PUBLISHED BY THE PUBLIC RISK MANAGEMENT ASSOCIATION JANUARY/FEBRUARY 2020
MANAGING THE
RISKS & C STS OF CANCER PAGE 6
ALSO IN THIS ISSUE
STRESS AND THE RISK MANAGER: AVOIDING BURNOUT
PAGE 11
WORKERS’ COMPENSATION PROVIDERS ARE REINVENTING NETWORKS BY INCREASING THEIR FOCUS ON EFFICACY AND EFFICIENCY PAGE 16
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JAN/FEB 2020 | Volume 36, No. 1 | www.primacentral.org
CONTENTS
The Public Risk Management Association promotes effective risk management in the public interest as an essential component of public administration.
PRESIDENT Scott J. Kramer, MBA, ARM County Administrator Autauga County Commission Prattville, AL PAST PRESIDENT Jani J. Jennings, ARM Risk Manager City of Bellevue Bellevue, NE PRESIDENT-ELECT Sheri D. Swain Director, Enterprise Risk Management Maricopa County Community College Tempe, AZ DIRECTORS Forestine W. Carroll Manager of Risk Management Memphis Housing Authority Memphis, TN
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Managing the Risks & Costs of Cancer By Arnel Mondejar, RN, BSN, CCM
Lori J. Gray, RMPE Risk Manager County of Prince William Woodbridge, VA JamiAnn N. Hannah, RMPE Risk Manager City of Gallatin Gallatin, TN Laurie T. Kemper Sr. Risk Management Consultant City/County Insurance Services Salem, OR Michael S. Payne, ARM, HEM Risk Manager City of Fresno Fresno, CA Melissa R. Steger, MBA, CRM Asst. Dir., WCI & Unemployment Ins. University of Texas System Austin, TX NON-VOTING DIRECTOR Jennifer Ackerman, CAE Chief Executive Officer Public Risk Management Association Alexandria, VA EDITOR Teal Griffey, MBA Manager of Marketing and Communications 703.253.1262 • tgriffey@primacentral.org ADVERTISING Teal Griffey, MBA 703.253.1262 • tgriffey@primacentral.org
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Stress and the Risk Manager: Avoiding Burnout By Joe Jarret
IN EVERY ISSUE
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Workers’ Compensation Providers Are Reinventing Networks by Increasing Their Focus on Efficacy and Efficiency By Kate Farley-Agee
Public Risk is published 6 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 2020 Public Risk Management Association
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JANUARY/FEBRUARY 2020 | PUBLIC RISK
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NOMINATE A COLLE AGUE OR YOURSELF FOR PRIMA’S NEWES T AWARD BY JA N UA R Y 31, 2020! PRIMA wants to recognize our long-term members who have made outstanding contributions to PRIMA and the public risk management industry. QUALIFIC ATIONS FOR AWARD: 1. Member of PRIMA for 15 years or more 2. Advancement of PRIMA membership goals 3. Knowledge of public entity risk management skills, industry goals, and trends THE AWARD WINNER WILL RECEIVE: • A framed and personalized Certificate of Excellence • A one-page spotlight in the Public Risk magazine • Celebratory announcements on PRIMA’s social media, including a photo and quotes
FIND THE NOMINATION FORM AT primacentral.org > Membership > Awards & Recognition
Submit your nominations by
JANUARY 31, 2020
MESSAGE FROM PRIMA PRESIDENT SCOTT J. KRAMER, MBA, ARM
ecently, my daughter told me she was considering asking a lady, “Rose,” from our church to be her mentor. Rose often led Bible studies for youth and adults and was both knowledgeable and engaging. As such, I felt it would be an excellent opportunity for my daughter if Rose were willing. My daughter was a little nervous about how the concept would be received, but Rose felt honored. Thus, a mentorship was born. Mentoring consists of a long-term relationship focused on supporting the growth and development of the mentee. The mentor becomes a source of wisdom, teaching, and support. At the 2019 PRIMA Annual Conference, I attended the session “Pathways to Career Development,” which included past PRIMA leadership. One of the members on the panel, former PRIMA President James Huckaby was asked a question about his career path. He responded by volunteering to be a mentor for this attendee. After the session, I saw them plan their future communication and next steps. The PRIMA member seemed so appreciative of Mr. Huckaby’s willingness to share his wisdom and experiences to further her professional development. This mentor’s expertise and help will no doubt have a tremendous impact on her future career. It reminded me that one of PRIMA’s core values is a willingness to share. Our members
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PRIMA’s seasoned risk managers
should consider sharing their knowledge
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R
New Year’s Resolution — Become a Mentor!
and experience with others in the risk management community. have valuable experiences and expertise, and we should never bottle that up! PRIMA’s seasoned risk managers should consider sharing their knowledge and experience with others in the risk management community.
“One of the greatest values of mentors is the ability to see ahead what others cannot see and to help them navigate a course to their destination.” — John C. Maxwell Sincerely,
Now that it’s a new year, make a resolution to mentor someone. Your company may have a mentor program you can look into or take the initiative and ask a less experienced coworker or friend if they could use the help of a mentor. It will be an experience that is rewarding for both you and the mentee.
