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CDC_Ebola-in-US_lrThe possible spread of the Ebola virus to persons in the United States has raised concerns regarding the handling of insurance claims that might result from this disease.

As the leading North American provider of claims management services, Sedgwick offers many resources to assist our clients during times of uncertainty. From the initial report of the claim, each line of business has best practices in place to manage claims related to threats to public health, such as the Ebola virus. We have developed these best practices with flexibility enterprise-wide to meet the needs of our clients and ensure we are prepared to handle these potential claims. Please be assured that if Sedgwick receives an Ebola claim, we will not only notify our clients and carrier partners immediately, but also follow any special handling instructions and our own established best practices.

To ensure we are prepared to assist our clients during this time of uncertainty, we have educated Sedgwick colleagues regarding Ebola, its transmission and proper medical treatment. Additionally, we have established an internal Ebola information site for our colleagues who handle claims. Continue reading to learn some of the Ebola facts we’ve shared with our colleagues and clients.

What is Ebola?
Ebola virus disease (EVD) is a severe, often fatal illness in humans caused by infection with one of the Ebola virus strains. There are five known strains of the Ebola virus, four of which are known to cause disease in humans. The Zaire strain is the source of the current outbreak.

Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. Since then, outbreaks have appeared sporadically in Africa. The 2014 Ebola epidemic is the largest in history, affecting multiple countries in West Africa.

How is Ebola transmitted?
According to the Centers for Disease Control and Prevention (CDC), the Ebola virus can be spread through direct contact of broken skin due to an open cut, wound or abrasion or mucous membranes in, for example, the eyes, nose, or mouth with:

  • Blood or body fluids including but not limited to urine, saliva, sweat, feces, vomit, breast milk and semen of a person who is sick with Ebola
  • Objects such as needles, syringes and medical equipment that have been contaminated with the virus
  • Infected animals

Ebola is not spread through the air or by water, or, in general, by food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats. There is no evidence that mosquitos or other insects can transmit Ebola virus.
Only mammals (e.g., humans, bats, monkeys and apes) have shown the ability to become infected with and spread Ebola virus.

How long can Ebola live outside the body?
In a perfect environment, Ebola can live for up to six days outside the body. In most cases, it is believed that it lives for only a few hours. UV light, heat and exposure to oxygen deactivate the virus over time. Ebola can be killed on surfaces by using bleach, any EPA approved disinfectants,
or household cleaning products like Clorox or Lysol. The virus depends on a human or an animal host to survive. It does not survive long in water, and contamination of our water system is unlikely.

What are the signs and symptoms of Ebola?
Symptoms may appear from two to 21 days after exposure to Ebola, but the average is eight to 10 days. A person infected with Ebola is not contagious until symptoms appear. Signs and symptoms of Ebola typically include:

  • Fever greater than 101.5 degrees Fahrenheit
  • Severe headaches
  • Muscle pain
  • Vomiting
  • Diarrhea
  • Stomach pain
  • Unexplained bleeding or bruising

Diagnosis and treatment of Ebola
There are several laboratory tests used to confirm the diagnosis of Ebola. Although experimental medications and vaccines for Ebola are under development, there is currently no cure and no vaccine for this virus. The patient is isolated to prevent the spread, and then symptoms are
treated as they manifest with interventions such as:

  • Providing intravenous fluids (IV) and balancing electrolytes (body salts)
  • Maintaining oxygen status and blood pressure
  • Treating other infections if they occur

Recovery from Ebola depends on the patient’s immune response. Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been found in semen for up to three months. People who recover from Ebola develop antibodies that last for at least
10 years or longer.

More information
Helpful Ebola information resources include:

How you are preparing for the possibility of Ebola claims? You can contact Sedgwick’s medical director, Dr. Teresa Bartlett, for more information on Ebola as a workplace health issue. For additional perspective on how potential Ebola claims may impact the U.S., post your questions for me in the comment section below.

Download a printable copy of this Ebola fact sheet or pick one up and discuss with our experts at this week’s National Workers’ Compensation and Disability Conference – booth #1617. 

Desiree Tolbert, National Technical Compliance Manager

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This blog article has been republished as originally run in Human Resource Executive magazine’s November 2014 issue

As an employer, you’ve most likely heard about the multimillion-dollar lawsuits and settlements related to the Americans with Disabilities Act and the ADA Amendments Act. These acts are designed to protect qualified individuals from job discrimination, but without a consistent management process, employers leave themselves open to costly legal fees and penalties for non-compliance.

