A Paramount Parable
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
Home for the Holidays
Neal Chambers surveyed the holiday turkeys on display at his local grocer on Nov. 23 and mused. Fresh or frozen? Tom or hen? Free range or kosher? Locally produced or from the foothills of the Smoky or the Sierra Mountains?
Chambers threw thrift to the wind and plunked down $52 for a 16-pound organic bird from Upstate New York.
What the heck? After four brutally slow years, the construction company he managed risk for was showing signs of reemergence.
True, the company’s estimators were not happy. Where once they needed to bid 10 jobs to land one, each job now took 30 or 40 bids to land.
Neal’s company, Paramount Construction Co., based in Des Moines, Iowa, worked with larger companies historically.
But in order to land projects, it was now moving down to the middle market and competing against smaller regional operators with local expertise. This was not an easy road to hoe.
But Paramount was doing what it felt it needed to do to compete successfully.
At the office holiday party on Dec. 19, held at the River Bluff Country Club, Neal could see signs that the C-suites were feeling a little better about things. Nice carving station, good wine in the glasses and some generous door prizes. He took in a deep breath and let it out.
Things had been tough for a while. He’d been working hard. He’d been worried.
“Go ahead, have a drink,” he told himself. “It’s free and now is as good a time as any.”
Neal had one glass of wine in him and was waiting his turn to fill his plate at the sushi appetizer table when he saw one of the vice presidents, Tom Murphy, lift his phone to his ear.
As he listened to the caller, Murphy turned and looked at Neal. With his other hand, he gestured to Neal to join him. Murphy’s hand was free because he did not drink at company functions … ever.
“It’s Constantine,” Murphy said in a whisper when Neal got closer. “Something’s up. He tried to reach you but…”
Murphy shrugged non-judgmentally.
Constantine, head of operations. Good guy. No nonsense.
“This is Neal Chambers,” Neal said into Murphy’s phone.
“Neal, it’s Jonny Constantine. We’ve got a bit of a situation.”
“Shoot,” Neal said.
Constantine exhaled audibly into the phone. Neal could tell that Constantine was a little upset.
Neal shot a look of worry at Murphy.
“Look, we just had an accident with an excavator operator on the site here in Mille Lacs. We’ve got one seriously injured employee and some structural damage to a neighboring building.”
“How bad is the injury?” Neal said.
“It’s not pretty. I think this poor kid is going to lose his left leg below the knee,” Constantine said.
“And the building?”
“Well. The wall on the demo wasn’t supported right and the operator knocked it into this neighboring wall. It was a pretty big bump.”
Neal hung up with Constantine and gave Murphy his phone back.
As he turned his own phone on to check messages, Neal Chambers felt any holiday warmth drain out of him. The wine that had been so enjoyable 20 minutes ago now struck him like a cheap depressant.
2014 was supposed to be Paramount’s breakout year. But now Chambers had a significant workers’ compensation and general liability claim to worry about.
Looking around the brightly lit room at his fellow employees, Neal Chambers had an uneasy feeling that 2014 wasn’t going to be that great after all.
No Bench Strength
What worried Neal Chambers were the personnel cuts Paramount undertook to survive during the brutal commercial construction downturn that seized the country during the Great Recession.
The most worrisome cuts came in the area of safety, where some highly paid talent had been laid off. But there were also cuts in estimating, where other senior personnel with beefier paychecks left the company.
You couldn’t put the cart before the horse. Although things were turning around, Paramount was not yet at a place where it could hire big ticket talent to fill the gaps. Not yet.
Yet the company was trying to grow again and take on more projects. The combination worried Neal Chambers.
The accident with the excavator in Mille Lacs wasn’t catastrophic. But it was the beginning of a series of workplace accidents that plagued the company through the first six months of 2014.
Neal’s conversations with finance added to his anxiety.
“We’re just not making the money on these projects I thought we were going to be,” said Tom Murphy’s elder brother Pat Murphy, the company CFO.
Bidding for projects in unfamiliar territories and on unfamiliar scales, Paramount’s overworked estimators were missing the mark time and again.
The combination of an increased injury frequency rate and thinner margins was not making a good impression on Paramount’s surety and insurance underwriters.
Both Pat and Neal feared that year-end premium increases could be in the works.
Paramount’s revenue shortfalls created friction with subcontractors.
Jonny Constantine got into several heated arguments with subcontractors, alleging that they were botching projects by not moving more efficiently.
