The Truth About The Keystone Pipeline
Did you know that the Keystone Pipeline is actually in operation?
Most people don’t.
But then again, most people believe that TRIA has actually covered terror events — but that will be a different article.
Maybe we should start with the facts:
- Phase I of the pipeline runs from Hardesty, Alberta, to Steele City, Nebraska (2147 miles), then on to a refinery in Wood River, Illinois. This was finished in 2010.
- Phase II runs 300 miles from Steele City to storage facilities in Oklahoma. This was finished in 2011.
- Phase III is from Oklahoma to Port Arthur, Texas, where it finished in 2014 with a lateral pipeline connected to refineries at Houston, Texas, to be finished in mid-2015.
So what is it that we keep hearing about? Well that would be Phase IV of the pipeline project. This would start in the same place in Canada, go to the same place in Nebraska, but be wider and have a shorter route. It is this phase that has been the focus of all the discussion, for what seems like forever.
Those who are opposed to the pipeline say, “It’s BAD. It’s bad for the climate, for health, for the environment, for the economy … just BAD.” Those who are for the pipeline say it will create 40,000 jobs, albeit temporary. (But aren’t all construction jobs temporary anyway?) It is also built without government financing. It helps our neighbors to the North, who have approved the project, and helps our economy.
In the United States, we have made it a political question. Congress has approved it, the President has vetoed it, but as the great philosopher Yogi Berra said: “It ain’t over ’til it’s over.”
Only in dreams can we live risk free, so we manage the risks to the best of the industry’s ability.
As for the alternatives, nothing really provides a consensus of agreement. For example, move it by rail. This can and has caused problems. In July of 2013, a parked train of crude oil came loose, rolled down a hill and exploded in a ball of fire in the town of Lac-Megantic in Quebec. The inferno claimed 47 people and the town was practically destroyed. Groups opposed to moving crude by rail commonly refer to the trains as “bomb trains.”
How about by water? In March of 2014, a barge carrying 924,000 gallons of crude oil collided with a ship in Galveston Bay, spilling 170,000 gallons along a route heavily travelled by birds during their seasonal migration.
Ok, let’s move it by truck … well, you get the point.
As a nation, we are now energy independent — something we have talked about since 1973. But we need to move the product from where it is, to where it is needed. We need to do it as safely as possible, human life is sacrosanct and our precious environment needs to be protected.
Only in dreams can we live risk free, so we manage the risks to the best of the industry’s ability. We insure them, we regulate them. What we can’t do is to say “no” to everything.
Let’s finish the pipeline.
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.
The Tools of the Trade
Integrating medical management with pharmacy benefit management is the Holy Grail in workers’ compensation. But getting it right involves diligence, good team communication and robust controls over the costs of monitoring technology.
Risk managers in workers’ compensation can feel good about the fact that opioid use is declining slightly. But experts who gathered for a pharmacy risk management roundtable in Philadelphia in June pointed to a number of reasons why workers’ compensation professionals have more than enough work cut out for them going forward.
For one, although opioid use is declining, its abuse and overuse in legacy workers’ compensation claims is still very much a problem. An epidemic rages nationally, with prescription drug overdose deaths outpacing those from the abuse of heroin and cocaine combined.
In addition, increased use of compound medications and unregulated physician dispensing are resulting in price gouging and poor medical outcomes.
Although individual states are attempting to address the problem of physician dispensing of prescriptions in workers’ comp, there is no national prohibition against it: That despite substantial evidence that the practice can result in ruinous workers’ compensation medical bills and poor patient outcomes.
“The issue is that there isn’t enough formal evidence to indicate improved outcomes from the use of compounds or physician dispensed drugs, and there are also legitimate concerns with patient safety,” said roundtable participant Jim Andrews, executive vice president, pharmacy, for Duluth, Ga.-based pharmacy benefit manager Healthcare Solutions.
Andrews’ concerns were echoed by another roundtable participant, Dr. Jennifer Dragoun, Philadelphia-based vice president and chief medical officer with AmeriHealth Casualty.
“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events,” Dr. Dragoun said.
Whereas two years ago, topical creams and other compounds with two to three medications in them were causing concern, now we’re seeing compounds with seven or more medicines in them.
How those medicines are interacting with one another, and in the case of a compound cream, how quickly they’re being absorbed by the patient, are unknowns that are creating undue health risks.
“These medicines haven’t been tested for that route of administration,” Dragoun said.
In other words, the compounds have not been reviewed or approved by the FDA.
Carol Valentic, vice president of cost containment and medical management with third-party administrator Broadspire, said her company’s approach to that issue is to send a letter to providers, through the company’s pharmacy benefit administrator, alerting them to the fact that compounds are not FDA-approved and could be dangerous.
Other roundtable participants said they employ utilization review of every prescribed compound medication. They’re finding that the inflation of the average wholesale price for prescriptions that pharmacy benefit managers are battling in the case of single medications is happening with compounds as well, to the surprise of probably no one.
“The cost of compounds is doubling every year,” Healthcare Solutions’ Andrews said.
Kim Clark, vice president of utilization management with Patriot Care Management Inc., a division of Patriot National, Inc., said Patriot has their own software, DecisionUR, and opioids as well as compound prescriptions can be directed from the PBM to Utilization Review.