Sedgwick recently hosted a webinar discussing ADA/ADAAA compliance, presented by Human Resource Executive. There was a high level of interest and employers asked many thought-provoking questions –reminiscent of the days when companies were adopting Family and Medical Leave Act policies and procedures. Organizations are dealing with overlapping complex employment issues, and as we look ahead to 2015, ADA/ADAAA compliance continues to be among the top concerns for human resource and risk professionals, particularly when considered alongside other disability and absence issues, including FMLA, or workers’ compensation requirements.

How can employers ensure compliance in these areas? Through consistency and integration. The keys to success include adopting consistent management practices to address all types of employee absences, along with an integrated claims system that brings all of the information together.

Developing a consistent process
For ADA/ADAAA accommodations, employers should make every effort to meet the employee’s request unless it truly has a significant impact on their business. The process typically begins when an employee requests a change in the way his or her job is performed or he or she exhausts all job-protected leave while remaining absent from work. For each request, your disability management team should follow a consistent process that includes:

  • Capturing the request. Make sure standard procedures regarding leave or accommodation are up to date, clearly communicated to the employee and trigger an interactive process review.
  • Working with the physicians to certify the impairment. Set expectations with employees, and request reasonable documentation to determine if they are disabled and if they can perform their jobs with an accommodation. A job accommodation specialist certified in vocational rehabilitation can be very beneficial at this point.
  • Navigating through the interactive process. Once the healthcare provider has established that the employee has an impairment but is able to perform job functions with an accommodation, the team will engage in an interactive discussion with the employee, set expectations up front and help them gain an understanding of possible accommodations.
  • Working together to determine the appropriate accommodation. Choose the accommodation (if there are more than one) that will allow the disabled person to do his or her job most effectively, such as modifying lifting tasks for a warehouse employee who injured his or her back. This may involve researching technical solutions and adaptive equipment.
  • Implementing the accommodation. Discuss the status and next steps with the employee along with a designated contact. The accommodation should be implemented as soon as possible. In some cases, a reasonable accommodation may be unpaid leave.

The advantages of an integrated claim system
An employee’s request for a job accommodation can arise as part of a claim for short- or long-term disability, FMLA or workers’ compensation. It may also stem from a condition that does not qualify for any of these. A claims management system that brings together the information on all types of employee absences, tracks each step in the process and enables comprehensive documentation helps ensure compliance on multiple fronts. Relying on manual tracking methods may lead to compliance violations and increased risk. A centralized information platform that supports multiple processes can greatly reduce that risk – and give the employer a significant advantage in the current regulatory environment.

Integrating claim systems not only helps streamline the information, it can also help employers reduce costs. In fact, over a three year-period, Sedgwick found employers that implemented integrated disability management programs reduced their internal administration costs by an estimated 10 to 20%.

The bottom line
State and federal regulations for ADA/ADAAA, FMLA and workers’ compensation are becoming increasingly complex. Developing a successful compliance program includes ensuring you have the right resources to provide a consistent process supported by a centralized information system that can easily adapt to regulatory changes.

To learn more, please see the additional resources below:

Darryl Hammann, EVP Disability Operations

 

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doctor-patient-evaluationEmergency Department (ED) staff members have all felt the anxiety of a potential missed diagnosis. For those who have actually witnessed a missed chance, it is not hard to understand how agonizing it would be to realize the missing piece of information was right at your fingertips…had the interview process nailed down the correct information during patient evaluation.

This brings to mind how dependent ED team members are during the interview process on what the patient shares. Patients will sometimes tell us things we really don’t need to know and in other instances will tell us very little. That makes it important to understand that it is our obligation, as healthcare providers, to use interview skills that encourage, evoke and extract information from the patient.

This might seem an easy task but really, in this day and age, we are dealing with so many diverse cultures and languages that asking the right questions in terms that are understood can be very difficult. Not only do we need a concise and accurate history and medication profile, we also need the interview skills to elicit an appropriate response from the patient. Several things come to mind, like asking open ended questions and giving the patient the opportunity to define the conversation. Of course, the most basic interview skill is listening and, if a language barrier exists, the information might not be accurate unless an interpreter is involved.

Maybe now is a good time to re-educate ourselves on the interview process and take ownership of the fact that the first line of defense includes the quality of the interview and the information obtained.

As a takeaway for your ED staff, share the patient-centered interviewing tips that promote two-way conversation – and the best chance at getting the full story – found in: “Five-Step Patient-Centered Interviewing” at http://members.aapa.org/aapaconf2005/syllabus/5024FortinSmithInterview.pdf.

