Study Supports Benefits of Evidence-Based Medicine
Workers’ comp claims that follow evidence-based medicine guidelines have shorter durations and lower medical costs, according to a new study. The research suggests significantly improved outcomes and cost savings can result when medical providers follow recommendations based on peer-reviewed evidence in workers’ compensation treatment guidelines.
While nearly all jurisdictions either have or are considering the adoption of evidence-based medicine guidelines in their workers’ comp systems, there is almost no published scientific evidence confirming their efficacy or mechanism for improvements. But a team from a workers’ comp insurance carrier and Johns Hopkins University School of Medicine have produced what they believe is the first scientific proof that consistently applied treatment guidelines are effective in treating injured workers.
“We set out to prove or disprove empirically that adherence to EBM guidelines was impactful,” said Jack Tower, senior data scientist at the Accident Fund Holdings Medical Center of Excellence. “We were able to do that.”
The researchers developed a methodology to measure adherence to the Official Disability Guidelines from the Work Loss Data Institute and used an adherence score to compare the outcomes for different case mix adjusted claims populations. They found that claims in which there was at least a 50 percent adherence to the guidelines had 13.2 percent shorter durations and 37.9 percent lower medical costs.
“That kind of gives a strong impetus to implement new medical management strategies based on the results,” Tower said. “Carriers and the work comp industry could benefit from developing programs that embrace the concepts behind EBM.”
The idea of evidence-based medicine is to improve the medical decision-making process by emphasizing the use of scientific research and medical consensus. While it has been around for the last several decades, evidence-based medicine has only recently become widespread in the workers’ comp system.
“The application of evidence-based medicine in workers’ comp is much different from the application of evidence-based medicine in the group health world,” said Jeffrey Austin White, director of Innovation for Accident Fund. “In group health the evidence-based medicine guidelines have been scrutinized by the medical professionals as they are limited in scope and typically used to control cost in a hospital setting by limiting reimbursement rates.”
“This study provides a mechanism for evaluating an EBM guideline and can be used to identify how they might be improved in the future.” — Jeffrey Austin White, director of innovation, Accident Fund Holdings
However, White argues that the workers’ compensation guidelines are much more focused and comprehensive. “Evidence-based medicine [in workers’ comp] encompasses tens of millions of claims having similar incoming diagnoses. The guidelines provide outcome expectations at the diagnosis and treatment level for the majority of workplace injuries,” White explained. “When the diagnosis is made, the evidence-based medicine guidelines define how often a treatment is administered, along with the expected cost and time off from work. It’s a much different way to apply evidence-based medicine than is typically done in the group health setting.”
In addition to the Official Disability Guidelines, the American College of Occupational and Environmental Medicine has also created evidence-based medicine guidelines. A majority of states have adopted or are considering adopting either of the two national guidelines, a combination of the two, or homegrown guidelines that are state-specific to improve consensus around the definition of “necessary and appropriate” treatments for injured workers.
But “there’s a paucity of research around evidence-based medicine and best practice protocols,” said Dr. Dan Hunt, corporate medical director of Accident Fund. “We wanted to use our research to come up with hard facts — things that are true — to help improve the care for injured workers whether it’s Official Disability Guidelines, ACOEM, or another to say ‘here’s objective research that shows these guidelines work.’”
The researchers wanted to show whether and to what extent evidence-based medicine works specifically in the workers’ comp population. “There is a lot of literature that suggests the correct ways to do things medically but many times they are not really proven from an outcomes point of view,” said Dr. Edward Bernacki, professor of medicine and director of the division of occupational medicine at the Johns Hopkins University School of Medicine. “The medical care may be better, but does it really affect costs and return to work?”
Previous research from Accident Fund in conjunction with Johns Hopkins has highlighted some of the reasons for the increasing use of opioids in the workers’ comp system. One study, for example showed the use of opioids was an independent predictor of catastrophic claims costs while another identified physician dispensing as a driver of the increased use and costs.
“We found that physicians were contributing to [the opioid problem] and asked ourselves ‘Why?’ Our hypothesis was that providers were not using guidelines to help make administration decisions,” White said. “We thought by developing an algorithm or methodology to analyze a historical cohort of claims that we might be able to see a difference in outcomes between case mix adjusted claims that had various degrees of compliance with the guidelines.”