Scott J. Kramer, MBA, ARM PRIMA President 2019–2020 County Administrator Autauga County Commission Prattville, AL
JANUARY/FEBRUARY 2020 | PUBLIC RISK
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NEWS BRIEFS
NEWS Briefs HOW MAPPING TOOLS ARE IMPROVING SCHOOL SAFETY IN NORTH CAROLINA
School officials can upload information and schematics into the School Risk Management Planning Tool, or SRMP, to design risk management plans. Another application, called the State Emergency Response Application, or SERA, converts that data into detailed aerial maps and updates the representations in real time when changes are made in the planning tool. Public safety officials can use the tools to coordinate with school administrators during emergencies, Morgan said, by consulting detailed, floor-by-floor schematics of K-12 schools, labeling everything from doors and specialized locks to rooms with lab equipment and water- and gas-main cutoff points. The applications were required to be created by a state law that passed in 2015, but Morgan told StateScoop that the idea to further emergency assistance for schools made sense. “In the midst of all of this, the active shooter issues came about, and it seemed to be happening more and more,” Morgan said. “They were teachers, educators, and
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PUBLIC RISK | JANUARY/FEBRUARY 2020
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Schools, higher education, emergency management, first responders and fire—if we can get them all in one room, even for an hour each year, then we can do the simple things.
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Students and teachers may participate in safety evacuation drills on a regular basis, but worrying about safety isn’t an educator or a student’s job, according to Hope Morgan, a technology official with the North Carolina Department of Public Safety. That’s why in 2016, in the midst of a rise in active shooter incidents, the state chose to develop two applications that generate safety plans and have mapped more than 2,400 K-12 and higher education facilities throughout the state—potentially shaving valuable time off of responses and evacuations.
administrators, so planning for safety was not something they really knew how to do.”
place” to access maps and school-specific evacuation plans.
School districts were initially asked to develop district-wide emergency plans, with help from the NCDPS emergency management division. The plans were then copied into the applications, and the characteristics of each school—including the number of emergency exits, fire extinguishers, whether it was located next to a train track or industrial area or other quirks—were added, letting first responders know what they would need to account for in the event of an emergency.
The applications were officially launched in May 2018 and since then, Morgan and her team have continued to meet with representatives of law enforcement agencies, K-12 districts, higher education institutions and prisons—for each of North Carolina’s 100 counties. Between job turnover and policy changes in each district, Morgan said, coordinating the emergency response plans for schools is a never-ending job.
By putting all 2,400 K-12 public schools in the state on the same application, Morgan said, first responders “only have to go to one
“Schools, higher education, emergency management, first responders and fire—if we can get them all in one room, even for an hour each year, then we can do the simple things,” she said.
WILL MORE STATES ADOPT PRIVACY LAWS IN 2020?
THE PLACES WHERE ‘FOOD INSECURITY’ IS MOST SEVERE
As 2020 draws closer, many states are poised to consider their own consumer privacy laws. Bills in Massachusetts, Minnesota, Pennsylvania, New Jersey and New York, among others, are pending and will be debated in the coming months.
Food banks and government programs meant to help people cover the cost of groceries are among the topics that might come up in discussions about how to assist Americans who are struggling to afford enough food for themselves and their families. Elaine Waxman, a senior fellow with the Urban Institute, hopes that a data package her organization released this week will give policy makers and others a clearer view of some of the factors that are driving high levels of “food insecurity” in counties around the U.S.
Yet, while the legislatures are now flush with bills, the degree to which these debates will bring greater regulation is anybody’s guess. Several laws that had been expected to pass this year—namely New York and Washington state—saw negotiations collapse, speaking to the difficulty of seeing a diversity of shareholders reach consensus on the complex issues at play. Those issues include the fraught interplay between commerce and consumer protections. Many bills modeling themselves heavily after the California Consumer Privacy Act (CCPA) focus on giving data transparency and ownership to consumers, greatly expand the definition of “consumer information,” and escalate the risk of litigation for companies that stepped outside those bounds. These issues proved too much for some privacy bills—some of which stalled or outright failed early on in this year’s legislative sessions, including in states like Arizona, Florida, Kentucky, Mississippi and Montana, among others. At the same time, a handful of other states are taking a slower, more cautious approach, forming task forces to study how to further expand or update current privacy laws. These include Connecticut, Hawaii, and Louisiana, where groups are studying data breaches and brokerage, Internet privacy and existing regulatory frameworks. Yet as states have looked to self-regulate, the tech lobby is still pushing vigorously for a federal privacy law. Critics characterize this as an attempt to “preempt” stronger regulation at the state level, but companies argue that a consistent, across-the-board approach is the only sane approach for businesses and consumers. “Nevada and California share a border and billions in economic activity, and both states have recently updated their own data privacy laws. Yet they fail to agree on basic elements of those laws,” Michael Beckerman, CEO of the Internet Association states. “Companies looking to operate on both sides of that border must navigate two separate laws that regulate the sale of data, but do so in two very different ways.” Still, those looking for a comprehensive national privacy bill should potentially be careful what they wish for—since federal regulations have the potential to be much more far-reaching and draconian than anything previously authored at the state level. Whichever way you slice it, more regulation means a more complicated landscape for business to navigate.
