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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
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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.

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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: Starr Companies

A Global Perspective

Political risk is on the rise in an increasingly unsteady world.
By: | August 3, 2015 • 5 min read
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As any traveler knows, the world is full of uncertainty and dangerous places, where the challenges of simply trying to run a profitable business far from home are complicated by even greater risks, such as political violence, civil unrest, credit risk, corruption, expropriation of private assets by the government, and more.

Anyone doubting this need only take a look at current events. Some 70 percent of the world’s nations currently have serious corruption problems throughout their governmental and civil service framework. Nearly 40 percent of all nations are experiencing some form of significant civil unrest. Signs of economic distress are everywhere, from falling oil prices to Eurozone debt crises to economic slowdown in China.

Despite such geopolitical risks, the world still needs its businesses to continue running amid dangers that range from warfare and terrorism to punishing economic conditions caused by international sanctions, to simple graft and hostility toward foreigners.

For global and multinational companies, keeping an eye on their political risk profile is as important as handling worker safety, environmental impact, products liability, or any other insurable risk. Thankfully, political risk exposures are insurable as well, and Starr Companies is there to provide its clients with robust political risk insurance coverage, a suite of unique support services that truly is second to none, and the ability to educate clients on how to manage their political risk.

Political risk hazards generally fall into one of the following categories:

Breach of Contract and Non-Honoring of Financial Obligations

Starr_BrandedContentThese related hazards involve the failure of a local actor to uphold their contractual or financial obligations to a foreign investor, and the inability or unwillingness of local authorities to intercede on the foreign investor’s behalf. This is perhaps the most common form of political risk hazard, as it is a major problem in any environment where there is substantial economic instability and/or corruption.

Confiscation of Property

Also known as “expropriation,” “ownership risk” and “nationalization,” this is when a government seizes property or assets without compensating the owners for them. An overt example of expropriation would be a revolutionary government seizing an office building or a factory belonging to a foreign-owned corporation. An example of creeping expropriation would be a series of successive events by a government to gradually deprive an investor of their property rights.

Regulatory Changes

This is when the local laws change in such a way as to constrict foreign investors’ economic activity in some way. It could range from creeping expropriation to changing taxation or labor laws that might simply make it far less profitable or far less efficient for a foreign entity to operate in a local jurisdiction.

Inconvertability of Currency

Also known as “transfer risk,” this is when a government takes action to prevent the conversion of local currency to another form of currency, making it difficult or impossible for foreign investors to transfer their profits elsewhere. This tends to happen in countries undergoing some kind of political crisis, like when Zaire—now the Democratic Republic of Congo—declared a new national currency in 1980.

Political Violence

Starr_BrandedContentProperty or income losses stemming from violence committed for political purposes, including, but not limited to declared and undeclared warfare, hostile actions taken by foreign or international forces, civil war, revolution, insurrection and civil strife (politically motivated terrorism or sabotage).

Kidnap and Ransom

Political violence might also manifest itself as a kidnap, ransom and extortion hazard, but that is typically covered by a separate, specialized policy.

To protect against these risks, insurers can provide comprehensive and custom-tailored political risk solutions, which at a client’s request can be broadened to cover investment contract repudiation, currency inconvertibility and political violence. Such policies typically last for periods of 5 to 10 years. Protected assets for this coverage include fixed assets (e.g., a factory, farm, warehouse or office), mobile assets (e.g., harvested natural resources, raw or manufactured inventory or mobile equipment), leased assets (e.g., aircraft, watercraft or construction vehicles) and investment interests in assets abroad (e.g., money dedicated to funding a foreign project, held in a host country bank and subject to expropriation).

Kidnap & ransom coverage protects company personnel and family by providing financial reimbursement for such an event. Depending on the insurer, some K&R programs also provide independent expert consultancy before and after a potential act of kidnapping, ransom or extortion.

Starr_BrandedContentGreat insurance coverage isn’t enough to adequately protect against political risk, however. Businesses need extra support to stay on top of their exposures, and to know what the latest geopolitical developments are.

 

Starr Companies, for example, does this through Global Risk Intelligence, a specialized team of political risk experts with long-standing backgrounds in national intelligence and international affairs. GRI delivers to Starr clients a unique risk advisory service that spans the gamut of commercial property & casualty exposures. GRI also produces two assets that are extremely helpful. The first is the Executive Intelligence Brief, a world-class monthly analysis of ongoing geopolitical developments (especially in emerging markets) available exclusively to a carefully selected readership of top executives. The second is the Global Risk Matrix, a quarterly ranking of the overall political security risk of every country on the planet.

The world’s geopolitical landscape is changing at a remarkable pace, with new risks and uncertainties arising in even the unlikeliest of places. And yet, as business becomes ever more globalized, insurers can provide their clients with tailored coverage to absorb the losses that stem from political turmoil. By finding the right insurer, with the financial strength to cover their risks as well as the analytical acumen to help turn risk into opportunity, businesses can create partners in prosperity anywhere in the world.

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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 Starr Companies. The editorial staff of Risk & Insurance had no role in its preparation.




Starr Companies is a global commercial insurance and financial services organization that provides innovative risk management solutions.
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