PBMs Under Scrutiny

PBM Legislation Worries Workers’ Comp Payers

Legislation to regulate group health pharmacy benefit managers could impact workers' comp payers.
By: | February 5, 2014
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Legislation introduced in several states seeking to impose new regulatory authority over group health pharmacy benefit managers could harm workers’ compensation PBMs and claims payers, sources said.

Introduction of similar bills in 11 states has raised concerns among workers’ comp insurers, third party administrators, and some large employers, said Brian Allen, VP of government affairs for Progressive Medical, a workers’ comp PBM.

“We have had customers calling us every day worrying about how it is going to impact us and them,” Allen said. “These are big insurance companies … they are nervous about it and want to know how it’s going to impact them.”

Brian Allen, VP of government affairs for Progressive Medical

Brian Allen, VP of government affairs for Progressive Medical

Overall, it appears the bills seek greater transparency in the way group health PBMs set their pricing, said Joe Paduda, principal at Health Strategy Associates. But group health PBM practices differ substantially from those of workers’ comp PBMs and the bills seek to address issues that “have nothing to do with workers’ comp,” he added.

Yet while the bills appear aimed at practices among PBMs serving the group health industry and not workers’ comp PBMs, Allen and others say a spillover into workers’ comp is possible. So several organizations want language inserted into the bills that would clearly exempt workers’ comp PBMs.

“It appears that workers’ compensation PBMs are not the target of this legislation,” the American Insurance Association said in a statement. “That said, AIA supports efforts to include clear exemptions for workers’ compensation PBMs in these bills in order to clarify legislative intent and avoid any confusion down the road.”

“Community” pharmacies seeking more revenue from products they dispense are supporting the bills that would put PBMs under certain state regulatory agencies, such as pharmacy boards, Allen said.

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State workers’ comp commissions or insurance departments already regulate workers’ comp PBMs, depending on the jurisdiction, Allen explained. But the legislation could add oversight from additional agencies such as state pharmacy boards.

Complying with regulations developed by two distinct agencies with potentially conflicting goals could cause an administrative burden for workers’ comp PBMs, Allen added.

“We want to make sure we are not swept up into crazy regulatory schemes that would be difficult to manage,” he said.

A new oversight body could also decide to impact workers’ comp PBM pricing, which is already regulated by state fee schedules, Allen said.

“If for some reason the pharmacy board said, ‘you have to pay pharmacists more money,’ that potentially would impact our customers because we would have to pass that cost onto payers,” Allen said.

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.
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2016 NWCDC

Technology Gives the Gift of Movement

Advanced medical technology is costly, but greatly improves quality of life for workers with catastrophic injuries.
By: | December 1, 2016 • 2 min read
Plastic brawny cyber arm

The ability to stand and walk unassisted is something most of us take for granted, but many catastrophically injured workers face a lifetime either confined to a wheelchair or relying on a prosthetic to help them move.

Luckily, advancements in medical technology are making movement easier.

Mark Sidney, VP, claims, Midwest Employers Casualty Co., and Clare Hartigan, project manager, Virginia C. Crawford Research Institute, Shepherd Center, discussed these advancements at a Thursday afternoon NWCDC session titled “The Bionic Claimant: Emerging Medical Technology’s Impact on Care and Cost.”

“Psychologically, being able to stand and look someone in the eye is a big deal.” — Clare Hartigan, project manager, Virginia C. Crawford Research Institute, Shepherd Center

Technology like myoelectric prostheses and exoskeletons can drastically improve quality of life for catastrophically injured workers, restoring some functionality and a sense of independence.

But this high-tech equipment comes with a hefty price tag.

Myoelectric devices, which use sensors and bioelectric signals to move the limb, can cost as much as $100,000. Exoskeletons are in the same ballpark, and this doesn’t include maintenance or the cost of replacing a device every five years or so.

“The difference in cost between a standard prosthetic and a myoelectric can be $1 million over the lifetime of a claim,” Sidney said.

More long-term studies are needed to prove the medical necessity of this technology, but the benefits are already clear.

