Page 1








Specialized Offerings. Public Entity Expertise. BITCO Insurance Companies1 Old Republic Aerospace2 Old Republic Specialty Insurance3

Old Republic Insurance Group offers a full suite of risk management and insurance solutions, and Third Party Administration (TPA) services, with specialized offerings and expertise to meet the unique needs of public sector clients.

PMA Companies3


Insurance contracts are underwritten and issued by: 1. BITCO General Insurance Corporation and BITCO National Insurance Company; 2. Old Republic Insurance Company; 3. Pennsylvania Manufacturers Association Insurance Company, Manufacturers Alliance Insurance Company, Pennsylvania Manufacturers Indemnity Company.

AUGUST 2018 | Volume 34, No. 7 | www.primacentral.org


The Public Risk Management Association promotes effective risk management in the public interest as an essential component of public administration.

PRESIDENT Jani J. Jennings, ARM Risk Manager City of Bellevue Bellevue, NE PAST PRESIDENT Amy J. Larson, Esq. Risk and Litigation Manager City of Bloomington Bloomington, MN PRESIDENT-ELECT Scott J. Kramer, MBA, ARM County Administrator Autauga County Commission Prattville, AL DIRECTORS Brenda Cogdell, AIS, AIC, SPHR Risk Manager, Human Resources City of Manassas Manassas, VA Forestine Carroll Risk Manager Memphis Housing Authority Memphis, TN



Meet Jennifer Hills, ARM-P, CRM By Jennifer Ackerman, CAE

Sheri Swain Director of Enterprise Risk Management Maricopa County Community College District Tempe, AZ Donna Capria, CRM, CIC, AINS Risk & Insurance Coordinator WaterOne of Johnson County Lenexa, KS Michael S. Payne, ARM, HEM Risk Manager City of Fresno Fresno, CA Melissa A. Steger, MPA Asst. Director, Workers’ Compensation University of Texas System Austin, TX NON-VOTING DIRECTOR Marshall Davies, PhD Executive Director Public Risk Management Association Alexandria, VA EDITOR Jennifer Ackerman, CAE Deputy Executive Director 703.253.1267 • jackerman@primacentral.org ADVERTISING Jennifer Ackerman, CAE 703.253.1267 • jackerman@primacentral.org

Self-Driving Cars:




16 Telemedicine and Workers’ Compensation

By Fernando Branco, M.D., FAAPM&R

Public Risk is published 10 times per year by the Public Risk Management Association, 700 S. Washington St., #218, Alexandria, VA 22314 tel: 703.528.7701 • fax: 703.739.0200 email: info@primacentral.org • Web site: www.primacentral.org Opinions and ideas expressed are not necessarily representative of the policies of PRIMA. Subscription rate: $140 per year. Back issue copies for members available for $7 each ($13 each for non-PRIMA members). All back issues are subject to availability. Apply to the editor for permission to reprint any part of the magazine. POSTMASTER: Send address changes to PRIMA, 700 S. Washington St., #218, Alexandria, VA 22314. Copyright 2018 Public Risk Management Association




72 happy children playing during recess. 24 busloads of students dropped off. 7 drinks spilled at lunchtime. 1 energy-packed elementary school day.

BETTER UNDERSTOOD BETTER PROTECTED™ Tailored coverage as unique as your business. As the #1 preferred business insurer,* we listen carefully to your unique needs and tailor coverage and services to fit them. To learn more, talk to your broker or visit libertymutualgroup.com/businessprotected.

Commercial Auto


General Liability




Workers Compensation

*Based on 2018 survey of business insurance buyers on preference of national carriers sold via independent agents. Š 2018 Liberty Mutual Insurance. Insurance underwritten by Liberty Mutual Insurance Co., Boston, MA, or its affiliates or subsidiaries.


ummertime is in full swing and the hot temperatures bring back memories of cut-offs, flip flops, baby oil and tan lines. I had the coolest job in town at 16. While other friends my age were sweating and laboring de-tasseling corn, I was twirling my whistle and walking the beat as a lifeguard at the city pool. This dream job was how I spent four summers, but I never took lightly the responsibility I shared in keeping swimmers safe, especially the little swimmers. Sadly, drowning happens to be the leading cause of death for young children five and under and the second leading cause of death for people age 5–24. Years ago, the biggest distraction to the girls on the lifeguard stands were the high school football players who would make their daily visit to cool off in between their “two-a-days.” Today, there are a whole new set of distractions facing our young lifeguards. In an age when everyone seems permanently attached to their smart-phones and multitasking is the rule rather than the exception, risk managers face a tremendous challenge to ensure swimmers, young and old, are given the attention they deserve. How many of us have listened to a heartbroken parent on the news say, “I only looked away for a second?” The problem with text messaging is that even a split second could cost a swimmer his life. It’s been labeled the Head Down Dilemma. Reading or sending texts always require you to take your eyes away from the pool. Some time ago, a Dartmouth swim team member was exercising in a Florida YMCA pool while on vacation with his family and attempted four laps across the pool without taking a

Summer brings warm, beautiful weather, outdoor activities and family fun. Let’s work this summer to keep all those families safe when it comes to family fun at our swimming pools.


