PUBLISHED BY THE PUBLIC RISK MANAGEMENT ASSOCIATION SEPTEMBER 2017
PUBLIC ENTITY RISK MANAGERS SPEAK OUT:
Results of the 2017 Public Entity Employee Safety & Loss Control Survey PAGE 6
ALSO IN THIS ISSUE
UNDERSTANDING THE FEMA INSURANCE PROCESS
PAGE 11
Managing the New Comorbidity:
DIABETES + OBESITY PAGE 15
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SEPTEMBER 2017 | Volume 33, No. 8 | 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 Amy J. Larson, Esq. Risk and Litigation Manager City of Bloomington Bloomington, MN PAST PRESIDENT Terri L. Evans Risk Manager City of Kingsport Kingsport, TN PRESIDENT-ELECT Jani J. Jennings, ARM Insurance & Safety Coordinator City of Bellevue Bellevue, NE DIRECTORS Brenda Cogdell, AIS, AIC, SPHR Risk Manager, Human Resources City of Manassas Manassas, VA
PUBLIC ENTITY RISK MANAGERS SPEAK OUT:
6
Results of the 2017 Public Entity Employee Safety & Loss Control Survey By Frank X. Altiere, III, RIMS Fellow, CPCU, ARM, AU, IIA, AIS
Scott J. Kramer, MBA, ARM City/County Director of Risk Mgmt Montgomery County Commission Montgomery, AL Forestine Carroll Risk Manager Memphis Housing Authority Memphis, TN Sheri Swain Director of Enterprise Risk Management Maricopa County Community College District Tempe, AZ Lori J. Gray Risk Manager County of Prince William Woodbridge, VA Donna Capria, CRM, CIC, AINS Risk & Insurance Coordinator WaterOne of Johnson County Lenexa, KS 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
11 Understanding the FEMA Insurance Process By Mark Ferraro
IN EVERY ISSUE
15 MANAGING THE NEW COMORBIDITY:
Diabetes + Obesity By Michelle Despres, PT, CEAS II
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 2017 Public Risk Management Association
| 4 NEWS BRIEFS | 19 ADVERTISER INDEX
SEPTEMBER 2017 | PUBLIC RISK
1
PUBLIC ENTITY EXPERIENCED TEAM, ACCOUNT DEDICATED CLAIMS, TAILORED COVERAGE AND RISK CONTROL
PROTECTION, EXPERTISE AND RELIABLE SUPPORT IN AN EVOLVING ENVIRONMENT CLIENTS: • Individual Entities with retentions • Intergovernmental Pools PRODUCTS: • Full range of public entity specific Liability and Professional Liability, including Law Enforcement, and Incidental Medical • Insurance and Reinsurance
WHY BERKLEY PUBLIC ENTITY: • We do not compete against our broker or client partners – we honor commitments. • We frequently manuscript coverage for single accounts – clients like certainty. • Over 96% of clients with claims have renewed – we work together when things get tough. • We invest in client desired risk control – reducing loss for both of us.
For more information, please contact: Berkley Public Entity Managers 30 South 17th Street, Suite 820 Philadelphia, PA 19103
Richard B. Vincelette President T: (215) 553-7366 C: (215) 528-0410 rvincelette@wrberkley.com
Brian T. Whooley Sr. Vice President, Underwriting T: (215) 553-7381 C: (215) 528-0374 bwhooley@wrberkley.com
Stephen D. Dzury Sr. Vice President, Claims T: (215) 553-7382 C: (215) 756-6118 sdzury@wrberkley.com
Products and services are provided by one or more insurance company subsidiaries of W. R. Berkley Corporation. Not all products and services are available in every jurisdiction, and the precise coverage afforded by any insurer is subject to the actual terms and conditions of the policies as issued. Certain coverages may be provided through surplus lines insurance company subsidiaries of W. R. Berkley Corporation through licensed surplus lines brokers. Surplus lines insurers do not generally participate in state guaranty funds and insureds are therefore not protected by such funds. © Copyright 2017 Berkley Public Entity Managers – a Berkley Company. All rights reserved.
MESSAGE FROM PRIMA PRESIDENT AMY J. L ARSON, ESQ.
t seems like just yesterday we were doing orientation for our seasonal staff and summer was upon us. Now, the programs are ending, and the “kids” are heading back to school. While thinking about a topic for this month’s article, I asked some of my school risk management friends to identify issues that they have to deal with regularly. I found it interesting that while school and municipal risk management issues have some similarities, they also identified a number of things that are more unique in a school setting. The following are just a thumbnail description of some of the exposures school risk managers deal with on a daily basis. Transportation issues—These issues are not just related to the school fleet, but also extend to drop off and pick up of students by their parents/caregivers. Does the school need to have specific procedures in place to minimize the possibility of injury/accidents? Is there a way to purchase insurance to cover school vehicle exposures? What about after school activities? Cyber Liability— In the movies, we’ve seen a student hack into the computer system at school to change his/her grade. But, with the sophistication of today’s cyber hackers, how does the school protect all of the stored confidential information about students? Has an evaluation been performed recently on the school’s computer system to identify potential weaknesses? What is the school’s liability if they are the owner/provider of the electronic device? Bullying—Hardly a week that goes by that we don’t hear another sad story of a child who has been bullied, either in person or via their electronic devices/social media. According to the experts, children often respond to being bullied by acting sad, lonely or nervous, feel sick, have problems at
“
As PRIMA members, we all have access to many
resources to address unique issues we deal with, whether it be occasionally or on a daily basis. You can tap into the expertise of others by posting a question on PRIMAtalk
“
I
School Days, School Days…
or accessing the Cybrary. We also provide educational
opportunities on hot topics in our profession at the Annual Conference, PRIMA Institute and through webinars.
schools, or bully other kids. In extreme situations, the victim may even take their own life. Is there a program in place that allows children to report the bullying to an adult without the fear of retribution? Are there resources for children to get help dealing with their feelings of despair and learn coping mechanisms? Infrastructure—The cost associated with maintaining the school’s infrastructure is ever increasing. At what point does the cost of maintenance prohibit the repairs from being done? Active Shooter/Student Safety Drills—It is important that active shooter and student safety (fire or shelter in place) drills be done periodically every school year. These drills benefit not only the students but also school staff. Do you know what to do? Concussion recognition—Training staff to recognize signs of concussions, whether it be from participation in sports or just playing at recess, is becoming an essential program. Is such training mandated in your state?
