Risk Scenario + Webinar

The Best Laid Plans

Treatment delays and other effects of health care reform implementation blind-side a deal between a regional employer and a health care system.
By: | September 27, 2013 • 8 min read
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

Part One

Hale Everson disliked silence and wasn’t bothered by visible distractions. A natural multitasker, he liked to keep D.C. Span, the 24-hour news channel devoted to Washington politics, on his office TV.

As the Human Resources director for the Southern operations of Fuego Motors, a leading European car maker, Hale had been working for years to create a state-of-the-art health care monitoring system for the automobile manufacturing plant’s employees.

On the computer monitor in front of him, there were no less than 10 open spreadsheets.

Hale loved data and along with the auto plant’s risk manager, he had compiled plenty of it.

Hale paused at his keyboard and shifted his attention to his TV set. The U.S. Senate was voting on the passage of the Patient Protection and Affordable Care Act.

“Come on boys, come on,” he said, as he watched the “yes” votes pile up. Hale wasn’t worried about the outcome of the vote. He’d been preparing for this day for years.

***

When it came to what he required to work well, Brady Heller, the CFO for Apex Care, a regional hospital, was a door-shut type, even though he had a corner office. Brady hated any sort of distraction.

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It wasn’t until he got home late that night and watched the 11 o’clock news that Brady found out the Affordable Care Act had passed. Brady watched impassively as his wife sat next to him.

Always keeping his cards close to his vest, Brady quietly calculated what Apex Care had spent over the past four years to acquire numerous specialty practices to build a state-of-the art Accountable Care Organization.

Brady wasn’t worried about the outcome of the vote either. He’d also been preparing for this day for years.

***

Brady and Hale, friends since college, were walking down the fourth fairway at the local country club when the two community leaders, key members of the local chamber of commerce, put their well-disciplined heads together.

“Nice job picking up Neil Zane’s cardiac practice buddy,” Hale said to his friend with a smile.

“Thanks,” Brady said, as he scanned the grassy rise for his golf ball.

“From what I can tell, you’ve got all the pieces in place,” Hale said.

“I sure hope I do. Cost us enough,” Brady said as he turned to set up a 2-iron shot.

“Brady, hold on just second,” Hale said. Brady turned and looked soberly at Hale, alert to the business-like tone Hale had switched to.

“I think I’ve got all my pieces in place too, and I don’t want to wait ‘til the wind changes. I want to bring my entire workforce to Apex on a direct contract. I’ve got all the data…”

“I bet you do,” Brady said.

“And with my documentation we can get this done sooner rather than later,” Hale said.

“You got everybody ready?” Brady asked.

“I’ve got everybody on board, from Turin to where we’re standing right here,” Hale said, and Brady could tell that Hale meant every word.

Within three weeks, the local business weekly ran a story under the following headline and subhead.

“Fuego and Apex Ink Healthcare Pact”

“Savings and better quality of care in focus in multi-million-dollar arrangement”

The story featured a picture of Brady and Hale shaking hands over a conference table.

Poll Question

How do you envision health care reform impacting your workforce’s health in general?

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Part Two

Under the direct contract with Apex, Fuego’s workers and their dependents would receive exclusive health care at the regional health giant for three years. The contract was set to renew as long as costs didn’t deviate more than five percent on an annual basis from projections.

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Seven months after the direct contract deal was announced, Serge Bernstein, head of Apex’s high-profile bariatric medicine and weight loss clinic, requested a face-to-face meeting with Brady.

“I have to ask you, did you have access to Fuego’s health care data before you agreed to this deal?” Dr. Bernstein asked Brady.

“I know as a matter of fact that the company keeps excellent records,” Brady said as an opening defense.

“Well, I keep pretty good data on my end as well,” Dr. Bernstein said, as he expertly swiped his digital tablet to bring ups some figures.

“The contract with Fuego says costs can’t deviate more than five percent from projections,” he said.

“That’s correct,” Brady said.

“What would you say if I told you that I am seeing instances of diabetes in that population at about 250 percent of projections?” Dr. Bernstein said.

“I’d be very concerned,” Brady said.

“Then you should be very concerned,” Dr. Bernstein said.

Two weeks later it was the hospital system’s head of orthopedics, Krishnan Gilani, who was sitting in Brady’s office.

“I’ve got a four-week waiting list for initial non-emergency evaluations,” Dr. Gilani said.

“Why?” Brady said.

