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A Tale of Two Physicians

Understanding work environments and practice structures can encourage collaboration and enhance outcomes.
By: | May 1, 2014 • 5 min read

There are many factors that influence the outcome of a workers’ compensation claim. Some, such as the body part and nature of injury, come as no surprise. Similarly, the state of jurisdiction and associated regulatory requirements are long-recognized as having an impact. One might not consider however, the role of the prescribing physician and how their demographics and behaviors influence outcomes.

To illustrate this, here is a tale of two physicians, Physician A and Physician B. Both are committed to caring for their patients but have markedly different work environments and practice structures that influence their prescribing behaviors.

Physician A

SponsoredContent_ProMed-PMSIPhysician A treats workers’ compensation patients in a big city. She is well-known and well-respected in the community and has a thriving practice. Physician A is employed by the local hospital and she supplements her salary by performing some in-office, minor procedures, such as skin biopsies and steroid injections for achy shoulders. She belongs to an accountable care organization (ACO) that has quality metrics in place to help its providers follow evidence-based medicine and best practice treatment models. These quality metrics, if met, result in some shared savings that are passed on to physicians as a financial reward for better outcomes.

Physician B

SponsoredContent_ProMed-PMSIPhysician B sees patients in a rural setting in his own, private practice. For him, the efficiency at which he can see patients determines whether or not he will meet his overhead each month. His nurse fields as many patient questions as possible in advance, and he does a quick exam and writes a prescription. Physician B feels constantly inundated with the increasing changes in healthcare and technology. He has tried to incorporate evidence-based guidelines into his practice but, with everything else on his plate, he is frustrated at the mere thought of keeping up with the constantly expanding medical research. To supplement his income, he works with a physician dispensing company and speaks on behalf of pharmaceutical companies.

Two Patients

A claims professional, in the process of working her caseload, discovers that Physician A’s patient is taking large doses of opioid medications yet has never had any urine drug screens or other documented opioid monitoring. Physician B’s patient was identified by the PBM’s early intervention program as requiring further review. Physician B’s patient is seeing multiple physicians, filling prescriptions at multiple pharmacies, and has a high-risk of long-term opioid use and a high likelihood of prolonged claim duration.

PBM Intervention

Both physicians receive correspondence from the PBM requesting a Peer-to-Peer medication review. In addition to including all requisite patient information, the letter is courteous and professional, relaying the objective of speaking directly with the prescribing physician in order to discuss the findings and recommendations.

Two Very Different Reactions

Upon receiving the reviewing physician’s phone call, Physician A was appreciative and freely commented that she had missed opportunities to apply opioid monitoring strategies provided by the PBM. She also agreed to convert the claimant’s antacid to an over-the-counter version. The reviewing physician completed a report detailing his conversation with Physician A and submitted copies to her, the claimant’s insurer, the PBM, and the claims specialist. The agreed-upon changes took effect on the next refill.


In contrast, it took several calls from the reviewing physician to convince Physician B’s receptionist to let him speak with Physician B. At first, Physician B was quiet and did not offer much feedback to the recommendations provided by the reviewing physician. He was irritated by the request to switch the claimant’s brand medications to generic, interpreting this request and the entire call to be solely focused on cost savings. Once discussion about the claimant’s opioids began, Physician B couldn’t contain his anger, declaring, “This is my patient! You have never even seen this patient before, so who are you to tell me how to manage his pain?”

Having anticipated such a possible reaction, the reviewing physician calmly deescalated the conversation with careful and sensitive language to reassure Physician B that the recommendations are entirely rooted on evidence-based guidelines and that the control of the patient’s pain remains a priority. The reviewing physician was able to refer to alternative dosing schedules and non-opioid treatment options to address the patient’s neuropathic pain. He also pointed out that the medications being prescribed for insomnia could interact with the claimant’s pain medications, possibly resulting in over sedation and death.

By the end of the call, Physician B realized that he had indeed overlooked some of the medication interactions and opportunities to more effectively manage the claimant’s pain without the use of opioid analgesics. He did not verbalize this realization, but agreed to make some changes to the medication regimen. He was still reluctant to change the claimant’s antacid to an over-the-counter version, citing his experience that they are not as effective as those dispensed by pharmacies. A few months later, the PBM performed a retrospective review; the medication therapy had changed – except for the antacid.

The Result

While traveling different paths, both physicians responded favorably to the Peer-to-Peer intervention.

By understanding the challenges some physicians are facing and the impact they can have on prescribing behaviors, payers can be better equipped to engage physicians in cooperative care management. A collaborative approach emphasizing the patient’s safety can enhance the physician’s willingness to compromise with medication therapy recommendations. In the end, the result is a better outcome for the payer, physician, and injured worker.

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

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

6 Emerging Supply Chain Risks You Should Know

Risks to your supply chain can come from unexpected sources.
By: | May 5, 2014 • 2 min read


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Sponsored: Liberty International Underwriters

A Wake up Call for Any Company That Touches Food

With costly outbreaks on the rise, don't let product recalls and contamination spoil your business.
By: | October 1, 2015 • 5 min read

It’s not easy to be in the food industry these days.

First, there is tougher regulation. On August 30, 2015, the Food Safety Modernization Act (FSMA) required companies to file planning paperwork for Preventive Controls for Human Food. The final FSMA rules take effect on August 30, 2016.

