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krista-mangulsone-53122-750x500Oh, how things change… I remember, growing up, the family dog slept outside in a dog house. Today, over 62% of our pets share our bed. Our pets are now considered part of the family  and we hold great emotional ties to them. Jump on a plane and you might see a companion pet in the seat next to you. Go shopping at Nordstrom and you might be sharing the aisle with a four-legged friend. This Thanksgiving, you may be making plans to curl up on the couch to watch the annual National Dog Show on TV with your favorite canine companion. Why? There are many theories on why our pets are now so woven into our lives. I share the theory that, in today’s world where stress is high, work is demanding, and news headlines talk of division and cruelty, our pets offer something that is most difficult to find – unconditional love and dedication.

There is no better example than a pooch named Arthur. If you have a few minutes, take a look at this following inspiring and heartwarming “dog story” from ESPN.

According to the American Pet Products Association, the pet industry has surpassed a whopping $63 billion in spending. 65% of our households own a pet, which is an increase of 10% from 12 short years ago. These are astonishing numbers that increase every year.

What does this all mean? The average annual cost of owning a pet can be in excess of $2,000, and that is without complications. Additionally, our love affair with our pets is translating into astronomical increases in veterinary spending.  Statistics from the American Veterinary Medical Association (AVMA) reveal that in 2016 pet owners spent over $44 million dollars taking their animals to the vet. Costs for some procedures rival that of healthcare. Common ailments such as joint injuries in dogs can cost around $3,480. Removal of foreign objects ingested can average $1,755. Cancer, which is diagnosed in 12 million pets annually, will set an owner back an average of $2,033. However, if an animal is injured or killed due to veterinarian malpractice, the same animal its owners spent thousands of dollars on for treatment is considered almost worthless.

We all know the state of medical malpractice in healthcare, but what happens when something goes wrong with the treatment of your beloved pet? Currently, the majority of courts view pets as personal property and restrict damages to their market value replacement cost, even in the event of proven wrongful death. Until the mid-part of the last century, the term “malpractice” did not even apply to veterinarians (and still does not in some states where the profession is not listed under the malpractice statute). Recently, however, veterinarians have become subject to state malpractice actions. As the value of animals subject to malpractice actions increases from the traditional “market value” approach, it is expected that the number of malpractice claims will increase. To date, most animal medical malpractice cases are settled outside of court and few have won big settlements or verdicts.

Will the law change? The AVMA is set against any change in the law. It threatens rising costs if the law is changed. As to malpractice costs, the AVMA doesn’t collect statistics on veterinarian malpractice suits. The group’s associated Professional Liability Insurance Trust, or PLIT, which offers malpractice insurance for vets, does not release numbers or costs. The mere fact that consumers are spending so much on pet care is directly related to the frustration caused by the absence of equal payment in the event that medical malpractice is sustained. This is the driving force for change in the industry.

There is a growing trend in many states to view animals in a more realistic light and, in response, the veterinary industry is at a crossroads in instituting good risk management. As you can see from the past, there was little financial incentive to engagement of loss prevention and reduction principles. Yet, over the last 20 years, there have been random cases of veterinarian malpractice verdicts and settlements ranging from $10,000 to $75,000. The frequency of cases being brought and those cases resulting in appreciable values is on the rise. A recent case found a court awarding $39,000 for a companion dog after its owner was originally offered a $400 settlement. States such as Florida and Texas are two examples were the law and courts are changing to view pets as more than personal property.

From my personal experience, the number one takeaway in considering veterinary risk management practices is acknowledgment of a failure in the therapeutic undertaking – whatever the cause. Take the example from the progression of risk management and bioethics: disclose and empathize, apologize that the outcome was not as expected. Veterinarians, like healthcare professionals, do not study long and hard and invest energy and resources in developing their practices because they want to do harm; their goal is to help, and when the outcome disappoints, whether because of human error or “fate,” share the experience as one human to another, acknowledging the pain of loss. Empathy and compassion can go a very long way to reduce total loss costs.

