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11 Critical Risks Facing the Healthcare Industry

The list of risks faced by healthcare providers is more severe than ever.
By: | May 21, 2015 • 5 min read
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From pandemics to violence in hospitals, alarm fatigue to healthcare-acquired infections, healthcare organizations will be put to the test in the coming months and years.

Added pressure from new regulatory requirements under the Affordable Care Act makes the future even more challenging.

ACE_BrandedContentWhen you factor in the daily demands healthcare organizations face in their quest to provide quality patient care, it’s clear that there are many hurdles that can disrupt facility operations and put employee and patient safety at risk.

”Today’s healthcare landscape is arguably the most difficult ever,” said Diane Doherty, Vice President, ACE Medical Risk Group. “If not managed properly, these critical issues can cause other unwanted outcomes such as an increase in medical malpractice and workers’ comp claims, government fines and penalties, and may negatively impact the organization’s brand and reputation.”

The following are some of the top critical issues facing hospital leadership.

1) Cyber Risk

ACE_BrandedContentThe healthcare industry’s move to electronic healthcare records has created new patient privacy exposures as records are more easily accessed by consultants, vendors and other third parties for efficient operation, and targeted by cyber criminals. Additionally, healthcare organizations face exposure to cyber risks that could have significant impacts on their operations, including shutting down critical, health-related systems.

Data breaches and network disruptions can jeopardize an organization’s financial stability, security and reputation. Standard general liability policies often do not adequately cover perils associated with cyber and technology related exposures. Cyber liability insurance can address coverage gaps while also enabling companies to transfer risks associated with cyber, such as patient privacy and notification, crisis management, and forensic analysis expenses as well as certain regulatory fines, indemnity payments and legal costs.

“Cyber hacks and data breaches are a major issue facing the healthcare industry today,” said Renee Carino, Vice President and Chief Underwriting Officer, ACE Medical Risk Group. “It’s important now more than ever, that healthcare organizations work closely with their insurance carrier to assess this exposure and develop effective risk management strategies and ensure the proper coverage is in place.”

ACE_BrandedContent”Today’s healthcare landscape is arguably the most difficult ever. If not managed properly, these critical issues can cause other unwanted outcomes such as an increase in medical malpractice … and may negatively impact the organization’s brand and reputation.”
— Diane Doherty, Vice President, ACE Medical Risk Group

2) Healthcare Infections

ACE_BrandedContentHealthcare-acquired infections (HAIs) cost the U.S. healthcare system billions of dollars each year and lead to the loss of tens of thousands of lives.  At any given time, about 1 in 25 hospital patients has at least one such infection, according to the Centers for Disease Control and Prevention. Healthcare-acquired infections also come with a financial price, costing up to $9.8 billion a year, according to research published in 2013 in JAMA Internal Medicine.

Among many solutions, healthcare organizations should ensure all sanitation systems are up to date, operational and ensure that staff understands how to properly use the systems to keep patients safe. They also should continue to remind staff and visitors about basic infection control techniques.

“Basic infection control techniques should be at the forefront of the risk management process,” said Doherty. “For example, it’s critical that medical personnel must wash their hands with antiseptic soap and water every time they treat patients to help reduce the spread of infections.”

3) Telemedicine

ACE_BrandedContentAdvances in technology, the current physician shortage and the dramatic increase in the number of patients seeking care under the Affordable Care Act have led a growing number of healthcare facilities to expand their use of telemedicine to deliver services to patients in hospitals as well as in remote locations. Over half of all U.S. hospitals now use some form of telemedicine to treat patients.

Telemedicine may also result in allegations of negligence if healthcare providers do not have the proper training, experience and credentials. Currently, there is no federal standard of clinical guidelines for telemedicine.

In developing strategies to mitigate this risk, a few key processes and areas that should be examined include credentialing and peer review, medical staff by-laws and of course, CMS guidelines.

