Ebola Sends Employers Wake-Up Call
Finally, it happened. The United State is experiencing its first cases of Ebola. A Liberian national living in Dallas died after being diagnosed with the virus, and now two of his treating nurses have now come down with the disease.
While the nation’s Ebola threat remains relatively minor right now, that’s hardly the case, of course, in the West African countries of Liberia, Nigeria, Guinea and Sierra Leone.
With the media reports as a backdrop, experts stress that recent Ebola media coverage on domestic shores is the perfect lynchpin for employers to review their emergency contingency plans already in place and update them, if necessary.
“The Ebola virus in Africa and the chikungunya virus in the Caribbean both demonstrate the need for employers and their employees to think about personal safety while traveling outside the United States,” said Dominick Zenzola, vice president and employee benefits manager for Chubb Accident & Health in Chicago.
“Employers have a duty of care to their employees who travel. Some prudent companies even have relocated business meetings and events to alternative destinations.” — Dominick Zenzola, vice president and employee benefits manager for Chubb Accident & Health
“Employers have a duty of care to their employees who travel. Some prudent companies even have relocated business meetings and events to alternative destinations,” he said.
Chicago-based Ed Hannibal, global leader of Mercer’s Mobility Practice, said that as more and more companies push deeper into global markets, safety and emergency planning for mobile employees has become an even more serious issue — from the executive on a single business trip to someone who locates to a country on a permanent basis.
Hannibal said employers should ensure their people systems are “linked up,” so they know where their employees are at all times, and where they have been or may be going.
Robert Quigley, U.S. medical director and senior vice president of medical assistance for International SOS, a Trevose, Pa.-based global medical and travel security risk services company, said employers have a “duty of care” to all their employees, but especially those who may need to work in high-risk countries or regions.
“The recent unfortunate Ebola outbreak should serve as a wake-up call for employers, to ensure they are doing the right thing,” Quigley said.
“Companies are reaching out to us, wondering if they are doing enough, or what is the benchmark in their industry segment. We have more than 10,000 clients, and many have a footprint in West Africa.”
Quigley also said it may be surprising that the companies with business in West Africa represent a wide spectrum of industry segments.
“Many of them want to know what everyone is doing in their segment, or what is [a] best practice for their industry,” he said. “One of our jobs is to help educate them, but depending on the sector, they will have a different risk tolerance.”
For example, a nongovernmental organization would have higher risk tolerance because their work typically takes them into some of the world’s most dangerous places.
Different clients have decisions to make, but the one thing they can’t do is make them on the fly, Quigley said.
Many plans, he added, are still based on the last pandemic with influenza, so it makes sense for employers to take a look at their current plan. For others who may not have any solution, they need to have something in place even if it’s somewhat generic and can be customized to meet special situations like Ebola.
“It’s not a decision to be made on the run and it must involve many levels of decision makers, from the C-suite down,” he said. “It requires systemic ownership and involvement.” — Robert Quigley, U.S. medical director and senior vice president of medical assistance, International SOS
“It’s not a decision to be made on the run and it must involve many levels of decision makers, from the C-suite down,” he said. “It requires systemic ownership and involvement.
“Having a pandemic plan on the shelf is not good [enough],” Quigley said, adding that employers should create a specific task force responsible for making sure such protocols and procedures are constantly updated.
Quigley compares the situation to company fire drills, which most employers conduct two or three times a year.
“You don’t want to [have to] invent protocol when there actually is a fire,” he said. “Call it whatever you want, but it needs to be planned and rehearsed. Having an updated plan is also a good morale builder, because it lets those employees know they mean something to the company because it is being proactive and taking measures to protect them.”
Mercer’s Hannibal emphasizes the importance of communications. He said plans must be very clear when sending employees out around the globe, noting that different locations will mean different levels of communication.
“For example, they should know that Ebola is not an easy virus to contract; they need to make sure they have briefed employees about the specifics for any potential risk,” he said.
At a basic level, Chubb’s Zenzola said, employers need to remind global travelers to check the list of travel alerts and warnings from the U.S. Department of State — which now includes Russia, Ukraine, Israel, Thailand, Egypt and Mexico — and from the Centers for Disease Control and Prevention before they book their trips and pack their bags.
