Category Archives: Health

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Workers Compensation Issues to Watch in 2014

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With 2013 behind us, here are my thoughts on some workers compensation issues to watch for in 2014:

Rates Continue to Climb

In most of the U.S., rates for workers compensation insurance continue to rise. Rates are being driven by rising medical costs, the low interest rate environment, and the general unprofitability of the line of business.

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Potential Expiration of TRIPRA

Unless Congress takes action, the Terrorism Risk Insurance Program Reauthorization Act (TRIPRA) will expire on Dec. 31, 2014. Companies with high employee concentrations in certain cities are already seeing fewer options, with some carriers scaling back their writings to reduce their exposure to a potential terrorism event.

Impact of the Affordable Health Care Act (AHCA)

There has been much speculation about the potential impact the AHCA will have on workers compensation. With a finite number of medical providers available to handle the increased utilization, it is imperative that workers compensation payers identify the providers who deliver the best clinical outcomes for injured workers.

Integrated Disability Management

More employers are realizing that the impact of federal employment laws, like the Americans with Disabilities Act and the Family and Medical Leave Act, must be considered on workers compensation claims. Companies are also recognizing the value of managing non-occupational disability so that valued employees can get back to the workplace and be productive. Integrated disability management programs are the next generation of claims-handling and will expand in the future.

State Legislative Issues

Several states that passed significant reform legislation in the last two years are working to implement those reforms. Passing a law is only the first step, as the rules, regulations, and implementation of those laws determine if they will achieve their intended purpose. The most significant states to watch are in California, New York, and Oklahoma.

When California passed SB 863 in 2012, the expectation from the state’s legislature was that it would increase benefits to injured workers, while lowering costs for employers in the state. Litigation and unanticipated consequences of the bill have resulted in increased complexity and continually rising insurance rates. There is currently talk of potential clean-up legislation to go along with continued efforts at implementation. We will know by the end of the year whether SB 863 will be able to produce the promised cost savings.

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New York streamlined its assessment process, resulting in a significant reduction of the assessment rate for most employers. Since these rates are adjusted annually, it remains to be seen if these assessment savings will continue into the future.

The big news in Oklahoma is the bill that allowed employers to opt-out of workers compensation starting in February 2014. There have been delays in developing the rules and regulations supporting the opt-out plans, and this has in turn delayed carriers’ development of policies to cover new benefit plans. It appears unlikely that everything will be in place in time for employers to opt out beginning in February.

Vendor consolidation

In the last few years, there has been significant vendor consolidation in the workers compensation industry. First on the third-party administrator side and most recently in medical management. All this consolidation is making buyers of these services uneasy.

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They question how this will impact the quality of the services they receive and wonder how their goals of reducing costs align with the vendors’ goals of increasing revenues.

Analytics

Despite the huge amount of premium, exposure and claims data produced by the workers compensation industry, many complain about the lack of actionable information. As an industry, we will see a continued focus on the use of more meaningful analytics that can assist in identifying savings opportunities, formulating action plans, and measuring the impact of change.

Assessing ROI for Medical Cost Management Efforts

Programs including bill review, utilization review, and nurse case-management are all necessary components of any successful workers compensation program. It is important, however, that these programs are constantly monitored to ensure they are being used appropriately.

Please join me Jan. 15, for a webinar discussing these issues and other potential legislative developments to watch in 2014.  Click here to register

Industry Comments on CMS SMART Act Implementation

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On September 19, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule (IFR) addressing implementation of the SMART Act (otherwise known as the Strengthening Medicare and Repaying Taxpayers Act) , and specifically Section 201 of the Act, which requires CMS to develop a final conditional payment process that would take 120 days from beginning to end. The IFR issued by CMS would significantly extend this process beyond the 120-day deadline, and likely undermine the SMART Act’s intended improvements of the Medicare Secondary Payer (MSP) process. Several industry groups took the opportunity to express their disappointment in CMS’s efforts.

The Risk and Insurance Management Society (RIMS) called on CMS to rescind the IFR and reissue a proposed rule:

“While we commend the Centers for Medicare and Medicaid Services for initiating the SMART Act implementation process, we are disappointed that it chose to issue an IFR rather than promulgating a rule through the regular notice and comment process. We have serious concerns that CMS failed to comply with statutory requirements to implement a final conditional payment process by October 2013, and that the process it has chosen to implement in the interim rule allows for over twice the statutory 120-day period to obtain a final payment amount. We urge CMS to rescind its IFR and to re-issue a new proposed rule through the regular comment process.”