In the end, consumers should do the same homework as in any healthcare situation. Research your providers and be aggressive in asking questions. Don’t be afraid to ask for a second opinion. One area that is key is care after surgery. While your surgeon may be the best, the quality of care from technicians after surgery is important to successful recovery. Remember, your pet can’t tell anyone if something is not right!

Tim Over, SVP, Specialty Operations

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The marine cargo industry has changed significantly over the past few decades, especially the way cargo is transported. Before sea containers were introduced, dry cargoes were usually shipped as break-bulk cargo or in bulk. Break-bulk cargo includes items that can be stacked on a pallet or crated, such as steel pipes and coils. Bulk cargo can also be shipped as break-bulk cargo in one- or two-ton bags. Today most break-bulk cargo is shipped in sea containers. Even cargoes traditionally transported on break-bulk ships, such as lumber and steel, are often transported inside sea containers now.

There are several distinct benefits to shipping in containers:

  • Reduced exposure of cargo to physical hazards
  • Easier stowage and securing on ocean vessels and other transport carriers
  • Shorter vessel turnaround time in port
  • Faster and much more efficient shipping across the multi-modal transportation system

Container shipping has a major disadvantage, however. The cargo is not visible once it is inside the container, making it impossible to tell if it is well-packed and secured fcargo-449784_1920-CC0or transport. Those responsible for packing, loading and securing the cargo in the container are the last people to view the cargo before container doors are shut and sealed. Unless the container is damaged or opened for customs inspections, the doors are not usually opened again until the container arrives at its final destination.

Inadequate packing, improper stowage and insufficient blocking and bracing can result in damage to the cargo, the container and the loading/discharge equipment. More importantly, these poor practices can cause serious injury to those handling and transporting the container. Workers in the transport chain have no choice but to rely completely on the skills of those who have packed and loaded the cargo into the container. Incorrect handling puts a number of people at risk, including:

  • Stevedores and dock workers at the load, discharge and transshipment ports
  • Crew members on ocean and inland waterways vessels
  • Road and rail workers
  • Surveyors, customs agents and personnel from other government agencies who may have to inspect cargoes

In addition, the general public is endangered on the roads and waterways by badly packed freight containers.

IMO-LO-UNECEThese safety concerns are addressed by the 2014 IMO/ILO/UNECE Code of Practice for Packing of Cargo Transport Units (CTU Code). The publication was jointly developed by the International Maritime Organization (IMO), the International Labour Organization (ILO) and the United Nations Economic Commission for Europe (UNECE) to mitigate risks through a non-mandatory global code of practice for the handling and packing of cargo transport units for transportation by sea and land.

The CTU Code provides comprehensive information on all aspects of loading and securing cargo in containers, taking into account the requirements of all sea and land transport modes. It is intended to assist employers’ and workers’ organizations, governments and the entire industry with ensuring the safe stowage of cargo in containers.

Regrettably, the CTU Code faces many hurdles, including a lack of training, language barriers and the volume and depth of its information. These issues are exacerbated by dramatic variations in the types of cargo now being carried in containers and the complexities of international supply chains. With the many challenges facing the industry in achieving widespread adoption, we continue to see many truck rollovers, train derailments, cargo spillages and fires and explosions onboard ships and in ports.

Credible statistics are difficult to obtain, in part due to state authorities’ lack of engagement with the IMO’s container inspection standard. However, an attempt was made to estimate the extent of the problem based on the United Nations Conference on Trade and Development (UNCTAD) trade statistics and the results of the relatively few inspections made during the last 15 years. Extrapolating from the UNCTAD data, it is estimated that 24% of inspected containers carrying dangerous goods (DG) were found to be badly packed – approximately 25.9 million containers each year. Considering that the cargoes declared as DG represent only about 10% of all containers, the potential number of improperly packed containers could be significantly higher, posing a threat on their journey through the supply chain.

To ensure the safety of people, equipment and cargo during transport, marine cargo surveyors are often employed to inspect, recommend and ensure that cargoes are adequately packed, loaded and secured inside containers on ships, trucks and other transport vehicles. They are usually familiar with the CTU code and have a wealth of experience with a variety of cargoes.