Federal estimates show that about 40 million Americans, including 12.5 million children, struggled with food insecurity in 2017. That’s about 12 percent of the nation’s total population. Food insecurity rates have improved since the Great Recession, Waxman noted, but still persist at relatively high levels in many places. “You don’t really move those numbers until you start tackling the root causes,” she said. “What we’re suggesting is that there needs to be cross-sector conversations.” In other words, efforts to address food insecurity would benefit if people working on the issue talked more with those focused on policy areas like transportation, public health, and housing. With this in mind, the Urban Institute published an interactive map that color codes counties based on their level of food insecurity and other related risks and pressures. By selecting a county, users can see other data for the jurisdiction, like the share of people in the county without health insurance, or with diabetes, or the proportion of people facing high housing cost burdens. There are statistics for credit scores and debt in collections as well. The online tool allows for comparisons between the different data points for each county with the county’s peer group of counties and with state and national figures. As she offered examples of how food security is linked to other topics that the data covers, Waxman pointed out that research has shown people having trouble affording food are more likely than others to get diabetes, and are less well positioned to manage the condition. Similarly, she said, if you could work with people in a community to improve their credit scores “that’s the equivalent of actually putting more money in their pockets to buy basic needs.” Even a quick glance at the map reveals that many of the counties with the worst food insecurity problems are located in southeast states, such as Alabama, Mississippi and Louisiana—places bedeviled for generations by poverty, poor health outcomes, and racial disparities. But Waxman emphasized that the counties in these states are not alone, noting for instance that there are places in the southwest with large Native American populations and high levels of food insecurity. There are also areas around booming cities where lower-income residents have been grappling with rising housing costs that are experiencing similar problems, according to Waxman. “Clearly there are pockets of the country that have an intersection of both higher food insecurity and other things, like for example, really significant health challenges,” she said. “But I think it’s always useful to point out to people that there’s not a single county in the United States that doesn’t have people who are food insecure.”
JANUARY/FEBRUARY 2020 | PUBLIC RISK
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MANAGING THE
RISKS & COSTS OF CANCER BY ARNEL MONDEJAR, RN, BSN, CCM
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PUBLIC RISK | JANUARY/FEBRUARY 2020
C
ANCER IS ONE OF THE LEADING CAUSES OF DEATH AND DISEASE IN THE UNITED STATES. Not only does it take an enormous toll on the health of patients, it also has a tremendous financial impact. Due to these concerns, public entities, human resources (HR) departments, and risk managers are starting to pay closer attention to this disease. Healthcare costs are already on the rise, and specific areas—such as cancer—require more vigilance and innovative approaches to control costs and improve outcomes.
A key reason is the incidence of cancer is increasing. Approximately 1 in 2 men and 1 in 3 women will be diagnosed with a life-threatening form of cancer in their lifetime.1 Second, new cancer drugs are being introduced to the market at staggeringly high costs. For example, 11 of the 12 cancer drugs that the Food and Drug Administration approved in 2012 were priced at more than $100,000 per person for a year2 (cancer treatment is usually long term). Unfortunately, these prices are becoming the norm. So much so that a new term has come into in the healthcare lexicon—financial toxicity—that refers to the emotional, mental, and physically debilitating and potentially life-threatening side effects induced by the costs of cancer treatment. Patients faced with high costs may skip medication or treatment or drop into depression, wondering how they’ll afford treatment. Today, cancer represents a significant portion of total U.S. healthcare spending. Roughly $87.8 billion was spent in 2014 in the U.S. on cancer-related healthcare.3 These costs were paid by employers, insurance companies, and taxpayer-funded public programs like Medicare and Medicaid, as well as by cancer patients and their families. In 2014, cancer patients paid nearly $4 billion out-of-pocket for cancer treatments.4 Public entities need to be aware of these issues, strive to increase awareness among employees, and develop new strategies to help address these challenges.
EARLY DETECTION: THE IMPORTANCE OF CANCER SCREENING
For cancer, an ounce of prevention is worth its weight in gold. A critical way public entities can help in the fight against cancer is to promote screenings. Many public entities work with their HR departments and risk management departments to organize a cancer awareness day or seminar as part of their wellness programs. Or they may choose to structure wellness benefits to provide members with financial incentives for undergoing timely cancer screenings according to recommended guidelines. Screenings aim to detect cancer early before symptoms are detected, when it may be easier to treat the disease successfully. If early detection and early intervention can occur, a patient has a better chance of successful treatment, recovery, and survival. However, if that same person is diagnosed at a later, more advanced stage of cancer, the likelihood for survival may decrease significantly—not to mention that more costly treatments, procedures, and drugs may be required.
The American Cancer Society (ACS) estimates that roughly 1.7 million new cases of cancer will be diagnosed in the U.S. More than 15 million Americans living today have a cancer history.
CANCER SCREENING GUIDELINES The CDC supports screenings for breast, cervical, colorectal (colon), and lung cancers as recommended by the U.S. Preventative Services Task Force. Review a sampling of screening guidelines below, but visit the CDC website 5 to obtain complete screening guidelines by sex, age, and other risk factors:
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MANAGING THE RISKS & COSTS OF CANCER
• Breast Cancer. Mammograms help detect breast cancer. • Cervical Cancer. A Pap test can help find abnormal cells that may turn into cancer. • Colorectal (Colon) Cancer. Colorectal cancer almost always develops from precancerous polyps (abnormal growths) in the colon or rectum. Screenings can help find polyps so that they can be removed. • Lung Cancer. Lung cancer screening with low-dose computed tomography (LDCT) can be used for those between the ages of 55 and 80 who either have a history of heavy smoking, smoke now or have quit within the past 15 years.