Hot Fun in the Summertime

breath. Unfortunately, he was not successful. His sister noticed him motionless on the bottom of the pool and alerted a lifeguard but it was too late. The swimmer had experienced shallow water blackout, an extremely dangerous phenomenon that tends to happen to strong, experienced swimmers who are trying to push themselves to the limit. Essentially the swimmer’s brain doesn’t tell them to breathe when they need to and they pass out underwater. It is concerning the swimmer’s sister had to notify a lifeguard that he stopped moving and heartbreaking that his life ended so tragically.

• Empower patrons and other guards. This is the most effective way to curb lifeguard distraction. Ask the pool’s patrons and the entire lifeguard staff to watch and speak up if they suspect a guard is distracted. Summer brings warm, beautiful weather, outdoor activities and family fun. Let’s work this summer to keep all those families safe when it comes to family fun at our swimming pools. Sincerely,

As risk managers, it is important to take the Head Down Dilemma challenge head on and institute a zero-tolerance policy: • Any lifeguard caught text messaging while on duty should be terminated immediately. No excuses. • Remove all temptations. Their phones should be left in their lockers, the office, or car. • Provide pocketless swim trunks/sweatshirts so they won’t carry them. If you do suspect a guard is texting, drill them by throwing a brick in the pool and ask them to show you proper pool entry. They’ll either remove the phone or ruin the phone.

Jani Jennings, ARM PRIMA 2018-2019 President Risk Manager City of Bellevue, NE




NEWS Briefs



A bill that would allow California voters to make Daylight Saving Time permanent passed the state legislature and is awaiting Gov. Jerry Brown’s signature.

A quiet, private space may be most ideal for meditation, but it is not always an option at the office. What many people don’t realize, though, is that you actually don’t need to be in a quiet space in order to meditate. Learning to meditate in a loud, chaotic space can help you keep your head on in your noisy, everyday life. At work, you might try meditating in the office bathroom, a conference room, a stairwell, or an elevator.

As approved by lawmakers, the bill would place a measure on a future statewide ballot to repeal California’s 1949 Daylight Saving Time Act. But even if voters approve the measure, Congress would have to act to make the change, the Mercury News reports.

Another option: If you have a decent amount of time and are able go out for a walk, try practicing “walking meditation,” a method in which you get into a rhythm and march.

Daylight Saving Time is governed by the federal Uniform Time Act, passed in 1966 to “promote the adoption and observance of uniform time within the standard time zones.” Prior to its passage, individual states worked out their own plans for implementing Daylight Saving Time, including the beginning and ending dates and, in some cases, which sections of the state should use it. The law specifies that clocks must “spring forward” one hour on the second Sunday in March to start Daylight Saving Time, and “fall back” an hour on the first Sunday in November to revert back to standard time. It also allows states to pass laws to exempt themselves, which does not require congressional approval unlike a full-time adoption of Daylight Saving Time. Hawaii, American Samoa, Guam, Puerto Rico, the Virgin Islands and most of Arizona have opted out. The ordeal began as an energy-saving measure during wartime, and the U.S. Department of Transportation says it also saves lives, prevents



traffic injuries and reduces crime. But plenty of people hate the shift, and researchers have found that the clock-switching can have negative health effects, noting spikes of strokes and heart attacks in the days following the shift. California is one of a handful of states that in recent years has looked at doing away with the time flip-flop. Florida attempted a similar permanent switch to Daylight Saving Time, noting in the legislation that implementation was contingent on Congress agreeing to the change. Massachusetts and Maine began considering measures to ditch the switch in 2016 by converting permanently to Atlantic Standard Time, which no state currently observes. Lawmakers in Virginia, Nebraska, Wyoming, Michigan, Kansas, Washington, Alabama and Vermont also have debated doing away with the time change, either by keeping Daylight Saving Time permanent or exempting the states from the switch altogether.

An easy way to start this while working is to set up your phone timer for however long you can mediate. Begin by starting with your left foot, then right foot, then left foot, and continue in that movement. Walk slowly. Remember you are trying to meditate, not racing to your next meeting. Let your anchor be your feet. Feel the sensation of your feet hitting the ground. If your mind happens to drift, bring it back. Recall the feeling of your feet touching the ground and hold on to that. Once you come to the end of your path (or the hallway) turn around and do it again. Left, right, left…

It’s unclear what Brown will do. If he doesn’t sign the bill or veto it within a certain time period, it becomes law automatically.

