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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 We received confirmation that CMS granted the request and has, in fact, withdrawn the proposal concerning liability MSAs.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

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James-Worthy-SpeechLast week at the California Workers’ Compensation and Risk Conference, we were fortunate to hear James “Big Game” Worthy, NBA Hall of Fame member and three time NBA champion, deliver the keynote address. The standing-room-only crowd was treated to a motivating message about how teamwork, leadership, talent development and management, and ego management are key ingredients to winning NBA championships, but it also applied to our industry and likely all others. As an industry, we deal with all of these issues every day as we handle claims, attract and develop employees, and try to improve our industry by working together. When we have great examiners handling claims, the industry working together to ensure the system is balanced, and we deliver timely and effective benefits to injured workers while maintaining a sustainable and cost-effective system, workers’ compensation is a win-win for everyone.  The following were Mr. Worthy’s key points on what a team is really all about.

  1. Buy into the philosophy

Teamwork is essential in the workplace no matter how talented your individual team members are. Without teamwork, your workforce is going to face high turnover and lack of satisfaction in  everyday responsibilities.

  1. Be a good listener

You have to be a good listener. It is important to receive the information you are given, gather your data and then take action. Listening allows you to learn to follow before you lead.

  1. Your superstar doesn’t always have to take the winning shot

Everyone on a team is a valuable contributor. Your superstar does not always have to be the one you turn to for that important project. You have to trust each team member to be the best at whatever role they play on the team. Sometimes your superstar has to step aside and let someone else step up. You never know – they might become the next Michael Jordan.

  1. Teamwork is about talent

We have to recognize what our platform is in the organization – it’s there for a reason. You are obligated to give back and raise those around you to help meet the bottom line. Magic Johnson was a great example of someone who could will the best out of his teammates. Refusing to accept mediocrity from those around us becomes contagious to the team.

  1. How to resolve conflict

You don’t have to like everyone you work with on the team to succeed. Even if you are a superstar, you still have to fall in line with the team or there will be conflict. Disconnected talent will fail in the end; communicating and showing respect to your team is very important. The Lakers relied on the “circle of communication” where everyone had to share their thoughts no matter if feelings were hurt. Participation by everyone was the first step toward success. The second important thing was hearing from the “12th man” – the fans and commentators who brought important insight by saying things the superstars didn’t see.

  1. Everyone deserves your time

If you are a leader, you must make time for everyone on your team. When you don’t listen, you demoralize your team. Mr. Worthy said his mother taught him that everyone can make time for everyone. Never discount what your team has to say when it comes to reaching your objectives.

What makes your team successful?

Darrell Brown, Chief Performance Officer

Sedgwick was pleased to sponsor Mr. Worthy at this year’s conference.

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RiskScenLogo_White_504x87

 

 

More and more, our clients and other risk managers and human resource directors in the industry ask how they can ensure compliance with the Americans with Disabilities Act (ADA/ADAAA). Sedgwick has sponsored the latest Risk Scenario, produced by Risk & Insurance magazine, which highlights the issue in a “real-life” way. This fictional story shows the potential repercussions of ADA/ADAAA non-compliance and offers some helpful suggestions for putting the right processes in place.

Additionally, Sedgwick recently addressed ADA/ADAAA challenges in more detail during an educational webinar in partnership with Human Resource Executive magazine. Read below for the full Risk Scenario and click here to view our recorded webinar discussion.

Darryl Hammann, EVP Disability Operations

The Scales of Justice

RiskScenario-ScalesOfJusticeTwo employee injuries at national grocery chain Better Harvest produce two very different outcomes. Cheerful and boisterous fish cutter Frankie Burns, who works in the Boston store, injures his back on the job. Testing reveals that he aggravated a chronic degenerative back condition and he is accommodated by his store’s GM under the Americans with Disabilities Act, per company policy.

Hector Velasquez is a fish cutter in Better Harvest’s Brentwood, Calif. store. While out dancing with his girlfriend, he takes a critical misstep and injures his back. He misses a few days of work and is in substantial pain but eventually returns, worried about bearing medical costs he cannot afford.

Velasquez starts a steady diet of ibuprofen and light beer to help him perform his job but when that is not enough, finally reports his injury to the store’s GM, asking for ADA accommodation.

The response from the Brentwood general manager is much different than the well-documented accommodation efforts made for Frankie Burns in Boston. Velasquez is accommodated and then terminated after 90 days.

Soon after, Hector finds a good employment rights attorney, who reaches a substantial settlement with Better Harvest over violations of its company policy and federal guidelines.

