Innovation is the key to staying relevant, differentiating your brand and gaining competitive advantage, but who is consistently driving innovation in the corporate world? The new state of affairs can be daunting. I don’t envy the work of talent acquisition teams. Stakeholders and business partners struggle to define the skill sets required, and, even when there is a clear mandate and job description, it can be so hard to find talented innovators that create real value and impact amid all the hype, fluff and buzzwords. The driving forces of innovation are human behavior, advancements in technology and economic viability, but for real, tangible innovation that creates and captures new value in new ways, diversity is crucial. See also: Innovation Happens at the Edge   Diversity is two-dimensional: inherent and acquired. Inherent diversity is associated with "who we are", i.e. the personality type we are born with, our gender, ethnicity and sexual orientation. Acquired diversity is about "how we behave" as a result of what we’ve learned and experienced. It consists of our mental models and mindsets developed over time. For example, I’m a Persian Hebrew, straight, woman with a commanding personality. Being a third culture child and having lived around the world, I am home everywhere and nowhere at all. My natural desire to grow, expand and explore leads me to travel, taking on eclectic responsibilities and experiences. I embrace the differences in people and connect the dots among those differences to achieve exciting outcomes, that continue to build trust and value in the digital age and expand the realm of the possible. But I am a rare breed. Two-dimensional diversity creates a powerful dynamic at work between diverse leaders and teams who know how to unlock each other's contributions. Inherently diverse people bring to the team an understanding of unmet needs in underleveraged markets. People with acquired diversity bring fresh perspectives, mindsets and notions that are globally relevant and connect to a wider consumer base. It takes leaders with inherent and acquired diversity to establish a "speak-up culture," which is essential in unleashing the innovative capacity of the team to its fullest. By giving equal airtime to diverse voices, these leaders are more likely than non-inclusive leaders to derive value creating insights. They ensure all members of the team get constructive feedback and support to extract breakthrough ideas. Listening to contrarian input and taking corrective actions that alter the course, they are more likely to arrive at effective solutions. Creating a culture of innovation is important for great ideas to translate to market share. As with any form of change, transformation of culture requires catalysts. In my experience, that means a vertically diverse workforce with strategic leadership that creates alignment to the vision. Research shows that executives must both embrace and embody the power of differences. After all, innovation stems from the collective genius of diverse teams managed by leaders who value perspectives and approaches outside their own experience or expertise. See also: Innovation: Not Just for the Big Firms   I am dedicating this article to one such leader : Derek Low, executive vice president, Liberty Mutual, a humble and passionate leader whom I respect, look up to, learn from and admire professionally.

Noncompliance is one of the greatest challenges and opportunities for savings and improved medical outcomes. One reason noncompliance has been such a difficult issue is its complexity. Patients don't take their medications for a multitude of reasons. Reasons for noncompliance vary from patient to patient. That rules out a one-size-fits-all solution. Noncompliance can be more of a challenge for workers' compensation claims, potentially because of perceived HIPAA privacy rules. Because of an approach that appears to mirror “don’t ask, don’t tell,” little is known by many of the workers' compensation physicians about the drugs that are being prescribed for chronic or underlying conditions to their industrially injured patients. Or, if doctors do discuss such issues with the patients, few if any include such information in their reports to the insurance companies.  Claims examiners also do not want to know about underlying medical conditions because of their fear of being roped into paying for this kind of treatment even if it may facilitate a faster recovery from an industrial injury. (Not knowing about underlying conditions, they are also limiting their ability to identify potential catastrophic claims early in the age of the claim.) Here are some of my thoughts and commentary on noncompliance:

• Compliance problems are one of the many reasons that the medications are doled out in a plastic weekly (with individual days) dispensing device.
• There are many new “apps” being developed for phones and computers that are designed to insure compliance.
• There are also new technologies being developed that will insure compliance for many of the chronic drugs. For instance, Proteus has a chip that is attached to the pill. It gives out a signal when the pill is taken. I was particularly impressed with these folks.
• Noncompliance is also tied to pharmacy fraud. This is particularly true for physicians who are allowed to dispense out of their offices as well as for those who are involved in prescribing and dispensing opiates.
• Compliance is significantly different for pain drugs vs. chronic drugs (such as heart medications or statins for cholesterol maintenance). We generally prefer that patients not use pain drugs unless those drugs are needed to maximize the recovery of the patient. Yet we want every patient to take the right medications at the right times to help them maintain appropriate blood pressure, sugar blood levels or anti-convulsive drugs needed to maintain a productive and healthy worker.
• Noncompliance is one of the problems that has helped fuel the opioid epidemic. A result of the reluctance of many to take all of the pain medication that was prescribed is the filling of medicine cabinets with dangerous pain pills (which are easily accessed by children and visiting friends). One interesting comment from a good friend: “Every time I have a party, my medicine cabinet is completely cleaned out.”
• I believe that many physicians are unable to keep up with the variety and nature of all the new drugs brought to market. This can result in poorer-quality drugs or poorly targeted drugs being prescribed, with no one the wiser. Education can be problematic with pharmacy, because there is really no independent body providing the education on the drugs.