As PRIMA members, we all have access to many resources to address unique issues we deal with, whether it be occasionally or on a daily basis. You can tap into the expertise of others by posting a question on PRIMAtalk or accessing the Cybrary. We also provide educational opportunities on hot topics in our profession at the Annual Conference, PRIMA Institute and through webinars. I would like to thank my risk management friends, Terri Evans, Cindy Mallett, Betty Coulter and Dan Hurley for extending their school risk management expertise to this article. As our summer comes to a close, I wish you all a safe and happy fall!
Amy J. Larson, Esq. Risk and Litigation Manager City of Bloomington Bloomington, MN
SEPTEMBER 2017 | PUBLIC RISK
3
NEWS BRIEFS
NEWS Briefs
DALLAS HIRES ITS FIRST FEMALE POLICE CHIEF City Manager T.C. Broadnax has hired Detroit’s Deputy Police Chief Ulysha Renee Hall, from a pool of seven finalists, three of them internal candidates. “Chief Hall is a proven leader with a stellar background and a passion for public service,” Broadnax said in a written statement. “These are qualities I believe are critical as we tackle crime to make our city safer while addressing organizational and policy issues within the department.” Dallas’ chief position had been vacant since October, when Chief David Brown retired from the department. Assistant Chief of Police David Pughes ran the department as interim chief while officials searched for a permanent replacement. Pughes didn’t apply for the job. The city manager’s office initially selected eight people as finalists for the job, but Grand Prairie Police Chief Steve Dye withdrew his application.
Three women—Hall, Dallas County Sheriff Lupe Valdez and Dallas County District Attorney Faith Johnson—now have some of the most powerful law enforcement jobs in the Dallas area. Hall, who has been on the force in Detroit since 1999, has dealt with several issues paralleling crises in Dallas. These include the increasing homeless population and the loose-dogs issue that has affected low-income neighborhoods. She now oversees officers on the east side of the city.
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PUBLIC RISK | SEPTEMBER 2017
“
Chief Hall is a proven leader with a stellar background and a passion for public
service… These are qualities I believe are
critical as we tackle crime to make our city
“
City officials haven’t said when Hall will formally take over.
safer while addressing organizational and policy issues within the department.
City Manager T.C. Broadnax
AMERICAN INDIANS WIN ELECTION MAP LAWSUIT The boundaries of election districts in a southeastern Utah county are unconstitutional and violate the rights of American Indians who make up roughly half the county’s population, a federal judge has ruled for the second time. San Juan County, a roughly 7,800-squaremile county that touches Colorado, New Mexico and Arizona, was ordered last year to redraw its county commission and school board election districts after U.S. District Judge Robert Shelby ruled that they were unconstitutional.
DELAWARE PLAYS CATCH-UP WITH MOST STATES’ NALOXONE LAWS Frances Russo-Avena won’t ever forget her son screaming for help. It was January and a family friend staying with them overnight began making a gurgling, snoring noise. Her son tried unsuccessfully to wake the friend, then realized he was overdosing. “It was the most frightening experience in my life,” said the nurse, who has spent much of her career in the emergency room and school nurse’s office in Red Clay Consolidated School District. Russo-Avena, however, had naloxone, an overdose-reversing drug that has saved the lives of thousands of Delawareans, including
her house guest that night in January. After administering two doses of naloxone, more commonly known by the brand name Narcan, through the intranasal spray, he came to and survived. Paramedics who arrived nearly 25 minutes later to their New Castle County home told her that was their fourth or fifth overdose that night. The signing of Senate Bill 48 by Gov. John Carney in Dover allows anyone to walk into a participating Delaware pharmacy and purchase naloxone from a pharmacist so the overdose antidote can be kept bedside, as Russo-Avena’s was, or in a first-aid kit.
Shelby ruled that the county’s new maps are still unconstitutional and primarily drawn on race. Shelby said that county officials did not explain why they had a compelling government interest to draw districts mainly based on race at the expense of other considerations, such as compact areas and following political boundaries. The Navajo Nation, which covers parts of Utah, Arizona and New Mexico, filed a lawsuit five years ago challenging the boundaries.
SEPTEMBER 2017 | PUBLIC RISK
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PUBLIC ENTITY RISK MANAGERS SPEAK OUT:
Results of the 2017 Public Entity Employee Safety & Loss Control Survey BY FRANK X. ALTIERE, III, RIMS FELLOW, CPCU, ARM, AU, IIA, AIS
W
ORKERS’ COMPENSATION CLAIMS can be very expensive for public entities, especially when you consider the indirect costs of claims and emerging issues impacting costs, including:
• Rising medical and pharmacy costs • Severity issues associated with an aging workforce • Claims with co-morbidities such as hypertension, diabetes, obesity, depression, and smoking • Chronic pain and opioid addiction
Now more than ever, the best strategy for public entities to address workers’ compensation costs is a holistic approach to prevent claims from occurring in the first place with loss control strategies. Given the importance of preventing workers’ compensation claims, PRIMA and PMA Companies co-sponsored the Public Entity Employee Safety & Loss Control Survey 2017 to examine safety-related risk management and loss control conditions and practices among public entities. The intent of the survey is to benefit public entity risk managers by providing them with credible, relevant information that enables them to: • Benchmark their safety/loss prevention program with those of their public entity peers • Gain a more in-depth understanding of the key challenges faced by their peers • Discover effective safety and loss prevention strategies The questionnaire was fielded and tabulated by an independent survey research firm. Qualified individuals who oversee safety programs for PRIMA member public entities were invited to take part. The survey generated a 26 percent response rate, above industry standards for surveys of this type. Survey respondents represent public entities in 39 states. Responses were primarily from risk management professionals who have significant responsibility for safety in their organizations. Types of public entity participants include cities and towns, counties, public school districts, special districts, state or state agencies, and airport, transit, and utility entities. Populations served by public entities ranged in size from under 10,000 to more than 1 million.