Read the full Scenario >

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When I began discussing medical marijuana as an emerging workers’ compensation issue more than five years ago, it had only been legalized in 12 states. In 2012, Colorado and Washington legalized the sale of marijuana for recreational use. Today, 23 states and the District of Columbia have since legalized medical marijuana with Maryland, Minnesota and New York enacting laws this year.

Legalization-of-medical-marijuana-ig0914
Eleven states passed laws this year that provide limited access to marijuana products with low tetrahydrocannabinol (THC) and high cannabidiol (CBD). In most of these states, the marijuana product is only available to patients with debilitating epileptic conditions.

In May 2014, in the case Vialpando v. Ben’s Automotive Services, the New Mexico Court of Appeals upheld an order by a workers’ compensation judge that required an employer and its insurance company to reimburse an employee for medical marijuana. It will be interesting to see the precedential value of this particular ruling, however. The employer argued that because marijuana is a controlled substance under federal law that reimbursing its use would essentially cause it to commit a federal crime. The court claimed that the employer did not cite a particular statute it was forced to violate and stated that the court would not look for one. It is probably safe to say that attorneys for employers and insurers will be careful to include this in the future.

Several other states have marijuana initiatives on the upcoming November ballots. If passed, Alaska, District of Columbia and Oregon would allow people age 21 and older to possess small amounts of marijuana and plants for recreational use. The Florida ballot initiative to be decided by voters on November 4, 2014 would legalize medical marijuana for debilitating medical conditions.

The rapid pace of change in state marijuana laws that currently contradict federal law continues to be a source of confusion in this fast-evolving national debate; additionally, there has been activity surrounding the topic within the federal government over the past year. In an interview published January 27, 2014 with The New Yorker magazine, President Obama said that while marijuana is a vice, a waste of time and not very healthy, it is no more dangerous than alcohol.

In May 2014, the U.S. House of Representatives voted 219-189 in favor of an amendment to prohibit the Drug Enforcement Administration (DEA) from investigating, prosecuting and incarcerating those who comply with state medical marijuana laws. This may be the most significant indicator this year of the change in public opinion regarding medical marijuana. There is currently no change in federal law, however, because the amendment – added to HR 4660, the Commerce, Justice, Science and Related Agencies Appropriations Act – has not passed the Senate. Interestingly, the language in the amendment that passed had been previously offered seven times since 2003.

In August 2013, the U.S. Department of Justice (DOJ) updated its federal marijuana enforcement policy that marijuana remains an illegal drug under the Controlled Substances Act (CSA) and that federal prosecutors will continue to enforce this statute. The announcement further indicated that the department would continue to rely on states and local law enforcement agencies to address lower-level marijuana activities by enforcing their own narcotics laws; the DOJ also informed the governors of Colorado and Washington that it was deferring its right to challenge their legalization laws at this time.

There have been multiple attempts to reclassify marijuana under the CSA schedule over the years. Most recently, the Americans for Safe Access petitioned the DEA to reclassify marijuana; the request was rejected, stating a lack of FDA-quality clinical trials confirming the drug’s value in treating medical conditions. Claiming the DEA ignored hundreds of peer-reviewed studies demonstrating marijuana’s efficacy, the Americans for Safe Access sued to overturn the agency’s decision. In January 2013, in Americans for Safe Access, et al v. DEA, the United States Court of Appeals for the District of Columbia Circuit upheld the DEA’s action. In October 2013, the United States Supreme Court rejected a petition to review the ruling.

Given the new report on the dangers and consequences of marijuana abuse, published by the DEA in May 2014, it does not seem likely that this agency will agree to reclassify marijuana in the near future. The report states, “Organizers behind the medical marijuana movement did not really concern themselves with marijuana as a medicine – they just saw it as a means to an end, which is the legalization of marijuana for recreational purposes.”

Whether research such as a multi-institutional study led by researchers at University of Pennsylvania’s School of Medicine will change the DEA’s current position is yet to be seen. In August 2014, a study published in JAMA Internal Medicine found that medical marijuana laws are associated with significantly lower state-level opioid overdose mortality rates; although, it is noted that further investigation is required to determine how medical marijuana laws may interact with policies aimed at preventing opioid analgesic overdose.

In the meantime, the largest paper in the nation has joined the discussion. In July 2014, the editorial board of The New York Times called for the federal government to repeal the ban on marijuana, comparing it to the prohibition of alcohol. What do you think?

Staying informed and developing a company policy to address the use and reimbursement of medical marijuana for on-the-job injuries is important. Are you prepared for legislative changes or an adverse decision like the one in New Mexico? How will changes to marijuana laws impact where you live or your business? Make your voice heard on this issue.

Darrell Brown, Chief Performance Officer