A coalition of leading cargo industry organizations representing the global supply chain is continuing its campaign for safer practices in packing freight containers and other cargo transport units (CTUs). In a recent meeting at the IMO, the group asked delegates of IMO member states to disseminate the content of the CTU code, as well as encourage and oversee its use within their jurisdictions.

Capt. Ruan Desouza, Vice President, Marine

Vericlaim Canada

References:

International Maritime Organization (IMO) http://www.imo.org/en/Pages/Default.aspx
Global Shippers Forum (GSF)
https://globalshippersforum.com/
ICHCA International
https://ichca.com/
TT Club
https://www.ttclub.com/
World Shipping Council (WSC)
http://www.worldshipping.org/
Chamber of Shipping of British Columbia
http://www.cosbc.ca/index.php/home

 

 

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lightbulb2-redClaims administrators have an invaluable opportunity to help future pharmacists understand the challenges regarding prescription drug use for occupational injuries. A pharmacist intern program, like the one we offer at Sedgwick, can provide excellent experiences for students to gain knowledge from an experienced team of pharmacists and physicians about the safety implications and personal impact of the pharmacy management process – firsthand insight they will carry into their future pharmacy practices.

At Sedgwick, pharmacy students enter the program during their final year before graduation and licensure as Doctors of Pharmacy, and then follow a syllabus prepared by our pharmacists to learn more about the process of providing prescription drug management services. Interns’ clinical rotations are designed to give them exposure to the world of workers’ compensation and claims management. They gain unique, real-life knowledge in a field of medical management many practitioners never get the opportunity to experience. Students work alongside claims examiners and nurse case managers and learn how managed care goes beyond cost savings, aligning resources to confirm the correct diagnosis using evidence-based medicine, and to ensure the patient is following the most beneficial protocols.

Pharmacists examine a claim and check that all medications being provided to the injured worker are appropriate, both in regard to drug choice and dose. They use their clinical knowledge to provide weaning protocols to the prescriber when needed, along with any other appropriate recommendations related to the care of the injured employee. Pharmacists are also a great resource for drug information and literature for clients, claims examiners and nurse case managers. They work closely with all stakeholders – including physicians, nurses and claims examiners – to ensure that the entire team is appropriately educated about medications utilized in workers’ compensation claims and aware of their implications for the patient’s specific needs as they plan recovery management

At the conclusion of the internship, pharmacy students can interpret and prioritize claim data to efficiently and effectively assess the prescribed treatment. They are taught to optimize drug therapy using patient-specific and evidence-based data and evaluate the medication dose. Finally, the appropriateness, evidence-based guidelines and cost-containment situations are considered in the recommendations provided to physicians.

Through our collaborative efforts with each respective university involved in the internship program with Sedgwick, students are able to gain the necessary tools to better understand the complexity of workers’ compensation and the importance of provider and injured employee education for safety. Students also learn to appreciate a collaborative and dynamic prescription drug management approach.

Claims administrators should strive to promote increased awareness about opioids and dangerous drug class combinations. Collaboration with pharmacists is one way we can accomplish this goal. Through exposure and experience, our future pharmacists can be equipped to educate both healthcare providers and the general population about the potential for medication abuse, misuse and addiction. Training the next generation of pharmacy experts will sustain the growing momentum towards improving drug safety in our nation.

Dr. Paul Peak, AVP, Clinical Pharmacy

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https://www.workcompcentral.com/events/awardsAs I think back on the past week, I feel reaffirmed that we are better together. This week, the 5th Annual Comp Laude™ Awards and Gala celebrated the good things our industry does to help those experiencing a workplace injury or illness, just as our dear friend the late David DePaolo, founder of WorkCompCentral, envisioned when he first proposed the annual gathering. I was there five years ago for the first event and, oh my, how things have changed from our small, intimate, one-day gathering in Burbank to this year’s bustling week of sessions, inspirational talks and networking. It is amazing to sit down with competitors and talk about how we can continue to improve as an industry and get people back to living their lives, sharing ideas freely on best practices that benefit the people we interact with on a daily basis.