If you are still unable to meditate at work (because maybe you work in an emergency room or drive a bus and the environment just doesn’t allow for it), we suggest trying “car meditation.” Arrive to work ten minutes early. Once you get there, park your car in the parking lot and just sit. Or, if you take public transportation, don some shaded sunglasses, put your headphones in, and listen to a guided app on your way to work. There are no rules for meditation. If you are breathing, you are halfway there.

RURAL AMERICA NEEDS HELP SOLVING ITS GROWING OBESITY CRISIS People living in rural America are more likely to suffer from obesity than those living in and near cities. And while there are a number of reasons for this, public health experts in the world’s largest economy say there aren’t enough programs being deployed to help people overcome the problem, reports Quartz. The finding, presented in a pair of newly published studies carried out by researchers at the U.S. Centers for Disease Control and Prevention, raises more questions than it does offer answers. To be sure, these are not the first studies to identify a disparity in obesity rates between people living in cities with more than a million people and more sparsely populated rural areas. They add to a growing body of evidence showing as much, increasing pressure on the public health community to figure out why the disparity exists and how to best go about solving the problem. Some research has shown that higher-thanaverage fried food consumption in the

so-called “stroke belt” of America—southern states including North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas, and Louisiana—raises the risk for obesity and stroke. Other studies have found that living in isolated parts of the country generally translates to having fewer healthy food options when shopping. Regardless of the individual contributing causes of greater risk of obesity in rural areas, experts are mostly in agreement that more effective programs are needed in rural areas to assist people in learning how to live healthier lives. One of the more surprising things to come out of the most recent studies, according to the researchers, is that there’s an increased likelihood of severe obesity among rural children and adolescents, as compared to those living in urban areas. Severe obesity is defined as when a person’s body mass index is calculated at 40 or higher. Body mass index is measured

by taking a person’s weight in kilograms and dividing that number by their height in meters squared. Of the nearly 7,000 children and adolescents analyzed between 2013 and 2016 by the researchers, the rate of severe obesity was almost 5 percent higher in rural areas than in urban areas. Across all of the youth and adults analyzed in these studies—17,655 people—higher rates of obesity and severe obesity were linked to older age and lower level of head-of-household education, regardless of where they lived. Another trend that cuts across the rural/urban divide is that obesity is more common among non-Hispanic black and Hispanic youth compared with non-Hispanic white youth.

Regardless of the individual contributing causes of greater risk of obesity in rural areas, experts are mostly in agreement that more effective programs are needed in rural areas to assist people in learning how to live healthier lives.








IKE MOST PUBLIC ENTITIES, KING COUNTY, WASH, WAS “RISK AVERSE.” But Risk Management Director Jennifer Hills is re-focusing King County’s risk efforts to be “risk optimized.” Hills change of focus for the county’s risk management team enabled her to direct conversations and strategic management plans toward value creation, as well as comprehensive assessments of risks to facilitate quality decision-making. This culture shift helps King County leadership tolerate the correct risks, and therefore respond timely and more effectively to growing demands for government services.

“Since Jennifer came on, we’ve had a sea-change,” said Michael Gedeon, chief administrative office for the King County Department of Health. “Where before people would avoid risk management, now people see risk management as a place to partner and engage to solve problems early.” Hills innovative approach has not only saved King County money, but earned her the prestigious PRIMA Public Risk Manager of the Year award. “I am really honored to get this award,” said Hills. “It recognizes the wonderful work being done by King County government and more importantly, the work of my staff. I have the most dedicated and talented risk management staff you can imagine.”

annual passenger boardings, provides passenger ferry service, and owns and operates King County International Airport/Boeing Field. The past five years have brought significant growth to King County, particularly in the areas of population; new commercial and residential construction; business and community development; and transportation infrastructure. This economic expansion affects all County departments and programs, ultimately increasing demand for and the strain on government services.

Hills received her award at PRIMA’s 2018 Annual Conference in Indianapolis in June.

As the King County Risk Manager, Hills is responsible for managing a comprehensive, cost-effective and nimble risk management program. She must incorporate the impacts of regional change into the County’s risk matrix, continuously monitoring the accuracy of that matrix against current conditions and resource constraints.