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PUBLIC RISK | SEPTEMBER 2017
50%
46% 42%
Developing strong safety attitudes among managers and supervisors
40%
PUBLIC ENTITY EMPLOYEE SAFETY & 30% LOSS CONTROL SURVEY RESULTS The following presents an overview of key survey results. 20%
Aging workforce
51%
Changing safety behaviors of employees
51%
Limited resources to address worker safety issues
31%
MOST EFFECTIVE Employee health issues STRATEGIES 24% FOR REDUCING ACCIDENTS What strategies have been most effective in reducing your workplace 0% 10% three 20% 40% 50% 60% 70% accidents? Select only.* 30%
HOW RISK MANAGERS RATED THEIR WORKERS’ 10% COMPENSATION PROGRAM PERFORMANCE 1% Based on your performance data, how would you describe your organization’s 0% Performing well “OK” Worse than No data workers’ compensation performance over the past 3-4 years?* available desired 10%
50%50%
62%
80%
46% 42% 41%
40%40%
Employee safety Developing strong safety attitudes among training managers and supervisors Increased safety communications and awareness Aging among employees 51% workforce Working on ways to improve ourbehaviors safety culture Changing safety 51% of employees Employees accountability 23% for safety Limited resources to address Empowering employees to influence 31% worker safety issues 21% safety-related changes
30%
30%30%
20%20% 13%
11%
10%
10%10%
Employee health issues Empowering safety 24% committees
5%
54%
62% 48% 45%
21%
1%
0% 0%
Performing well Significantly underfunded
“OK” Underfunded
Worse than Adequately AdequatelyNo data Don’t know desired available funded funded with ability to meet some emerging needs
0%50% 0%
Mandatory safety training for employees
and procedures
58%
79%
55%
80% 71%
60%60%
58%
Increasing Empowering safety employee accountability 21% committees measures for safety Using wellness strategies as part of a safety program
80%60%
70%70% 54%
55% 49%
70%
60% 20% 50%
Lim
10%
Emp
42%
0%
17%
20%
30% 41% 30%
20%
40%
40%
50%
50%
60%
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80%
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70% Aging workforce
69%
Employee fitness 49% 13% for duty Attracting qualified job applicants
30% Unrealistic 20% 0%expectations Significantly underfunded 20% Enterprise risk 17% management 10%
71% 70%
Empow s
55% 11% 42%
Under20% funded
Em
E 5%
Adequately Adequately Don’t know funded 16% funded with ability to meet some emerging needs 6% 6%
0%
0% 0%
Our from an BLS or Other We do not Data Forty-one ofData respondents rated their programs 10%percent 20% 30% 40% 50%safety60% 70%as 80% documented insurance/ other benchmark from historic TPA or safety government an industry underfunded, with 13 percent describing their programs as significantly results organization data association Safety 80% inspections 80%underfunded. Adequate funding was chosen by 30 percent of respondents, while 11 percent said their programs Safety were not only adequately funded, they79% 70% 70% committee(s) also had funding to meet some emerging needs.
80%80%
When asked to select their top three challenges to workplace safety, the Increased safety communications and awareness 48% employees most frequently selected among response was developing strong safety attitudes Working on ways to improve among managers and supervisors, followed by an aging workforce and 45% our safety culture More safety 74% changing safety accountability behaviors of employees. training Employees 23% for safety Safety leadership training across more Empowering employees to influence of the organization 21% safety-related changes
10%
10% 40%
74%
*Chart displays top selections by respondents from among 11 survey choices. 50%50%
0%
40%
74% 80%
Using wellness strategiesprogram as part to determine Accident investigation 49% of a safety theprogram root cause of loss 20% 30% 40% 50% 60% Purchasing or upgrading Formal safety policy 46% safety-related equipment and procedures
20%20% Employee 30%30%safety 40%40% training
10%
80%
51%
Employee health issues Increasing employee accountability Mandatory safety training 24% measuresfor foremployees safety
10%10%
0%50%
80% 30%
Limited resourcesSafety to address leadership31% training across more Safety worker safety issues of the organization committee(s)
0% 0%
Enterprise risk management
51%
Changing safety behaviors More safety Safety of employees training inspections
10%
70% 50%
BUDGET FOR PUBLIC ENTITY SAFETY PROGRAMS 1% In relation to current program needs, how would you describeNoyour safety Worse than data desired available program’s budget?
71%
Aging workforce
0%
40%60%
54%
Employees accountability 23% for safety 10% Attracting qualified applicants Empowering employeesjob to influence 21% safety-related changes Unrealistic 20% 0% Empowering safety Performing well 21% “OK” expectations committees
74%
Adequately Adequately Don’t know funded funded with ability to meet some needs 60% 10% 20% safety30% 40% emerging 50% 70% Developing strong attitudes among 62% managers and supervisors
0%
50%
30% Employee safety training wastraining the most highly rated strategy for impacting Increased safety communications awareness Aging and 48%selections were the number of workplace accidents. The next most frequent 80% 69% among employees workforce 20% increased safety Working communication and awareness among45% employees and on ways to improve Employee fitness our safety culture 79% 55% working on ways to improve our safety culture. for duty
MOST SIGNIFICANT CHALLENGES TO WORKPLACE SAFETY 13% 11% Accident investigation program to determine 71% What are your three most significant challenges to workplace safety? the root cause of loss 10% 5% Select three only.* Formal safety policy Underfunded
40%30%
Employee safety
41%
Significantly underfunded
30% 20%
42%
When 40% asked to describe their organization’s performance during the Safety past 3 to 4 years, 46 percent of public entities described their program as inspections 30% “performing well,” while 52 percent rated their performance as “OK” or as 30% Safety committee(s) “worse than desired.”
0%
10%20% 46%
40% displays top selections by respondents from among 12 survey choices. *Chart
*Adds 50% to 99 percent due to rounding.