In the area of new worries in workers’ compensation, and there are plenty of them, Dragoun also pointed to the introduction of extremely high cost, albeit extremely effective specialty medications, such as those being used to treat Hepatitis C. Treatments in this area can run into the hundreds of thousands of dollars.
Domestic drug manufacturers, pressed to pursue profits as their product lines mature and their margins level off, are jockeying for dominance in this area.
“This seems to be a route that a lot of drug makers are going after. Very narrow markets but with extremely high cost medications,” said Deborah Gleason, clinical resources manager, medical programs, with ESIS, the Philadelphia-based third-party administrator that is part of ACE Group.
Tools of the Trade
Given how substantially the use of prescriptions can balloon the cost of a workers’ compensation claim and undermine outcomes, a number of tools are in the market that can help risk managers rein in costs.
One is urine drug monitoring, which can catch cases of drug diversion, or instances where an injured worker is ingesting unprescribed substances. But the use of that test can create its own problems, namely overutilization.
Gleason, with ESIS, Inc., and others use urine drug monitoring. But when the test is overused, say by being conducted every month instead of quarterly as is recommended, the members of the Philadelphia roundtable said its costs can outrun its usefulness.
Test results are frequently inconsistent, signaling that the injured workers aren’t taking the prescribed medication or are taking something they shouldn’t be. Drug testing shouldn’t be used in isolation but rather as a component of integrated medical management.
“What’s emerging today, and in some companies more prevalently, is the integration of managed care with pharmacy benefit management,” roundtable participant Valentic said.
“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events.”
— Dr. Jennifer Dragoun, Vice President and Chief Medical Officer, AmeriHealth Casualty
In other words, it’s not enough to flag a script or pick up a urine drug monitoring test result. There needs to be a plan or a system in place that says what action should be taken with the patient once that information has been received.
Identifying a potential problem early and taking action on it is key, said ESIS’ Gleason. She added that the patient’s psychological state, including how they react to and perceive pain, is something that more risk practitioners should consider.
Obstacles to assessing someone’s psychological or psychosocial state, according to roundtable members, include a lack of awareness or acceptance of its possible advantages on the part of patients and physicians. After all, we’re talking about an assessment, a list of questions, that should take no more than 15 minutes to carry out.
If a treating physician or case manager doesn‘t conduct a psychological test but is still concerned about the potential for pain medication abuse, there is one key question they can ask an injured worker, according to AmeriHealth Casualty’s Dragoun.
“There is one question that predicts far more than any other attribute of a patient whether they are likely to abuse narcotics, and that is if they have a personal or family history of substance abuse,” Dragoun said.
“You know they may ask that about the patient, but I don’t know how many ask it about the family,” Patriot Care Management’s Kim Clark said.
Pharmacogenetic testing, that is testing an individual for how they might react to certain drugs or combinations of drugs, and not — let’s be clear about this — whether they are predisposed to addiction, is also entering the market.
But as is the case with urine drug monitoring, the use of pharmacogenetic testing is no cure-all and the cost of it needs to be carefully managed.
Some vendors are pitching that it be applied to every case in a payer’s portfolio. The roundtable participants in Philadelphia agreed that it should be used with far more discretion than that.
Regulating the Regulators
It’s a given in the insurance business and in workers’ compensation that regulators in all 50 states call the shots. There are few national laws that regulate the hazards faced by workers’ compensation risk managers and injured workers.
Having said that, is it really such a pipe dream to think that the federal government could step in and provide leadership in an area that is so prone to confusion, risk and self-serving behavior on the part of some vendors and medical practitioners?
If the Philadelphia roundtable as a group could point to one place where federal regulators could do some good it would be in the area of physician dispensing. Many states have enacted legislation to curb the practice, as there is no data to prove better outcomes, and regulation by the federal government would be of benefit, the Philadelphia roundtable concluded.
Another area would be to require FDA oversight for compounds.
“The minute you need to have FDA approval of a compound, that’s going to stop it,” Broadspire’s Valentic said.
It’s a notion worth considering. After all, lives are at stake here.
Given the lack of oversight from the federal government, the roundtable participants pointed to measures in a number of states that are worth emulating. The Texas closed formulary, which limits the range of medications that can be prescribed, is one example.
The requirement in the State of New York that a prescribing physician check a state registry — what’s known as a prescription drug monitoring program — to check whether a patient is already taking or has a prescription for a controlled substance, is another good example of a state government stepping in to ensure the safety of its residents.
“The minute you need to have FDA approval of a compound, that’s going to stop it.”
— Carol Valentic, Vice President of Cost Containment, Medical Management, Broadspire
Pennsylvania also earned praise from the roundtable for recently passing a measure limiting the amount of medication that a physician can dispense to an initial supply.
With different regulations in every state and with the average wholesale cost of prescriptions constantly on the rise, pharmacy benefit management is an art requiring constant vigilance.
“It’s not an original thought, but if you stop and think about all the things that are happening in society with the addictions and the costs, the cost of doing nothing is greater than the cost of doing something.
I think that’s why everybody is doing something,” Healthcare Solutions’ Andrews said.
For more information about Healthcare Solutions, please visit www.healthcaresolutions.com.
Opinions of the roundtable participants are the opinions of each individual contributor and are not necessarily reflective of their respective companies.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthcare Solutions. The editorial staff of Risk & Insurance had no role in its preparation.