The Gap in the Clouds
Cloud computing is integral to modern business. According to market research firm Gartner, the global cloud service industry will be worth $180 billion by 2015, while cloudhypermarket.com estimated a third of all IT expenditures in 2013 would be on cloud computing.
The cloud network is maintained by nearly 35,000 data centers (cloud service facilities containing physical servers), about 25,000 of which are located in the United States. These facilities are extremely well protected, employing the very best physical and cyber security systems, and are usually located in secretive locations away from obvious natural perils.
However, these facilities still require traditional property coverage to insure against risks including flood, fire, storm, earthquake, sabotage, civil commotion and terrorism. If one or more major cloud service facilities were damaged, service could be disrupted and data lost, with far-reaching economic implications for businesses that rely on the service.
Last year, Superstorm Sandy shut down data centers in Manhattan, while Amazon suffered two separate power outages at its Northern Virginia cloud facility forcing many popular websites including Netflix, Instagram and Pinterest offline. But it’s not just media outlets that suffer — thousands of businesses are now actively using the cloud for business purposes, with basic data storage only accounting for 13 percent of cloud usage, according to research firm IDC.
Despite growing reliance on the cloud, Florence Levy, senior vice president and head of Lockton’s Global Technology and Privacy Practice, believes there is a gap in the insurance market that could leave cloud users uninsured for lost data or business interruption in the event of a physical event damaging a cloud facility.
“Traditionally, property policies address physical triggers and harm, while cyber and even errors and omissions policies are intended to address non-physical triggers and economic damage,” she said. “In the event of a physical trigger causing non-physical harm, property underwriters and cyber underwriters will be left pointing fingers at each other.”
According to Jim Charron, Technology Practice leader for Zurich, it is possible to insure data under a property policy, although coverage language often doesn’t capture the entire exposure. “Some [policies] are very clear that they cover computing resources and will specifically state that the coverage includes voice, data and even video, while others are not,” he said. “There are requests for this exposure to be covered and underwriters are responding, but the wording isn’t always reflective of the exposures.”
Charron added that underwriting becomes even more complicated when data is being held by a third-party on behalf of potentially millions of clients.
“Traditional property and business interruption risks already existed for insureds who maintained their computing resources within their own buildings, but with the use of the cloud those risks are subject to equipment not owned by the insured. Once the risk has been transferred to another party the insurance needs to change along with that,” he said. “I think there is an opportunity for insurers to refresh their approach.”
“People are starting to realize this may be a bigger issue than we had previously allotted for in the last couple of years. Savvy clients are asking a lot of questions,” said Levy, adding that brokers are trying to encourage insurers to develop enhanced coverage to ensure cloud users’ data is properly insured.
“The market is trying to figure out a way to address this, whether it is some sort of ‘difference in conditions’ policy that sits above the property and cyber policies, or more collaboration between the property and cyber underwriters and brokers to come up with a more effective solution,” she said.
Levy admitted, however, that creating some kind of hybrid product would be very challenging for insurers. “Cyber and property are two very different coverages with different profitability standards and historical data sets. The most likely solution is an umbrella or difference in conditions policy rather than stretching either set of underwriters beyond their comfort zone,” she said.
Another major challenge is aggregation of risk, with tens of thousands of businesses potentially facing disruption if any of the leading cloud providers went down.
“What is the aggregated business interruption and property damage exposure of one or several of these facilities if they were attacked all at once or there was a large weather event?” asked Charron. “If a major facility is taken down it could have a dramatic impact on the insurance industry.”
When in Doubt, Sue
Cloud users may have another form of protection. Robert Parisi, Network Security and Privacy Practice leader at Marsh, who places E&O and professional liability (PL) risks for cloud service providers, believes providers are vulnerable to PL claims, even if interruption or loss of data was caused by a physical risk rather than negligence.
“I don’t think there are gaps in coverage. If a cloud provider is unable to provide their service, it is going to come back at them as a PL claim. The end user is not going to care one whit why the cloud provider wasn’t there when they needed them — they just know they have a contract and the provider didn’t honor it,” he said.
Accordingly, cloud providers have to ensure their E&O and PL policy wordings are airtight in their response to ‘act of God’ type risks or even deliberate physical sabotage and terrorism risks.
“From an end user’s perspective, the principal recovery vehicle is going to be that PL policy, so the cloud providers and their brokers need to look under the hood of their policies,” said Parisi. “The market has evolved and is getting better at providing solutions, and the coverage is fairly broad. It is up to the broker to be aware those solutions exist and stitch them together for [the cloud provider].”
Parisi said PL claims against cloud providers are common, particularly in the litigious United States where cloud users also have very high expectations — anything less than 24-hour service at optimal speed could result in a PL claim, particularly from users whose businesses rely on real-time data feeds, he said.