“Right now, Ebola is the flavor of the month, but before it there was Mad Cow, SARS (severe acute respiratory syndrome), bird flu, West Nile. There will always be something,” said SOS’ Quigley.
“The Ebola outbreak must remind employers to ensure they have updated, effective emergency procedures and protocols in place.”
In mid-August, Boart Longyear Co., a global mineral exploration company, removed nine employees from Liberia after the Ebola virus broke out in a nearby village.
“Our customer shut down operations, and we’re evacuating,” said Rob Osha, global director of risk management at the company in August.
“There’s a lot of talk about closing borders and not letting air travelers out, so we’re working right now to make sure our crews leave Liberia.”
Video: The Ebola crisis continues to worsen, with a “best case” estimate of 500,000 dead by end of January 2015.
It’s not just deadly diseases that worry risk managers.
“A few years ago,” said Jan Randolph, director of sovereign risk at IHS Country Risk, “I was stuck in Qatar, due to go to Bahrain to visit some banks. This is when Bahrain had quite a lot of demonstrations and rioting going on.
“We checked our website, and there was a UK travel government advisory that advised all UK nationals not to travel to Bahrain. That means if we went, our insurance cover was potentially not valid.
“In practice, it probably would have been okay, but that advisory made it a no go,” he said.
As economies become more interconnected, businesses expand globally and more employees are sent abroad, scenarios like Osha’s and Randolph’s may become the norm. Yet too many risk managers may be unaware of the risks involved with global travel or take the proper steps to ensure employees’ safety.
Growth of International Travel
According to the Global Business Travel Association, U.S. spending on international travel may jump as much as 6.6 percent, to $289.8 billion in 2014, while total person trip volume is expected to increase 1.7 percent, to 461 million trips for the year.
“In this world that is smaller and more mobile, emergency evacuations happen more often than they did 10 years ago,” said Charlie LeBlanc, vice president of security services at UnitedHealthcare International (formerly FrontierMEDEX).
“That also has a lot to do with the fact that the world, politically, is much more volatile than in the last 20 or 30 years. We have to be able to react quickly.”
Steve Kellner, global head of intelligence and risk assessment for Verizon International Security Group, said: “I saw a news article recently that said there are only 11 countries not at war. The same article also said roughly only 60 percent of companies monitor their employees’ travel. It’s a big world, and a lot to keep up with.”
Kellner’s team monitors 15,000 to 18,000 employee trips per year.
Many smaller businesses or nonprofit organizations don’t have the budget for a security department that can educate their travelers [about security risks], so they depend on others, Kellner said. Problems can easily arise with “the little things that you don’t plan on.”
“Mining and oil and gas people have this buttoned up pretty tight,” Osha said. “They work in some of the most remote, tricky areas of the world.
“But there are a lot of companies that send a lot of business travelers that don’t necessarily work in the field. Even if you’re just traveling for a business meeting, things can change on a dime,” he said.
Pre-Travel Risk Mitigation
Travel preparation should begin before a flight is even booked.
“For very high risk countries, it’s a no go unless you get approval from the executive committee,” Osha said.
“I would do research on the security environment where they’re going, what I think the relative risk is and what the mitigations might be. Is the trip business-critical? Do we need to put that person at risk? Are there other ways to mitigate or not?”
“The most important asset you can have is information intelligence,” Randolph said.
“You need to know if the risk level is green or yellow or red, or if a developing scenario could reach a flash point.”
Video: The families of expat employees may be more at risk than the employees themselves.
Bob Gill, vice president of global security for Quintiles, a consulting firm for the life sciences industry, said his team develops risk profiles for every country they visit or may visit in the future.
“We cover security and safety, health and medical situations, medical infrastructure, regulatory issues, human rights issues, economic sanctions, bribery and corruption. Those are the key areas,” he said.
Even when companies give the green light, travelers should receive safety and awareness training tailored to the area they’re visiting.
“We have to look at risk from a variety of angles,” LeBlanc said.
“We look from the perspective of, when do our travelers start to feel uncomfortable? What are their risk tolerances?”
Political stability, crime, and cultural differences should all factor into a risk assessment, he said.
“As companies and economies are growing, their workforces are going to countries they didn’t go to five years ago,” LeBlanc said.
“That means a lot of novice travelers. For some, it may be their first international trip. And it’s not to London; it’s to Bangkok.”