IDENTIFYING RISK FACTORS FOR CANCER
When assessing a member’s risk for cancer, several factors are taken into account. The most common are age, sex, tobacco use, exposure to sun, radiation, chemicals or other substances, some viruses and bacteria, certain hormones, family history of cancer, alcohol use, poor diet, lack of physical activity and being overweight.6 Some of these risk factors can be prevented or reduced, but others, such as age or family history cannot.7 Health plans collect member demographics, claims data, and health risk information. Advanced analytics can help them mine through this data to identify and stratify members according to their risk level. For example, patients previously diagnosed with cancer are at high risk of remission, and those with a history of cancer in their family have a higher chance of developing it as well. When a high level of risk is detected, the analytics tool will trigger an alert to the plan’s care management team. Clinicians can then reach out to those members and may recommend they obtain a specific type of cancer screening.
EARLY INTERVENTION: ENABLING A GOOD PROGNOSIS
If someone has a positive screening, the next step is to confirm that it’s actually cancer and not a false-positive result. A CT scan or MRI might be ordered to determine if
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there’s a mass. A biopsy might be performed to ascertain the type and stage of cancer and whether it has spread to other parts of the body. If the cancer diagnosis is confirmed and the type and stage are known, treatment may begin and would follow an evidence-based clinical pathway. STAGES OF CANCER There are generally four stages of cancer, which describe the size of the cancer and how far it’s spread: • Stage 0 means there’s no cancer, only abnormal cells with the potential to become cancer. • Stage I means the cancer is small and only in one area. This is also called early-stage cancer. • Stage II and III means the cancer is larger and has grown into nearby tissues or lymph nodes. • Stage IV means the cancer has spread to other parts of the body. It’s also called advanced or metastatic cancer. In stage II and III, the cancer cells have begun to evolve, and it’s more difficult to intervene. But, if cancer is identified early, there’s a high probability that it can be treated successfully, so the cancer does not spread. For example, with early-stage cancer, there might be a small lump that can be treated with a short course of radiation to shrink the mass, so it can then be surgically removed.8
CONTROLLING THE QUALITY AND COSTS OF CARE
An employee who’s been diagnosed with cancer will often have questions about providers, treatment options, prescriptions, and what their health plan will and will not cover. A public entity and its HR department should ensure that they have a quality health plan and a plan administrator with the expertise to help employees get the answers they need. The administrator can also help outline various treatment options and the breakdown of quality and costs. A member’s health and safety are paramount, but it’s important to remember that the same level of quality care can be obtained—often at a significantly lower cost. When patients understand the costs, they often want to make wise treatment decisions that won’t break the bank and drive them into debt.
Let’s take a look at some important care management strategies: PATIENT ADVOCACY As soon as plan members are diagnosed with cancer, they should be assigned a nurse case manager who will serve as their advocate. Nurse case managers can help members understand this disease state, treatment options, types of specialists, and the different diagnostic tests that may be needed. They will also help members navigate the complex healthcare system to obtain the services they need—whether it’s radiology therapy, chemotherapy, or surgery. A nurse case manager can also provide emotional support. Members with a cancer diagnosis may feel a sense of hopeless and may even get depressed. A nurse case manager can educate them and guide them step-by-step through the process. As a result, members feel supported and empowered to make their treatment decisions. Some health plans use a condition-based case management program. This means nurses specialized in oncology are assigned to patients diagnosed with cancer. These nurses have in-depth knowledge about cancer treatment pathways. This type of case management is designed to provide a more specialized approach. COSTS OF CANCER CARE Cancer care and treatment can be costly. Plan members should try to understand upfront what the various costs will be and what their health plan will cover. They might ask the following type of questions:9 • How long will I need to be treated? What is the estimated total of my treatment plan? Are there treatment options that might be less expensive? Are they just as effective? • How much of treatment will my health plan pay for, and how much will I be responsible to pay? • Does my health plan need to pre-approve any part of the treatment before I start? • Is there any way I can get help or financial assistance with my treatment? • Where will I get treatment? Will it be in a hospital, oncology office, a clinic, or at home?
One way that plan members can save out-of-pocket costs is to ensure the physicians, specialists, imaging facilities, and treatment centers that they use are all within their plan’s provider network. The plan administrator and their assigned nurse case manager can help point them to the quality providers and centers of excellence within their network that can provide treatment for their particular type of cancer.
NETWORK PROVIDERS One way that plan members can save outof-pocket costs is to ensure the physicians, specialists, imaging facilities, and treatment centers that they use are all within their plan’s provider network. The plan administrator and their assigned nurse case manager can help point them to the quality providers and centers of excellence within their network that can provide treatment for their particular type of cancer. LOCATION OF TREATMENT Where a plan member seeks treatment can have a significant impact on costs. For example, can the member obtain treatment at a cancer treatment center, rather than in a costly hospital setting? For example, chemotherapy may be administered at an oncology office, rather than an or outpatient hospital setting. Whether treatment includes radiation or chemotherapy, a plan administrator can help the member mitigate costs simply by letting them know about the more cost-effective options—although those options are equal in terms of quality. HELP PAYING FOR PRESCRIPTION DRUGS As we discussed, the costs of cancer drugs are skyrocketing. Plan members will want to understand if their health plan has a pharmacy benefit managers (PBM), and if certain cancer drugs are less expensive—but equally effective—that
are on the PBM’s drug formulary. The plan’s care management team can also determine if the member might qualify for patient-assistant programs, which help to provide further discounts on cancer drug costs, especially if the member is experiencing financial hardship.