“Tech companies are regularly sued for failing to provide service or failing to render the service non-negligently. Tech is not perfect, and when it goes wrong, usually the first thing a client of a tech company is going to do is assume the tech provider must have done something wrong,” he said.
“Not only is the cloud provider going to be held to rendering the service and having the service functioning as intended, there is also an element of latency risk; clients want their service working now, on demand, and without any delays.”
In order for the cloud providers to ensure they get adequate coverage against such claims, they must demonstrate high levels of risk management including building redundancies into their systems so that if one facility is damaged, the data can be switched rapidly to another network or facility without being lost.
“One of the large tech companies runs an entirely parallel network right next to their production network so if anything happens they can switch their customers from the day-to-day network to the parallel redundant network in the blink of an eye,” said Parisi.
“That’s an extreme example – most providers don’t have a parallel network. But if they are going to guarantee 100 percent up-time they need to make sure they have the facilities that can do that — and if that means geographically separating their data centers then that is what must be done.”
When it comes to liability for data loss or service downtime, much hinges on the service level agreement between the two parties.
“This agreement defines what level of liability the provider assumes. In that contracting process the provider can say they will deliver their service but there are things outside of their control, and if those things prevent the service the user will have to live with that,” said Parisi. “That won’t always necessarily fly in the negotiation process — in which case the provider may put liquidated damages or limitations of liability clauses with pre-agreed settlements or caps on liability into the contract.”
Parisi added that one of the best things a cloud provider can do to limit their liability is to manage the expectations of the cloud user.
“The quickest way for someone to think the provider did something wrong is for the provider to overpromise,” he said, noting that startup cloud providers are most susceptible to this as they aggressively compete for business.
Ultimately, though, cloud users must take responsibility for their own data — particularly if it is critical to their business. “Cloud users should take it as incumbent upon them as part of their risk management policy to ensure they have their data backed up, and most of them probably do,” said Zurich’s Charron. “The rub is if they are creating new data all the time and there is value in the creation of this new data being generated. Identifying whether data is confidential or mission-critical can help the user understand how often they should back up their data.”
Parisi said cloud use should be treated with the same common sense as any other enterprise risk.
“If you’re relying solely on a third party for the sanctity and security of your data, you are probably making a lot of other mistakes in your business,” he said.
Coping with Cancellations
Airlines typically can offset revenue losses for cancellations due to bad weather either by saving on fuel and salary costs or rerouting passengers on other flights, but this year’s revenue losses from the worst winter storm season in years might be too much for traditional measures.
At least one broker said the time may be right for airlines to consider crafting custom insurance programs to account for such devastating seasons.
For a good part of the country, including many parts of the Southeast, snow and ice storms have wreaked havoc on flight cancellations, with a mid-February storm being the worst of all. On Feb. 13, a snowstorm from Virginia to Maine caused airlines to scrub 7,561 U.S. flights, more than the 7,400 cancelled flights due to Hurricane Sandy, according to MasFlight, industry data tracker based in Bethesda, Md.
Roughly 100,000 flights have been canceled since Dec. 1, MasFlight said.
Just United, alone, the world’s second-largest airline, reported that it had cancelled 22,500 flights in January and February, 2014, according to Bloomberg. The airline’s completed regional flights was 87.1 percent, which was “an extraordinarily low level,” and almost 9 percentage points below its mainline operations, it reported.
And another potentially heavy snowfall was forecast for last weekend, from California to New England.
The sheer amount of cancellations this winter are likely straining airlines’ bottom lines, said Katie Connell, a spokeswoman for Airlines for America, a trade group for major U.S. airline companies.
“The airline industry’s fixed costs are high, therefore the majority of operating costs will still be incurred by airlines, even for canceled flights,” Connell wrote in an email. “If a flight is canceled due to weather, the only significant cost that the airline avoids is fuel; otherwise, it must still pay ownership costs for aircraft and ground equipment, maintenance costs and overhead and most crew costs. Extended storms and other sources of irregular operations are clear reminders of the industry’s operational and financial vulnerability to factors outside its control.”
Bob Mann, an independent airline analyst and consultant who is principal of R.W. Mann & Co. Inc. in Port Washington, N.Y., said that two-thirds of costs — fuel and labor — are short-term variable costs, but that fixed charges are “unfortunately incurred.” Airlines just typically absorb those costs.
“I am not aware of any airline that has considered taking out business interruption insurance for weather-related disruptions; it is simply a part of the business,” Mann said.
Chuck Cederroth, managing director at Aon Risk Solutions’ aviation practice, said carriers would probably not want to insure airlines against cancellations because airlines have control over whether a flight will be canceled, particularly if they don’t want to risk being fined up to $27,500 for each passenger by the Federal Aviation Administration when passengers are stuck on a tarmac for hours.