• In Canada, some pharmacists are allowed to prescribe as well as dispense certain drugs. There are no studies on the impact of this in prescribing or dispensing patterns. But studies in the U.S. have shown that, if there is a potential financial incentive, then more drugs are prescribed. As more baby boom doctors retire, and they are not replaced through our teaching system, more of the medical care will responsibility will be demanded of pharmacists, PAs and NPs. With more prescriptions being written by the pharmacists, compliance can be even more problematic because far less time is spent with the patients by pharmacists than by the doctors.
• Off-label use of pharmacy is more problematic with regard to compliance because of the lack of evidence-based medicine (or any research at all) supporting the new uses of the existing drugs.
• Blood, urine or oral swab testing for compliance is expensive and problematic but can be useful.
• One of my favorite stories of noncompliance was the case where the prescribing physician was confronted with a blood test that demonstrated that the patient was not taking any of the prescribed (and dispensed) opiates. The doctor’s response was that the blood test proved that the patient was not abusing the drugs, and he continued to prescribe the same dose and volume for the next three months. (I believe that the patient was selling the drugs.)
• The advent and expansion of universal medical records will assist treating physicians overcome the siloed medical approach that has existed in WC for years.
• Some of the reasons for noncompliance are also the same reasons that we find it so hard to help injured workers recover.
• I did not see any statistics, but I am willing to bet that noncompliance is higher with the 20% subset of population who have had ACEs (Adverse Childhood Experiences) and are the ones we have designated as at risk for delayed recovery in the workers' compensation system.

Here is an article from Doug Benner, which is worth the read for good insight into this very complex issue: The number of patients who are noncompliant with regard to their pharmacy usage has reached epidemic proportions, and doctors' inability to provide optimal care as a result has mushroomed into one of the most pressing problems in healthcare today.

• In the U.S., some 3.8 billion prescriptions are written every year, yet more than 50% of them are taken incorrectly or not at all.
• In a survey of 1,000 patients, nearly 75% admitted to not always taking their medications as directed. A study of more than 75,000 commercially insured patients found that 30% failed to fill a new prescription, and new prescriptions for chronic conditions such as high blood pressure, diabetes and high cholesterol were not filled 20% to 22% of the time.
• Even among chronically ill patients who regularly fill their prescriptions, only about half the doses taken are taken as their physicians intend.
• Poor compliance accounts for 33%  to 69% of drug-related adverse events that result in hospital admissions.
• Poor compliance with medication regimens is associated with as much as 40% of nursing home admissions.
• In a study of more than 8,400 senior health plan enrollees, only one in three of those who began treatment with concurrent antihypertensive and lipid-lowering drugs were taking both medications as directed or at all at six months.
• In a study of more than 240,000 patients who were given a new prescription for an antidepressant, less than 30% were still taking the medication six months later.
• Compared with patients who follow instructions, patients who don't take their medications as intended have a risk for hospitalization, re-hospitalization and premature death that is 5.4 times higher if they have hypertension, 2.8 times higher if they have dyslipidemia and 1.5 times higher if they have heart disease.
• The number of patients with serious cardiac conditions who don't take their medications is especially baffling and problematic. In a study of 34,501 patients age 65 or older, only 26% of those who began a statin regimen to reduce the risk of coronary heart disease maintained a high level of use five years later; the greatest decline occurred during the first six months of treatment.
• Even after a life-threatening event, compliance with medication regimens remains surprisingly poor. Within two years of initiating therapy, only half of patients hospitalized for acute myocardial infarction (MI) were still taking their prescribed statins, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).

One upshot: Poor medication compliance is implicated in more than 125,000 U.S. deaths per year. Yet compliance — which is used interchangeably with the term “adherence,” although the latter term is gaining ground — has been exhaustively studied. More than 40,000 peer-reviewed papers on the subject have been published, “yet the rates of poor adherence have not changed significantly over the past several decades and continue to remain at an unacceptable level,” observes URAC, a healthcare accreditation organization, in a white paper prepared for industry leaders. Or, as former Surgeon General C. Everett Koop once put it with his customary forthrightness, “Drugs don't work in people who don't take them.” The $290 billion question — $290 billion being how much poor compliance is estimated to cost the U.S. healthcare system each year — is: Why? See also: How to Pick a Health Plan (Carefully)   An unbelievably complicated problem One reason noncompliance has been such a tough nut to crack is its daunting complexity. Patients don't take their medications for a multitude of reasons, many of them emanating from the murky depths of human psychology and many of which the patients (not to mention medical researchers) may not fully understand. To complicate matters, these reasons vary from patient to patient. That rules out a one-size-fits-all solution. Internist William Shrank, MD, MSHS, chief scientific officer and chief medical officer of Provider Innovation and Analytics at CVS Caremark, has served as lead author or coauthor in more than 100 studies on patient compliance with medication. His conclusion: “There is no silver bullet.” Researchers have analyzed the steps involved in compliance to better understand where the process breaks down. First, the patient must receive the right prescription from a doctor or another provider. The new prescription must then be filled, a seemingly simple act that can be a major barrier to compliance. The patient must then make it