20%
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50% 40% 30%
49%
Mandatory safety training for employees
74%
Accident investigation program to determine the root cause of loss
SEPTEMBER Formal safety policy and procedures
U ex
71%
2017 | PUBLIC RISK
71%
7
Ente man
among employees Changing safety behaviors Safety Working on ways improve inspections of to employees our safety culture
30%
30% 20%
resources to address Employees Limited accountability 23% worker safety issues for safety
20%
51% 45%
80%
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79%
10% employees influence RESULTS OF THE 2017 PUBLIC ENTIT Y EMPLOYEE Empowering SAFET YEmployee & toLOSS CONTROL health issues Mandatory safetySURVEY training 21% 24% 10% 13% safety-related changes 11%
10% 0%
Performing well
1% 5% Worse than No data desired available Adequately Adequately Don’t know funded funded with ability to meet some emerging needs “OK”
SAFETYSignificantly STRATEGIES CURRENTLY IN USE BY PUBLIC ENTITIES Underunderfunded funded Which safety strategies are being used by your organization? Select all50% that apply.*
0%
41% Developing strong safety attitudes among managers and supervisors
40%
Aging workforce
30%
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30%
0%
0%
Formal safety policy Significantly Under20% 30%procedures 40% and underfunded funded
10%
20%
30%
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51% 51%
79% 74%
11%
5% 71%
to meet some emerging needs
50%
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70%
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80%
0%
10% 0%
54%
*Chart displays top selections by respondents from among 17 survey choices. Increased safety communications and awareness Safety among employees More safety Working on waystraining to improve our safety culture
48%
inspections
80%
74%
48%
Aging on ways to improve Working 69%45% workforce our safety culture More safety training Employees accountability Employee fitness 23% 55% for forsafety duty Safety leadership training across more 58% Empowering employeesof to influence the organization 21% Attracting qualified safety-related changes 42% job applicants Increasing employee accountability Empowering safety 55% 21% measures for safety committees Unrealistic 20% expectations Using wellness strategies as part 49% of a safety program Enterprise risk 17% 0% 10% 20% 30% 40% 50% management Purchasing or upgrading 46% safety-related equipment
80%
80%
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40% 30%
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60% 50% 40% 30% 60%20% 10%
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Safety in use,45% Safety inspections was the leading safety strategy selected by 80 Employee fitness 79% 55% committee(s) 60% for duty Safety leadership training across more percentEmployees of respondents, followed by safety committees, with 79 percent When asked about the safety strategies they plan to implement in the next accountability 58% 23% 49% for safetyof the organizationMandatory safety training qualified 50%74% 42%next most selected choices, saying they used this strategy. Mandatory safety training for employees was three years, moreAttracting safety training outpaced the for employees job applicants Empowering employees toemployee influence accountability Increasing 21% 55% changes the nextsafety-related most popular selection. safety leadership training across more of the organization and increasing 40% measures for safetyinvestigation program to determine Accident Unrealistic 71% 20% the root cause of loss Empowering safety expectations employee accountability measures for safety. 21% Using wellness strategies as part committees 30% 49% of a safety program Formal safety policy MOST SIGNIFICANT EMERGING SAFETY AND LOSS Enterprise risk 71% 20% 17% and procedures management 20% 16% or upgrading CONTROLPurchasing ISSUES BENCHMARKING WORKERS’ COMPENSATION EXPERIENCE 46% safety-related equipment 0% 10% 20% 30% 40% 50% 60% 10% 6% 6% What are your three most significant emerging issues in regard to safety and loss How do you benchmark your organization’s workers’ compensation experience? 0% 30% 40% 50% 60% 70% 80% 0% 10% 20% 30% 40% 50% 60% 70% 80% control? Select three 10% only.* 20% Select all that apply. 0% 0%
10%
20%
30%
40%
Aging workforce
80%
50%
60%
70%
More safety training
Unrealistic expectations
71%
Enterprise risk management
71%
80%
0%
0% 10%
20% 30%
30% 40%
70%
49%
30% 20%
46%
20%
16%
10% 40% 50%
50% 60%
We do not benchmark
40%
49%
Purchasing or upgrading 17%safety-related equipment
10% 20%
50%
55%
Using wellness strategies as part 20% of a safety program
Other
60%
58%
Increasing employee accountability Attracting qualified 42% measures for safety job applicants
74%
70%
74%
69%
Safety leadership training across more Employee fitness of the organization 55% for duty
79%
Our Data from an BLS or Data documented insurance/ other from historic TPA or safety government an industry 80% results organization data association
80%
60% 70%
70% 80%
80%
0%
Our Data from an BLS or Data documented insurance/ other from historic TPA or safety government an industry results organization data association
6%
6%
Other
We do not benchmark
*Chart displays top selections by respondents from among 12 survey choices.
80% 74%
70%
70%
Two worker conditions—age and fitness for duty –ranked as the most 60% outstanding concerns for public entity risk managers regarding safety and 49% 50% loss control. The next most cited concern was attracting qualified job applicants. 40% 30% 20%
20%
16%
10% 80%
0%
8
Our Data from an BLS or Data documented insurance/ other from historic TPA or safety government an industry results organization data association
PUBLIC RISK | SEPTEMBER 2017
6%
6%
Other
We do not benchmark
Enterp mana
0%
69% workforce *Chart70% displays top selections by respondents from among 13 survey choices.
70%
Un exp
71% 70%
training
Adequately Adequately Don’t 71% know 50% 60%with ability 70% 80% funded funded
40%
21% Accident investigation program to determine the root cause of loss 10% 20% 30% 40% 50% 60% Formal safety policy and 20% 30%procedures40% 50%
STRATEGIES PUBLIC ENTITY RISK MANAGERS PLAN 71% 10% 60% TO IMPLEMENT Which safety strategies do you plan to implement in the next three years? 0% 10% 30% 40% 60% 70% 80% Employee safety 50% Select all that apply.*20% 54%
0%
62%
committee(s) 20% Limited resources to address 31% worker safety issues Mandatory safety training 13% for employees Employee 10% health issues 24% Accident investigation program to determine the root cause of loss 0% 10%
0%
74%
for employees
Empowering safety committees
More than two-thirds of respondents used their own documented historic results to benchmark their workers’ compensation experience and almost 50 percent of respondents benchmarked with data from an insurance company/TPA or safety organization. Other methods, including BLS or other government data and industry association data were named much less frequently.
0%
SELECTED SOLUTIONS TO ADVANCE YOUR EMPLOYEE SAFETY AND LOSS CONTROL PROGRAM
The 2017 Public Entity Employee Safety & Loss Control Survey revealed the importance of developing a safety culture, engaging your workforce in safety and leadership and accountability for your loss control initiatives. The survey also emphasized the key role of safety training and data analytics, as well as the need to help public entity employees improve their health and well-being. Consider the following areas to advance your public entity’s loss control program. ENHANCE YOUR SAFETY CULTURE Safety cultures develop over time and are influenced by many factors. The safety leadership of an organization is one of those factors. Many suggest that employees tend to gauge management’s commitment to safety, and this too, can influence the eventual safety culture.
