Report Addresses Overlapping Injury Vulnerabilities
Hispanic immigrants accounted for about 20 percent of the construction workforce in the U.S. during 2013.
They were the “only racial/ethnic group with an increase in the number of workplace fatalities,” according to a new report by the American Association of Safety Engineers (ASSE) and the National Institute for Occupational Safety and Health (NIOSH).
As the number of immigrant workers in the construction industry grows, so does the number of occupational injuries, primarily among those under 25 years old.
Why is this group facing higher rates of injury? Why hasn’t their exposure been mitigated?
A joint presentation by ASSE and NIOSH identified a key roadblock in designing and implementing safety interventions for the particular group of at-risk workers. Namely, lack of data that explores overlap of high-risk populations.
In its report “Overlapping Vulnerabilities: the Occupational Health and Safety of Young Immigrant Workers in Small Construction Firms,” ASSE and NIOSH analyzed the risk factors that place young Hispanic workers (under age 25) employed by small construction firms at increased risk.
Each of these groups – young workers, immigrant workers, and workers in small businesses – face increased risk for work-related injury and illness, but the Bureau of Labor Statistics does not collect specific data on the number of workers that fall into multiple buckets.
ASSE and NIOSH sought to create a conceptual model for examining areas of overlap, but pointed out that there is “nothing magic” about the groups chosen as a focus in this report. They plan to conduct further research addressing other at-risk groups in different industries.
“Data is not collected on these vulnerable populations in a way we think they should be,” said Christine Branche, the principal associate director of NIOSH and director of the Office of Construction Safety and Health. “This report invites organizations to work together in ways we haven’t before.” She and ASSE president Patricia Ennis presented the report at The National Press Club in Washington, D.C. on May 6. They highlighted the need for partnerships between ASSE and NIOSH, employers (especially small businesses) and other safety organizations.
Many small business owners simply don’t know what laws apply to them, or how to comply within their limited means and resources.
Construction is inherently a high-risk industry, which claims more workplace fatalities than any other, accounting for 8.8 percent of workplace illness and injury among 16- to 24-year-olds in 2013. Young workers in particular lack experience on the job, and often hesitate to ask for help due to a desire to prove themselves. Add to that the language and cultural barriers between Hispanic workers and their English-speaking supervisors, and lack of safety training and resources chronically characteristic of small firms, and you get a perfect storm of safety risks.
The report includes some suggested interventions for reaching this subset of at-risk workers. NIOSH, for example, partnered with the Mexican government to “identify and address occupational health inequities among immigrant workers.” This includes greater outreach efforts in the U.S. to link the workers to health promotion resources and legal services.
Other efforts target small businesses through intermediary organizations like trade associations, chambers of commerce and unions. These organizations can better connect small businesses with the resources they need to become educated about OSH requirements and strategies to implement interventions. Many small business owners simply don’t know what laws apply to them, or how to comply within their limited means and resources. More importantly, they don’t know what resources are available to them to help navigate those issues.
The Labor and Occupational Health Program at the University of California, Berkeley, for example, developed a model training program that teaches small business owners how to develop and implement their own injury and illness prevention programs, according to the report. Some techniques to incorporate include more directed training like simulations and storytelling techniques, ASSE president Patricia Ennis said during the presentation. These can help to overcome language barriers and more clearly demonstrate key technical skills, which are critical in dangerous construction jobs.
Safety certification programs for vulnerable workers can also be touted as a competitive advantage, since many larger employers require a certain level of safety training as a condition of employment. If smaller employers adopt this tactic, it can be an incentive for workers to receive training before they even show up to work.
Ultimately, any development of targeted interventions depends on the collection of the appropriate data. ASSE and NIOSH conclude their report by emphasizing the need to analyze existing data to identify overlapping at-risk groups, as well as to add data fields to make sure those subsets are captured more clearly.
Both NIOSH’s Branche and ASSE’s Ennis stressed that the key to improving safety programs and culture comes down to collaboration and communication between employers and safety organizations so that data can be turned into action.
There are no hard statistics confirming a shortage of safety and health professionals, but there is a lot of circumstantial data.
An October 2011 study prepared for the National Institute for Occupational Safety and Health (NIOSH), for example, concluded that the need for health and safety engineers in 2011 and over the next five years “is substantially higher than the number estimated to be produced from … training programs.”
The U.S. Bureau of Labor Statistics predicts 11 percent growth in the number of health and safety engineers between 2012 and 2022.