As a check-and-balance, let your ED’s healthcare professionals perform a self-assessment of their interview skills by checking off this list of common problems that trip us up, as published by Peter Lichstein, in Clinical Methods: The History, Physical, and Laboratory Examinations, 3rd edition:

  1. Confusing the traditional, rigid order of the written medical history with the actual process by which information emerges during the medical interview.
  2. Relying too heavily on directed, closed questions. This style discourages the patient’s associations and spontaneous report of symptoms.
  3. Ignoring the patient’s emotional responses and concerns during the interview process.
  4. Narrowing the scope of inquiry too early in the interview.
  5. Failure to clarify the seven dimensions of a symptom in the patient’s own words.
  6. Insisting that the interview must be accomplished in one session (experienced clinicians return to the patient again and again to clarify the history).
  7. Limiting the list of diagnostic hypotheses before adequate data has been collected.
  8. Using questions that are leading, too complex, double-barreled or unclear.
  9. Failure to follow basic courtesies in the interview: lack of clear introductions, ignoring the patient’s comfort, failure to establish an atmosphere of trust and confidentiality.
  10. Failure to elicit the patient’s own ideas about the cause of the problem and the patient’s fantasies about what the doctor will do.
  11. Note-taking that interrupts the flow of the interview.

(More content available at: http://www.ncbi.nlm.nih.gov/books/NBK349/)

Finally, if interpreter services are utilized as part of the interview process, be sure to document the interpreter’s name, what language was being interpreted and any other relevant points around questions asked and answered through this intermediary.

With a renewed focus on interviewing skills, ED team members – and healthcare providers in general – can avoid common problems that could lead to a missed diagnosis. When we ask the right questions and listen to the patient, we can target our response and provide the most appropriate treatment every time.

Do you have stories of how you overcame communication barriers through interviewing or how potential issues were avoided? Share them with us in the comments.

Cynthia D. Bullard, RN, Senior Professional Liability Claims Specialist

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Fun-Fair-1001290If you have been trying to keep up with the latest Medicare compliance changes, you might feel like you are watching the carnival vendor who used to say, “around and around it goes and where it stops nobody knows.” Fortunately, with these answers you don’t have to guess.

Liability: CMS withdraws proposal for liability MSAs
Sometimes the biggest developments come from the changes that don’t happen; this was the case for Medicare set-asides (MSAs) in liability cases. In 2012, the Centers for Medicare and Medicaid Services (CMS) intimated they were going to issue rules and regulations about Medicare set-asides (MSAs) in liability cases. This raised concern in the industry because the proposed rules made little sense in the context of liability cases. Sedgwick was concerned the proposed rules would unreasonably delay and drive up the costs of resolving liability cases. Last month, we, as a member of the Medicare Advocacy Recovery Coalition (MARC), met with CMS representatives to address many outstanding items related to Medicare compliance. When this issue came up, MARC asked that CMS withdraw the current proposal. We received confirmation that CMS granted the request and has, in fact, withdrawn the proposal concerning liability MSAs.

Despite the recent developments, our best practice regarding liability MSAs remains unchanged, so things are “business as usual” for Sedgwick. We believe our established approach to be reasonable based on the uncertainty involving liability MSAs.  Input from the defense attorney and the client will be necessary to determine if a liability MSA is applicable in any given case.

January 2015 change in reporting of SSNs
What might be one of the best changes to come about – and I think you will agree – is the pending change in Social Security number (SSN) reporting, as it will greatly simplify a burdensome process. CMS recently announced that, beginning Jan. 5, 2015, only the last five digits of a claimant’s SSN will be required for Medicare reporting purposes. This change reduces the burden on our claims handling teams to collect full SSNs from claimants who may not want to provide this information. We anticipate the removal of this obstacle will significantly simplify the Medicare reporting processing for our colleagues. More detail about the new rule can be found in the announcement linked above.

I think both of these changes – or, rather, one non-change and one change – are significant to how you do business. Particularly, the change on Social Security number reporting is a very positive step and one that will reduce administrative time and potential errors. We will continue to keep you updated on important changes in the Medicare compliance space. In the meantime, please feel free to contact us. Our expert team is ready to work with you.

Michael Merlino, VP, Medicare and Medicaid compliance

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ebola-price-blogThe recent appearance of Ebola in the United States has given rise to claims concerns at multiple levels for hospitals and other healthcare providers. The first U.S. case of Ebola came after a traveler from West Africa reportedly arrived without symptoms and sought care in a Dallas emergency department, only to be released home. When symptoms arose, he soon returned to that same hospital, was diagnosed with Ebola, and was treated but succumbed to his disease.

At its core, Ebola is a public health matter with significant similarities to other infectious public health events of the past. However, from a claims perspective, public health claims involve primary and secondary exposures for hospitals like the one at the center of current U.S. Ebola developments.