through the first six months on the medication, when the risk for noncompliance is highest. If the medication is for a chronic condition, it must then be taken as intended — indefinitely. “Adherence is the result of getting through these four steps successfully,” notes the RAND Corporation, a nonprofit research organization, in a report aimed at policymakers in Washington, “and a single policy option is not going to address each of these challenges to adherence.” To thicken the plot, a patient's unique cluster of reasons for not complying at any given time isn't stable. With the loss of a job, for example, medications may become unaffordable, so the patient stops taking them, cuts the pills in half to make them last longer or skips some doses. After a divorce, job loss or any traumatic event, depression may set in; taking medication as directed may then be the last thing on the patient's mind. Or, a compliant patient may suffer a medication-related adverse event. As a result, she may stop taking her pills, as up to 20% of patients do because of perceived side effects. Does the patient tell the doctor? Probably not. Why? The doctor is so busy; she doesn't want to be a bother. Or, she doesn't like the doctor, so this is how she retaliates. Or, she decides that her ill effects are a sign that she's taking too many drugs, so she goes off-regimen. Or, she consults with a friend on a social networking website for patients with similar chronic conditions, and the friend advises her to try alternative medicine instead. “Is it widely known that adherence is a cluster of behaviors and not a single construct?” asks internist John F. Steiner, MD, MPH, research director at Kaiser Permanente's Institute for Health Research in Denver and a thought leader on medication compliance issues. “No, that's actually a radical claim.” It may be radical, but researchers are putting patients, doctors and the healthcare system itself under a microscope to better understand this ever-shifting cluster of behaviors and why it so often results in noncompliance. While many questions remain unanswered, here's what has been learned to date. Patient beliefs and behaviors are often barriers Patients with chronic conditions may spend only a few hours a year in your office, but they spend roughly 5,000 waking hours each year living the rest of their lives. During that time, out of touch with their doctors and generally unmonitored by the healthcare system, many are allowed to quietly, invisibly slip off their regimens. In 2009, a team of researchers at Kaiser Permanente combed through much of the vast literature on compliance and distilled the sea of data down to several important patient-related barriers. They include forgetfulness; lack of knowledge about the medication and its use; cultural, health and religious beliefs about the medication; denial or ambivalence regarding the state of their health; financial challenges; lack of health literacy; and lack of social support. Forgetfulness is the No. 1 barrier to compliance, experts believe, although a survey of 10,000 patients found that only 24% ascribed noncompliance to forgetfulness. Up to 20% failed to take medications because of perceived side effects, 17% had cost issues and 14% didn't feel the need to take medication because they believed it would have little to no effect on their disease. Among patients with chronic conditions (such as high blood pressure and high cholesterol), noncompliance tends to be highest if symptoms aren't experienced. Myopic? Perhaps. But when doctors are patients, they tend to act just like everyone else. Steiner likes to ask an audience of physicians for a show of hands of who has ever taken an antibiotic. Many hands are raised. He then asks how many doctors took the full course of antibiotics even after their symptoms abated. Many hands go down. Even the Sickest Patients May Not Take Their Drugs Noncompliance is plentiful in patients who exhibit symptoms, too — even for life-threatening conditions. Not even a brush with death is enough to get some patients to stick to their regimens. According to one study, after hospitalization for acute MI, about 24% of patients still hadn't filled their cardiac medication prescription a week after being discharged. In another study, among patients discharged with prescriptions for aspirin, statins and beta-blockers after an episode of acute MI, about 34% stopped at least one medication and 12% stopped all three medications within a month. A third study found that only about 40% of patients were still taking statins two years after hospitalization for acute coronary syndrome. Compliance was even lower for patients taking statins for chronic coronary artery disease. A major reason why many patients go off-regimen is the cost of drugs. But even when patients are given drugs gratis, compliance improves only slightly. One much-discussed study looked at 2,845 Aetna health plan members discharged from the hospital after an acute MI episode who were given all of their drugs — statins, beta-blockers, ACE inhibitors, ARBs — for free. That was then compared with 3,020 Aetna enrollees who had the usual prescription coverage. In the usual-coverage group, compliance rates were 36% 49%. But without the cost barrier, the rates were only 4% to 6% higher. What could account for this underwhelming result? Could depression play a role? Although the investigators noted cardiac-related comorbidities of patients at baseline, they didn't ask about depression. Yet a meta-analysis of 31 studies that collectively included 18,000 people found that depressed patients with a variety of chronic illnesses, including diabetes and heart disease, had 76% greater odds of being noncompliant compared with patients who weren't depressed. At least you can understand why depressed patients may lack the motivation to stay on regimen, but, confoundingly, so do many patients who aren't depressed. As Shrank and cardiologist Lisa Rosenbaum, MD, noted in a 2013 paper: “Though patients may be forthcoming about the more practical challenges (to adherence), the psychological barriers are tougher to identify and articulate. Patients don't generally tell their physicians, ‘Every time I look at that pill bottle, it reminds me that I'm ill,’ or ‘I tend to discount future benefits as long as I feel well today.’ Such underlying psychological mechanisms probably contribute to nonadherence far more than we realize and help explain why existing interventions have brought only modest improvements.” In reality, however, the teamwork concept isn't working out too well. One reason is a chronic lack of time. The mean duration of a primary care visit ranges from 7.6-17.6 minutes. To be efficient, the doctor must control the conversation, with less time for listening and discussing topics such as medication reviews and preventive care. Even if more time were available, it's not what every patient wants. In one study of doctor-patient relationships, behavioral economists used game-theory techniques to identify the factors affecting treatment decisions in patients with a life-threatening disease — in this case, breast cancer — who were considering adjuvant therapy. They found that when patients disregarded their doctor's treatment recommendations, the doctors responded by telling them in more detail about the benefits of treatment. However, this produced a perplexing result: The more information the patients received, the less likely they were to be compliant. The researchers conceded that, “Patients want more specific disease and treatment information,” but “the provision of this information might lead to therapy decisions which diverge from the physicians' recommendations.” But the larger problem is that too little information is offered to patients who want — and need — more. The average time that a doctor spends discussing all aspects of a newly prescribed medication is a mere 49 seconds. Surveys show that no medication instructions are given by physicians in 19% to 39% of prescriptions; in observational studies, 17% to 25% of prescriptions are not accompanied by instructions from the doctor. For a new prescription, doctors discuss dosing directions in fewer than 60% of cases and review potential adverse events — a major reason why patients quit taking their drugs — only 33% of the time. Nor do busy doctors typically have the time or skill to sit down with a patient and tease out his or her unique personal barriers to compliance, which is why so much of their advice goes in one ear and out the other, contends behavioral psychologist Kim Lavoie, PhD, associate professor at the University of Quebec at Montreal, co-director of the Montreal Behavioral Medicine Centre and an expert on motivating patients to stick to their regimens. “Health is not necessarily the patient's main priority,” Lavoie observes. “If you have a 40-year-old woman who smokes, and you want to get her to quit, what's likely to be her No. 1 concern? The answer,” she says, “is weight gain. If the conversation doesn't address that obstacle, my prediction is that she's not going to quit." The authors of a paper that analyzes the doctor-patient interaction note, “Doctors' communication style can positively influence (patient) beliefs and therefore lead to better adherence to recommendations. However, they are often unable to understand differences in patient preferences regarding information and participation during consultations. They often fail to listen to patients and explore their views on their disease and medication.” Explore their views? Who has the time for that? But doctors' failure to listen may not be just a function of time. Doctors, after all, are also psychological beings, who may, at times, act irrationally in counterproductive ways. “The doctor, just as the patient, also experiences feelings during the consultation such as anxiety or anger, which have been shown to decrease the overall satisfaction of both parties with the consultation and also the patient's adherence to recommendations,” researchers have discovered. See also: Is the ACA Repeal Taking Shape?   Conflicting perspectives on compliance When you prescribe drugs for patients with chronic conditions or advise them to go on a diet, it's natural to assume that because patients come to you as their medical expert you share the same goal: the patients' long-term health. But this may not be the case. In fact, doctors and patients tend to have conflicting perspectives on the burden of adhering to the medication and lifestyle regimens the doctors prescribe. Doctors “want to maximize patients' health outcomes in the future and are less interested in patients' anticipatory feelings in the present,” one paper points out.  Patients “put more weight on leading an easier life now rather than thinking of the consequences of their future health status.” It might be easier to bridge this gap if the doctor-patient relationship still had the influence it once did, but with many patients switching health plans — and, often, doctors — on a yearly basis as premiums are raised, the relationship now is often perfunctory. The more patients you are forced to see to pay the bills, the less time you have to explore and address patient barriers to compliance. Too-brief visits with doctors and leaving with more questions than answers may be a reason why many patients seek medical advice elsewhere. The prospect of patients visiting healthcare websites (where the quality of information can be highly variable) rather than trusting doctors to know what they're doing may make smoke come out of your ears. But now patients are visiting social networking sites, specifically for patients with chronic diseases, where they compare notes. They discuss their medications, dosages and adverse events with each other, give each other advice and often take that advice. One study found that 55% of patients rely entirely on their physician to make treatment decisions. That means 45% are seeking advice elsewhere. In another study, 68% of patients turned to other sources to validate information received from their doctors. These other sources, needless to say, aren't other physicians. Even when doctors take the time to explain things to patients, many patients have little or no idea of what the doctors are talking about. Nearly half of all adults in the U.S. — 90 million people — have trouble understanding what the doctor tells them about why they are sick and about how to adhere to medication regimens, according to the Institute of Medicine. “Each patient, in reality, has his or her own unique barriers, which can vary by disease and medication,” a team of RAND researchers concluded. “Programs for improving adherence must find a balance between ‘customized’ interventions and effective programs that work for large groups or classes of patients. “This is not to say that society needs thousands of different programs for each barrier,” the researchers continued, “but it needs programs that can identify these barriers and take the diversity of individuals and barriers into account.” We are