King County, which includes the Seattle-Bellevue metropolitan area, is the most populous county in Washington and the 13th largest county in the United States, serving a population of more than 2 million. 14,000 county employees provide direct and regional government services such as public health and community services; parks and recreation including more than 175 miles of maintained trails; wastewater treatment; building and land use services; roads engineering, construction and maintenance; and criminal justice through law enforcement, District and Superior Courts, the Prosecuting Attorney’s Office, adult and juvenile correctional facilities, and the Office of the Public Defender. King County also operates regional bus, light rail, and street car services with more than 140 million

Historically, King County government has positioned itself as risk-averse. There are good reasons for a large government to exercise caution and avoid negative outcomes; but avoiding risk can also lead to underachievement of strategic objectives, even those most prioritized by agency leadership. Hills’ challenge as King County’s risk manager is to change the risk culture of King County from excessively risk averse to risk optimized. This involves Hills promoting a risk-aware culture, as well as thoughtful change management. Hills has evolved King County’s risk management program from advanced risk management that was proactive about preventing and reducing




operational risk to enterprise risk management (ERM) that aligns risk management to the County’s mission and values, is integrated into budget and strategic planning processes, and includes risks and opportunities. “Jennifer brought enterprise risk to the county,” said Chauntelle Hellner, deputy director of the county’s business resource center. “ERM helped us to look at risk more proactively.” Hills has used the success of the ERM program to further move the risk culture toward risk optimization. Hills’ approach has changed the shape of risk in King County. Risk is a now bell-shaped curve. Enterprise Value Risk Optimization Point

Flash Point


Risk Optimized

Smoldering Crisis

Risk Tolerance Zone


Risk Level

Risk Optimization Zone

The risk-value curve comes from King County’s membership and Hills’ leadership in the Consortium for Advanced Management International (CAM-I.) CAM-I is an international consortium of private sector and government organizations who have elected to work cooperatively to solve management problems and critical business issues that are common to



the group. Hills is using this risk-value framework to shift King County thinking about risk, and support leaders’ abilities to take the right risks to advance enterprise value. The concept demonstrates how an organization can take on measured risk and increase value within a risk optimization zone. Continued risk taking beyond an optimal zone could result in value decline and a possible crisis.


With a staff of 28 and a $32 million annual budget, Hills also ensures quality and effectiveness in the following areas: • Loss Control: $1 Million annual fund for County loss control initiatives; • Allocating Cost of Risk: Based on loss history, with financial incentives for departments to reduce losses; • Claims: Nine adjusters who investigate and resolve 1800 claims filed annually against the County; • Recovery Claims: Averaging $2 Million in annual recoveries for damage to County vehicles and assets; • Risk Finance: Using actuarial projections to estimate and fund all incurred liabilities; • Insurance: Procuring all insurance policies for King County (property, excess liability, excess worker’s compensation, cyber, aviation, marine, pollution, fiduciary, crime, terrorism, foreign liability); • Contracts: Establishing insurance requirements and contractual risk transfer mechanisms for all County contracts; and • Open Government: Public records program, ethics program, and financial/lobbyist disclosure programs.


It’s important to Hills to communicate the value of what her department does to all of the County’s elected officials. Therefore, Hills reports King County’s total cost of risk in the annual Risk Management Report. She measures the overall costs associated with managing risk as a percentage of the total operating budget. The costs include claim and litigation expenses, insurance premiums, and administrative expenses. Although workers’

compensation claims are not managed within risk management, the measure also includes the cost of King County’s Workers’ Compensation program, which is part of King County Human Resources. The target for the cost of risk is no more than 2 percent of the County’s operating budget. King County’s total cost of risk for 2016 was 1.85 percent of the County’s total operating budget, and the County has performed well within the target for several years. Year

Risk Management Cost of Risk

Worker’s Comp Cost of Risk

Operating Budget

Total Cost of Risk Compared to Operating Budget 1.60%






























The cost of risk was higher in 2016 due to three significant claims that resolved using King County’s Early Case Assessment Strategy. These claims were projected to resolve in 2017 and 2018, however liability was quickly determined and the risk management team focused on obtaining key pieces of information to evaluate damages and reach an early resolution with the injured parties. While the early case assessment strategy shortens the time from claim filing to closure and can impact financial projections, it also uses resources efficiently, saves costs, and achieves better outcomes for claimants and King County’s tax payers.


Over the past few years, King County has experienced a significant reduction in the length of time it takes to resolve claims in excess of $250,000. Hills and her colleagues in the Litigation Section of the Prosecuting Attorney’s Office adopted an early case assessment strategy which includes written case management plans for significant claims and lawsuits. With this approach, major losses are reviewed to assess liability and damages, establish case reserves, and select a team to manage them. The claims and litigation team is tasked with early outreach, an appraisal of what essential information is needed, and a written plan to acquire that information. The team makes a short list of information needed for analysis rather than investigating every potential angle. Once comfortable with the information gathered to adequately evaluate the case, work begins to resolve the matter. The goal is to reduce the amount of time it takes to reach resolution. Ultimately, using resources efficiently saves costs and achieves better outcomes for claimants and King County’s tax payers. It requires a mature process to evaluate liability and assess damages. This approach works at King County because Hills, her staff, and the County’s in-house lawyers have the experience and judgment to stay focused on the issues that determine outcomes.