There were now a handful of legal proceedings underway. In those cases, Paramount was alleging that subcontractors violated the terms of their contracts by not completing the work in time, or completing it in substandard fashion.
Win or lose, those lawsuits meant one thing to Neal Chambers and Pat Murphy. They meant more costs, more margin erosion.
“We’re in a tight spot,” Neal Chambers said.
“I know we are,” Pat said, somewhat impatiently.
“The thing is, I don’t know what we can do between now and 2015 renewals to make a better impression,” Neal said.
“It’s almost like a roll of the dice,” he added. “I don’t know what else we can get out of the safety department in terms of management.”
“We need better talent and more of it,” Pat said.
The question was where.
A Horse With No Name
The answer to Neal’s question, as it turned out, was “nowhere.”
The talent crunch that Paramount was experiencing, and which was causing it so much pain, was not isolated to Paramount. But some of its competitors moved more quickly than Paramount in acquiring and retaining the talent to help them take full advantage of the upturn.
Others moved even less effectively than Paramount. But in a competitive economy, being in the middle was no place to be.
As 2014 moved from the second quarter to the third and fourth, adding to Paramount’s workers’ compensation woes and its sinking profit margins came yet another issue.
That issue was increasing commodities prices. Paramount’s overworked estimators, working in the unfamiliar middle market, failed to take into account a gradual increase in the cost of steel, copper wiring and other key construction materials.
There simply was no place to turn to hire the sort of experience in safety or in estimating that could put Paramount back on track.
As Paramount’s executives looked forward to their year-end renewals for their insurance programs, the company was looking at unpalatable premium increases.
“You’re looking at a 30 percent mark-up with your workers’ compensation premiums and at least a 25 percent increase in the amount of collateral you’re going to have to put up in workers’ compensation and in surety,” said the company’s broker, Ed Scarborough. “You’re also looking at an increase in your general liability.”
The construction market continued to recover. But Paramount now needed to play defense.
Faced with insurance and surety increases and declining margins, Paramount had no choice but to do what it didn’t want to do. Already bereft and hamstrung due to a lack of talent, Paramount undertook more layoffs.
One of the first to go was Neal Chambers.
In November of 2014, Neal Chambers and his daughter Annabelle went shopping for a turkey. Annabelle was fourteen and well versed in sustainable agriculture practices at school.
“We’re getting an organic turkey, right?” she asked her father.
“No, Annabelle, I’m afraid not,” Neal said.
Neal reached into the meat freezer and pulled out a frozen Honeybreast turkey and threw it into his shopping cart with a disheartening “clang.”
Risk & Insurance partnered with Liberty Mutual Insurance to produce this scenario. Below are Liberty Mutual Insurance’s recommendations on how to prevent the losses presented in the scenario. These lessons learned are not the editorial opinion of Risk & Insurance.
1. Value is replacing price: It’s no longer enough to be the lowest bidder. Contractors must now prove to clients that they have the capacity to deliver a project that is the most cost-effective in the long term. That means not only delivering a quality product, but having the risk management program and coverage in place to mitigate potential finger pointing and costly litigation down the road.
2. Keep an eye on commodities: Nowhere are the realities of the global economy more evident than in the area of commodities. Demand cycles for copper, steel, coal and other materials in developing or maturing economies are going to have an impact on prices here at home. Models that take into account commodities fluctuations will be increasingly important. In addition, any new rating programs based on Construction Value should be carefully evaluated compared to a payroll based program.
3. Talent rules: Qualified estimators and safety officers left the construction industry in droves during the downturn. Making sure the talent is in place to take advantage of the upturn in the rebounding commercial construction business is an important consideration. Don’t overlook the added value of a well-documented quality assurance program.
4. Understand new geographies: Competing in this new market may mean having to enter new geographic areas to find business. Trying to compete in New York state without understanding its Byzantine labor laws would be a mistake. So would entering into any new geography without an understanding of local regulations and how they could impact costs. Conversely, demonstrating local experience to a client would be a key selling point here.
5. Delivery methods matter: New markets mean new delivery methods. Whether it is design-build, identifying a construction manager at risk, or the complexities of public-private or international partnerships, insurance and risk mitigation are going to have to be adequate to cover these trending delivery methods. Effective communication amongst all parties including contractual relationships continues to be a vital aspect of any project.
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
The scenario begins with the brief video below:
It’s five weeks since the day Reggie first felt that twinge in his knee. The pain is still not so great that Reggie can’t live with it, but he’s getting a little tired of it.