Pre-travel training should cover basic “Safety 101” principles — like moving in groups and not opening the hotel door if no visitors are expected — but it should also include general background information on the destination country.
Travelers should know everything from what weather to expect, to what behaviors are acceptable in different cultures, to what inoculations they may need. Gender-specific training may also be necessary; women face greater risk in certain places, LeBlanc said.
“We have a traveler tracking system that is tied into our corporate reservation system,” Kellner said.
“When employees book travel, my group is alerted two weeks to 30 days ahead of time. We meet with them, whether they’re a naïve traveler or a group that goes constantly.”
At Verizon International Security Group, the company organizes a “meet and greet” program through its local offices to pick up incoming travelers or arrange transportation for them. Boart Longyear coordinates with their customers to see if they can provide transportation.
Some risk management and security departments utilize traveler tracking software to centralize employees’ flight and hotel reservations, so they always know who is in what part of the world.
Being able to locate people anywhere in the world in real time allows risk managers to focus their attention and resources where they’re needed. Ensuring safe travel on the ground requires coordinated efforts and constant communication.
For example, if 18 out of 20 employees are accounted for in a region hit by an earthquake, more time and energy can be devoted to tracking down the last two, instead of everyone in the group. If no employees are in the area, then attention can be focused elsewhere, to the next evolving crisis.
Travel assistance companies like UnitedHealthcare International (UHI), iJET and Europ Assistance offer software programs that not only track where employees are, but can push out automatic communications notifying them of potential threats in the area — like earthquake or tsunami warnings — or reminding them to check in.
Typically updated at least once per hour, the systems provide real-time data that is so crucial to crisis response.
“In the really risky countries, we establish check calls,” Osha said, “where an employee checks in every few hours to our outsourced security company’s operations team.
“In some places in Africa, they actually hire military to follow their company convoy,” he said, “or we see if they can fly point-to-point to cut out some of the risk of traveling on the ground.”
The advent of advanced cell phone technology has made the job of employee monitoring and communication much easier.
“As little as 10 years ago,” LeBlanc said, “I’d be carrying four or five different cell phones depending on what country I was going to. Now I just need one. That kind of power is extremely beneficial; risk managers need to be able to account for their people in a very short period of time.”
Call centers that operate 24 hours a day — also manned by third party travel assistance providers — help ensure that employees can always reach someone if they run into trouble.
“Communication is your lifeline in many cases,” Randolph said. “You have to think, as an employee, what would you expect from your company? Who would you want to contact in an emergency?”
Boart Longyear’s crisis hotline, provided by iJET, routes employees’ calls to the appropriate department, whether it’s a medical emergency, security issue or internal problem. More often than not, though, simple text messages or emails suffice to keep everyone connected.
“The best part of working for a telecommunications company,” Kellner of Verizon said, “is that most of our travelers go with a global phone. We can always text or call them to check on them and make sure they’re safe.”
Sometimes, no amount of intelligence can prevent simmering tensions from bubbling over, and no amount of monitoring can keep employees away from a natural disaster. Travel risk management should include policies and plans for when companies need to pull their people out of harm’s way quickly.
The most common reason for evacuations is a medical issue, rather than violence or political unrest. Travelers, rather than their employers, usually make the call as to whether they will abandon their travel due to a health issue.
“In medical situations, there tends to be a wider circle of hesitance to go,” LeBlanc said. Potential for violence doesn’t seem to stop travel as surely.
The Ebola outbreak in West Africa, for example, posed a relatively small risk to Western travelers but still sparked a worldwide scare. Flying out of the affected countries of Liberia, Nigeria, Ghana and Sierra Leone became more challenging as other countries were unwilling to take on the risk of accepting any visitors from those areas.
Luckily, governments rarely set strict travel restrictions in such situations, so while evacuations can get tricky when a pandemic hits, it is still possible to leave the country.
“In today’s world, economies are so interconnected that complete isolation isn’t feasible,” said Nita Madhav, analyst and researcher at catastrophe modeling firm AIR Worldwide.
“The best way for companies to mitigate is to stay aware of the global situation and which countries may be at risk for circulating diseases, and make sure that employees are up to date on vaccines,” she said.
Madhav identified the Middle East and Brazil as up-and-coming markets for air travel, which could make them riskier from a health perspective as business travel picks up.