COMBATTING CANCER INTO THE FUTURE
Cancer is a complex disease that affects millions of people. A preventative approach with the use of cancer screenings that follow recommended guidelines is the best strategy to detect and treat cancer early when there’s the highest likelihood of treatment success. As we outlined, certain factors can increase a person’s risk of cancer, including age, family history, and exposure to certain risk factors, such as sun and tobacco use. New drug therapies are emerging every year, which offer the hope and promise of new ways to combat the disease. The industry as a whole must continue to examine and identify the best clinical pathways that provide a value-based approach, emphasizing therapies that are most effective for their price point. In the meantime, tried and true strategies, such as nurse case management and patient advocacy, are continually being honed to help cancer patients navigate the healthcare system and their coverage, receive emotional support, and quality, cost-effective treatment options.
Arnel Mondejar, RN, BSN, CCM, is the vice president of care management at HealthComp. REFERENCES 1 Whiteman, Honor, “1 in 2 people will develop cancer in their lifetime,” Medical News Today, February 4, 2015. 2 Moore, Peter. “The High Cost of Cancer Treatment: Avoiding financial disaster can add stress to patient’s battle against the disease.” AARP The Magazine, June 1, 2018. 3 American Cancer Society, “The Costs of Cancer: Addressing Patient Costs,” April 11, 2017. 4 Agency for Health Care Research and Quality. Total Expenses and Percent Distribution for Selected Conditions by Source of Payment: United States, 2014. Medical Expenditure Panel Survey Household Component Data. Generated interactively. 5 https://www.cdc.gov/cancer/dcpc/prevention/screening.htm 6 https://www.medicinenet.com/cancer_ causes/article.htm 7 https://www.medicinenet.com/cancer_ causes/article.htm 8 https://www.webmd.com/cancer/cancerstages#1 9 “Managing the Costs of Cancer Treatment: What to ask about the costs of your cancer treatment,” American Cancer Society website, www.cancer.org.
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STRESS and the RISK MANAGER:
AVOIDING BY JOE JARRET
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STRESS AND THE RISK MANAGER: AVOIDING BURNOUT
HETHER IT’S THE DAY-TO-DAY MANAGEMENT
of risk, adjusting claims, securing excess or primary insurance, managing self-insurance retentions,
writing reports, training, and keeping the workplace safe, the risk manager can be prone to burnout.
Burnout, if left unchecked, can result in a reduction in cognitive ability, make one more susceptible to acute and chronic illness, and adversely
affect overall job performance. Because workplace burnout and stress can
prove to be major impediments to healthy, productive work environments, the World Health Organization (WHO) has officially recognized workplace burnout as an occupational hazard. In so doing, WHO included the term in its “International Classification of Diseases” (ICD).1
THE DANGERS OF BURNOUT:
Recently, the WHO has expanded its definition of burnout from a “state of vital exhaustion,” to: • Feelings of energy depletion or exhaustion, • Increased mental distance from one’s job, or feelings of negativism or cynicism to one’s job, and • Reduced professional efficacy While related to stress, burnout presents itself differently. Stress is characterized by having too much to do. Burnout is characterized by not having enough within to address and deal with stressors adequately. People who are burned out may experience a lack of motivation or feel mentally exhausted. A recent Gallup Poll revealed that employees who are very often or always burned out are 63 percent more likely to take a sick day and 23 percent more likely to visit the emergency room. Those burned-out employees are more than twice as likely to strongly agree that the demands of their job interfere with their family life. Not surprisingly, these employees are nearly three times as likely to leave their current employer, which translates into recurring recruiting costs, workplace performance interruptions, and a significant loss of institutional knowledge.2
COMPASSION FATIGUE
Because risk managers are often called upon to investigate catastrophic loss in the form of injured or killed co-workers, or citizens outside of the entity, as well as severe property damage,
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and more, they are susceptible to compassion fatigue. Dr. Charles Figley3 has defined compassion fatigue to mean a state experienced by those helping others in distress, accompanied by an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it can create secondary traumatic stress for the helper. Compassion fatigue manifests itself in various forms, the most common being burnout. Other manifestations of compassion fatigue include: • Secondary Traumatic Stress (STS), a form of compassion fatigue, is often found in professionals called upon to help others. It usually manifests itself in the same way as Post Traumatic Stress Disorder (PTSD); however, the trigger is the experience of the person working with, or being assisted by, the risk manager, rather than the risk manager’s own experience. For instance, after a crisis or disaster, the risk manager may have to deal with injured employees, citizens, and even animals. STS is common when working with people who have suffered catastrophic loss. • Vicarious Trauma (VT), while similar, differs from STS because it develops over time. As a result, sufferers often view the system within which their working as inadequate, broken, or bureaucratic to the point that it stymies productivity and the ability to do one’s job efficiently and professionally. • Moral injury occurs when a professional engages in activities resulting
in moral disorientation when policies, procedures, or work assignments do not align with their professional ethics or, at a minimum, create distance between their core values and the organization’s culture. This can occur when people in the risk manager’s chain of command attempts to politicize the risks manager’s decisions.4 Although the risk manager may not be as adversely affected by workplace stressors as members of the organization in less stressful jobs, nevertheless it is essential to note that, according to Gallup, the factors most commonly associated with burnout are: • Unfair treatment at work • Unmanageable workload • Lack of role clarity • Lack of communication and support from manager • Unreasonable time pressure According to the Mayo Clinic,5 job burnout is a workplace hazard that can result from various factors, including: • Lack of control. An inability to influence decisions that affect your job—such as your schedule, assignments, or workload—could lead to job burnout. So could a lack of the resources you need to do your work. • Unclear job expectations. If you’re unclear about the degree of authority you have or what your supervisor or others expect from you, you’re not likely to feel comfortable at work. • Dysfunctional workplace dynamics. Perhaps you work with an office bully, or you feel undermined by colleagues, or your boss micromanages your work. This can contribute to job stress. • Extremes of activity. When a job is monotonous or chaotic, you need constant energy to remain focused—which can lead to fatigue and job burnout. • Lack of social support. If you feel isolated at work and in your personal life, you might feel more stressed. • Work-life imbalance. If your work takes up so much of your time and effort that you don’t have the energy to spend time with your family and friends, you might burn out quickly.