“Just being able to get up and move leads to muscle strengthening and improved blood cholesterol and glucose levels,” Hartigan said.

“Psychologically, being able to stand and look someone in the eye is a big deal.”

To determine when a myoelectric device or exoskeleton is appropriate, workers’ compensation professionals should look at the patient’s lifestyle. What type of activities do they do? Are they more happy indoors or out? How often will they use their device?

Ultimately, it comes down to whether or not this advanced machinery will enable them to do things that are impossible with standard devices.

Katie Siegel is a staff writer at Risk & Insurance®. She can be reached at [email protected]
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Sponsored: Liberty Mutual Insurance

From Drones to Defects: Planning for Construction’s Top Challenges

Construction buyers must be more vigilant about protecting projects before breaking ground.
By: | November 2, 2016 • 6 min read

The construction industry is firing on all cylinders. New projects spring up every day, but not all go according to plan.

Three out of every four construction projects fail to finish on time. Every party involved – owners, designers, contractors and subcontractors – expects perfection, with the final product delivered on schedule and on budget. Those expectations leave little room for uncertainty, so even a small hiccup can have ripple effects that disrupt a project for everyone.

As outlined in a recent report by McGraw Hill Construction “a lack of thoroughness of preconstruction planning, estimating and scheduling” is a leading cause of uncertainty.1

“There’s often a big disconnect on the front end of project planning,” said Doug Cauti, Senior Vice President, National Insurance, Chief Underwriting Officer, Construction, Liberty Mutual.

Proactive risk mitigation is also important to manage emerging challenges facing the construction industry ‒ drone regulations are evolving, commercial auto losses are rising, and so is uncertainty about which party might be held responsible for a construction defect. Without the proper planning, these issues can easily be overlooked and result in major losses and project disruption.

Liberty Mutual’s Doug Cauti discusses key challenges facing the construction market.

“Key risk management strategies have to be aligned among all parties from the beginning to minimize these uncertainties.”

Before construction begins, there are actions that project owners, designers and contractors can take to address these challenges and better protect their projects and businesses:

Drone Dangers

Drones can be useful tools on construction sites, providing an extra set of “eyes” for large commercial projects or tall buildings. They provide a real time aerial glimpse of works in progress, giving supervisors an added perspective to spot potential flaws, assess safety hazards, and check on workers. But many challenges remain in the safe — and legal — operation of drones.

Liberty Mutual’s interactive infographic highlights risks related to managing drones at construction sites, and also includes a pre-planning drone use guide and a pre-flight checklist that includes making sure to review the latest drone regulations.

How construction buyers can manage the insurance implications of using drones in their operations.

General contractors and project owners need to stay up to speed on FAA regulations, which changed in August, 2016.

“For one thing, operators need to have the drone in sight at all times,” Cauti said.

“And you need to make sure any operators are appropriately licensed and trained, that the drones are regularly maintained, and that the machines don’t impede on others’ safety and privacy.”

Clear flight paths and work zone boundaries can minimize the risk of a drone striking another property, or worse, a person. Operators should also know how to conduct an emergency landing if the drone suddenly loses power. It’s also important to consider how you are going to manage and use drone footage. Advertising liability can be a concern if third party images are captured and released. Know who is in charge of the data collected, who has access to it, and how you are going to protect it.

“If the contractor owns the drone, it takes on more liability. The contractor should review its insurance policies to make sure the coverage will respond to that risk,” Cauti said.

SponsoredContent_LM“As an insurance carrier, we may have a role to play in those proactive discussions. We are uniquely positioned to help project stakeholders see their risks and work to minimize them.”

— Doug Cauti, Senior Vice President, National Insurance, Chief Underwriting Officer, Construction, Liberty Mutual Insurance

Contractors and project owners can protect themselves through enhancements to their commercial general liability policies or through separate aviation policies, he said.

If a general contractor leases a drone through a third party, “they bear the responsibility of making sure the vendor is fully insured,” Cauti said. Vendors should have “non-owned” aviation coverage with limits suitable to handle the size of the risk.