ACE_BrandedContent“It’s important now more than ever, that healthcare organizations work closely with their insurance carrier to assess this exposure and develop effective risk management strategies and ensure the proper coverage is in place.”
— Renee Carino, Vice President and Chief Underwriting Officer, ACE Medical Risk Group

4) Violent Incidents in Hospitals

ACE_BrandedContentHospitals may be places of healing, but they also have become the scene of an increasing number of violent incidents. Such incidents not only put patients at risk but also medical professionals, who are often the targets of attacks, harassment, intimidation and other disruptive behavior.

The incidence rate for violence and other injuries in the healthcare and social assistance sector in 2012 was over three times greater than the rate for all private industries. The Joint Commission, meanwhile, reports increasing rates of assault, rape and homicide in healthcare facilities. Perpetrators can include patients, family members, visitors and vendors as well as current and former healthcare employees.

Hospitals and healthcare organizations should enact a zero-tolerance policy, one that states that no form of violence — physical, verbal or psychological — will be tolerated, and that all offenders will be subject to disciplinary action, including termination.

“Healthcare organizations should develop a comprehensive violence prevention program that is specific to their organization and analyzes potential safety hazards and implements strategies to prevent them,” Carino said.

5) Alarm Fatigue

ACE_BrandedContentHospital nurses hear them constantly — the beeps and chirps of alarms on medical devices, such as ventilators, cardiac monitors and pulse oximetry devices. While alarms are designed to draw attention to a potential problem, they can easily be tuned out by overwhelmed medical professionals, who may then fail to respond as they should.

Alarm fatigue is a growing problem for hospitals and the consequences can be fatal. The Joint Commission’s Sentinel Event database includes reports of 98 alarm-related events between January 2009 and June 2012. Of the 98 events, 80 resulted in death, 13 in permanent loss of function and five in unexpected additional care or extended stay. Alarm fatigue was rated a top concern by 19 out of every 20 hospitals in the United States, according to a national survey presented at the annual meeting of the Society for Technology in Anesthesia in 2014.

To reduce the risk of patient harm from alarm fatigue, the Joint Commission, along with the Association for the Advancement of Medical Instrumentation and the ECRI Institute, offered a list of precautions, including ensuring that there is an effective process in place for safe alarm management and response in high-risk areas.

Additional Risks

6) Preparedness for Pandemics

7) Healthcare Reform/Physician Integration

8) Disruptive Staff Behavior

9) Environmental Pollutants

10) Emergency Preparedness

11) Obesity Epidemic

Please download the whitepaper, “Critical Risks Facing the Healthcare Industry” to learn more about the additional risks listed above. The paper also provides a deeper perspective on the risks covered in this article as well as additional risk management recommendations.

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BrandStudioLogoThis article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with ACE Group. The editorial staff of Risk & Insurance had no role in its preparation.
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With operations in 54 countries, ACE Group is one of the largest multiline property and casualty insurance companies in the world.
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Risk Insider: Jason Beans

When Yelp Reviews Are Better Than Hospital Rating Systems

By: | May 12, 2015 • 2 min read
Jason Beans is the Founder and Chief Executive Officer of Rising Medical Solutions, a medical cost management firm. He has over 20 years of industry experience. He can be reached at Jason.Beans@risingms.com.

There is widespread industry agreement that moving towards reimbursing quality versus quantity of care is an important means for controlling medical costs. But how do we define “quality?” And, how do we quantify “quality”?

A recent Health Affairs study illustrates the difficulty of those questions.

The study reviewed four popular hospital rating services (Consumer Reports, Leapfrog, Healthgrades, U.S. News & World Report), and the measures they used were so divergent that their rankings became strikingly different:

  • Not one hospital received high marks from all services.
  • Only 10 percent of the hospitals rated highly by one service also received top marks from another.
  • Twenty-seven hospitals were simultaneously rated among the nation’s best and worst by different services.

We deal with this frequently in our networks. We’ll have one client “absolutely” refuse to work with a provider, while another “absolutely” demands that same provider in their network.

Why such amazing disparity? It’s apparent that both hospital rating services and our clients utilize different factors to measure quality, and weigh those factors differently.