not there yet. Medication regimens can be too complicated It's easy to lose sight of the fact that, especially when doctors are dashing off prescriptions every 15 minutes, the drug regimens being prescribed — even though they may be evidence-based — may not be easy for patients to follow, even if they wanted to. In a 2012 paper, Kaiser Permanente's John Steiner calculated how many behaviors per year are required of a hypothetical 67-year-old patient with well-controlled hypertension, diabetes and hyperlipidemia. It came to more than 3,000 behaviors. “And that's a conservative estimate,” he says. Writing in the New York Times, internist Danielle Ofri, MD, associate professor of medicine at New York University School of Medicine, told of a small experiment she conducted with a group of medical students. They wrote up prescriptions for several common medications: metformin, furosemide, albuterol, lisinopril and rantidine. Each student received two prescriptions and two boxes of Tic Tacs and was instructed to take the “medicines” for a week. “When we met for our next session, I asked them how they did, and they all had abashed expressions on their faces,” Ofri writes. “Not one was able to take every single pill as directed for seven days.” Compliance, it turns out, is inversely proportional to the number of times a patient must take medication each day. For medication taken only once daily, the average compliance rate is nearly 80%; for medication that must be taken four times a day, the average rate drops to about 50%. See also: Potential Key to Tackling Opioid Issues   One study found that the average patient who takes a statin for dyslipidemia currently takes a total of 11 medications, makes five pharmacy visits over a three-month period and synchronizes — that is, picks up multiple prescriptions at the same time — just half of his or her refills. However, 10% of statin users take 23 or more medications, make 11 or more pharmacy visits to two or more pharmacies over 90 days, have four or more prescribers and only synchronize 10% of their refills. Picture a Medicare patient whose memory may not be what it once was and who may lack the social support to get to the pharmacy regularly trying to adhere to all of this. “We're asking patients to adopt obsessive-compulsive behavior,” admits internist Edmund Pezalla, MD, MPH, national medical director of Pharmacy Policy and Strategy for the health insurer Aetna. “Taking medication every day is hard to do. We're asking people to deal with the same boring situation over and over again. We're not programmed to do that. Machines do that. Humans don't do it very well.” Fragmented care is a culprit Even if doctors had more time to spend with patients and if patients were more willing to take their doctors' advice, the healthcare system creates numerous obstacles to subvert their efforts. A major obstacle is fragmented care. “In decades past, community-based physicians not only authorized a patient's admission to the hospital, they performed regular hospital rounds, supervised overall patient care and authorized the patient's discharge,” notes a report by the New England Health Policy Institute (NEHI). “In theory, medication management was seamless because the admitting physician, the discharging physician and the ‘receiving’ physician in the community were the same individual.” That's not the situation today. Patients with chronic conditions now see primary doctors, who, in turn, refer them to specialists. If the patients are hospitalized, a hospitalist likely as not will take over their care. Many patients are discharged, not to their homes, but to long-term acute care hospitals, inpatient rehabilitation hospitals or skilled nursing facilities, where more doctors will prescribe medications for them. “Transferring patients from short-term acute care hospitals to post-acute providers increases the number of times information needs to be passed between providers and increases the opportunity for errors and medication errors in particular,” the NEHI report points out. Other systemic barriers to compliance include lack of access to healthcare, inconvenience in obtaining prescription refills, wide variations in the cost of the same drugs from one health plan to another and pharmacy policies that limit prescription size and require frequent refills. Access to pharmacy data is a problem Even in accountable care organizations and integrated delivery systems, with resources far beyond those of the average doctor, care teams typically lack access to pharmacy data, such as the rate at which a prescription is filled and refilled by a given patient. If you knew which of your patients weren't picking up their drugs, you would know who needs help with medication compliance. “For patients with coexisting conditions who take multiple medications prescribed by multiple physicians, there is a vital need to reconcile the prescribed regimen with what a patient is actually taking and to understand why there is a difference between the two,” note David M. Cutler, PhD, and Wendy Everett, ScD, in a 2010 paper. “But optimizing and reconciling medications require substantial investments of time by a skilled healthcare practitioner, as well as electronic data sharing among practitioners — neither of which is widely available in today's model of healthcare delivery.” Even if time, skill and electronic-data-sharing were widely available, the complexity of each patient's barriers and the ever-shifting nature of those barriers would probably still thwart many efforts to improve medication compliance. “Although the multifactorial nature of nonadherence means there will never be a one-size-fits-all solution, interventions ranging from education to elimination of selected copayments to telephone-based counseling have achieved modest improvements in clinical trials,” Rosenbaum and Shrank point out. “But even if we had more robust interventions,” they write, “we'd lack simple, cost-effective ways of targeting the right intervention to the right patient.” Why research hasn't been more helpful Advances in medicine generally stem from peer-reviewed studies that produce statistically compelling, evidence-based data for doing one thing or another. The more studies, the better and more refined the evidence — or so one would think. This hasn't, by and large, been the case with compliance. The ocean of data on the subject has stubbornly resisted attempts at synthesis into a statistically compelling, evidence-based, systematized plan or plans of action for