“How could an insurance product work when the insured is the one who controls the trigger?” Cederroth asked. “I think it would be a product that insurance companies would probably have a hard time providing.”
But Brad Meinhardt, U.S. aviation practice leader, for Arthur J. Gallagher & Co., said now may be the best time for airlines — and insurance carriers — to think about crafting a specialized insurance program to cover fluke years like this one.
“I would be stunned if this subject hasn’t made its way up into the C-suites of major and mid-sized airlines,” Meinhardt said. “When these events happen, people tend to look over their shoulder and ask if there is a solution for such events.”
Airlines often hedge losses from unknown variables such as varying fuel costs or interest rate fluctuations using derivatives, but those tools may not be enough for severe winters such as this year’s, he said. While products like business interruption insurance may not be used for airlines, they could look at weather-related insurance products that have very specific triggers.
For example, airlines could designate a period of time for such a “tough winter policy,” say from the period of November to March, in which they can manage cancellations due to 10 days of heavy snowfall, Meinhardt said. That amount could be designated their retention in such a policy, and anything in excess of the designated snowfall days could be a defined benefit that a carrier could pay if the policy is triggered. Possibly, the trigger would be inches of snowfall. “Custom solutions are the idea,” he said.
“Airlines are not likely buying any of these types of products now, but I think there’s probably some thinking along those lines right now as many might have to take losses as write-downs on their quarterly earnings and hope this doesn’t happen again,” he said. “There probably needs to be one airline making a trailblazing action on an insurance or derivative product — something that gets people talking about how to hedge against those losses in the future.”
The Tools of the Trade
Integrating medical management with pharmacy benefit management is the Holy Grail in workers’ compensation. But getting it right involves diligence, good team communication and robust controls over the costs of monitoring technology.
Risk managers in workers’ compensation can feel good about the fact that opioid use is declining slightly. But experts who gathered for a pharmacy risk management roundtable in Philadelphia in June pointed to a number of reasons why workers’ compensation professionals have more than enough work cut out for them going forward.
For one, although opioid use is declining, its abuse and overuse in legacy workers’ compensation claims is still very much a problem. An epidemic rages nationally, with prescription drug overdose deaths outpacing those from the abuse of heroin and cocaine combined.
In addition, increased use of compound medications and unregulated physician dispensing are resulting in price gouging and poor medical outcomes.
Although individual states are attempting to address the problem of physician dispensing of prescriptions in workers’ comp, there is no national prohibition against it: That despite substantial evidence that the practice can result in ruinous workers’ compensation medical bills and poor patient outcomes.
“The issue is that there isn’t enough formal evidence to indicate improved outcomes from the use of compounds or physician dispensed drugs, and there are also legitimate concerns with patient safety,” said roundtable participant Jim Andrews, executive vice president, pharmacy, for Duluth, Ga.-based pharmacy benefit manager Healthcare Solutions.
Andrews’ concerns were echoed by another roundtable participant, Dr. Jennifer Dragoun, Philadelphia-based vice president and chief medical officer with AmeriHealth Casualty.
“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events,” Dr. Dragoun said.
Whereas two years ago, topical creams and other compounds with two to three medications in them were causing concern, now we’re seeing compounds with seven or more medicines in them.
How those medicines are interacting with one another, and in the case of a compound cream, how quickly they’re being absorbed by the patient, are unknowns that are creating undue health risks.
“These medicines haven’t been tested for that route of administration,” Dragoun said.
In other words, the compounds have not been reviewed or approved by the FDA.
Carol Valentic, vice president of cost containment and medical management with third-party administrator Broadspire, said her company’s approach to that issue is to send a letter to providers, through the company’s pharmacy benefit administrator, alerting them to the fact that compounds are not FDA-approved and could be dangerous.
Other roundtable participants said they employ utilization review of every prescribed compound medication. They’re finding that the inflation of the average wholesale price for prescriptions that pharmacy benefit managers are battling in the case of single medications is happening with compounds as well, to the surprise of probably no one.
“The cost of compounds is doubling every year,” Healthcare Solutions’ Andrews said.
Kim Clark, vice president of utilization management with Patriot Care Management Inc., a division of Patriot National, Inc., said Patriot has their own software, DecisionUR, and opioids as well as compound prescriptions can be directed from the PBM to Utilization Review.
In the area of new worries in workers’ compensation, and there are plenty of them, Dragoun also pointed to the introduction of extremely high cost, albeit extremely effective specialty medications, such as those being used to treat Hepatitis C. Treatments in this area can run into the hundreds of thousands of dollars.
Domestic drug manufacturers, pressed to pursue profits as their product lines mature and their margins level off, are jockeying for dominance in this area.
“This seems to be a route that a lot of drug makers are going after. Very narrow markets but with extremely high cost medications,” said Deborah Gleason, clinical resources manager, medical programs, with ESIS, the Philadelphia-based third-party administrator that is part of ACE Group.