It was truly humbling to hear about our industry friend Dwight Johnson, the 2016 Comp Laude People’s Choice Award winner, who passed away earlier this year, but inspired so many. His son, who is attending college thanks to a Kids’ Chance scholarship, reminded us that our support is vital to improving the lives of others. Kids’ Chance, a charity dedicated to providing educational opportunities and scholarships for the children of workers who are seriously injured or killed, also shared incredible stories of other young people who are going to make a difference in the world because of the scholarships they receive. The organization’s biggest need is actually to find students who need scholarships. It is important for those in our industry to continue to support Kids’ Chance and more broadly share the availability of its resources.

During the Comp Laude event, we also stood as a group and applauded five injured workers who were honored for overcoming profoundly difficult circumstances and showing courage as they go about life with a “new normal” and changing the lives of others for the better. Their stories were uplifting and inspiring, and we were all motivated after hearing them speak about those in the claims industry who had helped in some way along their journey toward recovery and health.

There is still much work to be done in our pursuit of helping those in need – we all agree on that. Many smart people within our industry are constantly looking for ways we can, and will, keep innovating – attorneys, judges, TPAs, vendors, doctors, nurses – the list goes on, representing those who truly care about people and passionately strive to be there at the moment when a person unexpectedly experiences an injury or illness on the job.

I encourage you to become involved, both at work and in your community, to show that we are better together. Be the change. Help others understand what you do and then find collaborative ways to show how caring counts within our industry and in your daily lives. And consider coming to San Diego next year for Comp Laude to experience a few days of celebrating achievements, making new friends, making a difference, and keeping David DePaolo’s dream alive.

Jonathan Mast, Social Media Director, Sedgwick

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Sedgwidrugs-takeback-1017ck routinely reminds clients and colleagues about the U.S. Drug Enforcement Administration’s (DEA’s) National Prescription Drug Take Back Days. The next Take Back Day will be this Saturday, October 28 from 10 a.m. – 2 p.m. In 2010, the DEA started organizing communities and local law enforcement to work together for safe disposal of prescription drugs in an effort to keep unnecessary and potentially hazardous or deadly prescription drugs out of homes and neighborhoods. The Take Back initiative is one of several tactics under the Secure and Responsible Drug Disposal Act of 2010. The Act was passed to help reduce and diversion throughout the U.S. and curtail the opioid epidemic.

Since then, communities nationwide have safely disposed of millions of pounds of unwanted prescription drugs. According to the DEA, the April 2017 Take Back Day resulted in the disposal of more than 900,000 pounds of medications.

If you have unwanted drugs, then you can help. The disposal service is completely anonymous and there is no charge for disposal. Contact the DEA’s call center at 800.882.9539 or check the DEA’s website for your local collection locations.

The service is a simple way to make our communities safer, including children and pets that could be harmed or killed by consuming medication not intended for them or discarded in an unsafe manner. We appreciate everyone’s participation.

Dr. Reema Hammoud, PharmD, BCPS, Director, Clinical Pharmacy

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Fostering awareness in the complex world of prescription drugs

It is vital for a claims administrator to have pharmacists on staff because the current reality in workers’ compensation injury care is that prescription drug activity is a dangerous and highly complex business. There are many reasons the system is prone to failure:

  • Providers balance large numbers of patients
  • Physicians and patients can be incentivized by profit motives
  • Opioid use disorder, misuse of opioid medications, is an increasing diagnosis
  • Providers have inconsistent communication protocols and disconnected operating systems

Systematic indicators are necessary to consistently alert a pharmacist employed by the claims administrator when a prescription is not a fit for the diagnosis or if it is not a fit for the acute or chronic stage of the injury. Also, automated indicators are necessary to connect the pharmacist to a claim that has multiple prescribers, adverse drug combinations or unsafe dosages.

Pharmpharmacist-claim-freepikacists routinely established in claims management practices act as sentinels, identifying multiple prescribers, dangerous combinations of medications, polypharmacy and unsafe dosages. They raise and sustain awareness among the prescribers, patients, claims examiners and nurse case managers involved in claims.