overcoming barriers to compliance across a range of patients, drugs and diseases. A 2007 Cochrane review of interventions for enhancing medication compliance didn't mince words: “With the astonishing advances in medical therapeutics during the past two decades, one would think that studies of the nature of non-adherence and the effectiveness of strategies to help patients overcome it would flourish,” the authors wrote. “On the contrary, the literature concerning interventions to improve adherence with medications remains surprisingly weak.” “There probably is a set of general principles that might emerge from the literature,” suspects Kaiser Permanente's John Steiner, “but they're not intuitively evident because of the way the studies are designed and carried out.” Even the definition of compliance is subject to debate. Is compliance mainly taking one's medications as instructed — a narrow definition adopted by most researchers because it simplifies research to study only one variable at a time, even if it sacrifices environmental complexity? Or should the definition be broader: “The extent to which a person's behavior — taking medication, following a diet or executing lifestyle changes — corresponds with the agreed recommendations from a healthcare provider,” as WHO maintains? Steiner tells of his 93-year-old father, who embodies this definitional dilemma: “He discovered to his great delight that, as long as he took his statin, he could eat anything he wanted,” Steiner says. “By being adherent with his medication, he didn't need to be adherent with his diet. Those are different adherence behaviors, but, in his case, one trumps the other.” “The problem is with the way the scientific literature evolves,” Steiner reflects. “It's reductionistic. You want to do a study on adherence with antihypertensive drugs, for example, and you disregard the six other drugs that the patient is taking. “That can make the literature seem fragmented,” he says. “We don't tackle the adherence problem at the patient level. We tackle it at the drug or disease level. It's easier to study at that level. Measurements are easier. Costs are lower.” How much compliance is enough? The Centers for Medicare and Medicaid Services has introduced uniform standards for compliance outcomes with its five-star rating system for Medicare Advantage plans. The top rating is awarded to plans that achieve 70% to 80% compliance in hyperlipidemia, hypertension and cholesterol management in their members. But this raises another niggling issue: From a population-based perspective, how much compliance is enough? Setting optimal compliance rates across the board at 80% is arbitrary and potentially counterproductive, Steiner believes. “There's almost no evidence that can allow us to set those sorts of thresholds in a scientific way,” he asserts. “For example, for first-generation antiretroviral drugs, studies showed that you needed adherence of 95% or greater to knock out the virus. An 80% adherence threshold would not have been stringent enough for those old drugs. See also: EpiPen and the Prescription Crisis   “The converse is also true. Years ago, when rheumatic fever was common, doctors prescribed penicillin to knock out strep throat, because that triggered rheumatic fever. However, studies showed that you only probably needed to take a third of the doses to knock out all the strep. So for that kind of situation, 30% to 40% adherence was probably just fine. If it were 80%, you would increase the risk for side effects, as well as the cost, without increasing the clinical benefit.” In the Annals of Internal Medicine in 2012, Steiner writes, “If lower levels of adherence are sufficient to achieve clinical goals, pursuit of higher adherence is wasteful. And if higher levels are required, even these adherence targets will not suffice.” Moderate progress on compliance issues Despite a tsunami of unanswered questions, the enormous amount of research that has gone into compliance has not been a waste of time. On the contrary, it has produced some valuable insights. The second article in this series looks at the healthcare industry's initiatives to improve compliance on the basis of this research. With more than 40,000 peer-reviewed studies on the subject conducted over several decades, you'd think we'd at least be at Compliance 2.0 by now in the state of our knowledge. In reality, it's more like Compliance 1.5. We aren't on the verge of solving this immensely complex problem. The outlines of what is, at best, a partial solution are only just starting to emerge. Despite moderate progress, “The heterogeneity in how adherence is assessed, measured and defined is a major limitation to the data on barriers of adherence,” investigators at RAND concluded in 2009. That continues to be the case.

Immigration has become a toxic subject. In the U.S., President Trump is trying to ban or block the entry of refugees and of people from Mexico and parts of the Middle East. Other nations, from the U.K., France and Germany to Australia and Thailand, face political pressure to curb numbers of incomers. Anger at the erosion of national competitiveness is the root of the rage in the U.S., in my view. Increasing financial inequity, changing racial and ethnic demographics and a widening knowledge gap between technology haves and have-nots are other factors. Immigrants and global trade have become the scapegoats. Blaming foreigners is not new; it happens when people feel disenfranchised. Throughout U.S. history, each wave of immigrants has forced preceding generations to compete. Newcomers often achieve great success, and face resentment. Chinese engineers helped to build U.S. railways in the nineteenth century, but faced riots and even massacres because they were hired on cheap wages preferentially over whites. The Italian immigrants who came after them were blamed for everything from domestic radicalism to organized crime. Then it was the Poles, the Japanese and the Germans who faced abuse. The U.S. has gained tremendously from foreign-born inventors. From Alexander Graham Bell, the Scot who invented the telephone, and Nikola Tesla, the Serbian who invented the laser and radio remote control, to Albert Einstein and the wave of scientists fleeing Nazi Germany, immigrants have made the U.S. the world's leader in technology. Indian and Chinese entrepreneurs fueled the dot-com boom in the late 1990s. A South African, Elon Musk, founded Tesla Motors and the aerospace firm SpaceX. But in the past decade, skilled immigration has