In addition, a survey of members by the American Society of Safety Engineers (ASSE) found about 1 percent unemployment, and the 30 or so annual graduates of the University of Michigan Center for Occupational Health and Safety Engineering usually get hired before they graduate.
Some experts, however, say the shortage is not so much a lack of entry-level talent as it is of experienced safety and health professionals. They said that what organizations are missing are competent professionals who are knowledgeable about both the industry in question, and the resources and tools that professionals can offer.
As Skip Smith, senior director of risk management and insurance at HOA Inc. (Hooters of America) said in a recent Risk Insider article, “But these days, if you’re charged with overseeing a corporate risk management department, it is very difficult to fill a safety position. There are a limited number of qualified candidates with the required educational background, experience and unique set of skills.”
It takes time, obviously, to gain the credentials, experience and even the terminology necessary to make an impact on a worksite. But the clock may be ticking on the profession as baby boomers get ready to retire and the influx of professionals is lower than necessary to fill the gap.
One problem is the low visibility of the profession to most young people, said Stuart Batterman, director, University of Michigan Center for Occupational Health and Safety Engineering.
“Typically, they don’t recognize the opportunities that are available in this field,” he said. “It’s also not the kind of field that most people have prior exposure to.”
For some industries, such as construction, manufacturing, and oil and gas, the need may be greater than others. Obviously, that’s because such industries are more hazardous than some, but it’s also because these sectors are more likely to have the increased risk of ramping up or ramping down operations. When that happens, the danger increases.
New employees, round-the-clock operations, different locales — all of them add uncertainty and potential risk to organizations. The continuing increase of Spanish-speaking workers as well as those native in other languages also makes it harder to educate and train employees.
As the difficulty mounts in finding experienced environmental, health and safety (known both as EHS or HSE) professionals, the number of consultants and service providers to fill that void is growing. Insurance companies and brokerages as well provide risk control services to their clients.
But consultants are generally not on the jobsite every day and have less insight into the daily demands of an organization.
The age issue is not one that will go away anytime soon.
“We have got a graying population,” said Carl W. Heinlein, senior safety consultant, American Contractors Insurance Group, a captive owned by 41 contractors around the country. “I can probably think of seven great safety jobs that are currently available right now. They can’t find quality, experienced people to fill them.”
The 2011 NIOSH study, prepared by Westat, projected that about 10 percent of safety professionals would retire within the next year, and estimated that a “large number” of such professionals are over the age of 50.
It forecast that employers would hire more than 25,000 more over the next five years, but that colleges were expected to graduate fewer than 13,000 HSE professionals. And the report noted that enrollment was projected to slightly decline over a five year period.
Leaders in construction, oil and gas, and other industries, Heinlein said, “have been begging for quality safety folks.”
Those industries, in particular, are dangerous ones to be in. According to the Bureau of Labor Statistics, construction fatalities, while down 36 percent since 2006, still account for the highest number of fatal work injuries of any industry sector in 2013, the latest year for which results are available.
It’s more difficult to pin down the fatalities in the oil and gas industry as it is covered by several different BLS categories. Overall, construction and extraction occupations accounted for 818 fatalities in 2013, or 18 percent of all workplace fatal injuries. Transportation fatalities numbered 1,184 or 27 percent of all workplace deaths.
BLS indicates that organizations involved in oil and gas extraction have the highest percentage of EHS employment in the private sector, at nearly 1 percent of all positions. Another six-tenths of 1 percent are employed in petroleum and coal products manufacturing.
To be effective, health and safety professionals need hands-on experience in troubleshooting problems, said Scott Harris, director of EHS advisory services at UL Workplace Health & Safety.
“We really haven’t seen a shortage,” he said.
“When I am out talking to folks, they have never said to us, ‘We can’t find someone.’ I have heard often, ‘It’s hard to find a good one,’ meaning they are looking for certain key skills and the young people just don’t have them.”
The ability to research and “textbook knowledge” are what college graduates can bring to a job, he said, but they often lack industry experience, the ability to solve problems, people skills and presentation skills, so they can command attention during meetings.
It’s also important to understand the value of redesigning a process or engineering out the risk instead of focusing just on training and education, said Matt Kupiec, assistant vice president of construction risk engineering at ACE Group.
And, he noted, it’s not always necessary to re-invent the wheel. There are vendors and service providers that have created products to meet many safety demands.
It takes about two years for an entry-level person to become “well versed as a generalist.” — Brion Callori, senior vice president, engineering and research, FM Global
At FM Global, which focuses a lot of attention on commercial property risk, Brion Callori, senior vice president, engineering and research, noted that it takes time for property risk engineers to become fully proficient.