After work one day, Reggie is having beers with Smitty Cheeks, one of the company’s mid to long-range truckers, who’s done driving for the week and will be spending the weekend in Memphis.
Smitty and Reggie are engaged in game of 8-Ball at their local blues and barbecue joint. Smitty slams the 8 ball into the corner pocket, winning the game.
“My game,” says Smitty.
Reggie eyes the waitress delivering food to their nearby booth.
“Good thing,” Reggie says. “ ’Cause our food is here.”
The two are tearing into some serious barbecue when Reggie notices Smitty pulling a pill from a vial in his pocket. Reggie’s already had a couple of beers, which makes him a little bolder.
“Watcha’ got there partner?” Reggie says.
“Vicodin,” Smitty says.
“My back’s a mess and I’ve been taking these Vicodins for a while. They help a good deal. Probably not best to drink and use these, but hey, whatever gets you through the night,” Smitty says with a beery wink.
Reggie pauses and then blurts out.
“Could you hook me up with a few of those? I’ve been having some aches and pains myself.”
Smitty pauses, then very efficiently strips the smoked meat off of a turkey wing.
“I can get you all you need buddy and the price is right,” he says, his lips smeared with barbecue sauce and this time not smiling.
The next day, Reggie, whose become more inactive and out of condition since his knee injury, is coming out of the bathroom at home with a towel around his waist.
He’s limping worse than he has been recently. The knee has begun to lock on occasion and feels like it might be giving out. His wife Arlene addresses him.
“When are you going to see a doctor?” she says to him with a worried expression on her face.
“I really don’t know,” says Reggie.
“I really think you should,” she says. “You don’t know what’s going on there and you should at least get it checked out.”
Reggie pauses, embarrassed. Arlene is looking at him compassionately and it softens his defenses.
“I tweaked my knee at work a while back. Tell you what, I’ll tell my boss on Monday and go see somebody.”
“Good,” Arlene says. “You don’t want to go too long before figuring out what’s up.”
Reggie tells his supervisor about his injury. Reggie’s injury is in turn reported to the company’s insurance carrier. But neither the claims adjuster or the employer discuss the idea of Reggie being offered modified duty.
Reggie is referred to an in-network physician, an occupational medicine specialist. The Occ-Med prescribes an anti-inflammatory for Reggie. He also orders an MRI for him and gives him a prescription for four sessions of Physical Therapy and orders him a hinge knee brace, due to the “giving out” feeling Reggie has reported in his knee.
The Occ-Med specialist gets the MRI results, which reveals a tear. Without calling Reggie into have another look at him or gauge how he’s done in therapy, the Occ-Med refers Reggie to an orthopedic surgeon.
Reggie is in the surgeon’s office looking at the MRI results with the surgeon when he gets the news.
“The MRI scan reveals a 4 mm acute medial meniscus tear, Reggie,” the surgeon says.
“We’re going to want to repair this,” he continues.
“You mean surgery?”
“Yes. I don’t want to let this sort of thing go in a man your age,” the surgeon says, patting Reggie on the shoulder compassionately.
Mollified by the surgeon’s kindly tone, Reggie doesn’t question the decision or seek a second opinion.
Reggie doesn’t think to ask about a less invasive approach, like more physical therapy, and the surgeon doesn’t bring it up. The surgeon puts in a request for surgery, which is approved by the adjustor with no follow up or questioning as to its necessity.
Reggie undergoes preauthorized, minor arthroscopic surgery and is initially given six weeks off of work under the direction of the surgeon.
The carrier’s claims adjustor makes a note of the surgery but doesn’t contact the employer or Reggie to check in on his condition.
“It’s a pretty minor procedure,” she tells herself while alternating between looking at her computer monitor, where the details of Reggie’s case are displayed, and checking her cell phone.
Then her phone rings.
“This is Janice,” she says, and clicks to another screen on her computer. Reggie’s case is out of sight, out of mind.
No one from Reggie’s company checks in with him to discuss the future possibility of modified duty or to check on his overall welfare.
The Wheels Come Off
It’s one week post-op and Reggie pays a visit to the surgeon for a wound check.
“Let’s have a look here,” the surgeon says, gently peeling off the adhesive bandage.
“Looking good,” he says.
“Good,” Reggie says.
The surgeon swabs Reggie’s knee with some antiseptic and distracts Reggie as he pulls out the sutures with a discussion about planning for the way forward.