COMBATING BURNOUT:
While the combating of employee burnout is often left to the Human Resources department, the risk manager should play a vital role in managing this risk, provided they have addressed their own mental health. One suggestion the risk manager can make (and also take), is to learn to simply say “no.” This is something that isn’t always easy—especially when one considers how our profession attracts people with Type A personalities. Employees need to know that if their plate feels too full, or they feel overwhelmed, it’s acceptable not to take on more work. Some employees may require therapy to deal with burnout; a trained and licensed professional who can speak objectively about one’s burnout and how to manage it can be invaluable. Therapy is great for putting things into perspective while assisting people in achieving the often-elusive work-life balance we all need.
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“Acknowledging burnout is the first step to addressing the emotional and physical symptoms of burnout,” said Elizabeth Malson, president and VP of marketing at the Amslee Institute. “When burnt out from work, it’s important to regain balance and force some perspective. Focus first on the physical by getting plenty of sleep, exercising, and eating healthy. Improve your mental state by taking time each morning to be grateful— for your health, family, home, etc. Instead of focusing on work 24/7, keep it to business hours, and retrain your mind to focus on relaxation and enjoyable activities each evening and weekend. Resolving burnout is a process. It took time to get burnt out, and it will take time to recover.”6 Recognizing and addressing workplace burnout, if approached like so many other workplace risks that need to be managed, will assist the risk
manager in staying healthy while contributing to a healthier workplace. Joe Jarret is an attorney, former public risk manager, and PRIMA’s 2016 Author of the Year. REFERENCES 1 See, https://www.who.int/classifications/ icd/en/ 2 See https://www.gallup.com/ workplace/237059/employee-burnout-partmain-causes.aspx 3 See https://www.compassionfatigue.org/ 4 Dziewulski, Robert, Compassion Fatigue, DICTA, 2019 5 See, https://www.mayoclinic.org/healthylifestyle/adult-health/in-depth/burnout/ art-20046642 6 See, https://www.amsleeinstitute.com/
Acknowledging burnout
is the first step to addressing the
emotional and physical symptoms of
burnout… Instead of focusing on work 24/7,
keep it to business hours, and retrain your mind to focus on relaxation and enjoyable activities
each evening and weekend. Resolving burnout
“
is a process. It took time to get burnt out, and it will take time to recover.
Elizabeth Malson, president and VP of marketing at the Amslee Institute
JANUARY/FEBRUARY 2020 | PUBLIC RISK
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Register for PRIMA’s JANUARY WEBINAR FREE TO MEMBERS
Ten Most Critical Risk Management Issues for Your Entity JANUARY 22 | 12:00 – 1:00 PM EST Speakers: Michael G. Fann, ARM-P, MBA George D. Dalton, ARM-P, MCM A critical examination of industry best practices and an entity’s loss experience can provide a reasonably clear road-map to addressing the bulk of risk exposures. Using a humorous approach and subtitle of: “The Top Ten Things Your Staff Says & You Know It’s Gonna Be a Bad Day,” this session provides a shortlist of issues that, if addressed adequately, can dramatically improve property and casualty losses. Attendee Takeaways: ➊ Honest assessment of your entity’s exposures ➋ Understanding of best practices and data-driven evaluation of a public entity’s risk issues ➌ List of solutions to dramatically improve an entity’s loss experience
Register at primacentral.org/webinars
PRIMA PODCASTS PRIMA Podcasts are a convenient and quick way to learn about hot topics in the public risk management sector.