stalled. Flaws in the U.S. visa system make it hard for well-educated and experienced immigrants to stay. Rather than set up companies and create employment in the U.S., foreign-born scientists and engineers have been returning home, taking their ideas and inventions with them. As a result, innovation has become global and the technology playing field has leveled across the world (see go.nature.com/2kmqmjq). Now, as dark clouds of nativism swirl around Capitol Hill, the country's leaders face an important choice. They can play the populism card, close the doors and watch U.S. global competitiveness fall — or they can welcome the world's best and brightest to boost innovation and create jobs. Technology will advance with or without the U.S. The nation needs to decide whether it wants the innovators on its side. Other countries seeking to limit immigration should ask themselves the same question. Global innovation Today, internet companies in China, such as Alibaba, Baidu and Tencent, are among the most innovative and valuable in the world. Facebook has mimicked features of their products; Apple has been accused of copying Chinese innovations in the iPhone 7; and search engine Baidu's artificial-intelligence system is more advanced than Siri. Chinese scientists will soon lead the pack on applying CRISPR–Cas9 gene-editing technology (see, for instance, Nature 539, 479; 2016). India has sent an orbiter to Mars and launched a record-breaking 104 satellites from a single rocket. Its new platform for digital currencies, India Stack, may allow its financial system to leapfrog that of the West. Chilean scientists have built cheap technologies that sanitize water by temporarily changing it into a plasma phase. South Korea has built autonomous cars that it aims to have on its roads before the Pyeongchang Winter Olympic Games in 2018. See also: Why Trump’s Travel Ban Hurts Innovation   One measure of globalization is the number of "unicorns," technology startup firms valued at $1 billion or more. As recently as 2000, nearly all of these were in the U.S.; other countries could only dream of creating a Google, Amazon or Facebook. By February 2017, of the 213 unicorns in the world, China had given birth to 55 and India 10. The U.S. is home to only 110 (Global Entrepreneurship); half of those have at least one immigrant founder. The U.S. share of unicorns is shrinking, and Silicon Valley is facing unprecedented competition. Gone are the days when, owing to the high costs of the core technologies, U.S. and European research labs held a monopoly on large-scale innovations. Whereas early generations of supercomputers cost tens of millions of dollars, today's smartphones, which outperform them, cost as little as $30. Sensors, artificial intelligence, robotics, genomics and 3D-printing technologies are globally available and inexpensive. Anyone, anywhere, can use these to build world-changing products. Government-built walls of visas and travel restrictions are no barriers to innovation, only to economic growth. Brain drain The contributions of immigrants to tech companies are well-documented. In 1999, regional economist AnnaLee Saxenian at the University of California, Berkeley, found that Chinese and Indian executives were at the helm of 24% of the businesses started in Silicon Valley between 1980 and 1998. That proportion doubled the following decade. My research team worked with her to show that between 1995 and 2005, foreign-born innovators founded 52% of technology companies in Silicon Valley and 25% nationwide. We also showed that immigrants generated $52 billion in revenue and employed 450,000 workers in 2005. They filed the majority of patents at technology companies such as Qualcomm (72%) and Cisco (60%), and more than 40% of U.S. government-filed international patent applications had foreign authors. Then things changed. A backlog of applications built up for employment-based visas that allow permanent residency (green cards). With sociologist Guillermina Jasso of New York University, we analyzed this backlog. As of Oct.1, 2006, there were almost half a million applicants (more than one million when family members were included). Because only about 120,000 visas are available each year, getting a green card can take a decade. We forecast that this wait would increasingly frustrate highly skilled workers, leading to a reverse brain drain. Indeed, by 2012, my team found that immigrant entrepreneurship had stalled. The proportion of companies founded by immigrants fell nationwide to 24% and in Silicon Valley to 44%. We believe from anecdotal evidence that highly skilled workers are returning to their home countries in even larger numbers today. [caption id="attachment_24542" align="alignnone" width="500"] Canadian-born chemist Michelle Zatlyn co-founded the US Internet company CloudFlare.[/caption] These are the people who set up the unicorns in countries such as China and India. Each of those companies has one or more U.S. returnees in senior leadership positions, and restrictive U.S. immigration policies put them there. Two decades ago, it was the norm for students who came to the U.S. from China and India to want to stay. No longer. On graduating from engineering courses, most overseas students say that they will work for a short time to gain experience, then return home. Human-resource directors of companies in India and China tell me that they are flooded with CVs from students from U.S. universities. Working for an exciting start-up such as Baidu or Alibaba is more enticing than being locked into a menial U.S. position for a decade awaiting your green card. When I visit technology centers in China and India, and increasingly in places such as Mexico City or Santiago in Chile, I see a beehive of startup activity. As well as social-media and Internet applications, overseas entrepreneurs are designing wearable medical devices, robots, drone-based delivery systems, microsatellites and agricultural-automation systems. They are building self-driving cars, solar technologies and 3D-printing systems to solve global problems. See also: Is U.S. Losing the War for Talent?   