• Be trusted communicators of consistent safety messages/actions; publish safety success stories • Hold management accountable for safety performance • Listen to, and, work with your employees on the mutual benefits of making safety a priority and communicate results of your safety programs
GAUGING THE EFFECTIVENESS OF LEADERSHIP AND ACCOUNTABILITY IN AN ORGANIZATION’S LOSS CONTROL INITIATIVES Key to establishing a strong safety culture with engaged employees is leadership. As stated in the book, The Nature of Leadership, “leaders of organizations embed and transmit culture in the thinking, feeling, and behavior of the group.”2
Accountability is a key part of leadership. Quint Studer stated, “accountability is the glue that holds the best laid plans together.”3 So how can you gauge if accountability is a hallmark of your culture? See if you agree with the following statements about your safety program:
Changing a safety culture involves five key steps:
ENGAGE YOUR EMPLOYEES IN SAFETY
A hallmark of a strong safety culture is employees who are engaged in safety and are empowered to advocate for a safe culture. A 2016 Gallup Study on Engagement and Safety revealed that top performers in employee engagement have 70 percent fewer safety incidents than the less engaged business units.1 Keep in mind that employee engagement must be earned, and that leadership is critical to engagement. The following strategies will help you engage your employees in safe working strategies. • Be unified and demonstrable about safety’s value, which begins at the top of your organization • Be strategic about policies and practices with ongoing discussion and hold leaders accountable for safety
We have a strong and clear safety vision for our organization We communicate our safety goals to employees We have implemented a safety strategy/plan People execute our safety plans consistently
The more statements you can answer affirmatively to, the more likely that your public entity has the “glue of accountability” to achieve your goals.
COMBINING EMPLOYEE WELLNESS AND SAFETY PROGRAMS
Employee wellness is critical to keeping your workforce safe and your workers’ compensation costs under control. To address employee wellness issues impacting workers’ compensation, it’s important to connect your organizational safety culture with non-occupational factors impacting your employees’ health and wellness programs. Integrating occupational health/ safety and wellness programs offers the benefits of better employee morale, improved employee health, reduced medical plan losses, increased productivity, reduced absenteeism and reduced workers’ compensation costs. OCCUPATIONAL HEALTH & SAFETY VS. WELLNESS PROGRAMS: A COMPARISON OCCUPATIONAL HEALTH AND SAFETY GOAL
Safety perception surveys (well-established feedback tools) help your entity’s leadership better understand your employees’ thoughts and perceptions about safety. This type of feedback can be vital to your organization’s safety efforts. Questions typically center on leadership, the work environment and safety norms, safety training and education, as well as employee satisfaction and engagement in safety.
• • • •
TYPICAL ELEMENTS
Implement a new approach about safety in your organization Develop a sustainable strategy to reform your safety norms Teach the impact of decision-making at every level Help new and positive stories get told (passed along to others) about safety in your organization and recognize safe work habits Consider conducting an organizational safety perception survey (formal or informal) to start changing your safety culture
WELLNESS PROGRAMS
Risk management program that strives to foster a safer work environment. Focuses on preventing workplace-related injuries and illnesses.
Focuses on enhancing the overall well-being of workers, addressing specific lifestyle behaviors, inside and outside of the workplaces.
• Incident investigation training • Safety planning • Rules and workplace procedures
• • • • • •
Nutrition education Smoking cessation program Stress management program Access to fitness centers Exercise program Information on health topics
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RESULTS OF THE 2017 PUBLIC ENTIT Y EMPLOYEE SAFET Y & LOSS CONTROL SURVEY
IMPLEMENT EFFECTIVE SAFETY TRAINING PROGRAMS
Safety training can be beneficial for your organization. However, the results of safety training depend upon factors such as: • Effectiveness of the training • Consistency of the training content with your in-force safety policies • Level of enforcement of safety policies by managers and supervisors When conducting safety training, it’s important to educate and train workers in a language and vocabulary they understand to ensure they know not only how to recognize hazards, but also can implement ways to eliminate, control, or reduce hazards. Also, consider the appropriateness of online training versus classroom-style training for your workforce. The following chart can help you gauge the mode of training most appropriate for your workforce and for the situations they face. ONLINE TRAINING: POSITIVE AND NEGATIVE ISSUES PROS
CONS
Consistent training content
Is your workforce a willing user?
Easy to assign and provide documentation
Will the course learning transfer to their jobs?
Great for pre-classroom training
How will you know if they can avoid these hazards (OSHA’s expectations)?
Interactivity keeps taking a step forward
Humans forget most of what they see once. Is that good enough for your hazards?
Simulation-type training can Do your managers really know the help with decision-making content and manage these expectations? Newer generations more Should you consider a strategic blend to willing to learn in this format achieve your safety goals?
USE DATA ANALYTICS TO IMPROVE YOUR SAFETY PROGRAM
Data analytics can be used to prevent claims, and keep your workforce safe. The more data you have, the better you can identify your loss potential and opportunities for improvement. Data analytics can help you with the following: • Identifying the greatest opportunities for improvement • Establishing long-term goals • Providing reporting that enables you to: • Simplify complex workers’ compensation data analytics into compelling visual information • Share the data with your leadership team • Communicate your safety success stories
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WHAT TYPES OF ANALYSIS SHOULD I BE DOING? The optimal strategy is to do a complete review of your claims data, including the following:
• Frequency rate analysis in relation to total claims reported for both lost-time and medical-only rates • Loss-leader analysis to show claims by type of injury, with both severity and frequency results • Department results by frequency and severity, as well as in the context of staff and other key indicators • Comparisons with your public entity industry peers The most effective workers’ compensation data analytics tell a story of exactly where and why claims are occurring, and provide useful information and strategies to improve long-term performance, including a long-term loss control plan to reduce both the frequency and severity of your workers’ compensation losses.