King County Sheriff’s Deputies went to a house to arrest a probation violator and search the home for weapons and other probation violations. After arresting their suspect, the deputies learned a young man was

“I am really honored to get this award… It recognizes the wonderful work being done by King County government and more importantly, the work of my staff. I have the most dedicated and talented risk management staff you can imagine.” Jennifer Hills, ARM-P, CRM

sleeping in a back bedroom. Although at this point the versions of how it occurred diverged, the deputies entered the bedroom and believed the young man was reaching for a weapon. They shot him 15 times and he survived. He was unarmed. There were obvious liability questions, and the injuries were substantial and permanent. When King County was approached by the young man’s attorneys, Jennifer and her colleagues considered whether they could obtain the critical pieces of information needed to evaluate the case for early resolution. They proposed interviewing the key fact witnesses who were in the house on the night of the event. Following the interviews and exchange of medical and wage loss information, each side submitted a life-care plan and economic analysis for the young man. With that information, the parties were able to present their positions on liability and damages and resolved a controversial law enforcement use of force case without the expense of litigation. Hills continues to execute innovative programs within King County government. Congratulations to Jennifer Hills for being selected as PRIMA’s 2018 Public Risk Manager of the Year! The Public Risk Manager of the Year award is sponsored by Aon.




You’ve relied upon our financial security and underwriting skill for a long time.

Visit our website at www.GenesisInsurance.com

And along the way, you’ve challenged us to do more. Well, we’ve been listening, and we’re proud to announce a new, more “can do” approach to your business. We’re actively seeking expanded opportunities. So whether you’re seeking broader coverage, new jurisdictions, or aggregate deductibles, we hear you, and it’s time to test our limits. Let’s talk. We’ll fly high together!

Genesis Insurance Company is licensed in the District of Columbia, Puerto Rico and all states. Genesis Insurance Company has its principal business in Stamford, CT and operates under NAIC Number 0031-38962

A.M. Best A++ XV


A Berkshire Hathaway Company


A Look Into Municipalities’ Future Responsibilities



HERE ARE MANY ORGANIZATIONS, INDUSTRIES AND INDIVIDUALS CAREFULLY FOLLOWING THE PROGRESS of self-driving vehicle technology and the developing infrastructure to support its integration into mainstream society. Currently there are 1.4 billion cars on the roadway; however, many of those cars will begin to be replaced by self-driving vehicles, potentially sooner than we expect. The public sector is a critical stakeholder with the potential to be significantly impacted by these advancements, as self-driving automobiles present a whole new risk exposure. In the same way self-driving vehicles will likely disrupt the structure of the automobile insurance industry, they will also alter the infrastructure of our communities—something that municipalities should begin to consider now.




As this technology continues to develop over the next couple of years, we will

discover insight as to what our roadway infrastructure responsibilities will be. If

your municipality has not begun discussing

the implementation of V2I technology, now is the time. The process will be extensive, but well worth the benefits.

V2V + V2I = DRIVING 2.0

Self-driving cars operate utilizing vehicle-tovehicle technology (V2V). V2V technology allows cars to wirelessly exchange information such as speed and positioning of surrounding cars, as well as detect obstructions created by traffic, terrain or weather and alert drivers with visual, tactile and audible alerts. This technology, to some degree, is already utilized in today’s new cars and doesn’t just allow drivers to drive smarter, it helps them drive safer. In 2015, there were 6.3 million police-reported vehicle crashes and it is estimated that 615,000 of those crashes could have been prevented with V2V technology. While V2V technology provides critical information exchange between vehicles, what about the world they are maneuvering through? Vehicle-to-infrastructure (V2I) technology allows vehicles to communicate with roadway infrastructure such as traffic lights, stop signs, work zones and school zones and is the second critical ingredient needed to successfully integrate self-driving cars into our communities. For example, utilizing V2I, traffic controllers will be able to communicate with vehicles about signal phasing and timing, alerting drivers to a



likely encounter with a red light based on his or her speed and helping them avoid having to brake suddenly or speed up through an intersection.