Primary exposure
Let’s look at the timeline for the patient who traveled from Africa to Dallas. He was infected in Africa and, therefore, the hospital is not responsible for that infection. Next, the issue of liability regarding the primary patient is one of a delay in diagnosis and the potential that his care was too late to be effective as a result of that delay. Recent publicity has cited the lack of timely diagnosis and care in the hospital. Based on known evidence, it seems likely that negligence exists. However, since the current Ebola strain is classified by the World Health Organization (WHO) as having a 70% mortality rate, and assuming a local jurisdictional causation standard of “more likely than not,” it seems reasonable to conclude that the primary patient was more likely than not going to survive.

Press articles report the family contends the patient was denied the therapy used with success on other Ebola-infected patients moved from West Africa to the U.S. for care. Those patients were given an untested anti-viral treatment and lived. News accounts report that anti-viral supply has been exhausted. If it develops that the Dallas hospital had this or other therapies available that were not used, the causation defense is jeopardized.

Secondary exposures
The major exposure in an infectious public health claim: one patient may become many. Those patients may be in a position to claim their infections were the direct result of healthcare negligence (or public health failure).

The secondary exposures thus far who have contracted the virus – two nurses who provided care for the primary patient – are hospital employees. It seems likely “exclusive remedy” under the Labor Code applies, and that a tort remedy is not available from the hospital. It remains to be determined if the involved physicians who did not make the diagnosis on the first emergency department visit have a non-employment exposure to the infected nurses.

The list of secondary exposures is long. There are the family members of the primary patient, others that he and his family and friends came into contact with prior to his diagnosis (estimated at 80, none of whom are reported as having symptoms thus far despite reaching the 21 day measure), the two infected nurses, both of whom spent at least a couple of weeks out in public prior to their diagnosis, including a commercial flight by one nurse.

It is easy to see that secondary infections may grow rapidly, causing health facilities to be busy with both infected patients and others who are frightened that they are infected.

The measure of communication in viral infections is Ro, the basic reproduction number. This can be thought of as the number of cases one case generates on average over the course of its infectious period, in an otherwise uninfected population. The Ro for Ebola in the United States is presently 2. Any value greater than 1 means that viral spread has occurred and, in the absence of other data or developments, is likely to continue. A list of Ro for a variety of viruses is below.

At this writing, it seems public confidence in the Centers for Disease Control and Prevention (CDC), perhaps public health broadly, and certainly the Dallas hospital at the epicenter, is rapidly waning. Ro is only one aspect. The low Ro for Ebola seems encouraging compared to the vastly higher Ro for measles or pertussis – but for two factors: the lethality of Ebola given the (current) lack of effective therapy and the new and dynamic outbreak. Note that the century-ago Spanish flu had an Ro 2-3, and yet killed 50 million to 100 million worldwide.

The claims issues with secondary exposures will mainly be a concern if the Ebola secondary exposures are relatively low. If, for example, a worst case scenario occurs with a broader exposure, it seems likely that the claims system will lack the funding necessary to handle the claims. And we are already seeing that hospitals linked to Ebola complications are losing other patients. Should an Ebola outbreak reach numbers sufficient to threaten the infrastructure, Federal government relief is likely.

The most important thing this event has shown us is the need for preparedness and education of healthcare operations. We work every day helping our clients prepare for such events. I would be happy to answer your questions or hear your thoughts on where you see our readiness in the U.S. stands today for a major epidemic.

Jerry Frick, Director, Professional Liability Claims

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Sedgwick recently hosted a webinar discussing Americans with Disabilities Act (ADA) and ADA Amendments Act (ADAAA) compliance, in partnership with Human Resource Executive. There was a high level of interest and employers asked many thought-provoking questions – many of which shared common themes, reminiscent of the early days of Family and Medical Leave (FML) adoption and the development of related policies and procedures. Organizations are dealing with overlapping complex employment issues; ADA/ADAAA compliance continues to be among the top concerns for human resource and risk professionals, particularly when considered alongside other disability and absence issues, including FML, or workers’ compensation requirements.

We compiled a list of the most prominent questions we answered in our webinar, as well as many of the frequently asked questions we continue to hear in the marketplace. It’s likely these may be questions you also have asked when considering your own ADA/ADAAA policies and compliance requirements. Read on and please continue the conversation by asking your own questions in the comments below or via our ADA/ADAAA inquiry form.

Q: What are our obligations under ADA/ADAAA?