Listen at primacentral.org Also available on
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PUBLIC RISK | JANUARY/FEBRUARY 2020
WORKERS’ COMPENSATION PROVIDERS ARE REINVENTING NETWORKS BY INCREASING THEIR FOCUS ON
EFFICACY AND EFFICIENCY
M
BY KATE FARLEY-AGEE
OST DISCUSSIONS ABOUT THE STATE OF U.S. HEALTH CARE quickly lead to a grim but straightforward diagnosis: the system is broken. The evidence abounds, and it’s compelling. The U.S. spends1 more per capita than any other country, yet often produces only lackluster outcomes.2 Access to care can be poor. 3 Even average life expectancy, which notched steady gains for decades, has ticked lower in recent years. 4 But it’s not all bad news. Unpacking the state of health care reveals that not every aspect of the system is dysfunctional. In fact, some parts have never been better. A profusion of medical research is arming clinicians with deeper insights into how the body works.5 Previously unimaginable treatments are poised to become commonplace.6 Technology is sometimes erasing enormous distances between caregiver and patient.7 Data analytics, including artificial intelligence, is making an impact on priorities and decisions in the system.8 There is another element of care delivery that’s seeing exciting reinvention: networks. In this era of rapid changes to health care, networks are becoming more important than ever. They’re evolving from relatively straightforward mechanisms for directing patients and controlling costs to collaborative partnerships between payers and providers; call it Network 2.0. This evolution of networks, particularly those focused on workers’ compensation,
prioritizes both efficacy and efficiency. The best clinicians can more easily rise to the top of the stack thanks to deeper insights into patient trajectories. In the emerging scenarios, powerful analytics and algorithms pull data to evaluate outcomes and push data to aid clinicians in doing what they do best—taking care of patients in supporting their return to work and a return to their daily routines.
HOW NETWORKS CAN HELP
Networks can, and should, continue to lean into being the best at what they’ve always done: managing the relationship with the provider. Also, workers’ comp networks offer providers another stream of revenue that features less administrative effort. Networks continue to work with providers to streamline administrative burdens. These steps include letting providers: • Bill insurers directly, preferably electronically, thereby reducing the guesswork and the burden of collections • Grow and diversify their patient base
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WORKERS’ COMPENSATION PROVIDERS ARE REINVENTING NETWORKS
• Benefit from being independently credentialed • Establish long-term relationships with patients extending beyond the care for work-related injuries or illnesses • Support employers in their communities • Reduce instances of coordination of benefits with multiple payers Workers’ compensation networks are unique in other ways. The pool of injured workers goes beyond patients who might solely be served by a particular payer or by Medicare, for example. This allows providers to expand the reach of their practice to new segments of the community in which they operate. And when providers seek to refer injured workers to other clinicians, a network offers an extension of their current referral patterns.
WORKERS’ COMP NETWORKS SIDESTEP PATIENTS’ FINANCIAL CHALLENGES
Treating those hurt on the job makes sense for other reasons as well. The injured worker isn’t responsible for paying a deductible or copay, an ever-more-important differentiator. That’s because out-of-pocket costs can be steep for patients to manage, especially as many are now expected to shoulder a larger share of the medical expense with the rise of high-deductible commercial plans.9 It’s worth considering how onerous this burden has become for many people, the provider, the patient, and the insurance company. More than one in four consumers with a credit report has at least one debt in collection. And more than half of personal debt in collection is tied to medical bills, reports the federal government’s Consumer Financial Protection Bureau.10 In 2018, consumers borrowed some $88 billion to pay for health care, according to a survey from Gallup and West Health, a nonprofit. The findings also revealed one in four Americans decided to forgo medical treatments because of concerns about cost.11 By sidestepping the need to collect copays, it’s easier for providers to receive the full contractual reimbursement directly from the payer promptly. Not having to pursue patients for past-due bills is a help, particularly concerning medical expenses and the administrative costs
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PUBLIC RISK | JANUARY/FEBRUARY 2020
associated with collections activities. That’s because some individuals put a lower priority on repaying medical debt, according to Benedic Ippolito, a research fellow and health economist with the American Enterprise Institute. He contends Americans often think medical debt is different than other types of debt. “It’s just so low priority relative to paying the mortgage, the car, they simply don’t pay it,” Ippolito notes.12 Workers’ comp also faces reduced risk from the ever-shifting winds of politics and health care. The concerns about the fate of the Affordable Care Act, for example, don’t come into play when an employee is hurt at work. This reality is all the more welcome given the fractious political environment. There are other long-standing benefits of workers’ comp networks that appear to be becoming more pronounced. The reimbursement rates for providers remain well above those seen in group health. One examination by the National Council on Compensation Insurance (NCCI) found prices in workers’ comp are 12 percent higher than those in group health.13 It’s worth recalling that part of the reason costs are higher is not just because of increased utilization but also because workers’ comp reimbursements are meant to meet the actual cost of administering the care. Too often, providers just can’t cover their expenses. Research highlights the problem. For example, the nonpartisan Congressional Budget Office (CBO) found private insurers pay physicians and hospitals well above what Medicare pays for a basket of common services.14 Doctors, of course, didn’t need the CBO report to understand the problem. A recent poll of about 475 physicians found two-thirds believed Medicare payments in 2019 wouldn’t prove sufficient to cover the cost of care.15 Some respondents contend the complexity and comorbidities often associated with caring for older workers make reimbursements all the more inadequate compared with workers’ comp care.