The idea of the study was to develop a technique for testing the safety and efficacy of an evidence-based medicine guideline rather than to drive public policy decisions on treatment practices.
It’s one of those situations where everyone wins — the employee returns to work and medical costs are constrained. To me, it’s a win-win.” — Dr. Edward Bernacki, professor of medicine and director of the division of occupational medicine, Johns Hopkins University School of Medicine
“If a state mandates the use of evidence-based medicine guidelines for the treatment of injured workers we are legally obligated to use them. If there are no mandated legislative guidelines, we are inclined to promote prospective guidelines that have been shown to reduce system costs and positively impact injured worker outcomes,” White said. “It’s important for us to know which guidelines work and why. This study provides a mechanism for evaluating an EBM guideline and can be used to identify how they might be improved in the future.”
Measuring Evidence-Based Medicine
The team developed two separate analytical techniques; one to stratify each claim for medical complexity and another to determine the adherence to the Official Disability Guidelines. The claims were divided into 10 levels of medical complexity and scored based on adherence.
“The number one challenge when doing claims research is being able to group claims into like claims,” White explained. “You don’t want to compare a claim with a broken finger to a claim with head trauma.”
The group started with non-catastrophic, indemnity claims that spanned the years 2008 to 2012 of the insurer’s data. They considered open and closed claims using a two-year development cutoff.
The researchers developed a compliance score to determine adherence to the Official Disability Guidelines. The score assigns a quantitative value to the claim indicating approximately how many of the treatments were consistent with the recommendations from the guidelines.
They case mix adjusted the claims and compared those with greater than a 50 percent adherence to evidence-based medicine guidelines to those with less than 50 percent adherence for the differences in claim durations and medical costs incurred. Using data from Official Disability Guidelines, the researchers identified the adherence of every procedure given a specific diagnosis for each claim based on the following four codes:
Green flags in the Official Disability Guidelines indicate the procedure is recommended based on prevalence, medical consensus, and historical claim outcomes.
Yellow flags indicate the procedure is a common treatment for that diagnosis and should be allowed on a limited basis with a restriction on the number of times it should be performed.
Red flags denote low prevalence in workers’ comp and that the treatment is not necessarily indicated based on current scientific research, i.e., recommendation is to review.
Black flags indicate inappropriate care and possibly denial of service.
“For every diagnosis and treatment, we label it with the corresponding colors; then we determine an adherence score at the claim level,” White said. “For a given claim, you can consider the cumulative number of green, yellow, red and black flags, and you can devise a score that indicates the level of compliance which can be compared against like claims.”
Based on the scores, the claims were separated. Those with mainly green and yellow flags, for example, were deemed as fairly compliant with the guidelines while those with many black flags were noncompliant.
“If you break the claims into two buckets, you can compare outcomes of the compliant group with the noncompliant group,” White said. “So for two broken finger injuries where one received compliant and the other noncompliant care, you can see how they differ in duration and medical cost.”
The average for all levels of medical complexity showed claims in the low compliance group had a 13.2 percent increase in claim duration and a 37.9 percent increase in medical costs compared to the high compliance group, the study found.
The numbers increased as the medical complexity of a claim increased. In looking at the top 10 percent of claims for medical complexity, there was a difference in claim duration of 18 percent and increased medical costs of 38 percent, between the low and high compliance groups.
The researchers also found there were more black flag procedures in the low compliance group — 3.5 times the number in the high compliance group.
“I think our research in essence provides evidence that if you do employ these guidelines the outcomes are better,” Johns Hopkins’ Bernacki said. “This is systematically over time that people return to work faster, for the insurers costs are a little lower, and for folks employing them the premium costs will be lower, so the cost of doing business will be lower. I think it’s one of those situations where everyone wins — the employee returns to work and medical costs are constrained. To me, it’s a win-win.”
“It’s awfully exciting to be a part of a landmark study. No one else has done this before,” Hunt said. “The ability to develop an adherence process for claims management will have a lot of applications across the whole health care spectrum.”
Hunt, who called the study a “gargantuan undertaking,” hopes it will lead to additional studies that drill down more into the findings. “Age, jurisdictional differences — there are a whole host of really interesting things we can do now,” he said. “You’re going to see additional papers once this method is established.”