The law is designed to be very employee friendly. Its goal is to keep people at work. An employer should make every effort possible – unless it truly creates a significant hardship for their business – to meet a disabled employee’s accommodation request and keep them within the work environment. In the past, prevalent thought may have been, “if we can accommodate, great, but if not, it’s no big deal.” Today, this type of thinking goes against the principles of ADA/ADAAA.

What are an employer’s obligations? The employer is entitled to pursue medical substantiation – is the disability certified and an accommodation appropriate? Then what comes next? If given a medically reasonable accommodation request, the employer is required to pursue the interactive process – engage with the employee to clearly understand the accommodation needed, look for potential options and consider parameters, and monitor that the accommodation is being carried out appropriately and consistently.

Q: ­Can you expand on what constitutes a hardship to the employer? ­

Based on communication from the Equal Employment Opportunity Commission (EEOC), an employer must prove that implementing an accommodation would put them in financial hardship. For a very large employer, there are not many modifications that would be officially seen as impactful enough to incur financial risk. For a smaller employer, major modifications may be more likely to be considered a hardship. Buying a piece of equipment, for example, is not usually going to be considered something that would put an employer into financial risk. Having to redesign the workplace or something of similar significance could possibly be seen as a hardship, depending on the size of the employer.

Truly, the buzzword is “significant” – very major, negative impact must be proven to the finances of your organization for a proposed accommodation to be recognized as a hardship. Especially for larger employers, we’ve seen that this is very difficult to prove under most circumstances, but each situation must be evaluated for specific determination.

Q: How can we protect ourselves from lawsuits?

The documentation proving consistency within the interactive accommodation process is of prime importance. Through the years, loose management and inconsistent accommodation – whether based on personal bias, informal policies, lack of training or other circumstances – has led to legal action for unfair employment actions. Consider an example where an employee is accommodated with generic restrictions. However, if nobody monitors for consistency and then, perhaps after years of working under these conditions, new management comes in and says, “I won’t accommodate that anymore,” the employer would be in compliance trouble. Under the law, if an accommodation has already been made available, it sets a precedent. We see more and more employers paying out large sums of money because, even if they’ve tried to do the right thing, if it’s not well-defined, well-documented and consistency and appropriate action can’t be proven in court, they will still end up in legal trouble.

More lawsuits have brought the compliance requirements under ADA/ADAAA into focus. Litigation is most easily avoided through clear adoption of the interactive process and complete documentation around the steps of this process, from the initial request through conversations taking place, medical records retrieved for substantiation, vocational rehabilitation options investigated, what accommodations have been proposed and/or why accommodations may not be considered reasonable.

While employers should have consistency across their entire organization when it comes to the evaluation process used, this doesn’t mean that every work location will be able to make the same accommodations based on the specifics of their business unit.

Q: ­Does Sedgwick’s platform integrate workers’ comp, FML/leaves of absence, disability and ADA/ADAAA systematically when all elements are overlapping?

One of the keys to reducing risk under ADA/ADAAA is to have standard procedures in place that will trigger the need for an interactive process review. The second key is to use an information management platform to support the accommodation process. Whether or not you utilize Sedgwick’s platform, these keys are critical for ADA/ADAAA compliance.

At Sedgwick, workers’ compensation, disability, absence and ADA/ADAAA are completely integrated so employers can see all of the pieces of the puzzle within one platform. Because of our integrated platform, our clients can look to a centralized source for resources and recordkeeping, and compliance becomes a far easier thing to accomplish.

Q: ­What guidance do you offer regarding prompting conversation with an employee who appears to have a disability but has not approached the employer for an accommodation? ­

Similar to the FML arena, an employee doesn’t have to ask for ADA accommodation. If you know an employee has been impacted by a disabling condition, for example if they have been away under FML or another leave type, we encourage employers to offer language in written communication or a conversation to be sure the employee explores the ADA process. Employers should approach ADA concerns in the spirit of collaboration and think creatively to find ways to accommodate any disability.

Q: ­How long should you extend time after FML has been exhausted?

Once an employer knows there is potential for extended disability-related need upon FML exhaustion, they have a responsibility to educate their employee and explore options under ADA/ADAAA. There’s no official limit on timeframe to allow for conditions that could change; opinions vary on reasonable amount of time – and most often, compliance experts discourage setting hard limits and instead encourage evaluating each situation individually. The employer should be focused on determining whether allowing extra time will ultimately allow their employee to come back into the workplace and return to their job, while also considering whether keeping the position open longer is reasonable.

­Q: How do you suggest we handle situations where we are not able to accommodate an employee in any position after engaging in the interactive process?