CONCLUSION
Your most valuable asset is your employees. Providing a safe work environment is critical. The cost of claims is obviously important, but an injured worker has an impact on your organization and their family. The good news is with a strong safety program, fewer employees will be injured. REFERENCES 1. 2016 Gallup Study on Engagement and Safety of 82,000+ business units, 1.8 million employees in 230 organizations, 49 industries, 73 countries 2. The Nature of Leadership, Antonakis, Cianciolo & Sternberg 3. Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference, Edition 1, Quint Studer
Frank X. Altiere, III, RIMS Fellow, CPCU, ARM, AU, IIA, AIS, is the president of PMA Management Corp.
BY MARK FERRARO
W
HEN DISASTERS STRIKE A COMMUNITY, public entities often find themselves in a dual relationship of being both the first responder to help their community recover and as a business enterprise trying to reestablish their own infrastructure, services and revenue streams to pre-disaster conditions. Because of their unique responsibilities related to public/community safety, public entities and private nonprofits have disaster recovery plans and hold drills to hone their responses to the constituents they serve. Often overlooked are the steps necessary to be a successful applicant for benefits under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121 – 5207. This article will focus on one element of the application process: insurance. Every public entity in the United States, including tribal governments and certain private nonprofits, are entitled to disaster assistance under the Stafford Act. The section of the Stafford Act that applies to public entities and private nonprofits is known as Public Assistance. The primary purpose of the Public Assistance program is to provide grant funding to return their infrastructure investments to pre-disaster conditions. Disaster assistance is divided into two broad categories: Emergency Work and Permanent Work. As an organization prepares their applications for reimbursement of expenses, the risk manager plays a critical role in helping the organization prepare a cogent explanation of the costs incurred in each of the categories. It is beyond the scope of this article to address the issue of what is an eligible cost in any of these categories. What can be shared is a systematic method of identifying costs by service provided.
WHAT IS EMERGENCY WORK AND PERMANENT WORK?
Emergency Work includes the following categories: Category A: Debris Removal – Any costs related to debris removal that is deemed in the public interest, which has been held to mean “... eliminate immediate threats to lives, public health and safety.”1 Category B: Emergency Protective Measures – Any costs as a result of activities undertaken by a community before, during and after a disaster that are “… necessary to eliminate or reduce an immediate threat to life, public health or safety.” 2 Permanent Work is defined by categories C through G: Category C: Roads/Bridges/Culverts Category D: Water Control Facilities Category E: Buildings and Equipment Category F: Utilities Category G: Parks, Recreational Facilities and Other Items
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UNDERSTANDING THE FEMA INSURANCE PROCESS
Categories C through G: “Permanent work is that which is required to restore a damaged facility, through repair or restoration, to its pre-disaster design, function and capacity in accordance with applicable codes or standards.”3 So now the logical question to ask is “What does insurance have to do with any of these program benefits?” Section 312 – Duplication of Benefits (42 U.S.C. 5155) of the Stafford Act requires that every application for benefits be reviewed for potential duplication of benefits from either another federal agency or insurance. Little known or understood by most applicants is that every application for benefits must go through an insurance review to avoid duplication of benefits, maximize insurance claim proceeds and reasonably insure against possible future damages. The insurance review is the last step in the eligibility review process. It can take 3-to-6 months from incident date to application formation. An application that makes it to the insurance review is deemed eligible and the goal of the insurance reviewer is to get the application through the review process so the applicant can receive funding as soon as possible. The insurance review process is mandatory and inflexible. So as a risk manager, how can your entity avoid an application from being held up or put on indefinite hold due to insurance concerns? The insurance review step has two primary goals: Verify that there is no potential insurance recovery for the items listed in the application. If there is potential insurance coverage, the review process then attempts to establish a reasonable estimate of “anticipated” insurance proceeds. If the damaged item is insurable, as defined by the Stafford Act, establish the reasonable types and amount of insurance required on the object. FEMA funding is always contingent on securing insurance for insurable items. One of the myths of the Stafford Act is that FEMA pays for “deductibles.” This is not true. All eligible costs in an application are reduced by actual or anticipated insurance proceeds. In a perfect world, actual costs to repair insured damaged items less actual insurance proceeds might equal the deduct-
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ible. But few things in the real world are this exact. Later in the article we will discuss when certain reductions are taken that reduce eligible recoveries.
your complete and true copy of the coverage, but schedules of locations, including your vehicles and mobile equipment.
Applications are held up for a number of reasons in the insurance review process. Here are the top five reasons:
Coverages in force during the declared storm period: • Property Insurance, including the following: NFIP Flood Insurance Policies Windstorm All Risk/Named Peril Vehicle Physical Damage Coverage/ Schedule of Vehicles Boiler & Machinery Mobile Equipment Contractors Equipment
a. No insurance policy submitted to FEMA b. No loss adjusters report c. No claim denial letter from the insurance company/pool d. Incomplete schedule of values/locations e. Conflicting information on coverage/claim payment information
Risk managers can improve the review processing time
of their applications by being involved in the application
process from the beginning… Unfortunately, the message is often not received or remembered until applications start piling up in the insurance review process. Risk managers can improve the review processing time of their applications by being involved in the application process from the beginning. Every potential applicant in a disaster is invited to a Kick-Off Meeting (KOM). At the meeting, the applicant will meet their state and federal disaster representatives and may also meet the project specialist who will help the entity with their applications. The agenda of the meeting always includes a specific request about insurance. Unfortunately, the message is often not received or remembered until applications start piling up in the insurance review process. Several regions of FEMA are experimenting with procedures to secure complete insurance information faster too avoid unnecessary delays in the insurance queue.