Fleet Safety

Commercial auto losses challenge many business sectors, and construction is no exception.

More vehicles on the road and more miles driven, combined with fewer experienced commercial drivers, are driving up the frequency of accidents. On construction sites in particular, congestion created by closed roads, piles of materials and roving heavy machinery may lead to work zone accidents. Rising medical costs and repair and replacement costs of high-tech vehicles increase claim severity.

“I don’t see this trend reversing any time soon,” Cauti said.

Mitigating commercial auto losses begins with driver hiring practices.

“Pay attention to who you put behind the wheel,” Cauti said.

“Motor vehicle reports (MVRs) and driving history can alert employers to previous accidents or tickets. But there also needs to be regular communication with the drivers you do hire, and clear protocols in place that define expectations of how the job should be performed,” he added.

Ways construction buyers can manage rising commercial auto loss costs and better protect their fleets and employees.

Those protocols include requiring the use of seat belts, prohibiting cell phone use while behind the wheel, mandating scheduled breaks, outlining maintenance procedures, defining if company vehicles can be used for personal use, and establishing crash report procedures that delineate who to contact and what information to collect in the event of an accident.

Contractors can also monitor fleet performance through telematics systems. These on-board systems can track unsafe driving behaviors like hard braking, sharp turns, and speeding. But the data is only as good as the person analyzing it. Contractors and project owners should partner with an insurer who can use fleet telematics data effectively to pinpoint common causes of accidents and recommend specific risk mitigation strategies.

Liberty Mutual’s Managing Vital Driving Performance is one tool that leverages insureds existing telematics data to identify unsafe driving behaviors and accident patterns.

“Our risk control consultants can drill deeper into the data and interview drivers to identify patterns and find out the root causes of bad driving behaviors in the first place,” Cauti said.

For example, a post-accident interview with a driver could reveal that he had been skipping breaks and spending too many hours on the road, leading to fatigue and inattentive driving.

Identifying those connections enables consultants to make specific risk mitigation recommendations, such as adjusting drivers’ schedules and workloads to reduce overtime, or adjusting dispatch protocols so employers can ensure drivers aren’t working too many shifts in a short period of time.

Construction Defects

Another uncertainty project owners, designers and contractors have to face is how insurance coverage will apply should a project end up in a dispute. “The struggle is around the definition of ‘faulty workmanship’ and who is responsible for the defect. Is it in the design or the build?” Cauti said.

“There can be a lot of finger pointing involved. This reinforces the need for contractors to have a systematic quality assurance (QA) program that adheres to best practices, and for every party to have a role in it.”

Elements of a QA program could include testing of construction materials, conducting regular walk-throughs and obtaining approvals from the owner at key phases, and final sign-off by the owner at the project’s completion.

How construction defects and the current legal climate are affecting projects.

Construction defect claims can affect a business’s reputation, profits, and ability to maintain insurance coverage. That’s why it’s so important to be vigilant about avoiding construction defects, whether you’re a designer, developer, owner or general contractor.

Ultimately, though, these risks should be addressed before ground is broken. Discussing these challenges and collaborating on loss prevention strategies up front reduces the likelihood that any “hiccups” will throw off project timelines or increase costs for the various stakeholders.

Pre-planning discussions also offer the opportunity for these parties to take advantage of carrier partners’ risk control services.

“As an insurance carrier, we may have a role to play in those proactive discussions,” Cauti said.

“We are uniquely positioned to help project stakeholders see their risks and work to minimize them.”

To learn more about Liberty Mutual’s solutions for the construction industry, visit https://business.libertymutualgroup.com/business-insurance/industries/construction-insurance-coverage.

[1] Managing Uncertainty and Expectations in Building Design and Construction SmartMarket Report

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty Mutual Insurance. The editorial staff of Risk & Insurance had no role in its preparation.








Liberty Mutual Insurance offers a wide range of insurance products and services, including general liability, property, commercial automobile, excess casualty, workers compensation and group benefits.
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