If ADA/ADAAA options are explored and the employee can’t remain in the workplace and perform their essential job functions through accommodation, it becomes an employment decision. We often see employers put employees on extended leave – personal leave or another leave type – for a period of time to make sure the condition is not one that can change in the short term. Yet, there may be situations where reasonable accommodation cannot be made and an employee is terminated as the end result. Interpretation is much tighter under ADAAA than was originally intended under ADA, but ADAAA changes did not create an environment where an employee can never be terminated. Collaborate with counsel in any situation where termination of employment is considered.

Q: ­How does an employer accommodate a request for intermittent leave for flare-ups? The employee either exhausted their FML entitlement or is not eligible. ­

Because leave can be a reasonable accommodation, an employee could potentially be eligible beyond their 12 weeks of federal entitlement, and leave as an accommodation could be used on an intermittent basis. It’s important to remember, even under requirements for reasonable accommodation, an employee must still be able to perform essential job functions and productivity levels must be maintained – lowering productivity standards is not a requirement. If someone is constantly away from work and cannot maintain standards, leave as an accommodation is not allowing them to do their job as defined.

The intent of the law is not to change someone’s job duties; for example, moving someone to part-time work/changing their productivity standards is not specifically the intent of ADA/ADAAA rulings but, if available, may be a good solution based on the employer’s circumstances and is not prohibited by ADA/ADAAA.

Q: ­Does Sedgwick’s ADA/ADAAA platform include vocational or ergonomic experts that assist employers in determining potential job modifications? ­

Yes, Sedgwick uses job accommodation specialists who all have vocational rehabilitation backgrounds. When we assist clients with ADA and return-to-work solutions, our job accommodation specialists help with certification, facilitating discussions with physicians to confirm the need for an accommodation, setting expectations with employees and requesting reasonable documentation to evaluate whether they can perform their job with an accommodation. These experts can assist with workplace evaluations to help define the essential tasks of a job and determine which possible accommodations can be made.

Shawn Johnson, SVP Client Services, Disability Administration

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Ebola-graphic-cdcI write this reflecting on the flurry of news around recent Ebola activity. There isn’t one of us in the healthcare risk management profession who wants our organization to be the subject of unfavorable news headlines, and it’s important to take lessons learned and contemplate how to use them to improve safety of our patients, staff and providers.

Based on news reports, the recent initial discharge from the emergency department of the patient in a Texas hospital appears to have been premature. The subsequent information about what data was available in the electronic medical record (EMR) gives the appearance that there was a failure in team communication. I am hopeful that a debriefing of the event by those involved provided insight into processes and teamwork that might be shared forward. This event is another pebble in the pond for risk managers, who now watch the ripples spread as nursing staff panic, public relations practices are challenged and risk managers themselves worry about the effectiveness of their EMR in improving communication across a busy healthcare team.

I put together a short list of steps to take today to assess the temperature of your organization’s preparedness for handling any infectious disease, even an extreme situation such as an Ebola patient presenting to your facility. Patients with highly contagious diseases come through your doors every day; make sure you are ready to respond.

  1. Start by looking at your hospital’s healthcare provider compliance with hand washing policy. Is there room for improvement? If so, you likely also need to partner with infection prevention team members to get short blasts out to staff, reminding them about universal precautions and how to comply with standard, contact and droplet precautions.
  2. Follow this exercise by conducting an inventory of personal protective equipment (PPE) throughout the house to ensure there are adequate supplies for immediate readiness and ongoing care.
  3. Third, reach out to EMS providers serving your community to assess their level of knowledge and readiness, should they be the first responders.
  4. Investigate the ability of your EMR to set custom alerts allowing you to program a series of criteria (i.e. Ebola Virus Disease (EVD) Screening) that, when checked, alert the care team to follow the CDC protocol and huddle as a team to ensure no steps are forgotten.
  5. Meet with your public relations team to review the appropriate participants and process for delivering news at press conferences and to news reporters.
  6. Lastly, if individual messaging has not come to your licensed healthcare providers from your state boards of medicine and nursing about Ebola or other highly infectious diseases outlining recommended protection measures, lobby on your employees’ and the public’s behalf to get these messages out.

Additionally, share these three links to resources that can be quickly accessed to support the healthcare providers in your organization as they increase awareness of Ebola and how to be effective in identifying and caring for affected patients:

What has your organization done to prepare for major risks like a possible Ebola outbreak? Join the discussion by leaving us a comment.

Ann Gaffey, RN, MSN, CPHRM, DFASHRM – SVP, Healthcare Risk Management and Patient Safety

Look for additional perspective on healthcare risk management and professional liability issues in our Professional Liability Risk Resource newsletters and visit our experts at ASHRM booth 425.