WORKING ON YOUR FEMA APPLICATION
The first step a risk manager should take when the entity starts working on their FEMA applications is to address the issue of organizing the insurance documents. Your agent/broker/ pool representative can provide you with a pdf copy of the coverage documents in force during the storm period. This should include not only
Report your damages to the insurance company and organize your claim payments/claim denial letters by coverage and insured items. Provide copies of any coverage determination bulletins from your insurance company or pool. These are common after a disaster is declared and can help speed up the review process. Identify buildings that are in Special Food Hazard Areas (SFHA) and your insurance treatment of those buildings. As a contractor to FEMA for the insurance review process, I see some amazing resistance from certain entities when they are asked to provide the required insurance information. As the insurance review is proscribed by federal law, there is no waiver provision to invoke. The insurance review process is absolute and can’t be waived. FEMA’s Office of the Inspector General audits all applications for benefits at some point. Their consistent message in their audit reports is that insurance reviews must be performed or they will “claw back” the funding from the applicant or reject their application for benefits if payment has not been made. One of the quirks of the FEMA application process is that all costs in an application must
be of the same Category. So clarity of claim payments and claim denials is paramount in an application. Sometimes the same information is critical in two different applications. There is no limitation on how much information can be included in an application, as long as it is germane to the determination of eligible benefits. Applications for disaster benefits are always paid based on eligible costs. As an example, Small Town USA has a building damaged during a disaster event. The estimated eligible repair costs are $100,000. If the insurance proceeds are $50,000, then FEMA will contribute $50,000. If the insurance proceeds are $135,000, then FEMA will contribute $0. FEMA will never contribute more than the eligible costs of an application, less any insurance proceeds. The insurance review process is the only review function in the disaster application process that can reduce eligible costs, as opposed to changing the balance of payments between insurance and FEMA funding. There are three conditions where the insurance review can reduce eligible costs: Previous Disaster Recovery – In plain language, FEMA will not pay for damages on any facility that received prior disaster assistance, up to the amount of such prior disaster assistance. Failure To Maintain Required Insurance – If an applicant receives disaster assistance for a building, contents, equipment or vehicles and the value of the assistance is more than $5,000, the applicant must maintain insurance on that item. If the facility is damaged in a subsequent disaster and insurance was not maintained, FEMA will deny or de-obligate assistance in the current disaster, deny future assistance for that facility and may take back any previous funding for that object in every previous disaster through the current disaster.4 Mandatory NFIP Reduction – Maximum Flood Insurance Proceeds Available – If the applicant has facilities located in Special Flood Hazard Areas (SFHA), the insurance review must reduce eligible costs by the maximum available flood insurance coverage available in a NFIP policy. The purpose
of this penalty is to encourage all applicants to purchase flood insurance for their vulnerable facilities in the SFHA. The reduction of the eligible costs by available NFIP insurance causes the most misunderstandings about the insurance review process. Known by its FEMA computer code 5902, this reduction is the most common reduction taken by the insurance review. Any structure with a roof and two rigid walls is considered insurable under the NFIP program if it is located in a SFHA. Further, any contents or equipment in the building that support the function of the building are subject to NFIP coverage. FEMA has a formula that dictates the dollar value of the 5902 reduction. FEMA will pay for the estimated lowest NFIP deductibles (currently $1,000 and $2,000) and depreciation (NFIP policies are written on an Actual Cash Value (ACV) basis). Deductibles and deprecation are applied separately for building and for contents. As the highest limit that can be purchased for a nonresidential building in the NFIP program is $500,000 for the building and $500,000 for the contents/equipment, the penalty can be severe. Many public entities do purchase flood insurance. The problem is that the penalty applies if the flood coverage is not equivalent to NFIP coverage available at the time of the loss. It is common to see commercial insurance or pool programs that carve out flood insurance coverage if the building is located in SFHA, usually the deductible is automatically $500,000 for that location, in recognition that NFIP can provide coverage to that limit. Public entities can always appeal insurance decisions that result in reductions to their applications. The easiest way to perfect an appeal is to secure a properly constituted denial letter from the insurance company/pool. What is a properly constituted denial letter? Well it should clearly document the coverage provided and then clearly explain why coverage is denied or payment is not being made. A good rule of thumb is that it takes at least four pages of letterhead to properly deny a claim. If FEMA believes the denial letter is proper, the insurance reductions can be reversed. However if FEMA believes the denial letter is insufficient to comply with the laws and regulations governing that disaster, FEMA can dispute the amount of the anticipated insurance funding until the applicant
has exhausted all means of recovery including arbitration, litigation, etc. Reasonable legal fees incurred by the applicant to secure a judgement can be applied against any potential insurance recovery, thereby reducing the mandatory insurance reductions. The final step in the insurance review process is to establish new insurance requirements for the objects funded in the application. Such insurance requirements can be appealed for some narrow issues as allowed in the Stafford Act. Insurance must be obtained and/or maintained for any building, contents, equipment or vehicle funded by FEMA. The flood insurance requirement, if any, cannot be appealed on the basis of cost or availability if the amount required is equal to or less than the maximum amount offered by NFIP. That appeal can only be based on NFIP definitions of an insurable building, contents or equipment or if the building is actually in a designated SFHP. If FEMA requires flood insurance higher than the maximum offered by the NFIP then it is possible that cost and availability become factors of reasonableness. If any portion of a building touches a flood zone boundary, the entire building is considered to be in the flood zone. Most applicants that provide well-organized insurance information with their applications experience little or no delay in their insurance review.5 Future articles in this series will address The Care and Feeding of Your Project Specialist and Understanding the New FEMA Self Insurance Standards. Mark Ferraro is a senior policy advisor for Kinne Associates, disaster planning and recovery consultants. FOOTNOTES/CITATIONS: 1. Public Assistance Guide FEMA 322/June 2007 – Chapter 2, page 67 2. Public Assistance Guide FEMA 322/June 2007 – Chapter 2, page 71 3. Public Assistance Guide FEMA 322/June 2007 – Chapter 2, page 79 4. Public Assistance Policy on Insurance FP 206-086-1/June 29, 2015- Page 7 – G. Consequences of Non-Compliance (Failure to Obtain and Maintain Insurance). 5. The latest Public Assistance guide is posted on the web and is effective for all disasters declared on or after Jan. 1, 2017. https://www.fema.gov/ public-assistance-policy-and-guidance
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Managing the New Comorbidity:
DIABETES + OBESITY BY MICHELLE DESPRES, PT, CEAS II
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MANAGING THE NEW COMORBIDIT Y: DIABETES + OBESIT Y
D
IABESITY, THE CLINICAL TERM referring to the occurrence of obesity and diabetes combined, is having a dramatic impact on the recovery of injured workers today. An injured worker with both these health issues is at risk for increasing health complications, slower recovery time, rising medical costs and a higher risk of re-injury.