The combination of V2V and V2I technology capabilities will create safer and less congested roadways. The National Highway Traffic Safety Administration (NHTSA) estimates that the combination of this technology could eliminate or reduce the severity of up to 80 percent of non-impaired crashes, including crashes that take place at intersections or while changing lanes. Additionally, such technology can alert drivers of numerous other scenarios, including but not limited to: • Pedestrians in the roadway • When a vehicle brakes suddenly • Warn drivers if they are about to run a red light • Warn drivers of vehicles in their blind spot • Warn drivers of icy roadways • Alert drivers of work zones or first responders on the side of the road • Recommend speed adjustments to avoid hitting a red light, idling or unnecessary stops to save gas


The Department’s Federal Highway Administration has issued guidance for V2I technology to assist transportation planners with integration. While it is the duty of the municipality to update their roadway infrastructure to assist in reducing vehicle crashes and to keep up with our advancing world, there are many critical questions regarding this new technology that need to be answered first. For example, where will funding come from, both initially as well as for ongoing maintenance and inspections? How long will it realistically take to implement this technology, and how will it impact the community? The Department of Transportation (DOT) hopes to answer all of these questions and more through their website—V2IDeploy.com— which is still under construction, but the DOT has indicated it will provide resources for local and state agencies interested in the use and implementation of V2I technologies. The website will provide information on planning, obtaining funding, contact information for subject matter experts, explanation of benefits, answers to frequently asked questions, news, and access to tools and resources to educate others including case

studies, presentations, infographics, talking points and more. In the meantime, municipalities should begin to think about the issues and areas of their organization that will be impacted, including: • Zoning: As the presence of autonomous vehicles grows, some visionaries think the need for large parking structures may decrease while the need for pick-up and drop-off areas for shared and on-demand ride services will likely increase. Additionally, municipalities may be asked to rezone large parking facilities for commercial or business use since autonomous vehicles, as mentioned above, may provide more shared and on-demand ride services eliminating the need for as many parking garages and spots.

• Revenue: Currently, many municipalities rely on a large stream of revenue from traffic violations, according to data this can be up to 59 percent. However, with smart and safer roadways and vehicles, this number will drastically be reduced, forcing municipalities to find new avenues of revenue. • Staffing: Due to safer roadways and vehicles, municipalities may be able to reduce the amount of police officers patrolling the roadways. Instead, staff may need to be shifted to support the back-office, in-field traffic and system operations. In addition, when it comes time to install the new infrastructure, municipalities may need to hire trained employees to install the advanced technology or alternatively, train their current staff.

The implementation of autonomous vehicles into municipalities will require many decisions and changes; however, the benefits of the new technology will forever change our roadways. But, until a viable autonomous vehicle actually arrives on our roadways the new vehicles will continue to integrate new V2V and V2I technology to assist the driver in the safe operation of the vehicle. As this technology continues to develop over the next couple of years, we will discover insight as to what our roadway infrastructure responsibilities will be. If your municipality has not begun discussing the implementation of V2I technology, now is the time. The process will be extensive, but well worth the benefits. Kenny Smith is a risk control manager for OneBeacon Government Risks.


PRIMA PODCASTS! PRIMA’s Podcasts are a quick and convenient way to learn on-demand and on your own time!

Meant to provide you with information on specific topics important to the public risk management sector and hot topics, PRIMA Podcasts are the perfect way to fit in education and training into your busy schedule.

Check www.primacentral.org for new Podcasts!

CURRENT PODCAST TOPICS INCLUDE: Comorbid Conditions The Aging Workforce





PRIMA Institute 2018 (PI 18) is the premier educational program for new and seasoned risk management professionals who want to learn more about emerging trends and best practices. PI 18 is an innovative educational symposium comprised of fundamental risk management curriculum, outstanding faculty and excellent networking opportunities.



SMALL SETTING. November 5–9, 2018 • West Palm Beach, Florida

Every community has a story. We help protect it. Travelers has solutions designed specifically for public entities. Our public entity experts work with local communities to design insurance programs tailored to their unique challenges — from public safety to catastrophic weather to online breaches of sensitive data. We are dedicated to helping communities protect themselves from the unexpected, so that they can continue to tell their stories. To learn more, contact your independent agent or broker.

travelers.com Š2015 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. 0427 Rev. 6-15





ELEMEDICINE IS A FAIRLY NEW WAY TO EVALUATE AND TREAT PATIENTS. However, the dream is not necessarily new. We know from historical records that in the American Civil War, Union battlefield surgeons regularly consulted via telegraph with specialists in Washington, New York and Boston on the best ways to treat their patients.

The first idea of telemedicine as we know it today appeared in the April 1924 issue of Radio News magazine. Yet other milestones mark telemedicine’s journey to where it is today. The first long distance consultations occurred in the beginning of the 20th century with the advent of radio and telephone. It took the invention and innovations of television, high fidelity radio and high speed data transmission to complete the first practical steps. The first uses of telemedicine to transmit video, images, and complex medical data occurred in the late 1950s. In 1959, for instance, the University of Nebraska used interactive telemedicine to transmit neurological examinations, which is widely considered the first case of a real-time video telemedicine consultation. It may seem that the highly publicized interest in telemedicine over the last few years can be attributed to our present telecom advances. The truth is that regular telemedicine has been around since the 1960s, when American astronauts first went into space. In fact, NASA built telemedicine technology into early spacecraft and spacesuits to monitor astronauts’ physiological parameters in real-time. From its slow start, telemedicine has evolved into today’s seemingly endless possibilities. For several decades, telemedicine was very limited. By the end of the last century with the explosion of communications via email and internet, several medical fields began to utilize telemedi-

