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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: Liberty International Underwriters

A Renaissance In U.S. Energy

Resurgence in the U.S. energy industry comes with unexpected risks and calls for a new approach.
By: | October 15, 2014 • 5 min read

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America’s energy resurgence is one of the biggest economic game-changers in modern global history. Current technologies are extracting more oil and gas from shale, oil sands and beneath the ocean floor.

Domestic manufacturers once clamoring for more affordable fuels now have them. Breaking from its past role as a hungry energy importer, the U.S. is moving toward potentially becoming a major energy exporter.

“As the surge in domestic energy production becomes a game-changer, it’s time to change the game when it comes to both midstream and downstream energy risk management and risk transfer,” said Rob Rokicki, a New York-based senior vice president with Liberty International Underwriters (LIU) with 25 years of experience underwriting energy property risks around the globe.

Given the domino effect, whereby critical issues impact each other, today’s businesses and insurers can no longer look at challenges in isolation one issue at a time. A holistic, collaborative and integrated approach to minimizing risk and improving outcomes is called for instead.

Aging Infrastructure, Aging Personnel

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Robert Rokicki, Senior Vice President, Liberty International Underwriters

The irony of the domestic energy surge is that just as the industry is poised to capitalize on the bonanza, its infrastructure is in serious need of improvement. Ten years ago, the domestic refining industry was declining, with much of the industry moving overseas. That decline was exacerbated by the Great Recession, meaning even less investment went into the domestic energy infrastructure, which is now facing a sudden upsurge in the volume of gas and oil it’s being called on to handle and process.

“We are in a renaissance for energy’s midstream and downstream business leading us to a critical point that no one predicted,” Rokicki said. “Plants that were once stranded assets have become diamonds based on their location. Plus, there was not a lot of new talent coming into the industry during that fallow period.”

In fact, according to a 2014 Manpower Inc. study, an aging workforce along with a lack of new talent and skills coming in is one of the largest threats facing the energy sector today. Other estimates show that during the next decade, approximately 50 percent of those working in the energy industry will be retiring. “So risk managers can now add concerns about an aging workforce to concerns about the aging infrastructure,” he said.

Increasing Frequency of Severity

SponsoredContent_LIUCurrent financial factors have also contributed to a marked increase in frequency of severity losses in both the midstream and downstream energy sector. The costs associated with upgrades, debottlenecking and replacement of equipment, have increased significantly,” Rokicki said. For example, a small loss 10 years ago in the $1 million to $5 million ranges, is now increasing rapidly and could readily develop into a $20 million to $30 million loss.

Man-made disasters, such as fires and explosions that are linked to aging infrastructure and the decrease in experienced staff due to the aging workforce, play a big part. The location of energy midstream and downstream facilities has added to the underwriting risk.

“When you look at energy plants, they tend to be located around rivers, near ports, or near a harbor. These assets are susceptible to flood and storm surge exposure from a natural catastrophe standpoint. We are seeing greater concentrations of assets located in areas that are highly exposed to natural catastrophe perils,” Rokicki explained.

“A hurricane thirty years ago would affect fewer installations then a storm does today. This increases aggregation and the magnitude for potential loss.”

Buyer Beware

On its own, the domestic energy bonanza presents complex risk management challenges.

However, gradual changes to insurance coverage for both midstream and downstream energy have complicated the situation further. Broadening coverage over the decades by downstream energy carriers has led to greater uncertainty in adjusting claims.

A combination of the downturn in domestic energy production, the recession and soft insurance market cycles meant greatly increased competition from carriers and resulted in the writing of untested policy language.

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In effect, the industry went from an environment of tested policy language and structure to vague and ambiguous policy language.

Keep in mind that no one carrier has the capacity to underwrite a $3 billion oil refinery. Each insurance program has many carriers that subscribe and share the risk, with each carrier potentially participating on differential terms.

“Achieving clarity in the policy language is getting very complicated and potentially detrimental,” Rokicki said.

Back to Basics

SponsoredContent_LIUHas the time come for a reset?

Rokicki proposes getting back to basics with both midstream and downstream energy risk management and risk transfer.

He recommends that the insured, the broker, and the carrier’s underwriter, engineer and claims executive sit down and make sure they are all on the same page about coverage terms and conditions.

It’s something the industry used to do and got away from, but needs to get back to.

“Having a claims person involved with policy wording before a loss is of the utmost importance,” Rokicki said, “because that claims executive can best explain to the insured what they can expect from policy coverage prior to any loss, eliminating the frustration of interpreting today’s policy wording.”

As well, having an engineer and underwriter working on the team with dual accountability and responsibility can be invaluable, often leading to innovative coverage solutions for clients as a result of close collaboration.

According to Rokicki, the best time to have this collaborative discussion is at the mid-point in a policy year. For a property policy that runs from July 1 through June 30, for example, the meeting should happen in December or January. If underwriters try to discuss policy-wording concerns during the renewal period on their own, the process tends to get overshadowed by the negotiations centered around premiums.

After a loss occurs is not the best time to find out everyone was thinking differently about the coverage,” he said.

Changes in both the energy and insurance markets require a new approach to minimizing risk. A more holistic, less siloed approach is called for in today’s climate. Carriers need to conduct more complex analysis across multiple measures and have in-depth conversations with brokers and insureds to create a better understanding and collectively develop the best solutions. LIU’s integrated business approach utilizing underwriters, engineers and claims executives provides a solid platform for realizing success in this new and ever-changing energy environment.

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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 Liberty International Underwriters. The editorial staff of Risk & Insurance had no role in its preparation.


LIU is part of the Global Specialty Division of Liberty Mutual Insurance.
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