It is estimated that 70 percent of Americans are obese or overweight. With obesity comes a variety of other potential health issues including diabetes, high blood pressure, stroke and cancer. Current research indicates that approximately 29 million Americans are already living with diabetes. According to the research Harbor Health Systems presented at the 2016 National Workers’ Compensation and Disability Conference, comorbid conditions have a significant impact on claims outcomes, including duration and total costs. Claim duration, for example, increased by 76 percent for claims involving multiple comorbidities. Claims with multiple comorbidities also saw a 341 percent increase in total costs incurred over the life of the claim. When diabetes and obesity occur in the same individual, risk and associated costs and liability will only increase. It’s important for risk managers to recognize and understand the significant impact of these comorbidities in order to proactively manage claims.
COMORBIDITY TRENDS TODAY Diabetes and obesity are considered comorbid illnesses, which are medical issues that an injured employee has in addition to the workrelated injury. As workers age, comorbidities increase. A 2012 NCCI report found that claims with a comorbidity diagnosis have about twice the medical costs of otherwise comparable claims. Comorbidities can directly influence medical, therapy care and outcomes. The Harbor Health Systems research found that multiple comorbidities was the most significant factor increasing total disability, medical costs, litigation, recidivism, and complications of surgery in workers’ compensation claims.
Clinically, risk managers need to identify potential comorbidities, such as obesity or diabetes, and address them with exercise prescriptions, concrete goals and a comprehensive clinical treatment plan.
DIABETES PLUS OBESITY = RISK An injured worker with diabetes is already at higher risk than someone without this condition. If not proactively managed throughout the life of a claim, an injured worker who has diabetes can develop health complications such as delayed healing, infections and slower recovery, all factors that can drive up claims costs and the duration of the disability.
When a diabetic worker is also obese, risk is increased. Diabesity can impact a worker through changes in physiology and biomechanics. For example, a worker presenting with diabesity will have low back misalignment that causes their center of gravity to change. This situation increases the risk of low back injuries. With diabesity, it is also more likely for musculoskeletal injuries to occur including injuries to the low back, hips, knees, wrists and shoulders.
DIABESITY TRENDS
• In June 2013, the American Medical Association (AMA) declared obesity as a disease. Any individual can be considered obese by examining their height and weight, and computing their Body Mass Index (BMI). Someone with a BMI of 30 or more is obese, according to the CDC’s definition of obesity . • By 2020, obesity will account for 20 percent of all healthcare costs . • Nearly 80 percent of Americans do not meet basic activity level recommendations . Because Americans are living such sedentary and inactive lives, there is a higher incidence of diabetes, heart disease, cancer, arthritis and lower back pain. • More than 29 million Americans are living with diabetes and a staggering 86 million are living with prediabetes. According to the CDC, more than 20 percent of healthcare spending is for people with diagnosed diabetes . • Without major changes, as many as 1 in 3 U.S. adults could have diabetes by 2050 . Medical costs for diabetics averages 2.3 times higher than non-diabetic workers . • Eighty percent of type II diabetes is related to obesity . When an injured worker presents with diabesity, there are increased health risks to consider such as increased risk for heart disease, stroke, blindness, kidney disease and amputation. • Diabesity can lead to increased medical costs, increased injury frequency, higher indemnity costs, slower recovery, heightened risk for re-injury and absenteeism.
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When managing a claim involving diabesity, it is important to be aware of the range of potential risk factors: • • • •
More low level back injuries Poor level of fitness Decreased flexibility Presence of additional comorbidities (arthritis, joint issues, and cancer can be exacerbated with diabesity) • Slower healing rates • Extended therapy durations • Higher rates of surgery and potential complications from surgery
SOLUTIONS FOR MANAGING THE DIABESITY EPIDEMIC Below are six solutions to help manage the diabesity epidemic in the workforce today:
Prevent injuries with pre-work screenings, fit-for-duty programs and wellness programs. It is also important to match an employee’s demands of their bodies to their duties. These kinds of programs can help establish realistic work demands, with the long term goal of reducing medical and workers’ compensation claims/costs. Reference clinical guidelines (ODG guidelines for example) when creating a clinical treatment plan. Implement physical/functional job descriptions as a preventive measure. Following an injury, an employer may engage professionals to create thorough job site analyses to learn from the existing injury and prevent future injuries.
Educating employees is critical. Arming employees with knowledge of the importance of ergonomics and making the necessary adjustments to the work area will greatly reduce risk in the workplace. By educating employees about posture, body mechanics, joint protection and work cycles, risk managers can also help address mechanisms of injury and overexertion. Implement a physical therapy program with diabesity-related claims, taking into consideration different balance levels and altered centers of gravity as a result of being overweight. Use Function Capacity Evaluations (FCEs) to objectively measure an injured worker’s work capacity, establishing safe return-towork levels. As obesity and diabetes rates continue to escalate, it is critical for the workers’ compensation industry to pay attention to these health issues and take a proactive approach to managing them. The diabesity epidemic will not abate in the near future. With clinical collaboration and proactive care strategies, risk managers can nevertheless reduce the workplace risks associated with diabesity. Michelle Despres, PT, CEAS II, is the vice president and national product leader at Align Networks, a division of One Call Care Management.
CASE IN POINT:
PROACTIVE CLINICAL OVERSIGHT PRODUCES OPTIMAL OUTCOMES FOR INJURED DELIVERY DRIVER WITH DIABETES A 55-year-old overweight worker with no symptoms attends a Department of Transportation (DOT) physical where it is found he has no previous health issues but his blood sugar reads over 500. According to the DOT guidelines in place, this individual cannot drive until his personal physician treats him for diabetes. Because he was unable to work, his commercial driver’s license (CDL) was temporarily revoked. When examining a claim involving diabetes, it is important to examine all the factors that could impact the claim outcome, as well as the injured worker’s history. In this case, his age was a factor, as well as his weight gain over the years and the fact that this claimant was now a type II diabetic. When his history was gathered, the risk manager learned that he had been with his company for over 30 years at the time of his diagnosis. For the first 16 years at the company, he had been very physically fit as a delivery driver because of the physical demands of his job. For the remaining 24 years of his career at this company, he drove tractor-trailer type trucks, pulling double trailers and crossing state lines, which moved him toward the more sedentary end of the spectrum. Because of the proactive diabetes management at the onset of the claim, he was educated about diet and monitoring of his blood glucose levels and was able to control his diabetes successfully with the assistance of oral medications. He was able to resume driving and continued until he retired at age 65.
SEPTEMBER 2017 | PUBLIC RISK
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