cine for regular assessment and recommendations, most especially the specialties of radiology and cardiology. Until the widespread use of smart phones and tablets, most individuals had no easy access to telemedicine. In the last decade, the practice has grown exponentially. Smart phones, laptops, the Internet, Skype, and Face Time are now just a few of the score of services available to the medical specialist and the patient. Telemedicine robots are now becoming more and more common in hospital and emergency treatment centers. There is no doubt telemedicine is here to stay. I don’t believe it is a fad. The need was here already. The biggest difficulties in its implementation were simply due to technology limitations and reimbursement of medical providers. Telemedicine now utilizes several medical specialties including dermatology, ophthalmology, nephrology, obstetrics, oncology, pathology, rehabilitation, pain management, psychology and psychiatry. Besides the increased use of personal devices, the amount of information that can be relayed to the doctors and nurses has increased greatly, including vital signs (blood pressure, heart rate, respirations, oxygen saturation, temperature, glucose tracking, EKG) along with high definition video. This allows for a more detailed evaluation and consequently a more accurate diagnosis and treatment plan.

There is some discussion on what should be considered telemedicine or telehealth. They can be used as synonyms, as telehealth is the overall use of technology in health care services and telemedicine is a type of telehealth with video or audio capability between a patient and a medical care provider. At present, telemedicine has its own regulations for each state. A license is required and most medical licenses do not cross state boundaries. This has been one of the greatest barriers for its full implementation. Despite its comparative infancy the telemedicine world is already crowded. I have counted more than 200 companies offering telemedicine services. Most are new comers and likely trying to cash in on the new and exciting medical care format. A few companies do have some history and expertise to offer a relevant product, but they are not the majority. If you are embarking on this endeavor, you should do diligent research to determine which company can best fulfill your needs. Consider experience in the field, technological expertise, and the provider network. Most of the initial implementation activity in telemedicine has been outside the workers’ compensation (WC) arena. This is mainly due to WC’s own idiosyncrasies, its litigiousness and reimbursement structure, WC has been slow to join this wave. AUGUST 2018 | PUBLIC RISK



In my opinion, there is a clear opportunity for the use of telemedicine in WC for occupational medicine, minor injuries, and nursing triage to include follow ups. Other uses can be surgery and pain medicine follow ups. Of course, with any new endeavor, there are pros and cons for telemedicine.


 Savings: on average telemedicine costs one third of the price of a regular consult. However, some new regulations are pairing telemedicine fees with a regular office visit. The savings will then be restricted to transportation and easy access, still clear benefits to the payer and the patient.  Around-the-clock (24/7) access to medical care professionals.  Potential less employee lost time, faster return to work, increased productivity.  Reduced or eliminated transportation costs.  An answer to the “doctor shortage.” In my opinion, I don’t believe there is a true doctor shortage but basically an unequal geographic distribution of medical care providers. This makes telemedicine an excellent tool for underserved and rural areas.  The wide use of smart phones and the millennials’ attitude toward new technology will make the tendency towards telemedicine stronger every year.  Specialty consults will be easier to schedule via electronic media.  Increased patient engagement: There will be fewer real reasons for patients to avoid the contact (“it’s too far, I’m too tired, it’s raining, too hot, too cold, too windy, etc, etc.”)  The injury site can be part of the initial evaluation.  Faster action, less bureaucracy with telemedicine. Remember the last time you visited YOUR doctor? Remember the outdated magazines. The waiting and more waiting, even past your scheduled appointment time. How quickly did you get to see your doctor and for how long? These are issues that can negatively impact on a WC case.


 Inappropriate use and patient harm: WC is a very litigious field and minor issues can quickly become major legal entanglements. If the lack of direct contact brings any lack of details for the medical providers to make a professional decision, legal consequences