“So, I’m going to give you a prescription for therapy. I want to see you do at least 12 visits to work on regaining full range of motion in the knee and getting your strength back.”
“Got it,” said Reggie.
“How’s your pain?” the surgeon says.
“It hurts, no doubt,” Reggie said.
“Well let me know if you need more pain medication,” the surgeon says.
“I just might do that,” Reggie says before gingerly slipping down from the table.
It’s a week later and Reggie is sitting on the couch at home with the channel changer in his hand and his leg up.
Reggie checks his iPhone, scanning his e-mail inbox.
“Have you heard anything about your physical therapy appointment?” Arlene says from the kitchen where’s she’s pouring some tea for her and Reggie.
“Nothing,” Reggie says.
“I think I’m going to call them,” she says. “We need to get you into physical therapy.”
“Go ahead. I doubt they’ll call you back,” Reggie says. He’s not out of it but his manner is resigned and sluggish.
“It hasn’t been approved or processed yet by the insurance company.”
“Has anybody from your company ever contacted you?” Arlene says.
“Nope. But I’m still getting my workers’ comp checks, I guess I can be thankful for that,” Reggie says.
Reggie palms a pain pill from a vial and swallows it with a sip of water. Arlene can’t see him do this from her vantage point in the kitchen.
“I don’t like it, they should be in touch,” Arlene says.
“You’re probably right,” Reggie says, over his shoulder, taking a break from look at the television.
It’s another week before Reggie gets into therapy. The therapist greets Reggie as he’s ushered into the treatment area.
“Hi, I’m Maggie,” the therapist says. “Come on over to this table and lie down. I want to put some electrical stimulation on your knee and then we’ll get to work on it a little bit.”
Reggie walks over to the table, limping noticeably.
“You had surgery when?” Maggie the therapist says.
“Three weeks ago,” Reggie says.
“Hmmm, you’re late getting in here,” the therapist says.
“After we get through our work here today, I’m going to give you some home exercises to help you get caught up. We need to keep this knee moving and build your strength back up,” she says.
We cut forward to see the therapist working on Reggie’s knee. She flexes the knee slightly and Reggie almost jumps off of the table.
“This joint is stiff,” the therapist says.
“It sure is,” Reggie says.
Reggie’s reacting to the pain and eyes the therapist warily.
Reggie’s back at home and back in front of the television set. This time he’s got the pain medication bottle out in full view.
Arlene comes in carrying some groceries.
“Have you done your therapy exercises today?” she says.
“Not yet,” Reggie says.
She eyes the vial of pills on the table next to Reggie.
“I thought you were done with those,” she says.
“I’m not taking that many of them,” Reggie says. “And I did move. I went to the bathroom.”
Arlene just looks at him. She’s concerned but clearly doesn’t want to start an argument.
Without another word, Arlene heads to the kitchen with the groceries.
It’s five weeks since Reggie’s last visit to the orthopedic specialist and he uses a cane to get into the examination room. The use of the cane was approved by the adjustor.
The surgeon enters the room and sees the cane propped next to Reggie as Reggie sits on the examination table.
The surgeon is very alarmed.
“What’s the cane for?” he says. “I didn’t order you one.”
“I need it to walk,” Reggie says. “My knee’s still killing me and it’s hard to move it.”
“Where’d you get it, the cane?” the surgeon says, clearly disturbed.
“The therapist gave it to me,” Reggie says.
The surgeon quickly scans his electronic pad, looking for the report from the therapist.
“You had six visits. You were late getting in there but you had six visits. Although you should have had 12,” the doctor says, not quite panicking but clearly unnerved.
“You should have been going twice a week.”
Reggie ignores him.
“You said I could have more pain pills if I needed them, right?”
“What?” the doctor says, jarred that Reggie is ignoring him and taking up another subject.
“Yes I said that but I didn’t think you’d…” the doctor says before Reggie interrupts him.
“I’m gonna’ need more pain pills,” Reggie says with an edge.
The doctor says nothing. He’s at a loss.
“Doctor, I want more pain pills,” Reggie says.
This scenario was originally presented at the 2015 National Workers’ Compensation and Disability Conference in Las Vegas.
As part of the discussion, panelists discussed key aspects presented in the scenario.
Panelists included Dr. Robert Goldberg, chief medical officer, Healthesystems; and Dr. Jeffrey Sugar, Associate Medical Director, Sharp Rees-Stealy Medical Group. The session was moderated by Tracey Davanport, director, National Managed Care, Argo Group.
