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Risk Insider: Jeff Driver

Joan Rivers: One More Legacy

By: | October 16, 2014 • 2 min read
Jeff Driver is the Chief Risk Officer- Stanford University Medical Center and the Chief Executive Officer - The Risk Authority, LLC. He can be reached at jdriver@theriskauthority.com.

This is the second of a two-part Risk Insider post on the death of Joan Rivers.

Over a month has passed since the death of Joan Rivers. Still, a full public explanation of the circumstances and cause of her demise has not surfaced.

Due to federal and state privacy laws, those details may never be revealed, just as we are not privy to most personal medical outcomes. Nor should we be from a medical privacy perspective.

Even when court cases are litigated or settled, most often the public is not informed of the result, or if it is, national attention soon shifts to other pressing issues of the day, and focus is lost in the blink-of-an-eye news cycle of our times.

Indeed, the traditional and social media rush to judgment did not wait long as a forensic evaluation proved inconclusive, and public health and safety regulatory reviews crawled along.

Within hours following the initial event, allegations of medical error, unprofessional physician conduct (search for “selfie” with Rivers under anesthesia), unauthorized physician medical practice at the clinic, faulty clinic administration, and medical treatment exceeding the patient’s consent began swirling over the airwaves and Internet.

Reactions such as these are dangerous as they unduly undermine and erode public confidence in a world-class medical system, and contribute to the defensive practice of medicine that significantly runs up the costs of health care for everyone.

Even before many facts were verified or discovered, accusations were commingled in confusion with words and phrases begging, “What ‘killed’ Joan Rivers?”

Worse, the media launched personal attacks and vilified some of the medical professionals involved. In social media’s diversity of public commentary, some even threatened some of the medical professionals involved.

Reactions such as these are dangerous as they unduly undermine and erode public confidence in a world-class medical system, and contribute to the defensive practice of medicine that significantly runs up the costs of health care for everyone.

The risk management and medical communities must do everything we can to counteract the perception that unexpected medical outcomes automatically equate to medical errors or the unsafe practice of medicine.

We must combat the human impulse to shame and blame that is now coupled with a modern trend of rush to judgment in a flash-mob, instantaneous, anything-goes traditional and social media culture.

Simultaneously, however, we must also acknowledge and speak publicly and individually of our innate human imperfections, even those of our medical professionals, and learn from medical errors when they do occur so that they can be prevented in the future as we strive to ensure that no patient ever suffers or dies from a medical error.

Perhaps a completely unexpected and ironic legacy of Rivers’ vivacious and notable life is that her case moves us all to engage in honest, healthy, thoughtful public discourse regarding the practice of medicine in the aftermath of an unexpected outcome, whether due to medical error or not.

Rivers’ signature one-liner will speak to me throughout the remainder of my life’s career, and hopefully to the risk management and medical communities, in a way it never has before: “Can we talk?” Yes, we must. Yes, we will, Joan Rivers!

Read the first of Jeff Driver’s posts, Joan Rivers: Can We Talk?

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Substance Abuse

This Is Your Doc On Drugs

Addicted health care professionals are part of the national issue of prescription drug abuse, but the hardest to find and treat.
By: | October 15, 2014 • 7 min read
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About 10 years ago, when Johnson City, Tenn., physician Stephen Loyd was practicing internal medicine, often in an intensive care unit, he was popping about 100 opioid pills a day, every day, ingesting mainly oxycodone and Vicodin.

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“You’d think that if a person was taking 100 pills a day like that others would know,” Dr. Loyd said. “But six weeks before I went into rehab, I stood at a medical students’ graduation ceremony where I was honored as one of 10 faculty members out of 100 who had the most influence on the students’ previous four years of education.”

Today, a recovering addict, Dr, Loyd is the 2014 Advocate for Action for the White House’s Office of National Drug Control Policy.

The scariest thing about his heavy drug addiction, Loyd said, “was that I thought I was a better doctor. I thought I was sharper, that I didn’t need to sleep, that I didn’t need to eat. I thought I could go longer and see more patients.”

In fact, his condition was worsening, though none of his colleagues wanted to question it.

Dr. Stephen Loyd, 2014 Advocate for Action for the White House’s Office of National Drug Control Policy

Dr. Stephen Loyd, 2014 Advocate for Action for the White House’s Office of National Drug Control Policy

“Nobody said anything to me,” said Loyd, who is now chief of medicine at the Mountain Home VA Medical Center. “They didn’t want to hurt my livelihood; they didn’t want to hurt my practice.”