For injured workers with long-term prescription drug use, pharmacists develop and individualize weaning plans and help facilitate tapering protocols by working with prescribers. They work alongside an interdisciplinary team to ensure safe and successful tapering of not only opioids, but other medications that may have withdrawal potential. Pharmacists also help identify drug-drug and drug-disease interactions in the claim profile and also against the injured employee’s  personal medical history.

Pharmacists play a pivotal role in prescriber and injured worker education regarding drug safety. The pharmacist’s input will drive the optimal outcome for an independent medical examination needed on a claim that includes prescription drug use.

Physician/pharmacist collaboration

Physicians and pharmacists working together on claims administration programs should be organized to facilitate collaboration and effective application of their respective skills for prescription drug management.

Pharmacist intervention can include:

  • Discuss medication-related issues with the treating provider
  • Discuss long-term usage of dangerous opioids, benzodiazepines, muscle relaxers and hypnotics
  • Discuss state-specific guidelines regarding opioid doses (morphine equivalent doses/MED), opioid monitoring and combinations of controlled substances
  • Develop weaning protocol based on guidelines and patient status
  • Work with the provider to safely wean the patient off of medications in order to avoid withdrawals or relapse

MD intervention can include:

  • Discuss patient’s occupational and non-occupational diagnoses
  • Discuss treating physician’s current treatment plan and recommendations
  • Discuss opioid monitoring tools such as urine drug screens
  • Make recommendations for improved patient safety and monitoring

Real-life application of pharmacy expertise

A claim was referred to a staff pharmacist because of increasing morphine dosage levels in the injured worker’s prescriptions. As the MED rapidly escalated, the injured worker experienced an increasing level of pain and was convinced that the pain would never decrease. He was being treated by four different specialty physicians and at times had his refills authorized by a receptionist without professional consultation.

The pharmacist was assigned, she reviewed the case and reached out to all of the injured worker’s prescribers, quickly contacting all but one. Two of the physicians were unaware of employee’s medication fill history and another one continued care from the previous provider. Through a series of physician outreach attempts and multiple peer-to-peer consultations, full awareness was achieved and a uniform treatment plan was created for the patient. Within months after implementation of the treatment plan, this individual was weaned from dangerous medications and the remaining medications were maintained at safe dosages. He also reported a decrease in pain intensity and there was an overall improvement in his psychosocial behavior.

Conclusion

A successful pharmacist intervention identifies unsafe areas, educates stakeholders, enables awareness, partners with the claims examiner and any assigned nurse case manager, and establishes a plan to wean an injured worker from unnecessary or unsafe prescription drugs, helping return them to a healthy, productive life and activity in the workplace. In today’s complex workers’ compensation environment, the pharmacist’s role is a necessity.

Dr. Reema Hammoud, PharmD, BCPS, Director, Clinical Pharmacy 

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communication-freepikOne of the most profound lessons I learned from implementing a workers’ compensation alternative dispute resolution (ADR) program was how employers could use a simple process to help reduce their litigation rate.

As I’ve seen in my own experience as a risk manager in California, ADR programs are designed to totally eliminate litigation by negotiating workers’ compensation benefits and the dispute resolution process between the employer and its unions.

In one specific case I encountered, even though the unions were not encouraging litigation, some employees still retained the services of an attorney. To find out why, we asked our ombudswoman to call every injured worker who had attorney representation and ask why they got an attorney.

The response surprised me. 100% of respondents said they got an attorney because they had not been contacted by their frontline supervisor and they were worried about their status within the company and their job.

Though our claims administration policies included a call to the injured worker from both the claim examiner and the ombudswoman (to explain the ADR program and the benefits), we had no process in place to encourage the frontline supervisor to remain in contact with the injured worker.

Some frontline supervisors do not realize the profound positive impact they can have on their employees. I believe many frontline supervisors do not remain in contact with injured employees because the workers’ compensation claims administration process is not designed to encourage that interaction. Supervisors can be uncomfortable trying to discuss a mysterious system that is expensive and complex. They also may be unsure of what they are allowed to discuss with the employee, out of concern for medical privacy.

Based on my own ADR program study, I believe employers can help reduce their litigation rate if they encourage their frontline supervisors to remain in contact with employees after an industrial accident and coach them on appropriate interaction.