Political and social tensions also pose an evacuation threat, though those risks are more rare than a medical threat.
Maintaining intelligence and proactively removing employees from potentially dangerous areas allows employers to avoid last-ditch evacuations. Government advisories, data from third party security firms, input from local employees and even social media trends help to paint a picture of emerging threats and areas to watch.
Still, things can change in an instant.
“We had to evacuate our expatriate staff out of Mali when they had a coup,” Osha said. “You do have to watch country elections, because violence and protests could follow.”
“In Libya,” Randolph of IHS Country Risk said, “they’re having a drawn-out civil war, and oil and gas companies have been involved in drawing out their staff, leaving behind only key personnel.
“You have to maintain your asset and your security as well as you can, but otherwise de-operationalize. You have a duty of care,” he said.
The Trickiest Risk
Natural disasters pose the trickiest travel risks to mitigate and often require the immediate, emergency response that risk managers try to avoid. Once tracking systems identify who’s in danger, it’s up to crisis management teams to get them to safety.
“You really need the right people in the room that are experienced with the global operations of their company,” said LeBlanc of UHI.
“They need the authority to make decisions quickly, whether they’re legal, financial, or human resource related. And they have to work well as a team.”
When UHI trains its clients on crisis management, it typically spends half a day on team-building alone, and keeps the core team limited to about 10 people.
Rapidly growing companies will face challenges learning how to manage increased travel to all parts of the world, but the realities of travel risk cannot be ignored. The consequences of shrugging off safe travel preparations are too great.
“Colleagues I work with have a keen sense of how travel has changed since 9/11,” Gill of Quintiles said.
“That was the issue that brought travel security and safety to the forefront.”
But others say more progress is needed.
“I’ve given travel risk presentations at RIMS for a few years now,” Osha said, “and I’m shocked by the people who approach me after the sessions — large, brand name companies — saying their programs aren’t robust enough.
“It makes me think that there are a lot more companies out there that need to start working on this than you may expect.”
Changing the WC Medical Care Mindset
Controlling overall workers’ compensation medical costs has been an elusive target.
Yet, according to medical experts from Healthesystems, the Tampa, Fla.-based specialty provider of innovative medical cost management solutions for the workers’ compensation industry, payers today have more powerful options for both offering the highest quality medical care and controlling costs, but they must be more thoroughly and strategically executed.
Specifically as it relates to optimizing patient outcomes and controlling pharmacy costs, the key, say those experts, is to look beyond the typical clinical pharmacy history review and to incorporate a more holistic picture of the entire medical treatment plan. This means when performing clinical reviews, taking into account more comprehensive information such as lab results, physician notes and other critical medical history data which often identifies significant treatment plan concerns but frequently aren’t effectively monitored in total.
Healthesystems’ Dr. Robert Goldberg, chief medical officer, and Dr. Silvia Sacalis, vice president of clinical services, recently weighed in on how using a more holistic, comprehensive strategy can make the critical difference in the ongoing medical care cost control battle.
Fragmentation, Complexity Obscure the Patient Picture
According to Dr. Goldberg, fragmentation remains one of the biggest obstacles to controlling overall healthcare costs and ensuring the most successful treatment in workers’ compensation.
Robert Goldberg, MD, discusses obstacles to controlling overall medical costs and ensuring the best treatment in workers’ compensation.
“There are several hurdles, but they all relate to the fact that healthcare in workers’ comp is just not very well coordinated,” he said. “For the most part, there is poor communication between all parties involved, but especially between the payer and the provider. Unfortunately, it’s rare that all the stakeholders have a clear, complete picture of what’s happening with the patient.”
Dr. Goldberg explains that health care generally has become a more complex landscape, and workers’ comp adds another level of complexity. Physicians have less time to spend with patients due to work loads and other economic factors, and frequently there isn’t adequate time to develop a patient specific treatment strategy.
“Often we don’t have physicians properly incentivized to do a complete job with patients” he said, adding that extra paperwork and similar hurdles limit communication among payers, nurse case managers and other players.
In fact, Dr. Sacalis emphasized that it’s not only the payer, but often the healthcare provider who is not getting a complete picture. For example, a treating doctor may not be the primary care physician and therefore they may not have access to the total healthcare picture for the injured worker.
