of $39 million from the program.

Chief Research Officer at Leavitt Partners, David Muhlestein said, “Medicare isn’t saving money.”

This is attributed to the fact that 95% of the Medicare ACOs (410) participated in Track 1 of the Medicare Shared Savings Program. Only 22% participated in tracks 2 and 3.

Two more articles go on to discuss a Medicare bundled-pay initiative and the Medicare Merit-based Payment System (MIPS) .

What does this all mean?

It has been long apparent to this observer that the American health care system is a failure through and through. Sure, there are great strides being made daily in new technology and therapies. A member of my family just benefited from one such innovation in cardiac care. But luckily, they have insurance from Medicare and a secondary payor.

But many do not, and not many can afford the second level of insurance. From my studies and my writing, I have seen a system that is totally out of whack due to the commercialization and commodification of health care services.

And knowing a little of other Western nations’ health care systems, I find it hard to believe that they are like this as well. We must change this and change this now.

If Medicare is losing money now, with the limited pool of beneficiaries, perhaps a larger pool, with little or no over-regulation and so many initiatives, models, and programs, can do a better job. Because what has been tried before isn’t working, and is getting worse.

The logical thing to do is to make a clean break with the past. Medicare for All, or something like it.

 

 

Florida Workers’ Comp Outcomes Similar to 14 Other States

Introduction

Earlier this week, the Workers’ Compensation Research Institute (WCRI), released a study that compared the outcomes for injured workers across 15 states. It can be purchased here.

Each state has a separate, multi-page report, so I requested a copy of the report for Florida, as that is where I currently reside (offers of employment elsewhere are greatly appreciated).

As this report has over 100 pages, it is reasonable to assume that 15 such reports would have a combined 1500 pages or more. So, I took the easy way and just looked at one state.

In the introduction to the report, there are two key dimensions of the performance of any workers’ comp system in the US:

  1. Post-injury outcomes achieved by injured workers and;
  2. Costs paid by employers.

The study measured the following worker outcomes:

  • Recovery of physical health and functioning
  • Return to work
  • Earnings recovery
  • Access to medical care
  • Satisfaction with medical care

The study was also conducted in three phases:

  • Phase 1: Eight states (IN, MA, MI, MN, NC, PA, VA, WI)
  • Phase 2: Four states: (IA, AR, CT, TN)
  • Phase 3: Three states: (FL, GA, KY)

The WCRI will collect data from other states and revisit states from earlier phases that implemented reforms to measure the impact of those reforms on outcomes in subsequent phases.

Key Findings for Florida

The WCRI found that workers in Florida reported outcomes that were similar to the median study on some of the key measures, but they reported somewhat higher rates of problems accessing desired services, accessing desired providers, and higher dissatisfaction with overall medical care.

For Recovery of physical health and functioning, they found that for Florida, it was similar to the other 14 states.

For Return to work, injured workers in Florida reported rates of return to work in the middle range of the study. 14% of Florida workers with more than seven days of lost time reported never having a return to work that lasted at least one month due to the injury as of three years’ post-injury; 17% reported no return to work within one year of injury. The median worker in Florida had a return to work about 12 weeks after injury.

For Earnings Recovery, 11% of Florida injured workers reported earning “a lot less” at the time of return to work; the median was 8%.

For Access to care, 21% of Florida injured workers reported they had “big problems” getting the services they or their provider wanted; 20% reported “big problems” getting the primary provider they wanted. Florida was among the states, the study reported, with higher rates of problems of access to care and providers, and higher or somewhat higher than in nine or eight other states.

For Satisfaction with care, the study found nearly three in four Florida workers were “somewhat” or “very” satisfied with their overall care (71%); however, 20% said they were “very dissatisfied”. This was higher than the median of the states, and higher than in 10 states.

Table 1 is a comparison of the medical costs and outcomes between Florida and the other 14 states in the WCRI study. What is interesting to note is that when compared to the other 14 states, Florida had similar outcomes in many of the measures, as the study suggested.

Table 1

Source: WCRI

The study found that medical costs in Florida, recovery of health and functioning, rates of return to work, duration of time before return to work were typical, while problems with getting desired services, and providers were somewhat higher or higher. Satisfaction was lower, but dissatisfaction was higher.

What I found interesting, and perhaps a little disturbing, but not unexpected, was that with the exception of the percentage of satisfaction, all the figures were below 50%, and while the score mechanism for recovery of health and functioning is not further discussed in the Summary, but is mentioned in the notes, those also seem to be very low.

I am not surprised that Florida has a higher percentage of dissatisfaction with medical care, this despite the fact that everywhere you look in Florida cities and towns, there are hundreds of medical offices, clinics, and many hospitals; some large, some small.

What to make of this?

While it is too early to tell how these 15 states compare with the other 35 states, what we can gather from this data is that the workers’ comp systems in these states are falling far short of where they should be in almost all of the measures.

Satisfaction percentages, notwithstanding, there are real issues with the way injured workers are treated in these 15 states.

That Florida is similar to 14 other states in five outcome measures, and not even above 50%, tells me that the industry needs to stop kidding itself that everything is honky-dory. It’s not.

How worse do you think it would be if the only current alternative being suggested is the opt-out option? If workers are not getting back to work or getting better care or better health and functioning under the current state systems, how do you think it would be if states like FL, GA, KY, NC, TN and VA go to opt-out as ARAWC is trying to do?

And without going into the details of each states report, it is hard to know just how much of these outcomes are related to common workers’ comp surgeries that could be provided for by outside medical facilities in other nations in the Western hemisphere?

Denying injured workers, the access to the services and providers they want or need is not a sign that everything is okay, having long-delayed return to work three years after injury is not okay, and earning less after an injury is also not okay.

WHEN ARE YOU GOING TO WAKE UP OUT OF YOUR DREAMSTATES AND REALIZE THERE ARE MAJOR PROBLEMS HERE THAT ARE NOT BEING SOLVED?

WHEN ARE YOU GOING TO STOP LISTENING TO PEOPLE WHO DO NOT WANT TO IMPROVE THE SYSTEM BECAUSE IT ONLY SERVES TO MAKE THEM WEALTHIER OR SOMEONE ELSE WEALTHIER?

WHEN ARE YOU GOING TO REALIZE THAT AMERICAN PHYSICIANS ARE NOT THE ONLY ONES WHO CAN PRACTICE MEDICINE, AND MAY EVEN BE BETTER THAN THOSE HERE WHO ARE ONLY IN IT FOR THE MONEY?

No matter how many studies or reports the WCRI or NCCI, or anyone else issues, until you disavow yourselves of the notion that workers’ compensation is failing and that there are ways to fix it, it will just get worse, until one day it is no longer here for anyone.


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’ Comp Blog is now viewed all over the world in over 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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