The most important aspect of the process is to send the message that the employee is valued, respected and wanted back at work. Supervisors do not have to be workers’ compensation experts; they should convey a sense of care and a willingness to keep the employee connected to their team.

Frontline supervisors may consider using questions and statements like these:

  1. How are you feeling?
  2. We miss you and the good work you do!
  3. We are having our holiday party; if you can attend we would love to see you. Do you feel up to coming by to participate?
  4. If you have any problems or concerns please call me and let me know so I can get the right person to help.

If problems or issues are identified, the information should be immediately conveyed to the claims examiner for action.

In workers’ compensation claims, sometimes the smallest gestures can make the biggest impact. Don’t forget to show injured or ill employees how much caring counts by encouraging frontline supervisors to maintain a sense of connection and support throughout the recovery and return to work process.

William Zachry, Senior Fellow, Sedgwick Institute

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In recent years, some innovative healthcare leaders and organizations have developed and implemented formal communication and resolution programs (CRPs) that, when combined with advances in patient safety, exemplify fairness and build trust. The intent of CRPs is to lower malpractice costs and maintain patient trust in the healthcare system.

One program in particular, implemented by the University of Michigan Health System, is multifaceted and involves not only open communication about adverse events but also the following (1):

  • A critical investigation of the event to determine if the care provided met the standard of care and was reasonable under the circumstances
  •  An apology to the patient
  • Early offer of compensation or settlement, when the care fell below standard or was deemed not to have been reasonable.

Known as “The Michigan Model,” the UMHS program has reported success in reducing malpractice claim costs. An important aspect of this model is the critical investigation by the risk management department at UMHS that leads to a multidisciplinary committee review of the event (or claim) to determine whether the care provided was medically reasonable and if the care had an adverse effect on the patient’s outcome. The event may or may not be referred to peer review, but it is always evaluated for learning opportunities and quality improvement so as to prevent a similar event from occurring again. ASHRM has described a model with similarities in regard to classification and culpability decision making about preventable harm events. [See: ASHRM. Serious Safety Events: A Focus on Harm Classification: Deviation in Care as Link. Getting to Zero™ White Paper Series — Edition No. 2: ashrm.org/pubs/files/white_papers/SSE-2_getting_to_zero-9-30-14.pdf]. It is important to note that the outcome of the investigation is communicated to the patient. When the care was deemed to meet the standard of care and to have been reasonably provided, no compensation is offered and, if a claim is brought, the care is rigorously defended.

Other factors favorable to the success of the UMHS program is that under Michigan law there is a six-month waiting period before the patient can file a lawsuit. This provides time for the investigation and committee review to take place. Also, the committee’s review of the event is protected from legal discovery in that state.  After several years of refinement, UMHS reported a claims rate more than 25 percent lower after implementation of its program and a decrease in average monthly cost rates for total liability, patient compensation and non-compensation related legal costs (2).

However, limitations cited for the Michigan Model’s results include that the state of Michigan enacted malpractice reform with caps on noneconomic damages, a six-month mandatory pre-suit notice period and certain expert witness requirements that resulted in an overall reduction in malpractice claims statewide during the UMHS study period.(3) In addition, UMHS is a well- resourced, closed health system that employs its physicians and owns its own captive insurance company—giving it a degree of control over its providers and liability program operations that many healthcare organizations do not have.

CRPs: Successes and Challenges
Two different types of CRPs have evolved. One, an early settlement model, such as the Michigan Model, and another, a limited reimbursement model, which is much more limited in scope with payouts not exceeding a modest amount such as $30,000 to cover out-of-pocket expenses, daily loss of time and sometimes write-off of medical bills. With the limited reimbursement model, patients do not waive their right to sue, as they do with early settlement. (4)

While most, if not all healthcare organizations have implemented disclosure communication following medical error, there are few published reports about organizations that have implemented either type of resolution program or the effects of the programs on malpractice costs.  An exception is a Colorado malpractice insurance company COPIC and its limited reimbursement program called the 3Rs program — Recognize unanticipated events; Respond soon after the event occurs and Resolve any related issues.  After its first five years in existence, COPIC’s 3Rs program reportedly had a 50 percent drop in malpractice claims against its insured physicians and a 23 percent reduction in claim settlement costs. (5)