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BI-virtual-conference-KG-graphicOn Wednesday, October 8, I will be presenting at the 2014 Business Insurance Workers Comp & Safety Virtual Conference. I certainly hope you will be able to join us for this great event where I will speak about Affordable Care Act (ACA) advancements and opportunities.

At no other point in our history has healthcare evolved at such a rapid pace. Health reform jump-started much needed transformation with healthcare delivery models, technology and consumer awareness. As a result, there is an abundance of opportunity within the workers’ compensation industry to capitalize on new innovations.

There is so much to discuss; I encourage you to read through this preview and start the dialogue by presenting your questions  in our blog’s comments, at the conference or following tomorrow’s discussion by returning to this post or joining the discussion in our LinkedIn group Transforming Healthcare for Tomorrow. Here are some of our key talking points to spark your thought process.

Healthcare delivery models

  • Patient centric – patient-centered care models
  • Physician extenders – care team advancements
  • Accountable care organizations

Digital health solutions

  • Improve access, deliver quality care
  • Expand delivery outside hospital and doctor’s office
  • Anytime, anywhere patient – provider connectivity

Culture of health

American businesses strive to deliver successful customer experiences, improve sales and retain colleagues; creating a culture of heath is one way in which many employers are looking to improve all three. Health policy is driving a higher level of consumer engagement from health plan selection to transparency outcomes data awareness. Likewise, key healthcare stakeholders are focused intensely on patient engagement and advocacy to improve health outcomes. With such emphasis on cultures of health surrounding employees, could workers’ compensation programs benefit from a culture of health model?

We will also look at “claim design considerations” – how you should approach them under the ACA, as well as the opportunities that may present themselves.

As you can see, there is so much to discuss and I can’t wait to exchange ideas on these topics. Please start asking questions now. You can also send me a Tweet @kimberlyanngeo prior to the conference. I look forward to our discussion tomorrow.

Kimberly George, SVP, Senior Healthcare Advisor

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RiskResource-PhysicianRiskBlog100214The rate at which hospitals and health systems are acquiring physician practices and hiring physicians from private practice continues to increase steadily. In the 2012 annual report published by Merritt Hawkins, it is reported that solo practices are disappearing, with projections that by the end of 2014, three in four doctors will work for hospitals.1 Describing the demographics further, Medscape reports more than twice as many physicians under 40 are employed versus self-employed, and more female physicians are employed than male physicians. However, in the age group over 40, more physicians are self-employed.2

This data may not be surprising, but it does lead risk managers to ask how they will manage this additional risk exposure. Along with an already long list of things to accomplish in a day, unfamiliarity with the risk issues related to physician practices can lead to uncertainty and frustration for even the most seasoned professional. Because office practices have variable settings with limited resources, establishing a framework to approach physician risk prior to acquisition or employment helps set the stage for well-structured risk mitigation.

As hospitals consider acquiring practices, there should be many questions running through the minds of organizational leaders, including:

  • Does bringing physicians on as employees into the hospital or system help meet the organization’s strategic goals?
  • Are other systems in the area snatching practices up such that your hospital may not be able to meet the community need for population management?
  • Is the philosophy to employ physicians before somebody else does?

Regardless of strategy, risk management should have a seat at the table early on and preferably before the physician is walking through the door for orientation.

Once the decision is made to pursue a particular physician or group, the following list for “pre-diligence” information gathering should be contemplated as a baseline. A high-level scan can include vetting the physician’s interest in and loyalty to your hospital and, for those already holding medical staff privileges, learning about their reputation among other physicians, staff, patients and community members, learning about the group dynamics and office staff turnover, seeking out satisfaction data in the public domain, conducting public internet searches for tax matters and bankruptcy filings, examining Board of Medicine data and more. As the organization’s interest piques and conversations begin with physicians about acquisition and employment, risk management should be poised and ready to get into assessment mode.

While there are many elements that should be covered during the due diligence process for practice acquisitions, spending time in providers’ offices can offer insight into practices and culture unlike any other due diligence method – an opportunity to maximize early. Having this window to meet and talk to physicians, practice managers, clinical support staff and others in their own space allows risk managers to assess the level of sophistication of office leadership and physician engagement in practice management. It’s not just these important conversations that are helpful with information gathering, but also the opportunity to tour the space, see the condition of equipment and exam rooms firsthand, observe handling of confidential information, assess patient flow and ask more pointed questions.

