Tag Archives: practitioner

Healthcare Reforms Aren’t Sustainable

A recent NPR program celebrated the success of the Affordable Care Act (ACA). The benchmark was that many really sick people finally had coverage and that many poor people were now obtaining coverage because of subsidies or because of the expansion of Medicaid. If measured by participation, the healthcare reform under ACA is a success, with more growth anticipated.

Unfortunately, the long-term benchmark must be sustainability and outcomes, not participation. Government programs are often popular in the short term but not sustainable in the long term. The National Flood Insurance Program, Medicare, Medicaid, the VA, etc. will ultimately have to be “adjusted” because 100% of the taxpayers are funding these systems and a very much smaller percentage of us use them.

At some point, the non-users scream “enough already.” “Other people’s money” always runs out, and the $2.6 trillion-plus spent on healthcare is not evenly divided. 47% is spent on the sickest 5% of the population, and just 3% is spent on the healthiest 50% of Americans, according to “Healing a Broken Healthcare System,” from the Louisiana Healthcare Education Coalition. Half of the people are hardly benefiting from the money they contribute under healthcare reform.

Our systems of healthcare and healthcare financing cannot be sustained as they are trending. Yesterday’s system was not sustainable; neither is today’s ACA. The marketplace must innovate. More government and more taxes are not the answer.

Obesity and diabetes are running rampant, and too many folks (especially young people) are living a sedentary lifestyle. This lifestyle adds to the “diseased population” and the future problems and costs.

Personal and family responsibility are a necessity. Nutrition (diet) and activities (exercise) are a start. Addressing the individual in all her elements — mind, body and spirit — is a must. Answers to this crisis are inside of us as individuals and populations — not just at the doctor’s office.

Providers and institutions delivering care must leverage technology for efficiency of operations and efficacy of results. Increased availability and utilization of naturopathic physicians, physician assistants, nurse practitioners, health coaches, nutritionists, counselors and tele-medicine will ensure increased patient engagement and ultimately satisfaction and enhanced results.

Preventive medicine for all and “bringing” care and prevention to populations who can’t get to the marketplace available to most will improve lives and reduce costs. We need fewer dollars to be spent on prescriptions and invasive surgeries. It’s okay for providers and payers to just say no to demands that are not in the consumer’s best interest — regardless of what the TV commercial suggests.

Genomics, improved diagnostics to ensure earlier interventions, a focus on extending life (versus delaying death), integrated/holistic care, marrying technology and touch and technology, natural medicine and other changes are in the works now.

Other hopes rest in vascular therapy, tailored and embraced wellness plans, systems that can intervene with populations in need during crises and tailored and personalized process management for chronically ill mental health patients. Accountable care, outcome-based payment mechanisms, new models of care and care delivery and consumer engagement (personal avatars facilitating our own motivation allowing us to design our own “road to well”) are solutions now or yet to be introduced in the market of tomorrow. These are our future. Marcus Welby, M.D., is dead, but the healing and caring he delivered can live on.

This article was written in August. Last week, I received proof of the concepts. A friend received his renewal for his ACA policy. Coverage was reduced from a 70/30 co-pay (insurer pays 70%,) to a 60/40 plan, yet his premiums increased 31%. This is just the beginning — it will get worse. When you insure a majority of sick people and you subsidize many of their premiums, you will get participation. When relatively healthy and unsubsidized policyholders receive prohibitive rate increases, they will discontinue coverage, and the insured pool suffers adverse selection. Did I mention that the situation will get worse?

The Best of Claims, the Worst of Claims

It was the best of claims; it was the worst of claims… the age of wisdom, the age of foolishness… belief vs. incredulity… hope vs. despair… etc., etc. The iconic opening paragraph from Charles Dickens’ A Tale of Two Cities makes one realize such conflicts do exist in the same space and time, albeit through different personal perspectives. Such is the reality in workers’ comp claims, where the single biggest factor in outcome is often the claimant’s attitude.

A client claim-audit project offers a jarring comparison between two claim files from different parts of the country. The claims exemplify how little control we actually have over an employee’s attitude in the disability management process, and show how vastly different the human tolls can be.

Both claims were in excess of 10 years old. Both involved exaggerated and evolving symptoms with eventual narcotic prescriptions for “pain management.” At approximately the same time, however, each took a different path.

One claimant found her own reasons and will-power to end the years she spent on prescribed pain-killers. She entered a drug treatment process on her own, eventually stopped her prescriptions and found a full-time job. The other claimant dove deeper into narcotic addiction and exhibited classic drug seeking behavior – such as “losing” his prescriptions and requiring early refills. He tested positive for other illegal drugs once his rightfully suspicious physician initiated a monitoring program.

There was no appreciably different set of claim management tools or tactics used for the claims – the stark difference in outcome came down to the want of the individual… an almost impossible aspect for the day-to-day claim practitioner or human-resources manager to reach or control. And, at the time of my audit, the claims were equally easy to close.

The woman free of prescriptions and carrying a full-time job was simply no longer a claimant. She was probably very happy to have her case closed and the dark chapter of her life over. We decided on an administrative closure of the claim.

On the other hand, the gentleman was barred from his erstwhile treating physician and pain management clinic for abusing meds and refusing a drug treatment program. A host of independent medical opinions indicated the man did not require further meds for the old injury. His everyday behavior was highly unfocused and erratic, apparently causing no attorney to take his WC case. He lived out of a tent in a relative’s backyard.

The man’s claim was also an easy administrative closure because of lack of any foreseeable prosecution. I have to admit his situation nicked at my coat of cynicism, the one layered thick from years in this profession. I hated the plain fact that he was a doomed victim of a WC system enabling his addictive conditions.

To my good readers, I ask: Which closure would you rather preside over?

Quick-Tip: Know When to Hold ‘Em But Don’t Wait to Fold ‘Em

Concept:

When reasonable medical treatment has no impact, quickly consider other options. A claimant with misguided intentions or extraneous problems and no desire to be “cured” might just be his own worst enemy and using the WC claim as a primary enabler.

Suggestions:

– Find appropriate ways to incorporate employee assistance programs (EAPs) or other specialty counseling services to support employees or WC claimants who have debilitating outlooks or possible addiction issues.

– Maintain a “no-fill” position on narcotic prescriptions. This will give you and your defense team at least an opportunity to block dangerous drugs before they are automatically initiated.

– Consider any “chronic pain” diagnosis to indicate maximum medical improvement (MMI). “Chronic” as a term arguably fits MMI. Try to settle the case under that premise. Fight the diagnosis and treatment plan, as a means to pressure settlement. If the plaintiff’s side argues against an MMI determination, then demand a treatment outlook and timeline that results in stopping pain medication.

– For claims with long-term narcotic situations, seek peer reviews to ascertain if the regimes are excessive and if a recommendation for detoxification is appropriate. Specifically set up medical evaluations to confirm addiction and substance abuse tendencies.

– Never presume a claimant with the wrong attitude and bleak outlook will be cured by any type of treatment. Know when you are wasting time and money. You must sense and act on this early. Don’t rely on adjusters to raise questions, as their inclination is to keep treating as long as medical opinion approves. You must take the role of disruptor.

Bottom line” It is distressing that workers’ comp enables addiction. Closing such cases is not always pretty. Learn from the disasters and take more responsibility in the future. Recognize that claimant attitude and outlook are of primary importance, for good or for bad.