One reason for the dearth of published reports of cost savings with CRPs programs may be that CRPs take several years to fully implement and even more time to determine the program’s effectiveness in reducing malpractice claims costs. Even the UMHS program took seven to 10 years to demonstrate cost savings or a reduced rate of cost increases over time. However, programmatic results from early CRPs adopters offer some insights into success factors as well as barriers to implementing an effective CRP. Researchers that studied CRPs reported the following factors contributing to their success (6)

  • Executive leadership support and a key champion who is passionate about making the CRP work
  • Dedicated human, educational and system resources
  • CRP design based on the organization’s structure, culture and needs
  • Knowledge about regulatory compliance such as reporting requirements for the National Practitioner Data Bank and state medical/licensing boards
  • Readiness for gradual but transformational culture change that takes place over time in order to reap returns on investment in a CRP.

Other investigators of disclosure, apology and offer programs reporting on barriers and strategies for broad implementation offered several insights on CRPs. Although focused on Massachusetts, findings may apply in other states. The following are some of the key barriers to CRPs with possible solutions to overcome them. (7)CRP-barriers-solutions

Summary
Seventeen years after the IOM report on medical errors and institution of accreditation standards requiring communication of unanticipated outcomes to patients, the logical next step of compensating injured patients fairly and without undue delay when medical care falls below standard or was not reasonable under the circumstances has not been widely achieved. To date, there is limited evidence for the return on investment in CRPs, even with the positive results shared by UMHS about its early settlement model and by COPIC about its limited reimbursement model.

In today’s rapidly evolving healthcare environment, the need to demonstrate value in terms of safety and quality has never been more apparent. As payment for healthcare services based on performance increases, better outcomes become the expectation for patients and health insurers. Informed and engaged patients demand transparency as well as restitution when medical errors result in harm. As barriers are overcome, adding offers of fair compensation to disclosure and apology through formal CRPs, when care is deemed not reasonable or substandard, could ultimately become the norm. In 2017, the Agency for Research and Quality published the CANDOR toolkit (Communication and Optimal Resolution) to assist healthcare organizations in implementing CRPs (ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html). Risk managers are poised to take a leadership role in achieving safe and trusted healthcare and CRPs offer a structure and approach to work to that end.

Originally published in the ASHRM Forum newsletter, June 28, 2017: https://forum.ashrm.org/2017/06/28/communication-and-resolution-programs-where-are-we-now/ 

  1. The Michigan Model: Medical Malpractice and Patient Safety at UMHS. Retrieved from: http://www.uofmhealth.org/michigan-model-medical-malpractice-and-patient-safety-umhs
  2. Kachalia A., et al., (2010, August 17). Liability claims and Costs Before and After Implementation of a Medical Error Disclosure Program. Annals of Internal Medicine; 17; 153(4):213-21.
  3. Ibid.
  4. Mello, MM., et. al. (2014, January). Communication and Resolution Programs: The Challenges and Lessons Learned from Six Early Adopters. Health Affairs; 33(1):20-29.
  5. Boothman, RC, et. al., (2009, January).A Better Approach to Medical Malpractice Claims? The University of Michigan Experience. J Health Life Sci Law; 2(2):125-159.
  6. Ibid.
  7. Bell, SK, et. al. (2012). Disclosure, Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation. The Milbank Quarterly; 90(4):682-705.

Kathleen Shostek, RN ARM FASHRM CPHRM CPPS, is vice president, Healthcare Risk Management, Sedgwick

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lightbulb3-orangeOver the past several months there have been direct communications from the Centers for Medicare & Medicaid Services (CMS) that liability Medicare set-aside arrangements (LMSAs) were on the horizon. In this blog we commented on a February announcement from CMS to providers about LMSAs. In the middle of September, CMS released another notice to providers reminding them that Medicare beneficiaries must make out-of-pocket payments for services if they had a workers’ compensation MSA (WCMSA) or a LMSA. These were both strong indicators that a formal LMSA announcement was right around the corner.