Insights from their discussion are highlighted below:
Compounding: Is it Coming of Age?
The WC managed care market has generally viewed the treatment method of Rx compounding through the lens of its negative impact to cost for treating chronic pain without examining fully the opportunity to utilize “best practice” prescription compounds to help combat the opioid epidemic this nation faces. IPS stands on the front lines of this opioid battle every day making a difference for its clients.
After a shaky start cost-wise, prescription drug compounding is turning the corner in managing chronic pain without the risk of opioid addiction. A push from forward-thinking states and workers’ compensation PBMs who have the networks and resources to manage it is helping, too.
Prescription drug compounding has been around for more than a decade, but after a rocky start (primarily in terms of cost), compounding is finally coming into its own as an effective chronic pain management strategy – and a worthy alternative for costly and dangerous opioids – in workers’ compensation.
According to Greg Todd, CEO and founder of Integrated Prescription Solutions Inc. (IPS), a Costa Mesa, Calif.-based pharmacy benefit manager (PBM) for the workers’ compensation and disability market, one reason compounding is beginning to hit its stride is because some states have enacted laws to manage it more effectively. Another is PBMs like IPS have stepped up and are now managing compound drugs in a much more proactive manner from an oversight perspective.
By definition, compounding is a practice through which a licensed pharmacist or physician (or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist) combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.
During that decade, Todd explains, opioids have filled the chronic pain management needs gap, bringing with them an enormous amount of problems as the ensuing addiction epidemic sweeping the nation resulted in the proliferation and over-consumption of opioids – at a staggering cost to both the bottom line and society at large.
As an alternative, compounded topical cream formulations also offer strong chronic pain management but have limited side effects and require much reduced dosage amounts to achieve effective tissue level penetration. In fact, they have a very low systemic absorption rate.
Bottom line, compounding provides prescribers with an excellent alternative treatment modality for chronic pain patients, both early and late stage, Todd says.
Time for Compounding Consideration
That scenario sets up the perfect argument for compounding, because for one thing, doctors are seeking a new solution, with all the pressure and scrutiny they’re receiving when trying to solve people’s chronic pain problems using opioids.
Todd explains the best news about neuropathic pain treatment using compounded topical analgesic creams is the results are outstanding, both in terms of patient satisfaction in VAS pain reduction but also in reduction potentially dangerous side effects of opioids.
The main issue with some of the early topical creams created via compounding was their high costs. In the early years, compounding, which does not require FDA approval, had little oversight or controls in place. But in the past few years, the workers compensation industry began to take notice of the solid science. At the same time, medical providers also were seeing the same science and began writing more prescriptions for compounding – which also offers them a revenue stream.
This is where oversight and rigor on the part of a PBM can make a difference, Todd says.
“You don’t let that compounded drug get dispensed when you’re going to pay for it without having a chance to approve it,” Todd says.
Education is Critical
At the same time, there is the growing, and genuine, need to start educating the doctors, helping them understand how they can really deliver quality pain management to a patient without gouging the system. A good compounding specialty pharmacy network offering tight, strict rules is fundamental, Todd says. And that means one that really reaches out to work with the doctors that are writing the prescriptions. The idea is to ensure that the active ingredients being chosen aren’t the most expensive sub-components because that unnecessarily will drive the cost of overall compound “through the ceiling.”
IPS has been able to mitigate costs in the last couple years just by having good common sense approach and a lot of physician outreach. Working with DermaTran Health Solutions and its national network of compounding pharmacies, IPS has been successfully impacting the cost while not reducing the effectiveness of a compounded prescription.
In Colorado, which has cracked down on compounding profiteering, Legislative change demanded no compound could be more than $350.00 period. What is notable, in an 18-month window for one client in Colorado, IPS had 38 compound prescriptions come through the door and each had between 4 and 7 active ingredients. Through its physician education efforts, IPS brought all 38 prescriptions down 3 active ingredients or less. IPS also helped patients achieve therapeutic success (and with medical community acceptance). In that case, the cost of compound prescriptions was down to an average of $350, versus the industry average of $788. Nationwide IPS has reduced the average cost of a compound prescription to $478.00.
Todd says. “We’ve still got a way to go, but we’ve made amazing progress in just the past couple of years on the cost and effective use of compound prescriptions.”
For more information on how you can better manage your costs for compound prescriptions, please call IPS at 866-846-9279.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.