“Most of all, payers need to adopt a more collaborative approach in their relationships with physicians, employers and patients, as well as networks involved. It will result in getting people back to work through appropriate medical care and moving the case along to a prompt closure.”
– Robert Goldberg, MD, FACOEM, Chief Medical Officer, Healthesystems
“It’s often difficult for multiple physicians to communicate and collaborate about what’s happening because they may not be aware of each-others involvement in that patient’s care,” she said. “Data sharing is lacking, even in integrated healthcare systems where doctors are in the same group.”
Done Right, Technology Can Bridge the Treatment Strategy Gap
Dr. Sacalis explained the role technology advancements can play in creating a more holistic picture of not only an injured workers’ post-accident state or pace of recovery, but also their overall health history. However, the workers’ comp industry by and large is not there yet.
“Today’s technology can be very useful in providing transparency, but to date the data is still very fragmented,” she said. “With technology advancements, we can get a more holistic patient view. However, it is important that the data is both meaningful and actionable to promote effective clinical decision support.”
Silvia Sacalis, PharmD, explains the role that technology advancements can play in creating a more holistic picture of an injured worker’s overall health.
Healthesystems, for example, offers an advanced clinical solution that incorporates a comprehensive analysis of all relevant data sources including pharmacy, medical and lab data as part of a drug therapy analysis. So, for example, the process could uncover co-morbidities – such as diabetes – that may be unrelated to a workplace injury but should be considered in the overall treatment strategy.
“Healthcare professionals must ensure there are no interactions with any
co-morbidities that may limit or affect the treatment plan,” Dr. Sacalis said.
In the majority of cases where Healthesystems has performed advanced clinical analysis, information gathered from the various sources has uncovered critical information that significantly impacted the overall treatment recommendations. Technology and analytics enable the implementation of best practices.
She cites another example of how a physician may order a urine drug screen (UDS), yet the results indicating the presence of a non prescribed drug were not reflected in the treatment regimen as evidenced by the lack of modification in therapy.
“Visibility and transparency will help with facilitating a truly effective treatment plan,” she said, “Predictive analytics are necessary tools for proactive monitoring and detection of trends as well as early identification of cases for intervention.”
Speaking of Best Practices …
Dr. Goldberg highlighted that the most important overall best practice needed to secure the optimal outcome is centered around getting the right care to the right patient at the right time. To him, that means identifying patients who need adjustments in care and then determining medical necessity during the entire case trajectory.
“It means using evidence-based medical treatment guidelines that are coordinated,” he said.
“You must look at the whole patient, which means avoiding the typical barriers in the workers’ comp treatment system, issues such as delays in authorizations, lengthy UR processes or similar scenarios that are well intentioned but if not performed effectively they can get in the way of expedited care.”
Dr. Goldberg and Silvia Sacalis provide recommendations for critical steps payers should take to achieve the best outcomes for everyone.
Dr. Goldberg noted that seeking out the most effective doctors available in geographic locations is another critical best practice. That requires collecting data on physician performance, patient satisfaction and medical outcomes, so payers and networks can identify and incentivize them accordingly.
“This way, you are getting an alignment of incentives with all parties,” Dr. Goldberg said, adding that it also means removing outlier physicians, those whose tendencies are to over-treat, dispense drugs from their office or order unnecessary durable medical equipment, for example.
“Visibility and transparency will help with facilitating a truly effective treatment plan. Predictive analytics are necessary tools for proactive monitoring and detection of trends as well as early identification of cases for intervention.”
– Silvia Sacalis, PharmD, Vice President of Clinical Services, Healthesystems
“Most of all, payers need to adopt a more collaborative approach in their relationships with physicians, employers and patients, as well as networks involved,” he said. “It will result in getting people back to work through appropriate medical care and moving the case along to a prompt closure.”
Dr. Sacalis added that from a pharmacy perspective, another best practice is becoming more patient-centric, using a customized and flexible approach to help payers optimize outcomes for each patient.
“Focus on patient safety first, and that will naturally drive cost containment,” she said. “Focusing on cost alone can actually drive results in the wrong direction.”
Dr. Goldberg explains how consolidation in the health care and WC markets can impact the landscape and quality of care.
Dr. Goldberg and Silvia Sacalis discuss if injured workers today are getting better treatment than they were twenty years ago.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthesystems. The editorial staff of Risk & Insurance had no role in its preparation.