Finally, it was his father who intervened on his behalf. “The truth of the matter was that I was going to die,” Loyd said. “And not only that, but there was the possibility of hurting a lot of people. Now, it makes me sick to think of the damage I could have done to other people.”

Today, in addition to his work with the White House and his practice, Loyd lectures on the dangers of drug abuse in the medical profession.

Epidemic of Abuse

Almost every day, medical professionals in the United States — from doctors to nurses to pharmacists — are censured for narcotics abuse, resulting in harm to themselves and sometimes, their patients.

These individual actions are part of what the Centers for Disease Control and Prevention has classified as a national epidemic of prescription drug abuse.

Video: Dr. Stephen Loyd talks to USA Today about his addiction.

According to the latest figures from the CDC, one in 20 people aged 12 or older has used prescription painkillers for non-medical reasons, and more than 2.1 million people in the country are addicted to opioid painkillers.

Prescription painkiller abuse is estimated to cost the United States more than $125 billion annually.

Consumer Watchdog, a California citizens’ advocacy group, said it examined federal data on the combined problem of alcohol and drug abuse by medical professionals and determined that 500,000 medical professionals in a given year self-report that they abused alcohol, prescription drugs or illicit drugs.

“This is according to federal data and yet we don’t have any way to detect this,” according to Consumer Watchdog. “We don’t have any way to stop doctors and other medical professionals from this activity.”

State-Level Oversight

Several factors contribute to a prescription painkiller epidemic in the health care field, said Joanna Shepherd-Bailey, a professor at Emory University School of Law in Atlanta.

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“A few rogue physicians and pharmacists enable drug abusers by illegally prescribing or supplying controlled substances,” said Shepherd-Bailey. “Other physicians do not have adequate training to recognize and address prescription drug abuse, and as a result, prescribe painkillers to illegitimate patients.”

Substance abuse among physicians, nurses, dentists and pharmacists can affect their personal lives, but it often is also linked to medical errors, liability and a decline in patient safety.

To counter such abuse, Minnesota Gov. Mark Dayton signed a new law in May that will tighten oversight of problem nurses and other licensed health care providers.

Provisions include requiring employers to report nurses who have stolen drugs, and requiring the state drug monitoring program to provide more data to the state Nursing Board about nurses who have harmed patients and stolen drugs.

Video: From 2003-2007, one-quarter of nurse disciplinary issues were traced to drug abuse in Nebraska.

One crucial aspect of the new legislation is tightening regulations to make it easier for health licensing boards to immediately suspend a health care worker if the board believes the person “presents an imminent risk of harm.”

“We did as much as we thought we could because legally, of course, a person has due process so there has to be a balance between a person’s right to due process and the need of the public to be safe from persons who might not be safe practitioners,” said Rep. Tina Liebling, D-Rochester, a key architect of the legislation and chair of the state’s House Health and Human Services Policy Committee.

“We did tighten things up considerably. We put in an immediate review by the board and also language that says if there’s an imminent risk of harm, they must temporarily suspend a person’s license.”

Federal Action

On a national level, the federal Drug Enforcement Administration (DEA) has proposed new restrictions that would change regulations for some of the most commonly prescribed narcotic painkillers.

The DEA proposal, open for public comment since March, would specifically affect hydrocodone-combination pills, also known as opioids, which combine hydrocodone with less potent painkillers such as acetaminophen.

Under the proposed regulations, patients would have to have a written prescription from a doctor — instead of a prescription submitted orally over the phone. Also, refills would be prohibited. Patients would have to check in with the doctor to get another prescription.

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Drug-abusing health care professionals, however, can be harder to detect and deter. According to the National Council of State Boards of Nurses, “Although a drug user would usually tend to experience a decrease in work performance, or might be frequently absent, health-care professionals who are abusing drugs tend to not show impairment related to job performance until they have already developed a significant substance abuse problem.”

Detecting Abuse

Numerous state governments have what are called Prescription Drug Monitoring Programs (PDMPs). But according to Emory University School of Law’s Joanna Shepherd-Bailey, many of the programs suffer from inadequate data collection, insufficient interstate data sharing and constraints on sharing data with law enforcement and state agencies.

By contrast, third-party prescription payment systems run by pharmacy benefit managers (PBMs) or health insurers have been effective in dealing with prescription drug abuse by health care professionals.