For now, the authors hope the findings will help spur action in states that currently do not use evidence-based medicine guidelines in their workers’ comp systems. With properly worded legislation and effective dispute resolution processes in place, evidence-based medicine guidelines should offer better outcomes for everyone.
They hope workers’ comp practitioners will begin using the methodology they’ve created to further refine evidence-based medicine guidelines. In fact, they have developed a 10-step process for companies to replicate the results.
“It’s like a recipe. With evidence-based medicine guidelines, you can quantify exactly how much of each ingredient you put in and therefore enhance your ability to refine, measure, and improve your results over time. At least that is what EBM tries to do,” White said. “It’s a recipe that applies to, say 80 percent of the population most of the time. The recipe should reduce system costs and facilitate cooperation from both sides of the business — payers and providers alike.”
Workers’ Comp Docket
Operator Wins Benefits for Guillain-Barre Syndrome From Flu Shot
Phillips v. Wyman Gordon Pennsylvania, 31 PAWCLR 128 (Pa. W.C.A.B. 2016)
Ruling: The Pennsylvania Workers’ Compensation Appeals Board affirmed the workers’ compensation judge’s decision awarding benefits to a worker, who alleged that he contracted Guillain-Barre syndrome after receiving a flu shot at work.
What it means: In Pennsylvania, a worker’s act of receiving a flu shot at work arises in the course and scope of his employment even though the shot is voluntary and he receives no benefit or penalty from the employer for receiving or refusing the shot.
Summary: The board affirmed the WCJ’s decision awarding benefits to a machine operator who alleged he contracted Guillain-Barre syndrome after receiving a flu shot at work.
The treating doctor testified that the operator’s condition was caused by the flu shot he got at work because there were no other potential causes identified and that GBS is one of the risk factors of a flu shot. This testimony constituted sufficient support for a finding that the operator’s GBS was caused by his flu shot.
Furthermore, the board found no error in the WCJ’s finding that the operator was in the course and scope of his employment when he was vaccinated at work. By opting to receive the flu shot that the employer made available, the operator was acting in furtherance of the employer’s business and affairs.
Despite the employer’s assertion that the operator’s decision to receive the flu shot was voluntary and that no employee received either a benefit or penalty for either receiving the shot or refusing it, it was clearly in the employer’s best interest to have its employees vaccinated.
By offering flu shots to its employees, the employer was attempting to ensure that there would be a sufficient number of healthy employees able to work and maintain production during flu season. Accordingly, the operator was within the course and scope of his employment when he was vaccinated at work.
Bystander Emotional Injury Claim Barred by Exclusive Remedy Provision
Velecela v. All Habitat Services, LLC, No. SC 19589 (Conn. 08/09/16)
Ruling: The Connecticut Supreme Court held that a suit brought by the wife of a deceased worker for bystander emotional distress was barred by the exclusive remedy provision of the workers’ compensation law.
What it means: In Connecticut, a suit against an employer for bystander emotional distress is barred by the exclusive remedy provision.
Summary: A worker for All Habitat Services was repairing an all-terrain vehicle that was elevated on a lift. During the repair, the vehicle slipped off the lift, crushing and killing him. The worker’s wife arrived to bring him lunch, and she discovered his body under the vehicle.
The wife received workers’ compensation survivor benefits. The wife also sued All Habitat, claiming bystander emotional distress. The Connecticut Supreme Court held that the wife’s suit was barred by the exclusive remedy provision of the workers’ compensation law.
The court explained that the language of the exclusive remedy provision is broad, abolishing “all rights and claims” that fall under the workers’ compensation law, including any rights and claims of workers’ dependents.
The court also noted that emotional distress, by itself, is not a bodily injury, so it can be compensable only if it flows from the bodily injury of another person. Bystander emotional distress results from and arises out of the underlying personal injury or death. When that personal injury or death is compensable under workers’ compensation, an action for bystander emotional distress is barred by the exclusive remedy provision.
Here, it was undisputed that the worker’s injuries and death arose out of and in the course of his employment and were compensable under workers’ compensation, and the wife’s alleged emotional injuries derived from and were caused by those injuries and death. Therefore, the wife’s claim was barred.
A concurring judge pointed out that a claim for a bystander emotional injury would be compensable if the underlying injury fell within an exception to the exclusivity provision.