Tools of the Trade
Given how substantially the use of prescriptions can balloon the cost of a workers’ compensation claim and undermine outcomes, a number of tools are in the market that can help risk managers rein in costs.
One is urine drug monitoring, which can catch cases of drug diversion, or instances where an injured worker is ingesting unprescribed substances. But the use of that test can create its own problems, namely overutilization.
Gleason, with ESIS, Inc., and others use urine drug monitoring. But when the test is overused, say by being conducted every month instead of quarterly as is recommended, the members of the Philadelphia roundtable said its costs can outrun its usefulness.
Test results are frequently inconsistent, signaling that the injured workers aren’t taking the prescribed medication or are taking something they shouldn’t be. Drug testing shouldn’t be used in isolation but rather as a component of integrated medical management.
“What’s emerging today, and in some companies more prevalently, is the integration of managed care with pharmacy benefit management,” roundtable participant Valentic said.
“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events.”
— Dr. Jennifer Dragoun, Vice President and Chief Medical Officer, AmeriHealth Casualty
In other words, it’s not enough to flag a script or pick up a urine drug monitoring test result. There needs to be a plan or a system in place that says what action should be taken with the patient once that information has been received.
Identifying a potential problem early and taking action on it is key, said ESIS’ Gleason. She added that the patient’s psychological state, including how they react to and perceive pain, is something that more risk practitioners should consider.
Obstacles to assessing someone’s psychological or psychosocial state, according to roundtable members, include a lack of awareness or acceptance of its possible advantages on the part of patients and physicians. After all, we’re talking about an assessment, a list of questions, that should take no more than 15 minutes to carry out.
If a treating physician or case manager doesn‘t conduct a psychological test but is still concerned about the potential for pain medication abuse, there is one key question they can ask an injured worker, according to AmeriHealth Casualty’s Dragoun.
“There is one question that predicts far more than any other attribute of a patient whether they are likely to abuse narcotics, and that is if they have a personal or family history of substance abuse,” Dragoun said.
“You know they may ask that about the patient, but I don’t know how many ask it about the family,” Patriot Care Management’s Kim Clark said.
Pharmacogenetic testing, that is testing an individual for how they might react to certain drugs or combinations of drugs, and not — let’s be clear about this — whether they are predisposed to addiction, is also entering the market.
But as is the case with urine drug monitoring, the use of pharmacogenetic testing is no cure-all and the cost of it needs to be carefully managed.
Some vendors are pitching that it be applied to every case in a payer’s portfolio. The roundtable participants in Philadelphia agreed that it should be used with far more discretion than that.
Regulating the Regulators
It’s a given in the insurance business and in workers’ compensation that regulators in all 50 states call the shots. There are few national laws that regulate the hazards faced by workers’ compensation risk managers and injured workers.
Having said that, is it really such a pipe dream to think that the federal government could step in and provide leadership in an area that is so prone to confusion, risk and self-serving behavior on the part of some vendors and medical practitioners?
If the Philadelphia roundtable as a group could point to one place where federal regulators could do some good it would be in the area of physician dispensing. Many states have enacted legislation to curb the practice, as there is no data to prove better outcomes, and regulation by the federal government would be of benefit, the Philadelphia roundtable concluded.
Another area would be to require FDA oversight for compounds.
“The minute you need to have FDA approval of a compound, that’s going to stop it,” Broadspire’s Valentic said.
It’s a notion worth considering. After all, lives are at stake here.
Given the lack of oversight from the federal government, the roundtable participants pointed to measures in a number of states that are worth emulating. The Texas closed formulary, which limits the range of medications that can be prescribed, is one example.
The requirement in the State of New York that a prescribing physician check a state registry — what’s known as a prescription drug monitoring program — to check whether a patient is already taking or has a prescription for a controlled substance, is another good example of a state government stepping in to ensure the safety of its residents.
“The minute you need to have FDA approval of a compound, that’s going to stop it.”
— Carol Valentic, Vice President of Cost Containment, Medical Management, Broadspire
Pennsylvania also earned praise from the roundtable for recently passing a measure limiting the amount of medication that a physician can dispense to an initial supply.
With different regulations in every state and with the average wholesale cost of prescriptions constantly on the rise, pharmacy benefit management is an art requiring constant vigilance.
“It’s not an original thought, but if you stop and think about all the things that are happening in society with the addictions and the costs, the cost of doing nothing is greater than the cost of doing something.
I think that’s why everybody is doing something,” Healthcare Solutions’ Andrews said.
For more information about Healthcare Solutions, please visit www.healthcaresolutions.com.
Opinions of the roundtable participants are the opinions of each individual contributor and are not necessarily reflective of their respective companies.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthcare Solutions. The editorial staff of Risk & Insurance had no role in its preparation.