THE BEST COMPANIES WANT WORKERS BACK ON THE JOB Payers and the companies they represent are eager to get injured workers back on their feet and back on the job. Many of these companies represent the heavyweights of corporate
America. Major employers like manufacturers, large retailers, and airlines rely on comprehensive return-to-work programs to help their injured employees recover. The best programs do far more than safeguard the bottom line. They focus on genuinely addressing the needs of injured workers themselves. That’s because the longer workers are away, the less likely it is they will return to the workplace. The New York State Workers’ Compensation Board has broken down some statistics and reports that there is only a 50 percent chance that an injured employee will return to work after a six-month absence.16 That drops to a 25 percent chance following a one-year absence. After two years away, the likelihood a worker will return plunges to a 1 percent chance. These figures underscore the importance of helping injured workers return to the job. Those who are out of work longer face greater risks from an array of challenges that include social isolation and depression in addition to financial stress to loss of skills and medical complications resulting from potentially being forced into a more sedentary lifestyle.17 Top companies understand that having a worker return to the job either under modified duty or, if possible, full duty, is the best outcome for workers and business. Therefore, these employers offer fair reimbursements to providers and pay on time. That’s because top-tier employers recognize the irreplaceable value providers bring. Alongside employers and payers, providers are part of a three-legged stool that helps injured workers return to the job. This rewarding role is what helps set marquee workers’ comp networks apart; it’s the shared focus on return to work that is essential to a patient’s ultimate success.
HOW NETWORK 2.0 LOOKS TODAY
The benefits that workers’ comp networks bring to employees, employers, and providers are clear. What’s most interesting is how networks are evolving to meet the needs of employers and patients. These next-generation networks often are tighter, specialty-focused, smaller—rightsized—networks that benefit providers by grouping together the best of the best. Many such networks pull together smaller groups of providers with specific expertise who can best
The benefits that workers’ comp networks bring to employees, employers, and providers are clear. What’s most interesting is how networks are evolving to meet the needs of employers and patients. These next-generation networks often are tighter, specialtyfocused, smaller—right-sized—networks that benefit providers by grouping together the best of the best.
help injured workers. And, of course, specialty networks focus on narrow areas to let clinicians do more of what drives them and what they’re best at doing. These newer networks present providers with opportunities to keep up with their peers who are utilizing new treatment regiments with emerging technologies such as telemedicine and remote patient monitoring. Workers’ compensation networks today are also doing more to support providers than some of their predecessors. In essence, a strong network means providers have someone blocking and tackling a range of issues so clinicians can focus on injured workers. These include: • Aiding providers with education and interaction on policies, procedures, and efficiency • Assisting providers’ office staff with quickreference guides and query support • Offering providers streamlined utilization review programs and scheduling services • Sharing insights into state and federal regulations Amid all the changes in health care—and all the challenges that remain—there are bright spots. One of them is a new form of networks. In Network 2.0, we see constructive partnerships between providers and payers in service of injured workers. This allows networks to promote both efficacy and efficiency. They allow
the best providers, with the support of payers, to deploy top clinical skills to help injured workers return to work.
8 See, https://www.pwc.com/gx/en/industries/healthcare/publications/ai-roboticsnew-health/transforming-healthcare.html
Kate Farley-Agee oversees Coventry’s national broad-based provider network and state-certified managed care organizations across the country.
9 See, https://www.healthsystemtracker.org/ brief/tracking-the-rise-in-premium-contributions-and-cost-sharing-for-families-withlarge-employer
REFERENCES 1 See, https://www.healthsystemtracker.org/ indicator/spending/per-capita-spending/ 2 See, https://fortune.com/2014/10/20/ health-insurance-future/ 3 See, https://www.commonwealthfund. org/publications/fund-reports/2017/ jul/mirror-mirror-2017-internationalcomparison-reflects-flaws-and 4 See, https://www.usatoday.com/story/ money/2019/07/09/u-s-life-expectancydecline-overdoses-liver-diseasesuicide/1680854001/ 5 See, https://www.nationalgeographic.com/ science/2019/08/newly-discovered-organmay-be-lurking-uinder-your-skin-sensespain/ 6 See, https://www.weforum.org/ agenda/2019/05/healthcare-technologyprecision-medicine-breakthroughs/ 7 See, https://www.ruralhealthinfo.org/ topics/telehealth
10 See, https://www.consumerfinance.gov/ about-us/newsroom/bureau-releasesreport-third-party-debt-collections/ 11 See, https://news.gallup.com/poll/248081/ westhealth-gallup-us-healthcare-costcrisis.aspx 12 See, https://www.usatoday.com/story/ news/health/2019/04/02/health-carecosts-gallup-survey-americans-borrowed88-billion/3333864002/ 13 See, https://www.joepaduda. com/2019/05/21/ncci-ais-research-reviewcomparing-work-comp-to-group-health/ 14 See, https://www.healthcaredive.com/ news/cbo-reports-show-private-insurerspay-physicians-hospitals-far-morethan-m/445949/ 15 See, https://www.healthexec.com/ topics/healthcare-economics/medicarereimbursements-dont-cover-cost-care 16 See, http://www.wcb.ny.gov/content/main/ ReturnToWork/RTW_Handbook.pdf 17 See, https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3635882/
JANUARY/FEBRUARY 2020 | PUBLIC RISK
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ADVERTISER INDEX
ADVERTISER INDEX States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Front Cover
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January 22 • Ten Most Critical Risk Management Issues for Your Entity February 19 • Managing Diversity & Inclusion Risk March 18 • It’s Not Just What You Say… It’s How You Say It April 15 • Liability and Auto Claims May 20 • Marijuana and CBD June 24 • Until Help Arrives July 22 • ERM Beyond the Risk Assessment— Framework, Principles and Integration August 19 • Weather Disaster: Emergency Response Plan September 16 • Leveraging Telehealth to Redefine Intake and Proactively Manage Care October 16 • Building a Peer Support Program November 4 • Emerging Risk and Insurance December 16 • Occupational Physicals and Employee Wellness: Redirecting Costs
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