Worker’s ‘Income Producing’ Activities Support Finding of Overpayment
State ex rel. Perez v. Industrial Commission of Ohio, No. 2015-0532 (Ohio 07/26/16)
Ruling: The Ohio Supreme Court held that a worker received an overpayment of temporary total disability benefits and that he fraudulently misrepresented that he was not working.
What it means: In Ohio, a finding that a worker committed fraud is proper when he misrepresented to the Industrial Commission that he was not working and was not forthcoming with his physicians about his activities.
Summary: A construction worker sustained a work-related injury and was awarded temporary total disability compensation. The worker had also owned and operated an auto repair business. The Bureau of Workers’ Compensation received information that the worker was operating his business while receiving TTD benefits.
During an investigation, the worker was observed performing auto work and meeting customers. Witnesses stated that the worker handled scheduling, diagnosed car problems, received payments, and picked up parts from an auto parts store. The Ohio Supreme Court held that the worker received an overpayment of TTD benefits and that he fraudulently misrepresented that he was not working.
The court rejected the worker’s argument that his business activities were unpaid and minimal and did not directly produce income for the business. The court concluded he was engaged in “more than minimal activities that were income-producing” for the business. Also, the court noted that during the relevant time period, he purchased more than $43,000 in auto parts, an amount that indicated that they were not merely for personal use.
The court also found that the evidence supported a finding of fraud. The worker misrepresented to the Industrial Commission on multiple occasions that he was not working. Also, he was not forthcoming to physicians about his activities with his business.
Psychological Condition Was Reasonably Contemplated at Time of Settlement
Ryan v. Potlach Corp., No. A15-1404 (Minn. 07/13/16)
Ruling: The Minnesota Supreme Court held that a worker had to bring a motion to set aside her settlement agreement with her employer before she could proceed with a claim for a psychological condition.
What it means: In Minnesota, a workers’ compensation settlement agreement can close out the work-related injury that is the subject of the agreement and also conditions and complications that arise from the injury and are within the reasonable contemplation of the parties at the time of the settlement agreement.
Summary: A worker injured her back while working for Potlach Corp. She and Potlach entered into a settlement agreement that provided for a full, final, and complete settlement of her workers’ compensation claims, excluding future reasonable and necessary medical treatment, in return for a lump-sum payment.
Later, the worker filed a claim for a consequential psychological injury. The Minnesota Supreme Court held that she had to bring a motion to set aside the settlement agreement before she could proceed with her claim for a psychological condition.
The court found that a workers’ compensation settlement agreement can close out the injury that is the subject of the agreement and also conditions and complications arising out of the injury. It is not necessary that the condition or complication be specifically referenced in the settlement agreement. The agreement must resolve any conditions or complications that arise out of the injury that were reasonable within the contemplation of the parties at the time of the agreement.
Here, the court rejected the worker’s argument that her depression was a new condition not within the contemplation of the parties at the time of the agreement. The court explained that her depression was a psychological condition that arose out of and was a consequence of her workers’ compensation injury, and therefore, it fell within the scope of the agreement. The court also pointed out that depression can arise from the pain and loss of function associated with a chronic back condition.
Dispute Over Timing of Termination Revives Mine Worker’s Retaliation Claim
Foster v. Mountain Coal Co., LLC, et al., No. 15-1025 (10th Cir. 07/26/16)
Ruling: The 10th U.S. Circuit Court of Appeals reversed and remanded a District Court decision granting summary judgment to an employer on a worker’s Americans with Disabilities Act claim. The 10th Circuit held that triable issues existed regarding the worker’s retaliation claim.
What it means: A worker who alleged he was terminated within hours of requesting an accommodation sufficiently showed causation for an ADA retaliation claim.
Summary: A worker for Mountain Coal Co. injured his neck at work and went to the emergency room. The ER doctor completed a return-to-work slip, but the company refused to accept it because it was not on the company’s form. The worker had his primary doctor complete the form, and he said he dropped it off at human resources. HR said they never received it, and the company accused him of lying. He later dropped off another form signed by his primary doctor.
At a meeting one week later, the worker was suspended. He claimed that he was suspended because he had his primary doctor complete the form even though he had not treated the worker’s neck injury. He told his supervisors that he was going to schedule surgery for his neck.
A week later, he received a letter terminating him effective a few days earlier, allegedly for lying about having dropped off the first note. The letter was written the same day he told another supervisor over the phone that he was going to have surgery. The parties disputed whether the decision to terminate him was made before or after the phone call.