One scoring system may value cost per episode, while another values cost per diem. Another system might reward great valet parking, while another focuses on infection rates. Even slight variances can massively impact ratings. At this point, a Yelp review is likely just as good … or better.

So how do we get to meaningful provider ratings? It’s clearly a pervasive problem. In Rising’s 2014 Workers’ Compensation Benchmarking Study, medical management ranked as the top core competency impacting claim outcomes, yet only 29 percent of respondents rate their medical providers. As demonstrated by the Health Affairs study, it’s really hard to delineate the best from the worst, and trying to make those determinations can cause organizational paralysis.

So, I recommend starting simple. First evaluate what outcomes are most important. Do you value customer experience, clinical, or financial outcomes and to what degree?  Do you weigh factors differently by service type (e.g., MRIs weigh convenience highly; surgeries weigh clinical outcomes highly)? If your measurements don’t correlate with your goals, your process won’t produce valuable results.

Even slight variances can massively impact ratings. At this point, a Yelp review is likely just as good … or better.

After determining your most important factors, then your second step is to carve providers from the bottom.  This avoids the inertia that can come from trying to rate “top” providers too soon. It’s much easier to eliminate the outlier providers that cause the majority of bad outcomes to instantly improve your program.

Only after these steps would I recommend trying to establish the “best” providers. The “best” often deal with the most difficult cases, with the longest recovery periods or possibly the “worst outcomes.” It’s easy to see how a gifted surgeon might suffer under many quality rating systems. On a positive note, the transition to ICD-10 will allow provider quality comparisons at a deeper level of specificity never possible with ICD-9. In other words, we’ll actually be able to compare apples to apples over time.

With this three-step iterative approach, you can create and refine measurements that bring real, long-term value to your organization…making your system better than Yelp.

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Mitigating Fraud, Waste, and Abuse of Opioid Medications

Proactive screening for fraud, waste and abuse situations is the best way to minimize their effects on opioid management.
By: | May 8, 2015 • 5 min read
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There’s a fine line between instances of fraud, waste, and abuse. One of the key differences is intent and knowledge. Fraud is knowingly and willfully defrauding a health care benefit program for personal gain or profit. Each of the parties to a claim has opportunity and motive to commit fraud. For example, an injured worker might fill a prescription for pain medication only to sell it to a third party for profit. A prescriber might knowingly write prescriptions for certain pain medications in order to receive a “kickback” by the manufacturer.

Waste is overuse of services and misuse of resources resulting in unnecessary costs, whereas abuse is practices that are inconsistent with professional standards of care, leading to avoidable costs. In both situations, the wrongdoer may not realize the effects of their actions. Examples of waste include under-utilization of generics, either because of an injured worker’s request for brand name medication, or the prescriber writing for such. Examples of abusive behavior are an injured worker requesting refills too soon, and a prescriber billing for services that were not medically necessary.

Actions that Interfere with Opioid Management

Early intervention of potential fraud, waste, and abuse situations is the best way to mitigate its effects. By considering the total pharmacotherapy program of an injured worker, prescribing behaviors of physicians, and pharmacy dispensing patterns, opportunities to intervene, control, and correct behaviors that are counterproductive to treatment and increase costs become possible. Certain behaviors in each community are indicative of potential fraud, waste, and abuse situations. Through their identification, early intervention can begin.