Drugs paid for with cash are not processed by PBMs or insurers, allowing drug abusers, including health care professionals, to evade detection.

However, these systems do not currently process all painkiller prescriptions. Drugs paid for with cash are not processed by PBMs or insurers, allowing drug abusers, including health care professionals, to evade detection.

Shepherd-Bailey said that a national drug reporting plan building on existing PBM networks that are augmented to record cash purchases could be significantly more effective than existing state PDMPs in detecting prescription drug abuse by health care professionals and others.

“Such a system would close the current loophole for cash transactions and interstate purchases of prescription drugs,” Shepherd-Bailey said. “Moreover, by utilizing existing PBM systems, including data mining and advanced analytics, it could detect and deter potential drug abuse.”

Treatment Options

Though legal action is sometimes necessary, the health care profession generally aims to provide treatment rather than rely on disciplinary action to achieve recovery.

In 1982, the American Nurses Association created a resolution which urged states to create “peer assistance programs” for health care professionals as an alternative to discipline.

Since the early 1980s, all of the major professional nursing associations have advocated alternative-to-discipline programs prior to initiating more formal disciplinary proceedings.

This way, health care providers are able to focus more on treatment services rather than worry about losing their position as health care professionals.

Since the early 1980s, all of the major professional nursing associations have advocated alternative-to-discipline programs prior to initiating more formal disciplinary proceedings.

These organizations recognized that more supportive recovery efforts help keep valuable nurse practitioners in a profession facing catastrophic labor shortages.

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Despite these recommendations, not all states have implemented alternative programs and there is little consistency in the approaches they use.

Another important part of successful treatment includes the use of self-help groups, such as Alcoholics Anonymous or Narcotics Anonymous, which allow for individuals to talk about their addiction stories while surrounded by a supportive group of people.

Health care professionals may also take advantage of employee assistance programs to receive individual and confidential assistance concerning issues of overcoming substance misuse in the workplace or at home.

Experts noted the need for individualized treatment. While some people may just need support from self-help groups, others may need in-patient treatment time and a change in profession to overcome their dependence on drugs.

Steve Yahn is a freelance writer based in Croton-on-Hudson, NY. He has more than 40 years of financial reporting and editing experience. He can be reached at riskletters@lrp.com.
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Sponsored: Helmsman Management Services

Six Best Practices For Effective WC Management

An ever-changing healthcare landscape keeps workers comp managers on their toes.
By: | October 15, 2014 • 5 min read

It’s no secret that the professionals responsible for managing workers compensation programs need to be constantly vigilant.

Rising health care costs, complex state regulation, opioid-based prescription drug use and other scary trends tend to keep workers comp managers awake at night.

“Risk managers can never be comfortable because it’s the nature of the beast,” said Debbie Michel, president of Helmsman Management Services LLC, a third-party claims administrator (and a subsidiary of Liberty Mutual Insurance). “To manage comp requires a laser-like, constant focus on following best practices across the continuum.”

Michel pointed to two notable industry trends — rises in loss severity and overall medical spending — that will combine to drive comp costs higher. For example, loss severity is predicted to increase in 2014-2015, mainly due to those rising medical costs.

Debbie discusses the top workers’ comp challenge facing buyers and brokers.

The nation’s annual medical spending, for its part, is expected to grow 6.1 percent in 2014 and 6.2 percent on average from 2015 through 2022, according to the Federal Government’s Centers for Medicare and Medicaid Services. This increase is expected to be driven partially by increased medical services demand among the nation’s aging population – many of whom are baby boomers who have remained in the workplace longer.

Other emerging trends also can have a potential negative impact on comp costs. For example, the recent classification of obesity as a disease (and the corresponding rise of obesity in the U.S.) may increase both workers comp claim frequency and severity.

SponsoredContent_LM“The true goal here is to think about injured employees. Everyone needs to focus on helping them get well, back to work and functioning at their best. At the same time, following a best practices approach can reduce overall comp costs, and help risk managers get a much better night’s sleep.”
– Debbie Michel, President, Helmsman Management Services LLC (a subsidiary of Liberty Mutual)

“These are just some factors affecting the workers compensation loss dollar,” she added. “Risk managers, working with their TPAs and carriers, must focus on constant improvement. The good news is there are proven best practices to make it happen.”

