Advice for Employers as Congress Considers Fate of Backstop
“As insurers evaluate their business in light of the uncertainty, some have limited their underwriting of workers’ compensation for companies with high concentrations of employees in major cities,” states a new report. “Because insurers cannot exclude terrorism-related losses and employers are required to buy it, the options available to buyers have been reduced and rate increases have accelerated.”
The statement is included in an update on the impending expiration of the Terrorism Risk Insurance Act. The risk management research briefing was produced by Marsh, as workers’ comp practitioners ponder the impact of the expiration of the government’s financial backstop program.
TRIA was implemented after the 9/11 attacks to cap insurance losses from a large-scale terrorist event. It has been extended twice, but the latest version, the Terrorism Risk Insurance Program Reauthorization Act of 2007, is due to sunset on Dec. 31.
Three separate bills before Congress would extend TRIA for five to 10 years. Organizations such as NCCI, the National Association of Insurance Commissioners, and industry trade associations have been speaking to members of Congress in support of the legislation.
According to NCCI, each bill has bipartisan support. However, the administration has not clarified its position on TRIA.
“Insurers in 2014 are underwriting workers’ compensation policies that contemplate coverage without the potential financial protections of TRIPRA, presenting challenges for some workers’ compensation buyers,” the Marsh briefing explains. “Most insurers are less willing to underwrite the risks of employers in certain high-profile industries, with large employee concentrations, or in certain major cities. Such employers are likely to experience higher rates and premiums as the uncertainty over TRIPRA continues.”
Other insurers are attaching endorsements to policies while still others are setting policy expiration dates to coincide with the expiration of TRIPRA, according to Marsh. The idea is to put the onus of the uncertainty of the program onto insurance buyers.
Marsh suggests starting the renewal process as early as 120 days or more to better manage the situation. “The importance of providing a differentiated view of an organization’s terrorism risk profile to insurers cannot be overemphasized,” the report says. “To achieve this, employers should work with their advisors to develop communication strategies and presentation tactics around all key risk exposures, including modeling and risk analytics in support of their renewal objectives.”
Employers are advised to prepare detailed information for underwriters on their exposures and operations, including loss trends, safety programs, and risk management practices. Insurers have “significantly increased questions focused on the risks associated with a potential terrorist event,” the briefing says. It suggests employers facing aggregation issues have the following information available:
- Employee marital/dependency status.
- Employee telecommuting/hospitality practices and impact on concentration.
- Physical security of the building, including guards, surveillance cameras, parking areas, and HVAC protections.
- How access to the building is controlled.
- Construction of the building and location of the offices.
- Management policies around workplace violence, weapons, and employment screening.
- Employee security procedures.
- Emergency response/crisis management plan and procedures.
- Fire/life safety program.
- Security staff.
Employers that have multiple shifts or operate in campus settings are advised to provide additional information to better reflect their actual exposure to catastrophic losses at a given time. Such information would include the total number of employees and the number working during peak shifts, the actual buildings where the employees are located, and the percentage of the workforce in the field or telecommuting rather than in the office.
New Thinking: Opioids as a Last Resort Only
“Routine opioid use is strongly not recommended for treatment of non-severe acute pain (e.g., low back pain, sprains, or minor injury without signs of tissue damage),” states a new guideline. “For acute pain, there is quality evidence that other medications and treatments are at least equivalent if not superior and no quality published evidence an opioid is superior for treatment of acute pain. … Among trials for treatment of acute pain, ibuprofen was reportedly superior to codeine or acetaminophen for acute injuries including fractures.”
The recommendations are included in the American College of Occupational and Environmental Medicine’s updated Opioid Treatment Guideline published by the Reed Group. They are based on extensive research of studies by more than two dozen professionals.
The guidelines address acute pain (up to four weeks), sub-acute pain (one to three months), and chronic pain identified as more than three months.
For injured workers with acute pain, the authors suggest opioids may do more harm than good. “Quality evidence indicates safety profiles are considerably worse for opioids,” the report says. “Studies also demonstrate worse functional outcomes for patients treated early with opioids. … Prolonged use of opioids after an acute event has been associated with worse functional outcomes.”
When acute, severe pain cannot be controlled by NSAIDs or other means, the guideline suggests the “lowest effective dose of a short-acting opioid” be prescribed. Additionally, it states:
- A morphine equivalent dose limit of 50 mg is recommended. Exceeding that should be based on documented need and increased surveillance for adverse effects. In fact, the researchers suggest that should also be the dose limit for patients with sub-acute and chronic pain.
- Lower potency opioids are recommended when sufficient for pain relief and dispensing only quantities sufficient for the pain are recommended.
- Prescription drug monitoring programs are recommended to be checked.
- NSAIDs or acetaminophen should generally accompany an opioid prescription.
- Opioids should be prescribed at night or while not working when possible due to risk of impairments and lost time from work.
- It is recommended to taper off the opioid in one to two weeks.
Injured workers with a variety of comorbidities may be at elevated risk of adverse effects and even death. Additionally, “there are considerable drug-drug interactions that have been reported.” Therefore, “considerable caution is warranted” when considering prescribing an opioid for a variety of conditions, including chronic hepatitis and/or cirrhosis, coronary artery disease, severe obesity, dysrhythmias, cerebrovascular disease, orthostatic hypotension, asthma, recurrent pneumonia, thermoregulatory problems, advanced age, osteopenia, osteoporosis, water retention, renal failure, testosterone deficiency, erectile dysfunction, abdominal pain, gastroparesis, constipation, prostatic hypertrophy, oligomenorrhea, pregnancy, human immunodeficiency virus, ineffective birth control, herpes, allodynia, dementia, cognitive dysfunction and impairment, gait problems, tremor, concentration problems, insomnia, coordination problems, and slow reaction time.