“Have you heard of the Affordable Care Act? This autoworker population requires a lot of care. Many of them are overweight, which complicates treatment. I’ve also got a threefold increase in overall caseload due to all the previously uninsureds coming on board under the new law,” Dr. Gilani said.

“Wow,” Brady said.

“Wow indeed, Mr. Heller,” Dr. Gilani said. “These are substantially out of whack figures and of great concern,” Dr. Gilani said.

***

Hale and Brady were mostly silent as Hale lined up a putt and the two of them digested the information that the increased number of insureds coming in for treatment was threatening to broadside their direct contracting arrangement.

“It’s the first year of the program,” Hale said after his putt lipped out. “I’m sure the numbers will settle down in years two and three.”

“You’re probably right,” Brady said as he stood over his putt.

“You’re probably right.”

Poll Question

What steps is your company taking to educate executives on the impacts of health care reform?

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Part Three

Hale’s view of his in-office television screen is obscured by the bulk of the autoworkers’ union vice president. To the vice president’s left is the union president. Neither of them looks healthy and neither of them looks especially pleased.

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“Eighteen months ago you sold this hospital deal to us, saying it would be better for the workers and their families. You said we’d get better treatment, cheaper, and better access to treatment,” the union president said.

“I did say that, that’s true,” Hale said

“None of that was true,” the vice president said.

“We got a guy on the line, he twists his back trying to keep an engine compartment bonnet in place. You know how long it takes him to see a back specialist?”

“I don’t…” Hale begins.

“How about five weeks?” the vice president said. “Five weeks!”

“And this is the only hospital we can go to,” the president said.

“I thought health care reform was about choice. You know what? We have no choice,” the union president said.

“Am I in Russia now because I feel like I’m in Russia,” the union vice president says to the union president.

The quarterly meetings between hospital management and the medical team leaders have become so fraught with tension for Brady Heller that they begin to feel like out-of-body experiences.

Dr. Bernstein, Dr. Gilani and Dr. Helen Beers, chair of the cardiac unit, have Brady in their cross-hairs.

“When you brought my practice into your system, I was assured that I could maintain my care standards, that my cost of risk would be reduced by 20 percent and that my revenues would increase by 30 percent,” Dr. Beers begins.

“None of that has happened,” she said, fixing formidable steel blue eyes on Brady through her titanium eyeglass frames.

“Instead I’m seeing delays in payment. I am seeing care standards that I never would have tolerated independently, and I am seeing this across a number of departments, not just my own,” she said.

“We want access to full financial documentation under the terms of our contracts or we are walking, I am not kidding you,” Dr. Bernstein said.

Brady looked from Dr. Bernstein to Dr. Gilani to Dr. Beers. Nowhere was there mercy or understanding.

Hale has a board meeting of his own to attend.

“If we pay them this $3 million that they’re asking for,” the CFO for North America says to Hale.

“On top of the contracted amount,” he says, looking around the table for emphasis, to make sure everyone is getting his point.

“On top of the contracted amount,” he says yet again, unmercifully.

“What assurances do we have that we’re not going to be shelling out another $3 million in six months to a year from now?” the CFO asks.

“I’m not sure that I can offer you any assurances,” Hale says.

“We’re seeing treatment delays and co-morbidities that are beyond the scope of our projections,” he adds.

“I thought this was the best health care money could buy,” the CFO says.

“It may be,” says the North American CEO, who has made a special point to be at this meeting.

“The issue is we didn’t know it would take this much money to buy it.”

The CEO fires Hale Everson that very evening.

Poll Question

How will Health Care Reform impact the level of involvement you have in the care delivery system for your employees?

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Summary

A sizable regional employer and a large health care system come to grief when their directly contracted health care arrangement is blind-sided by health care reform implementation. The planners of the deal fail to take into account the delays in treatment that large numbers of previously uninsured patients coming into the system will create. Contrary to their promises, standards of health care deteriorate and key stakeholders become alienated.

1. The importance of good data: Data is only actionable if it is good data. Fuego Motors thought it had adequately measured the health care risks inherent in its employee population, but events proved it to be woefully wrong. The advent of the Affordable Care Act is going to impact medical treatment and loss projections are going to have to be altered.

2. Assess your contract: Direct contracts to provide health care services to employers might make a lot of strategic sense, but they can turn into straightjackets if not written with enough flexibility to account for increasing health care costs and the unknowns of health care reform.

3. Medical practice acquisition is fraught with perils: Bigger is not necessarily better when it comes to health care business management. Conflicting work cultures and compensation and quality of care expectations can lead to disagreements, litigation or worse if contractual provisions aren’t spelled out adequately.