Once armed with data gleaned from an onsite visit, risk managers can offer risk treatment solutions to address the identified gaps that, when filled, will improve patient safety and reduce risk. One example in the office setting is establishing a clear process to track and report the results of lab and other diagnostic tests. Sedgwick healthcare risk management has established a data profiling system that assigns a risk score to physician offices based on their compliance with best practices. From this profile score, risk management goals can be established that can be objectively measured for increased compliance over time. For those with a self-insurance vehicle for liability coverage, these compliance measures can be used to establish premium credits or surcharges during each liability policy year.

In addition to introducing risk management services and event and claim reporting expectations during the visit, risk managers can assist physicians and practice managers in complying with best practices by providing sample policies and procedures and toolkits, periodic telephone support calls, and by organizing self-audits to monitor compliance with new initiatives. Establishing collaborative relationships with physicians and office staff opens opportunities to integrate relevant practices that are already well-embedded on the hospital side of the business into the office setting. These include practices for release of medical record information, patient identification and specimen management. Education of office staff in basic risk management principles helps extend the risk manager’s reach and empowers staff to engage in proactive activities addressing patient safety in each setting.

It’s important for risk managers to take a holistic view of what to bring to the table to ensure each physician and their office staff members have what they need to function efficiently, safely and in a manner that will ensure the best outcomes for patients in the most cost-effective way. Being accessible as an information resource, planning regular visits to the offices and resourcing risk reduction opportunities identified during the assessment process are practical ways to manage the new risks of employed physicians and acquired practices. A collaborative approach based on sound data metrics and a little mentoring can lead to a win-win partnership.

Read additional perspective on healthcare risk management and professional liability issues in our latest Professional Liability Risk Resource newsletter and visit us to share your own experience at ASHRM booth 425.

Ann Gaffey, RN, MSN, CPHRM, DFASHRM – SVP, Healthcare Risk Management and Patient Safety


References

  1. 2012 Review of Physician Recruiting Incentives: An Overview of the Salaries, Bonuses, and Other Incentives Customarily Used to Recruit Physicians. Found at: http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2012survpreview.pdf
  2. Kane, Leslie. (March 11, 2014) Employed versus Self-Employed: Who is better off? Found at: http://www.medscape.com/features/slideshow/public/employed-doctors
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Voice_ProviderBenchmarkingMedical directors with California-based hospital systems recently met for a discussion focused on the quality of medical care provided to Sedgwick workers’ compensation clients. We covered many areas, including provider scoring, fraud, legal challenges, communication and healthcare innovation.

One hot topic was the Sedgwick approach to the selection of quality in-network providers and the outcomes yielded. The providers in the Sedgwick Medical Provider Network (MPN) have been classified by using a 1 to 5 star ranking with 5 stars representing those with quality outcomes and associated lower overall claims costs. Data and trends have been analyzed for a number of years reaffirming our unique approach to provider selection at the time of injury. As a result, clients who have their injured workers treated by 4 and 5 star providers have experienced an overall claims cost reduction of 61% and a litigation rate that is 46% less than that experienced with the selection of a 1 star provider.

A major initiative based on these results is to educate 1 star providers, giving them industry tools and evidence-based practice recommendations that will impact their ranking and subsequent quality outcomes. Giving the medical director roundtable group a copy of provider rankings and collaborating throughout the year with them helps to improve this educational process.

Additionally, in response to the rising drug spend nationally and the notable long duration of claims in California, Sedgwick’s dedicated Complex Pharmacy Management program – supported by a team of physicians and nurses specially trained in pharmaceutical management – is working directly with prescribing providers. The Sedgwick pharmacy team is engaged in the following:

  • A point of sale off-formulary alert system
  • Creative solutions to weaning from opioids and narcotics
  • Establishing drug testing protocols for suspected diversion
  • Opioid contracts between the injured worker and the treating physician to establish proper medication management

All key components of this program have had a profound impact to date on the overall medical spend and the health and well-being of our mutual patients. Provider prescribing patterns were also changed. Specifically we have experienced:

  • 25% reduction in the morphine equivalent doses prescribed
  • 19% reduction in the book of business pharmacy spend
  • 8% of the medications have been discontinued through alternative options and weaning
  • 11% have been discontinued prior to the next fill
  • 5% of the medications were blocked as unrelated to the workers’ compensation claim

“This sharing of experiences and brainstorming of treatment modalities provides a great depth and breadth of knowledge to our provider community,” states Dr. Teresa Bartlett, SVP, Medical Quality for Sedgwick, “It is our goal to provide a forum for collegial discussion with an end result of quality, impactful outcomes for our mutual injured worker population.”

What are your thoughts on this formula for quality medical outcomes? Learn more by reading our latest provider benchmarking study.

Terri Riley, SVP Managed Care Practices and Client Services