Through our membership in the Medicare Advocacy Recovery Coalition (MARC), we were able to communicate with CMS that the LMSA rollout was premature. MARC was able to secure a meeting with CMS senior leadership in late September. We are thankful to CMS for not only having the meeting, but also listening to our concerns and recommendations. Several positives were achieved, including:

  1. CMS rescinded the September communication days after the MARC meeting
  2. CMS stated that no formal LMSA communication is imminent
  3. CMS will honor a promise it made to MARC in 2016 that it will confer with the industry before implementing any formal LMSA communication

A big thank you to our leadership at MARC and CMS leadership in reaching a consensus on the status of LMSAs. We will continue to share updates with our clients and partners as the move toward LMSAs progresses. In the meantime, please reach out to us with your questions.

Michael R. Merlino II, ESQ.
SVP of Medicare compliance and structured settlements

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Methadone is an opioid medication most commonly used for detoxification, maintenance treatment of opioid addiction, and limited use for chronic pain. The drawbacks to its use stem from the risk of addiction and abuse with the medication, even at recommended doses. Alarmingly, the Centers for Disease Control and Prevention (CDC) found that methadone is responsible for 30% of all opioid overdose deaths, despite the fact that it only accounts for 2% of opioid prescriptions. [1] Why are we seeing this trend and what can we learn about methadone’s risk july_overdose_pic08_580pxfactors to help increase awareness and patient safety?

Methadone has complex pharmacokinetics which results in a significantly longer half-life. The way it is processed by the body makes its pain relief duration much shorter than the length of time the drug remains in a person’s system. This requires the dosing three times a day, making the drug’s concentration build up in the body at a faster rate. The chronic dosing of methadone causes it to accumulate in the patient’s tissues, taking longer for the drug to be eliminated from the body and causing the tissue to slowly release methadone into the blood. This also makes the morphine equivalent dose of methadone increase at an exponential rate as subsequent doses are taken.

In a claim recently referred to Sedgwick’s clinical team, a patient was utilizing methadone for chronic pain. The patient was also taking Xanax for anxiety, oxycodone for breakthrough pain, gabapentin for neuropathy and cyclobenzaprine for muscle spasms. Individually, these medications might not draw alarm, but when we look at the therapy as a whole, there is great cause for concern. Along with the many adverse events that can be posed by methadone’s kinetic properties, methadone is associated with multiple drug interaction issues, due to it being metabolized extensively by liver enzymes. Using methadone in connection with alcohol, benzodiazepines (Xanax), antidepressants, barbiturates and other opioids (oxycodone) puts the patient at high risk for drug-related adverse reactions, such as respiratory and central nervous system (CNS) depression. The U.S. Food and Drug Administration (FDA) issued a “black box” warning in the summer of 2016, alerting physicians and patients against the combined use of any opioid and benzodiazepine due to the serious risks associated with their use.

Drug interactions are not the only thing we have to consider when dealing with methadone. The patient’s comorbidities can also pose complications. In the same case as noted above, the patient has sleep apnea, high blood pressure and is a current smoker. The drug interactions for the patient alone put them at risk for respiratory depression, but when mixed with comorbidities of sleep apnea and smoking, the risk for a negative outcome is far greater. Other comorbidities, such as cardiovascular disease, contribute to potentially fatal consequences, including CNS and respiratory depression, and cardiovascular effects such as swelling and QT prolongation, impacting heart attack risk.

This patient’s case may seem to be an outlier due to its complex drug interactions and comorbidities, but this is actually a common occurrence with patients escalated to methadone. Even with the dangers of methadone, it is becoming more popular to treat pain, partially due to its inexpensive cost compared to other opioids. Caution should be exercised when dealing with this medication, as there are clearly many variables that need to be examined to ensure the patient’s safety.

Dr. Andrew Newhouse, Sedgwick pharmacist

Reference:

  1. Trends in Methadone Distribution for Pain Treatment, Methadone Diversion, and Overdose Deaths — United States, 2002–2014 CDC / Morbidity and Mortality Weekly Report / July 8, 2016 / 65(26);667–671