FM Global hires between 100 and 150 property risk engineers yearly.
There are two levels to proficiency, he said.
“We expect someone out of engineering school to think like an engineer. We have to give them cross-discipline training and have developed a hands-on training approach to expedite the process.”
It takes about two years for an entry-level person to become “well versed as a generalist,” he said, and then the carrier moves the focus to specific natural hazards, such as windstorms, power generation, chemicals, etc.
“It probably takes another three years of that to become top flight and really specialized in something,” Callori said.
One issue with the energy industry in particular, said Jay Doherty, partner, workforce sciences institute, Mercer, is the tremendous number of contractors on major projects, with investment levels ranging from $100 million to several billion dollars.
“You have less control and more variation in the skills, compliance and knowledge of safety [with contractors],” he said.
“The industry has, unfortunately, had incidents, serious incidents, more often with the subcontractors than with the prime contractor or operator.”
BLS statistics bear that out — for all industry sectors.
Fatal injuries of contractors accounted for 17 percent of all workplace deaths in 2013, and half of all contractors who were fatally injured were working in construction and extraction occupations.
The importance of experience when it comes to HSE professionals is not so much on the increasing compliance requirements but on problem-solving and prevention, Doherty said.
The career structure and the time to competence is complex for HSE, he said, because “the discipline is not simply defined by hierarchy or level. Often the best HSE experts don’t begin in that role.” Development requires broad knowledge not only of OSHA and other governmental regulations, but also knowing the protocols of companies and specific industries.
It also depends on the span of control, Doherty said. It takes more than HSE professionals to look after safety. Supervisors often perform a compliance role and when cost pressures reduce spans or there is simply a lack of experience in the workforce, there is greater likelihood of safety incidents, he said.
“Companies need to examine the career paths for their HSE professionals,” he said, “to make sure top talent is rewarded commensurate with other critical skills. That sends a clear signal of the priority placed on safety and the environment.”
But, some companies just don’t value the position enough. When times are tight, occupational health and safety professionals are often near the top of the chopping block, and many organizations continue to look at the profession as an expense instead of a way to improve production and margin.
“This is a margin-making opportunity. It’s an opportunity for a company to look at it more as a business asset than as a cost or expense of the operation.” — James Merendino, vice president and general manager, commercial insurance risk control services, Liberty Mutual
As UL’s Harris noted, the profession has its own gallows humor: It’s always safety first … unless it interferes with production or “gets in the way of something else.”
But, said James Merendino, vice president and general manager, commercial insurance risk control services, Liberty Mutual, effective safety and risk management strategies affect both the top and bottom lines of a company.
“This is a margin-making opportunity,” Merendino said.
“It’s an opportunity for a company to look at it more as a business asset than as a cost or expense of the operation.”
It’s more than ensuring regulations are complied with, he said. It’s making safety a strategic priority of the organization, which may result not only in fewer and less severe injuries, but also in lower insurance premiums, and better terms and conditions.
It also is less disruptive of production deadlines, and more protective of an organization’s brand and an industry’s reputation.
“Safety has to be elevated to the position that production is,” said George Cesarini, vice president of construction risk engineering, ACE.
“Organizations need to elevate safety from, ‘Insurance wants this’ or ‘OSHA wants this’ to elevating it to the same level as production, to making it a core value within the organization.”
Finding the experienced professionals to fill that role, however, may continue to be a problem.
Mitigating Fraud, Waste, and Abuse of Opioid Medications
There’s a fine line between instances of fraud, waste, and abuse. One of the key differences is intent and knowledge. Fraud is knowingly and willfully defrauding a health care benefit program for personal gain or profit. Each of the parties to a claim has opportunity and motive to commit fraud. For example, an injured worker might fill a prescription for pain medication only to sell it to a third party for profit. A prescriber might knowingly write prescriptions for certain pain medications in order to receive a “kickback” by the manufacturer.
Waste is overuse of services and misuse of resources resulting in unnecessary costs, whereas abuse is practices that are inconsistent with professional standards of care, leading to avoidable costs. In both situations, the wrongdoer may not realize the effects of their actions. Examples of waste include under-utilization of generics, either because of an injured worker’s request for brand name medication, or the prescriber writing for such. Examples of abusive behavior are an injured worker requesting refills too soon, and a prescriber billing for services that were not medically necessary.