Michel outlined some of those best practices risk managers can take to ensure they get the most value from their workers comp spending and help their employees receive the best possible medical outcomes:

Pre-Loss

1. Workplace Partnering

Risk managers should look to partner with workplace wellness/health programs. While typically managed by different departments, there is an obvious need for risk management and health and wellness programs to be aligned in understanding workforce demographics, health patterns and other claim red flags. These are the factors that often drive claims or impede recovery.

“A workforce might have a higher percentage of smokers or diabetics than the norm, something you can learn from health and wellness programs. Comp managers can collaborate with health and wellness programs to help mitigate the potential impact,” Michel said, adding that there needs to be a direct line between the workers compensation goals and overall employee health and wellness goals.

Debbie discusses the second biggest challenge facing buyers and brokers.

2. Financing Alternatives

Risk managers must constantly re-evaluate how they finance workers compensation insurance programs. For example, there could be an opportunity to reduce costs by moving to higher retention or deductible levels, or creating a captive. Taking on a larger financial, more direct stake in a workers comp program can drive positive changes in safety and related areas.

“We saw this trend grow in 2012-2013 during comp rate increases,” Michel said. “When you have something to lose, you naturally are more focused on safety and other pre-loss issues.”

3. TPA Training, Tenure and Resources

Businesses need to look for a tailored relationship with their TPA or carrier, where they work together to identify and build positive, strategic workers compensation programs. Also, they must exercise due diligence when choosing a TPA by taking a hard look at its training, experience and tools, which ultimately drive program performance.

For instance, Michel said, does the TPA hold regular monthly or quarterly meetings with clients and brokers to gauge progress or address issues? Or, does the TPA help create specific initiatives in a quest to take the workers compensation program to a higher level?

Post-Loss

4. Analytics to Drive Positive Outcomes, Lower Loss Costs

Michel explained that best practices for an effective comp claims management process involve taking advantage of today’s powerful analytics tools, especially sophisticated predictive modeling. When woven into an overall claims management strategy, analytics can pinpoint where to focus resources on a high-cost claim, or they can capture the best data to be used for future safety and accident prevention efforts.

“Big data and advanced analytics drive a better understanding of the claims process to bring down the total cost of risk,” Michel added.

5. Provider Network Reach, Collaboration

Risk managers must pay close attention to provider networks and specifically work with outcome-based networks – in those states that allow employers to direct the care of injured workers. Such providers understand workers compensation and how to achieve optimal outcomes.

Risk managers should also understand if and how the TPA interacts with treating physicians. For example, Helmsman offers a peer-to-peer process with its 10 regional medical directors (one in each claims office). While the medical directors work closely with claims case professionals, they also interact directly, “peer-to-peer,” with treatment providers to create effective care paths or considerations.

“We have seen a lot of value here for our clients,” Michel said. “It’s a true differentiator.”

6. Strategic Outlook

Most of all, Michel said, it’s important for risk managers, brokers and TPAs to think strategically – from pre-loss and prevention to a claims process that delivers the best possible outcome for injured workers.

Debbie explains the value of working with Helmsman Management Services.

Helmsman, which provides claims management, managed care and risk control solutions for businesses with 50 employees or more, offers clients what it calls the Account Management Stewardship Program. The program coordinates the “right” resources within an organization and brings together all critical players – risk manager, safety and claims professionals, broker, account manager, etc. The program also frequently utilizes subject matter experts (pharma, networks, nurses, etc.) to help increase knowledge levels for risk and safety managers.

“The true goal here is to think about injured employees,” Michel said. “Everyone needs to focus on helping them get well, back to work and functioning at their best.

“At the same time, following a best practices approach can reduce overall comp costs, and help risk managers get a much better night’s sleep,” she said.

To learn more about how a third-party administrator like Helmsman Management Services LLC (a subsidiary of Liberty Mutual) can help manage your workers compensation costs, contact your broker.

Email Debbie Michel

Visit Helmsman’s website

@HelmsmanTPA Twitter

Additional Insights 

Debbie discusses how Helmsman drives outcomes for risk managers.

Debbie explains how to manage medical outcomes.

Debbie discusses considerations when selecting a TPA.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Helmsman Management Services. The editorial staff of Risk & Insurance had no role in its preparation.


Helmsman Management Services (HMS) helps better control the total cost of risk by delivering superior outcomes for workers compensation, general liability and commercial auto claims. The third party claims administrator – a wholly owned subsidiary of Liberty Mutual Insurance – delivers better outcomes by blending the strength and innovation of a major carrier with the flexibility of an independent TPA.
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