Injured workers

  • Prescriber/Pharmacy Shopping – By going to different prescribers or pharmacies, an injured worker can acquire multiple prescriptions for opioids. They may be able to obtain “legitimate” prescriptions, as well as find those physicians who aren’t so diligent in their prescribing practices.
  • Utilizing Pill Mills – Pain clinics or pill mills are typically cash-only facilities that bypass physical exams, medical records, and x-rays and prescribe pain medications to anyone—no questions asked.
  • Beating the Urine Test – Injured workers can beat the urine drug test by using any of the multiple commercial products available in an attempt to mask results, or declaring religious/moral grounds as a refusal for taking the test. They may also take certain products known to deliver a false positive in order to show compliance. For example, using the over-the-counter Vicks® inhaler will show positive for amphetamines in an in-office test.
  • Renting Pills – When prescribers demand an injured worker submit to pill counts (random or not), he or she must bring in their prescription bottles. Rent-a-pill operations allow an injured worker to pay a fee to rent the pills needed for this upcoming office visit.
  • Forging or Altering Prescriptions –Today’s technology makes it easy to create and edit prescription pads. The phone number of the prescriber can be easily replaced with that of a friend for verification purposes. Injured workers can also take sheets from a prescription pad while at the physician’s office.

Physicians

  • Over-Prescribing of Controlled Substances – By prescribing high amounts and dosages of opioids, a physician quickly becomes a go-to physician for injured workers seeking opioids.
  • Physician dispensing and compounded medication – By dispensing opioids from their office, a physician may benefit from the revenue generated by these medications, and may be prone to prescribe more of these medications for that reason. Additionally, a physician who prescribes compounded medications before a commercially available product is tried may have a financial relationship with a compounding pharmacy.
  • Historical Non-Compliance – Physicians who have exhibited potentially high-risk behavior in the past (e.g., sanctions, outlier prescribing patterns compared to their peers, reluctance or refusal to engage in peer-to-peer outreach) are likely to continue aberrant behavior.
  • Unnecessary Brand Utilization – Writing prescriptions for brand medication when a generic is available may be an indicator of potential fraud, waste, or abuse.
  • Unnecessary Diagnostic Procedures or Surgeries – A physician may require or recommend tests or procedures that are not typical or necessary for the treatment of the injury, which can be wasteful.
  • Billing for Services Not Provided – Since the injured worker is not financially responsible for his or her treatment, a physician may mistakenly, or knowingly, bill a payer for services not provided.

Pharmacies

  • Compounded Medications – Compounded medications are often very costly, more so than other treatments. A pharmacy that dispenses compounded medications may have a financial arrangement with a prescriber.
  • Historical Non-Compliance – Like physicians, pharmacies with a history of non-compliance raise a red flag. In states with Prescription Drug Monitoring Programs (PDMPs), pharmacies who fail to consult this database prior to dispensing may be turning a blind eye to injured workers filling multiple prescriptions from multiple physicians.
  • Excessive Dispensing of Controlled Substances – Dispensing of a high number of controlled substances could be a sign of aberrant behavior, either on behalf of the pharmacy itself or that injured workers have found this pharmacy to be lenient in its processes.

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Clinical Tools for Opioid Management

Once identified, acting on the potential situations of fraud, waste, and abuse should leverage all key stakeholders. Intervention approaches include notifying claims professionals, sending letters to prescribing physicians, performing urine drug testing, reviewing full medical records with peer-to-peer outreach, and referring to payer special investigative unit (SIU) resources. A program that integrates clinical strategies to identify aberrant behavior, alert stakeholders of potential issues, act through intervention, and monitor progress with the injured worker, prescriber, and pharmacy communities can prevent and resolve fraud, waste, and abuse situations.

Proactive Opioid Management Mitigates Fraud, Waste, and Abuse

Opioids can be used safely when properly monitored and controlled. By taking proactive measures to reduce fraud, waste, and abuse of opioids, payers improve injured worker safety and obtain more control over medication expenses. A Pharmacy Benefit Manager (PBM) can offer payers an effective opioid utilization strategy to identify, alert, intervene upon, and monitor potential aberrant behavior, providing a path to brighter outcomes for all.

This article was produced by Helios and not the Risk & Insurance® editorial team.



Helios brings the focus of workers’ compensation and auto no-fault Pharmacy Benefit Management, Ancillary, and Settlement Solutions back to where it belongs—the injured person. This comes with a passion and intensity on delivering value beyond just the transactional savings for which we excel. To learn how our creative and innovative tools, expertise, and industry leadership can help your business shine, visit www.HeliosComp.com.
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