Actions that Interfere with Opioid Management
Early intervention of potential fraud, waste, and abuse situations is the best way to mitigate its effects. By considering the total pharmacotherapy program of an injured worker, prescribing behaviors of physicians, and pharmacy dispensing patterns, opportunities to intervene, control, and correct behaviors that are counterproductive to treatment and increase costs become possible. Certain behaviors in each community are indicative of potential fraud, waste, and abuse situations. Through their identification, early intervention can begin.
- Prescriber/Pharmacy Shopping – By going to different prescribers or pharmacies, an injured worker can acquire multiple prescriptions for opioids. They may be able to obtain “legitimate” prescriptions, as well as find those physicians who aren’t so diligent in their prescribing practices.
- Utilizing Pill Mills – Pain clinics or pill mills are typically cash-only facilities that bypass physical exams, medical records, and x-rays and prescribe pain medications to anyone—no questions asked.
- Beating the Urine Test – Injured workers can beat the urine drug test by using any of the multiple commercial products available in an attempt to mask results, or declaring religious/moral grounds as a refusal for taking the test. They may also take certain products known to deliver a false positive in order to show compliance. For example, using the over-the-counter Vicks® inhaler will show positive for amphetamines in an in-office test.
- Renting Pills – When prescribers demand an injured worker submit to pill counts (random or not), he or she must bring in their prescription bottles. Rent-a-pill operations allow an injured worker to pay a fee to rent the pills needed for this upcoming office visit.
- Forging or Altering Prescriptions –Today’s technology makes it easy to create and edit prescription pads. The phone number of the prescriber can be easily replaced with that of a friend for verification purposes. Injured workers can also take sheets from a prescription pad while at the physician’s office.
- Over-Prescribing of Controlled Substances – By prescribing high amounts and dosages of opioids, a physician quickly becomes a go-to physician for injured workers seeking opioids.
- Physician dispensing and compounded medication – By dispensing opioids from their office, a physician may benefit from the revenue generated by these medications, and may be prone to prescribe more of these medications for that reason. Additionally, a physician who prescribes compounded medications before a commercially available product is tried may have a financial relationship with a compounding pharmacy.
- Historical Non-Compliance – Physicians who have exhibited potentially high-risk behavior in the past (e.g., sanctions, outlier prescribing patterns compared to their peers, reluctance or refusal to engage in peer-to-peer outreach) are likely to continue aberrant behavior.
- Unnecessary Brand Utilization – Writing prescriptions for brand medication when a generic is available may be an indicator of potential fraud, waste, or abuse.
- Unnecessary Diagnostic Procedures or Surgeries – A physician may require or recommend tests or procedures that are not typical or necessary for the treatment of the injury, which can be wasteful.
- Billing for Services Not Provided – Since the injured worker is not financially responsible for his or her treatment, a physician may mistakenly, or knowingly, bill a payer for services not provided.
- Compounded Medications – Compounded medications are often very costly, more so than other treatments. A pharmacy that dispenses compounded medications may have a financial arrangement with a prescriber.
- Historical Non-Compliance – Like physicians, pharmacies with a history of non-compliance raise a red flag. In states with Prescription Drug Monitoring Programs (PDMPs), pharmacies who fail to consult this database prior to dispensing may be turning a blind eye to injured workers filling multiple prescriptions from multiple physicians.
- Excessive Dispensing of Controlled Substances – Dispensing of a high number of controlled substances could be a sign of aberrant behavior, either on behalf of the pharmacy itself or that injured workers have found this pharmacy to be lenient in its processes.
Clinical Tools for Opioid Management
Once identified, acting on the potential situations of fraud, waste, and abuse should leverage all key stakeholders. Intervention approaches include notifying claims professionals, sending letters to prescribing physicians, performing urine drug testing, reviewing full medical records with peer-to-peer outreach, and referring to payer special investigative unit (SIU) resources. A program that integrates clinical strategies to identify aberrant behavior, alert stakeholders of potential issues, act through intervention, and monitor progress with the injured worker, prescriber, and pharmacy communities can prevent and resolve fraud, waste, and abuse situations.
Proactive Opioid Management Mitigates Fraud, Waste, and Abuse
Opioids can be used safely when properly monitored and controlled. By taking proactive measures to reduce fraud, waste, and abuse of opioids, payers improve injured worker safety and obtain more control over medication expenses. A Pharmacy Benefit Manager (PBM) can offer payers an effective opioid utilization strategy to identify, alert, intervene upon, and monitor potential aberrant behavior, providing a path to brighter outcomes for all.