4. Health care regulation is in conflict: Federal health care reform is not the only wind sweeping the waters. There are numerous federal and state entities regulating health care and their missions and mandates are not in step with each other. Understanding the full lay of the land moving forward is a must.

5. Move with measured steps: There is so much going on in health care practice and regulation right now that the unknowns outnumber the knowns. Look at acquisition targets with more caution than ever before.

6. Be fully transparent: Both sides thought they had all the data they needed. But in the end, their failure to completely share with their data with their respective teams created unpleasant surprises. Being fully candid about all risks is the best strategy in this unsure environment.

The Webinar

The issues covered in this scenario were in part based on the impact of health care reform. This follow-up webinar focused on specific changes to the health care market in the wake of Affordable Care Act implementation and presented actions insureds can take to prepare themselves moving forward.

Download a copy of the slide presentation here.

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]
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Risk Scenario

Hard Crash

An equipment breakdown harms a company and kills a career.
By: | August 31, 2015 • 7 min read
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

Part One: Pressure Builds

Barry Little cast an appreciative glance back at the front door of the elementary school where he’d just dropped off his little girl Lila, age 5, for her morning kindergarten class. He was grateful that he trusted Lila’s teacher and the rest of the school staff.

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Walking to his car, with the late September sun warming his face, he ticked off the other reasons he had for being happy. Ten minutes before dropping Lila off, he’d dropped off her little brother Benjamin at daycare. Benjamin was a joy, now speaking in full sentences and displaying a wry sense of humor.

Driving to work, Little ruminated on his further good fortune. He was celebrating the one-year anniversary of his promotion to plant manager of the Glaucus Inc. ammonia plant in nearby Edmonton, in the province of Alberta, Canada.

His promotion coincided with increased natural gas production in the fields close to the Edmonton plant. Natural gas is the feedstock for ammonia, and its recent abundance and lower cost was a boon for the company.

Just that week, his managers asked him to extend the current ammonia production run out two years to take advantage of the lower cost of natural gas and the burgeoning demand for fertilizer in the emerging economies of India and China.

Ammonia is a key raw material for the production of fertilizers. But there are inherent risks. Ammonia production is a demanding process on plant equipment. And the extended production run was being performed at the expense of regularly scheduled equipment maintenance.

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Partner

Little knew the reasons for management’s decision. With global revenues at close to $1 billion annually, publicly traded Glaucus could run that figure close to $1.25 billion in this two-year window.

There was another factor gnawing at Little. The vastly increased production of natural gas in North America meant that chemical manufacturing was on the upswing. New plants were being built and existing plants expanded which increased lead times for equipment and spare parts

In this high-demand environment, contingency plans that included the purchase of spare parts were important to minimize any downtime due an equipment breakdown. Little, relatively new to this position, was in the process of drafting contingency plans, but they weren’t complete. The plant had some spare parts and equipment, but it was questionable whether that was adequate.

***

Little was relaxing that night after dinner, keeping half an eye on an Edmonton Eskimos game, when his cell phone lit up.

A fast moving storm was moving through Alberta. No sooner had Little seen that news on his phone, when he got a call. A lightning strike at the Glaucus plant tripped the electrical system off line, triggering a “hard crash” and a complete shutdown of the plant.

“Gotta go,” Little said to his wife as he jumped up and grabbed his raincoat.

“Where to?” she said.

“The plant’s been knocked out by a lightning strike. I gotta get over there!”

“Drive safely!” she called after him but he was already out the door.

Driving to the plant with rain pelting his windshield, Little’s mind raced.

“What to do?”

The truth was, he didn’t know.

Poll Question

To what degree is risk management given a voice in key business decisions at your company, such as extending a manufacturing production run?

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Part Two: Break Down

When Little arrived at the stricken plant, his assistant plant manager, Denny Ashe, was waiting for him just outside the door.

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“It’s a complete shutdown, nothing is on line,” Ashe said as he and Little walked into the plant together.

Little strode out into the plant’s main control room. Nothing seemed amiss, but everything was shut down.

“Do we have power?” he asked Ashe.

“Yep, we’re just reconnected,” Ashe said. “The strike tripped our system, but the circuit breakers have been reset and service has been restored.”

Little stood, looking at the idled control panels for the plant’s equipment and at the faces of the operators, who were watching him expectantly. The faces of the watching operators triggered something in Little.

It looked like they were expecting him to act, so he did.

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Little turned to Ashe.

“Let’s start it back up.”

“Are you sure?” Ashe said.