result. However, we know that quite often many medical providers see the claimants in person and yet never examine them--which is probably a good topic for another discussion.  Will quality of care be better, if not the same as traditional office practice? The jury is still out considering the short term use of telemedicine. Time will tell, but I am optimistic.  Possible negative doctor-patient relationship: The patient may not be followed by the same doctor every time. The human connection may not be there.  Less access to real “live” providers: It is possible the real life encounters will become more expensive and rare. Remember (if you are old enough) doctors making house calls? If one comes to your house now (likely a boutique doctor), how much do you have to pay? What is the convenience fee?  Delayed care or missed diagnosis for an injury that needs immediate assistance. However, these are always potential issues even with the present “in-office” system. They need to be corrected in each venue.  Possible electronic medical data compromise. Even though WC is not under HIPAA‘s rules, it has to maintain data privacy.  Possible poor quality of electronic connection.  High initial equipment cost.  “Con jobs” by phony companies and unscrupulous doctors  Long distance is only permitted for schedule III and IV. At present this limits the scope of treatment by prescriptions In my opinion, the pros are stronger than the cons. As the system becomes more widespread, costs of equipment will decrease. Connections will continue to improve with changes in bandwidth and transmission and hardware. More medical providers will become increasingly adept and comfortable with the system and continue its evolution. So where are we now? I see telemedicine being useful right now in WC to provide the following:  Decreased emergency room visits.  Providing speedy Initial evaluation for injuries such as strains and small cuts.  Providing simple medication refills.  Simple follow ups in general.  Non-complicated post-surgical follow ups.

Official Disability Guidelines (ODG) already accepts telemedicine for mental health, pain and diabetes. Providers still have to be experienced in dealing with WC cases, no matter in what system they practice. Many doctors still do not keep in mind “return to work” or the consequences of not having a global plan for the claimant. Quite often doctors still practice in their own “bubble,” completely missing or paying no attention to co-morbid issues and operating without knowledge of—or interaction with—professionals already engaged. This will not change with the widespread use of telemedicine, but hopefully with the fully implemented Electronic Medical Records System (EMR), providers will have less reason (or excuse) to be ignorant of the full picture. However, EMR also increased the bureaucracy of medical information. We will need to find ways to search and locate the relevant pieces in the enormous amount of electronic data that is generated. As a physician, it may seem overwhelming to try and find the information you need in some electronic files. Hopefully telemedicine will not have the unintended effect of actually complicating things, as EMRs did in some cases. So what should we expect for the future of telemedicine?  Even more sophisticated and cheaper equipment, making telemedicine easier to operate, more accessible and accurate  Increased possibility of procedures and surgeries performed long distance, as is already happening in Centers of Excellence and the military.  An even greater general public interest and demand for telemedicine. Telemedicine is here to stay. We need to be prepared and attentive to all the positive changes and potential drawbacks of this new form of professional interaction. As the old saying goes, “The future is now.” Fernando Branco is the Chief Medical Officer for Midwest Employers Casualty (A W.R. Berkley Company).



Genesis Management and Insurance Services Corporation. . . . . . . . . . . . . . . . . . . . . . . . . . page 10 Liberty Mutual Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 2 Munich Reinsurance America. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back Cover Old Republic Insurance Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Front Cover Rimkus Consulting Group, Inc.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Back Cover Travelers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 15 HAS YOUR ENTITY LAUNCHED A SUCCESSFUL PROGRAM? An innovative solution to a common problem? A money-saving idea that kept a program under-budget? Each month, Public Risk features articles from practitioners like you. Share your successes with your colleagues by writing for Public Risk magazine! For more information, or to submit an article, contact Jennifer Ackerman at jackerman@primacentral.org or 703.253.1267.


CALENDAR OF EVENTS PRIMA’s calendar of events is current at time of publication. For the most up-todate schedule, visit www.primacentral.org.

PRIMA ANNUAL CONFERENCES June 9–12, 2019 PRIMA 2019 Annual Conference Orlando, FL Gaylord Palms June 14–17, 2020 PRIMA 2020 Annual Conference Nashville, TN Gaylord Opryland June 13–16, 2021 PRIMA 2021 Annual Conference Milwaukee, WI Wisconsin Center

PRIMA INSTITUTE November 5–9, 2018 West Palm Beach. FL

ISO 31000 TRAINING November 14–15, 2018 Alexandria, VA The Alexandrian Hotel

Keep up with what’s happening at PRIMA and connect with your risk management peers! Visit us at www.facebook.com/primacentral.



You Know Risk Management is Valuable. Why Doesn’t Everyone? Introducing the PRIMA

VALUE OF RISK MANAGEMENT SERIES Public sector risk management is often not well understood or supported by other public entity staff and policy makers. To overcome this, we must be able to measure the value of risk management and communicate it to others This five webinar series provides you with the tools to do exactly that. TOPICS INCLUDE: Module 1 — Overview Module 2 — Total Cost of Risk Module 3 — Risk Maturity Models Module 4 — The Risk Appetite and Risk Tolerance Framework Module 5 — Strategies for Communication and Change Management In addition to the webinars, PRIMA members will also have access to reference guides and case studies.

For more information, visit primacentral.org/vrms.

Profile for Moire Marketing Partners

August issue of Public Risk  

The Public Risk Management Association promotes effective risk management in the public interest as an essential component of public adminis...

August issue of Public Risk  

The Public Risk Management Association promotes effective risk management in the public interest as an essential component of public adminis...