An American Insurance Association (AIA) task force also found the IFR severely lacking:

“AIA’s Task Force does not support the method, manner and time frames contained within the IFC for obtaining final conditional payment amounts via a web portal. The main purposes of the SMART Act are to allow the parties to resolve claims in a timely manner, with finality, to streamline compliance and make it more practical, while ensuring that CMS receives reimbursement for conditional payments quickly. The IFC as written undermines these goals, imposes impediments to prompt claim resolution, allows CMS to delay providing necessary information to beneficiaries and insurers and will not accomplish these goals. The IFC states it specifies the process and timeline for expanding CMS’ existing MSP web portal to conform to the SMART Act. Unfortunately, the provisions of the IFC do not comport with the SMART Act and in many instances go well beyond the purposes and provisions of the terms of the Act.”

The Medicare Advocacy and Recovery Coalition (MARC), a group created in 2008 by various stakeholders and beneficiaries to advocate for the improvement of the Medicare secondary payer system, stated that the IFR is in clear violation of Section 201:

“The IFR is in direct violation of Section 201, which explicitly required CMS to develop a portal process that, from beginning to end, took 120 days. The statutory language could not be more clear: ‘In the case of a payment made by the Secretary pursuant to clause (i) for items and services provided to the claimant, the claimant or applicable plan (as defined in paragraph (8)(F)) may at any time beginning 120 days before the reasonably expected date of a settlement, judgment, award, or other payment, notify the Secretary that a payment is reasonably expected and the expected date of such payment.’ The language of Section 201 is unambiguous; the entire process – from beginning to end – is to take 120 days, which is triggered by the notice, and which includes the 65 day response period within the 120 day period in which the Secretary is to provide the final number.”

An interim final rule differs from typical proposed rules and regulations in that it is in effect even as the public is still commenting on the proposal. The comment deadline for this IFR was November 19. It remains to be seen what, if any, changes CMS will make in response to the comments.

Supreme Court Upholds Health Care Law

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In one of the most closely-watched decisions in recent years, the Supreme Court upheld the Affordable Care Act, including the controversial individual mandate requiring most Americans to purchase health insurance or face a financial penalty. SCOTUS Blog posted a succinct one paragraph summary of the decision:

The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.

The 5-4 decision was seen as a victory for the Obama Administration and will certainly become a key issue in the upcoming November election as Mitt Romney has already vowed to repeal the law should he win the presidency. In fact, this division was likely anticipated by Chief Justice John Roberts in his majority opinion:

We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.

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Roberts did conclude, however, with regard to the constitutionality of the individual mandate:

The Affordable Care Act is constitutional in part and unconstitutional in part. The individual mandate cannot be upheld as an exercise of Congress’s power under the Commerce Clause. That Clause authorizes Congress to regulate interstate commerce, not to order individuals to engage it. In this case, however, it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance.

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Such legislation is within Congress’s power to tax.

Regardless of its ultimate fate, the Affordable Care Act stands, much to the benefit of the some 30 million Americans without health insurance.

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To illustrate where these uninsured are concentrated, the Atlantic offered the following map.

 

Inefficient Health Care Bureaucracy Costs Physicians $27 Billion Per Year

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Everyone knows that the U.S. health care system is inefficient. This hurts both the nation and the employers that offer coverage to their workers. But a new study by researchers at Cornell University and the University of Toronto claims that the average U.S. physician pays $61,000 more in administrative costs per year than their Canadian counterparts.

In sum, this adds up to a $27 billion overage each year.

The U.S. health insurance bureaucracy costs doctors some $27 billion extra per year compared with Canada’s single-payer system, researchers found.

The study, published in the journal Health Affairs, found per-physician costs in the United States averaged $82,975 annually, while physicians in Ontario averaged $22,205 — primarily because Canada’s single-payer healthcare system is simpler.

The researchers also found that nurses and physicians staff spend nearly 21 hours per week on administrative duties. Those in Canada spend just 2.5 hours.

The systems, population and health factors of each nation are, of course, not identical. But these are staggering numbers — particularly on top of yesterday’s news that family health care coverage has eclipsed $15,000 per year for the first time.

The New York Times explains this in the “Survey of Employer-Sponsored Health Benefits, 1999-2011,” a joint study conducted by the Henry J. Kaiser Family Foundation and Health Research & Educational Trust.

A new study by the Kaiser Family Foundation, a nonprofit research group that tracks employer-sponsored health insurance on a yearly basis, shows that the average annual premium for family coverage through an employer reached $15,073 in 2011, an increase of 9 percent over the previous year.

“The open question is whether that’s a one-time spike or the start of a period of higher increases,” said Drew Altman, the chief executive of the Kaiser foundation.

The steep increase in rates is particularly unwelcome at a time when the economy is still sputtering and unemployment continues to hover at about 9 percent. Many businesses cite the high cost of coverage as a factor in their decision not to hire, and health insurance has become increasingly unaffordable for more Americans. Over all, the cost of family coverage has about doubled since 2001, when premiums averaged $7,061, compared with a 34 percent gain in wages over the same period.

Here is a link to the full study.