Ashe was just asking a question, but it angered Little.

“Yes I’m sure!” Little thundered.

“Start it up like I said!”

Just then, the phone number of Little’s manager flashed on his phone. Flustered, Little didn’t answer the call.

What Little didn’t know and didn’t take the time to find out was that a critical steam turbine driving a process compressor was damaged when the lightning strike shut the plant down so suddenly. The turbine was vulnerable because it hadn’t been properly maintained due to production demands.

Little went out and stood in the middle of the compressor building with his hands on his hips as Ashe worked with the operators in the control room to get the plant back on line.

When the plant restarted, the turbine started to vibrate excessively. Without vibration trips, the turbine continued to operate. The vibration caused a lubrication oil line to break, which in turn started a fire.

“Fire!” one of the turbine operators yelled as he ran to grab a fire extinguisher since there was no sprinkler protection installed, but another turbine operator beat him to it. The fire was so intense that it burned the two workers severely.

Denny Ashe shut the plant back down as calls went out to the emergency response team.

As a member of the emergency response team used a first-aid kit to attend to the turbine operators, Little stepped back, realizing that he still held his phone in his hand.

He couldn’t look at the injured workers laid out on the compressor building floor, with their co-workers offering them aid. He couldn’t face it.

Little just stared at his phone in shock, unwilling to dial his boss’s number.

***

It took a week of meetings between plant operational personnel to determine just how bad the situation was.

The team determined that the $10 million turbine, which was crucial to the plant’s production process, was totally destroyed.

The plant was powerless without the turbine; it couldn’t produce ammonia.

“I can’t tell you,” is what the equipment manufacturer said when Little called him and asked when they could deliver a replacement.

“It could be six months, it could be nine months, it could be longer,” the manufacturer’s representative said.

“When are we going to be back up?” is what Little’s manager asked him, two weeks after the shutdown and the turbine fire.

“I can’t answer that question,” Little said.

Poll Question

Does your company have a documented preventive maintenance program in place that addresses when key pieces of equipment should be inspected to maintain asset integrity and reliability?

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Part Three: A Chilling Dawn

Seven months after the lightning strike and the turbine fire that injured two workers, Little finally had an answer to that question.

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With a date for the delivery of the replacement turbine now firm, it would be two more months before Glaucus Inc.’s Edmonton plant could resume ammonia production.

Little’s initial inability to tell senior management when the plant would reopen motivated them to send an engineering team from the company’s Shreveport, La., plant to conduct a complete inspection of the Edmonton plant.

“I want to state for the record that I was asked by management to extend the production run at the expense of the regularly scheduled maintenance,” Little told the inspection team as they sat down with him and some of the senior management team to report on their findings.

“Barry, we’re not here to officiate between you and your manager,” the head of the Shreveport engineering team told him.

“We’re just here to report on what we found.”

The engineering team reported that the Edmonton plant’s electrical system was well used and wasn’t adequately maintained. It didn’t matter that Barry Little had only been plant manager for a year, the fault lay at his feet.

The engineering team also faulted the Edmonton operation for extending production without maintaining the plant’s equipment; not installing vibration trips on the critical turbine; not adequately maintaining turbine integrity; failing to have a written contingency plan, including maintaining spares for critical pieces of equipment and not installing sprinkler protection on the turbine.

Instead of being on track to increase its revenues from $1 billion to $1.25 billion, Glaucus Inc. saw its revenues in the year of the Edmonton plant failure slip down to $900 million. The work stoppage at Edmonton cost the company $125 million in plant repairs and lost revenues.

When it reported its full-year figures, the company’s stock price tumbled 20 percent.

The fact that Barry Little was in the process of writing a contingency plan when the plant experienced the lightning strike and hard crash didn’t help him much. He was fired in the first quarter of the following year.

Poll Question

Does your company have documented contingency plans that include key part or machine replacement in the event of an equipment breakdown event?

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Risk & Insurance® partnered with FM Global to produce this scenario. Below are FM Global’s recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance®.

No company can afford the loss of property, lives and productivity from destruction caused by fire, natural hazards or equipment outage. Equipment damaged in minutes can take many months to repair or replace. If there is business interruption, revenue, stock price and shareholder confidence all can take a major hit. Market position may be lost. Inflation and material shortage may make rebuilding difficult and costly.

Of course, insurance helps alleviate some of the cost associated with property damage. But insurance isn’t the only answer, especially when considering the loss of customers, productivity, goodwill and staff.

Reliable equipment delivers resilient service to your production, utility and support systems, can reduce risk to your business and help your organization maintain a competitive advantage.




Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]
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Sponsored: Healthcare Solutions

Specialty Drugs Show No Signs of Slowing Down

The emergence of specialty drugs in the workers' comp market comes with a new set of complexities and a hefty price tag.
By: | August 31, 2015 • 4 min read
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A decade ago, high-cost specialty drugs were commonly referred to as “injectable drugs” and were used to treat conditions not typically covered in workers’ compensation, such as cancer, rheumatoid arthritis and multiple sclerosis.

“Today, however, new specialty drugs are emerging that will be used to treat other chronic and inflammatory conditions,” said Joe Boures, president and CEO of Healthcare Solutions, an Optum company providing specialized pharmacy benefit management services to the workers’ compensation market.

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Joe Boures, President and CEO, Healthcare Solutions

“Payers in the workers’ comp market are just beginning to feel the cost impact of greater utilization of these drugs, which come with expensive price tags.”

Specialty drugs are often manufactured using biologic rather than chemical methods, and they are no longer just administered by injections. New specialty drugs can also be inhaled or taken orally, likely contributing to the rise in their utilization.

“There isn’t a standard definition of specialty drugs, but they are generally defined as being complex to manufacture, costly, require specialty handling and distribution, and they difficult for patients to take without ongoing clinical support or may require administration by a health care provider,” said Boures.

In 2014, more than a quarter of all new therapies that the FDA approved were through its biologics division. Biologics, and similar therapies, are representative of a future trend in prescription drug spend.

“As the fastest growing costs in health care today, specialty drugs have the potential to change the way prescription benefits are provided in the future,” said Jim Andrews, executive vice president of pharmacy for Healthcare Solutions.

Workers’ Compensation payers may not recognize how specialty drugs are affecting their drug spend.

Specialty drugs like Enbrel®, Humira® and Synvisc® can be processed in conjunction with other medical procedures and, therefore, not recognized by payers as a pharmacy expense.

This leaves payers with little visibility into the costs of these medications within their book of business and a lack of tools to control these costs.

Due to the high costs of specialty medications, special due diligence should be utilized when claimants receive these medications, up to and including utilization review, said Andrews.

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Jim Andrews, Executive Vice President of Pharmacy, Healthcare Solutions

“Healthcare Solutions recommends that claimants using specialty drugs are monitored for proper medication handling and that the medication is administered appropriately, as well as monitoring the claimant to determine whether the medication is having its desired results and if there are any side effects,” he said.

“At $1,000 per pill for some of these specialty medications, making sure a claimant can tolerate the side effects becomes vital to making sure the claimant achieves the desired outcomes.”

Hepatitis C drugs have made their way to the workers’ compensation market, largely through coverage of healthcare workers, who have exposure to the disease.

“Traditional drug treatments that began in the 1990’s had a success rate of 6% and costs ranging from $1,800 to over $88,000,” said Andrews.

“The new Hepatitis C specialty medications have a treatment success rate of 94-100%, but cost between $90,000 and $226,000.”

Although the new treatments include higher drug costs, the payer’s overall medical costs may actually decrease if the Hep C patient would have required a liver transplant as part of the course of treatment without the drugs.

While the release of new Hepatitis C medications in 2014 demonstrated the potential impact specialty medications can have on workers’ compensation payers, there are some specialty medications under development that target more common conditions in workers’ compensation.

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Pfizer Inc. and Eli Lilly and Company are currently developing tanezumab, a new, non-narcotic medication to treat chronic pain, which is common in workers’ compensation claims.

Tanezumab has demonstrated benefits of reducing pain in clinical trials and may provide non-addictive pain relief to claimants in the future.  This may change how pain management is treated in the future.

Healthcare Solutions has a specialty medication program that provides payers discounted rates and management oversight of claimants receiving specialty medications.

Through the paper bill process, Healthcare Solutions aids payers in identifying specialty drugs and works with adjusters and physicians to move claimants into the specialty network.

A central feature of the program is that claimants are assigned to a clinical pharmacist or a registered nurse with specialty pharmacy training for consistent care with one-on-one consultations and ongoing case management.

The program provides patients with education and counseling, guidance on symptoms related to their medical conditions and drug side effects, proactive intervention for medication non-adherence, and prospective refill reminder and follow-up calls.

“The goal is to improve patient outcomes and reduce total costs of care,” said Boures.

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



Healthcare Solutions serves as a health services company delivering integrated solutions to the property and casualty markets, specializing in workers’ compensation and auto liability/PIP.
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