Next, increases in food recalls, some deadly, are on the rise. In early September, 9,000 cases of frozen corn were pulled from shelves after a listeria scare. A few days later, a salmonella outbreak in cucumbers imported from Mexico resulted in one death, while sickening hundreds of consumers nationwide.

Courts are getting tougher, too, as owners/executives in particularly egregious cases involving consumer deaths have been prosecuted criminally, with one receiving a recommendation for a life sentence.

Finally, advances in science – including whole-genome sequencing technology, which maps DNA of microbes to more easily pinpoint precisely where contamination occurs – can expose every player in the supply chain to potential losses and lawsuits.

“Few companies have the balance sheet or brand loyalty to survive a serious recall. Outbreaks, new regulations, prosecutions and science have made purchasing product recall and contamination insurance literally an act of survival for companies of all ages and sizes,” said Jane McCarthy, Senior Vice President of Global Crisis Management at Liberty International Underwriters (LIU), who has over 30 years of industry experience.

Working with growers, processors, manufacturers, importers, shippers, packagers, distributors, wholesalers or retailers, LIU’s policy provides indemnity to pay for losses a company might incur from a recall, including logistic expenses, lost income and access to crisis management and public relations consultants.

Legislation tightens on food-related companies

LIU_SponsoredContentPassed in 2011, the FSMA gives the Food and Drug Administration a far more proactive weapon in the war on tainted food, as the focus shifts to prevention combined with the FDA’s newfound authority to close businesses that aren’t complying with FSMA rules and regulations.

In addition to the August 30, 2015 deadline for filing paperwork for preventive controls, as part of the law, all companies need to be registered if they do anything with food in the United States, or a company is a foreign entity bringing food into the U.S.

“It’s the law and every regulation and benchmark has to be met,” McCarthy said. “The FDA will shut someone down if they don’t think a company is handling a food product properly. With these new rules and regulations, the whole industry has to change.”

With LIU’s product contamination policy, companies have 24/7 access to pre-loss consultancy through red24, one of the world’s leading security consultants and global crisis management consultancies. For example, they’ll work with clients to best prepare them to meet the FDA’s 48-hour response deadline should a food contamination or product recall incident occur.

Costly outbreaks on the rise

LIU_SponsoredContentAccording to a Wall Street Journal article, food recalls from 2012 to 2014 increased more than five times compared to the total number of recalls from the prior eight years combined. The Journal also reported that foodborne illness is often never formally reported, so about 48 million Americans, or one in six, get sick each year from food. The CDC estimates 128,000 hospitalizations and 3,000 deaths from tainted food.

Food contaminations happen in two main categories: allergens (peanuts, etc.) and pathogens (bacteria). There were four listeria outbreaks in 2014 alone, compared with one in each year from 2011 to 2013. Listeria is a particularly tricky and virulent pathogen that continues to survive and blossom, even in refrigerated environments. Listeria does not impact the appearance, taste or smell of food it invades, so a company in the food industry can only confirm contamination through testing or, unfortunately, once a customer becomes ill.

“Listeria is one of the worst nightmares. Not only is it deadly, but once it gets into a plant, it’s very difficult to eradicate,” said industry veteran Meg Sutton, LIU’s Senior Claim Officer. “It sneaks into drains and crevices that you thought were clean. Attempts to clean those drains and crevices, if done improperly, can result in aerosolizing the listeria and spreading it throughout the facility. In some cases, companies are forced to shut down the plant for extended periods of time, resulting in significant business interruption and loss of revenue.”

Courts get tough on deadly cases

LIU_SponsoredContentWith the increase and severity of food contamination recalls rising, the courts are getting tougher too. The food industry was rocked last month by a recommended life sentence for the ex-CEO of a peanut manufacturing company following a multiple-felony conviction for knowingly selling tainted peanut butter that ended up killing nine people.

“The judge ended up sentencing him to 28 years in federal prison, still the harshest penalty ever in a case of food contamination. While our policy won’t cover your defense if you’ve committed a crime, the penalty is another wake up call for the food industry that executives at the highest levels will be held accountable,” McCarthy said.

Science boosts detection, transparency

LIU_SponsoredContentAdvances in DNA mapping are on the rise. “Before this technology, people would say, ‘It wasn’t us! Prove it!’ and that was pretty much impossible,” McCarthy said. “Those days are gone now.”

By using today’s scientific methods to trace back to the source (grocery store, restaurant, wholesaler, etc.), experts can determine the production facility or farm that originated the food or food additive. They can swab the facility for DNA matches and pinpoint the contamination.

Considering those four prime drivers, it’s not surprising that interest in food product recall and contamination coverage from companies of all sizes is gaining momentum.

“We don’t want them to just buy our insurance,” McCarthy said. “We want them to be better for it with us as their partner by making sure they have the right coverage in place and improving their business from a health, safety and compliance standpoint.”

Liberty International Underwriters is the marketing name for the broker-distributed specialty lines business operations of Liberty Mutual Insurance. Certain coverage may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds and insureds are therefore not protected by such funds. This literature is a summary only and does not include all terms, conditions, or exclusions of the coverage described. Please refer to the actual policy issued for complete details of coverage and exclusions.

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

LIU is part of the Global Specialty Division of Liberty Mutual Insurance.
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