The worker sued, claiming that his statements, once at the meeting and once over the phone, that he was going to have surgery were requests for accommodation and that he was terminated in retaliation for making them. The 10th Circuit held that there were triable issues regarding his claim.
The company argued that the worker’s alleged requests for accommodation were not specific enough to constitute protected activity. The court disagreed, concluding that a reasonable jury could interpret his statements that he was going to need surgery as adequate requests for accommodation.
The company contended that even assuming the requests were adequate the worker could not show causation. The court explained that where the protected activity “is closely followed by an adverse employment action” a worker can rely solely on temporal proximity to show causation.
Here, the court concluded that “because the purported protected activity occurred mere days or even hours before the adverse employment action” the worker sufficiently showed causation.
Furthermore, the parties disputed the reasons for the suspension and termination. The court concluded that if a jury credited the worker’s account — that he was suspended for one reason and terminated for another — then it could find that these inconsistent reasons were sufficient to show pretext.
Worker’s Volunteer Work Falls Outside Scope of Employment
Gray v. Bank of America, 24 ILWCLB 102 (Ill. W.C. Comm. 2016)
Ruling: The Illinois Workers’ Compensation Commission held that a worker’s accidental injury while performing volunteer work at a community event did not occur in the course of her employment even though she cochaired the employer’s community volunteer team.
What it means: In Illinois, where a worker is not paid extra for her work as cochair on her employer’s community volunteer team, her performance reviews are not tied to her volunteer participation, and her volunteer work is not ordered or assigned by the employer, the worker’s injury while participating in a volunteer event does not occur in the course of her employment.
Summary: A project manager for Bank of America was also the cochair of the bank’s community volunteer team. As such, she was responsible for establishing relationships between the bank and the community, including nonprofits as well as different lines of businesses within the bank.
She was reimbursed as part of her salary for the services she performed as cochair of the community volunteer team, but her salary stayed the same regardless of whether she volunteered. The manager was at an event organized by the Girl Scouts of America that bank volunteers were encouraged to attend. While at the event, the manager fell and broke her leg.
The arbitrator found the evidence was insufficient to show that the manager’s injury occurred from an activity that was compulsory or occurred in the course of her employment. The arbitrator noted that the manager was not ordered or assigned to participate in any volunteer program or activity by the bank. Rather, her participation at the event was purely under her own volition and not mandated by the bank.
The arbitrator agreed that the bank encouraged its employees to volunteer in the community, and the bank derived a benefit from employee attendance at community events. However, the manager was not paid extra for her participation, and her performance reviews were not tied to her volunteer participation.
Also, the Girl Scouts event was not sponsored by the bank. The fact that the bank’s corporate presence in the community may have resulted in some benefit incidental to its actual business of banking was too tenuous and intangible to be persuasive in this case. Also, bank employees could choose not to participate in the volunteer networks without negative effect at work. The commission affirmed and adopted the decision of the arbitrator.
Your Workers’ Safety May Be at Risk, But Can You See the Threat?
Deadly violence at work is covered extensively by the media. We all know the stories.
Last year, ex-reporter Bryce Williams shot and killed two former colleagues while they conducted a live interview at a mall in Virginia. In February of this year, Cedric Larry Ford opened fire, killing three and injuring 12 at a Kansas lawn mower manufacturing company where he worked. Also in 2015, 14 people died and 22 were wounded by Syed Farook, a San Bernardino, California county health worker, and his wife, who had terroristic motives.
Active shooter scenarios, however, are just the tip of the iceberg when it comes to violence at work.
“Workplace violence is much broader and more pervasive than that. There are smaller acts of violence happening every day that directly impact organizations and their employees,” said Bertrand Spunberg, Executive Risks Practice Leader, Hiscox USA. “We just don’t hear about them.”
According to statistics compiled by the FBI, the chance that any business will experience an active shooter scenario is about 1 in 457,000, and the chance of death or injury by an active shooter at work is about 1 in 1.6 million.
The fact that deadly attacks — which are relatively rare — get the most media attention may lead employers to underestimate the risk and dismiss the issue of workplace violence as media hype. But any act that threatens the physical or psychological safety of an employee or that causes damage to business property or operations is serious and should not be taken lightly.
“One of the core responsibilities that any organization must fulfill is keeping employees safe, and honoring that duty is becoming more challenging than ever,” Spunberg said.
“Workplace violence is much broader and more pervasive than that. There are smaller acts of violence happening every day that directly impact organizations and their employees. We just don’t hear about them.”
— Bertrand Spunberg, Executive Risks Practice Leader, Hiscox USA
Desk Rage and Bullying: The Many Forms of Workplace Violence
Bullying, intimidation, and verbal abuse all have the potential to escalate into confrontations and a physical assault or damage to personal property. These violent acts don’t necessarily have to be perpetrated by a fellow employee; they could come from a friend, family member or even a complete stranger who wants to target a business or any of its workers.
Take for example the man who killed three workers at a Colorado Spring Planned Parenthood in April. He had no affiliation with the organization or any of its employees, but targeted the clinic out of his own sense of religious duty.
Companies are not required to report incidents of violence and many employees shy away from reporting warning signs or suspicious behavior because they don’t want to worsen a situation by inviting retaliation. It’s easy, after all, to attribute the occasional surly attitude to typical work-related stress, or an office argument to simple personality differences that are bound to emerge occasionally.
Sometimes, however, these are symptoms of “desk rage.”
According to a study by the Yale School of Management, nearly one quarter of the population feels at least somewhat angry at work most of the time; a condition they termed “chronic anger syndrome.” That anger can result from clashes with fellow coworkers, from the stress of heavy workloads, or it can overflow from family or financial problems at home.
Failure to recognize this anger as a harbinger of violence is one key reason organizations fail to prevent its escalation into full-blown attacks. Bryce Williams, for example, had a well-documented track record of volatile and aggressive behavior and had already been terminated for making coworkers uncomfortable. As he was escorted from the news station from which he was terminated, he reportedly threatened the station with retaliation.
Solving Inertia, Spurring Action
Many organizations lack the comprehensive training to teach employees and supervisors to recognize these warning signs and act on them.
“The most critical gap in any kind of workplace violence preparedness program is supervisory inertia, when people in positions of authority fail to act because they are scared of being wrong, don’t want to invade someone’s privacy, or fear for their own safety,” Spunberg said.
Failing to act can have serious consequences. Loss of life, injury, psychological harm, property damage, loss of productivity and business interruption can all result from acts of violence. The financial consequences can be significant. In the case of the San Bernardino shootings, for example, at least two claims were made against the county that employed the shooter seeking $58 million and $200 million.
Although all business owners have a workplace violence exposure, 70 percent of organizations have no plans in place to avoid or mitigate workplace violence incidents and no insurance coverage, according to the National Institute for Occupational Safety & Health.
“Most companies are vastly underprepared,” Spunberg said. “They don’t know what to do about it.”
Small- to medium-sized organizations in particular lack the resources to develop risk mitigation plans.
“They typically lack a risk management department or a security department,” Spunberg said. “They don’t have the internal structure that dictates who supervisors should report a problem to.”
With its workplace violence insurance solution, Hiscox aims to educate companies about the risk and provide a solution to help bridge the gap.
“The goal of this insurance product is not so much to make the organization whole again after an incident — which is the usual function of insurance — but to prevent the incident in the first place,” Spunberg said.
Hiscox’s partnership with Control Risks – a global leader in security risk management – provides clients with a 24/7 resource. The consultants can provide advice, come on-site to do their own assessment, and assist in defusing a situation before it escalates. Spunberg said that any carrier providing a workplace violence policy should be able to help mitigate the risk, not just provide coverage in response to the resultant damage.
“We urge our clients to call them at any time to report anything that seems out of ordinary, no matter how small. If they don’t know how to handle a situation, expertise is only a phone call away,” Spunberg said.
The Hiscox Workplace Violence coverage pays for the services of Control Risks and includes some indemnity for bodily injury as well as some supplemental coverage for business interruption, medical assistance and counseling. Subvention funds are also available to assist organizations in the proactive management of their workplace violence prevention program.
“Coverage matters, but more importantly we need employees and supervisors to act,” Spunberg said. “The consequences of doing nothing are too severe.”
To learn more about Hiscox’s coverage for small-to-medium sized businesses, visit http://www.hiscoxbroker.com/.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Hiscox USA. The editorial staff of Risk & Insurance had no role in its preparation.