Meanwhile, the U.S. visa backlog is climbing. I estimate that there are more than 1.5 million skilled workers in immigration limbo in the U.S. today. Each one is a lost opportunity and a waste of talent. Everyone loses. The precarious position of foreign-national staff leaves them open to mistreatment by their employers. Rules prevent employees from changing jobs while waiting for their green cards — even to other jobs in the same company. H-1B visas for temporary stays allow employers to replace U.S. workers with people who are paid less than they should be, given their skills. This is one of Silicon Valley's darkest secrets — and it is why tech companies lobby for more H-1B visas rather than more green cards. Skilled people become frustrated as their careers stagnate. The jobs that would have been created in startups go overseas. Unless it changes its immigration outlook, the U.S. will forgo economic benefits and jobs in a misguided effort to protect both. It will have to watch as the rest of the world leaps ahead. It doesn't have to be this way. Embrace outsiders The U.S. needs to expand the number of permanent-resident visas and clear the backlog. These people are already working in the country legally and have the experience and skills needed. Retaining them will boost the economy. Accelerated granting of permanent residency could be contingent on buying a house, making investments or starting companies that create jobs. Imagine the benefits of 10,000 new technology startups. “The U.S. needs to decide whether it wants the innovators on its side.” We need to make it easy for entrepreneurs abroad to bring startup firms to the U.S. One solution is to provide a "startup visa" as a path to permanent residency. This would perhaps be valid for five years, with an upgrade to permanent residency dependent on the firm's employment of U.S. workers. The Kauffman Foundation in Kansas City, MO, has estimated that such a visa would create 1.6 million jobs within 10 years and boost the U.S. economy by $224 billion a year. See also: What Trump Means for Best Practices The solution to the mistreatment of foreign workers is easy: untether the H-1B visa from the employer. Let people change jobs, and let the market decide what their salaries should be. This would remove the financial incentives for companies to replace Americans with cheaper foreign workers and would encourage them to hire the best talent. By becoming the best place in the world for entrepreneurs to study and work in, the U.S. could again be in the driving seat of technology innovation. Then we can share the resulting prosperity in a more equitable way to mitigate the anger of the electorate.

Because of the arrival of autonomous vehicles, a good number of prognosticators are loudly heralding the end of auto insurance and the insurers that rely on this income stream. While there is no doubt that the auto insurance will change over time because of autonomous vehicles, the doomsday folks paint a picture of an almost certain — and right-around-the-corner — cataclysmic change, with the general population cheering wildly about not having to pay for auto insurance anymore. Disappointingly for those people, this is a highly unlikely scenario. At the most fundamental level, autonomous vehicles are expensive. Until the bulk of the population can afford autonomous cars and trucks, we will be living in a world with a foot on each side of the driving paradigm. This means that, while the autonomous vehicle might not hit the car in front of it, the vehicle behind it may very well end up in its back seat. Uninsured and underinsured coverage, comprehensive coverage, coverage for property damage and liability coverage will be needed for a long, long time. See also: Connected Vehicles Can Improve Claims   In the meantime, auto insurers will have the opportunity to work out the liability paths with the autonomous auto manufacturers. And auto insurers will have the time to adjust their product mixes and financials. Underwriters and claims personnel will adjust processes and practices. Believe me, I am not suggesting that change won’t happen. It will. And some of the changes will be painful from several perspectives. But with all the various factors potentially reining in the spread of autonomous vehicles — cost, regulators, consumer wariness — insurers will adjust. At least the insurers that believe in innovation and data and analytics will adjust — and flourish. What people are not focusing on is the rapid change in the products and services that are coming from the convergence of emerging technologies — and this is happening right now. Take a quick perusal of the topics in SMA’s Next-Gen Innovation Community, and some examples come to light:

• To diagnose a rare genetic disorder, a physician combined an exomes analysis with a facial comparison using an app called Face2Gene, which was developed by the same programmers who taught Facebook to find your face in your friends’ photos.
• To reduce manufacturing times and production periods, Adidas will use 3D printing or additive manufacturing methods as the core technology of its factory that produces sneakers.
• The use of “cobots” — collaborative robots that perform tasks alongside humans — is rapidly gaining popularity, and it is the fastest-growing segment of the U.S. robotics industry.
• The global semiconductor industry is pushing to develop new chip designs, materials and manufacturing processes. One reason is the widening use of the artificial-intelligence technique known as deep learning in products — both consumer and manufacturing products.

Additional examples could consume volumes of space. But what does this convergence mean for the insurance industry? It means unknown risk and unknown liability. Unlike the autonomous vehicle world, where underwriters and claims adjusters understand the general risk and liability landscape, the convergence of emerging technology is generating significant numbers of unknowns. Relationships between the unknown risks and liabilities will be the most challenging. The insurance industry should not be as concerned about the impact of autonomous vehicles as it should be about what is happening now in the rapidly changing world of products and services because of the effects of emerging technologies. Underwriters and claims personnel must be supported by sophisticated data and analytics capabilities using AI, machine learning and cognitive computing (pick your favorite advanced tool!)  because risk and liability will not be in the same forms as are currently familiar to insurance professionals. See also: Autonomous Car Tech Reaches Mid-Market   There are a lot of reasons that insurers will not look the same in five to seven years. Core modernization, digital capabilities and, yes, autonomous vehicles will generate change. But the halls of successful insurers will not be empty. They will be filled with technical experts in product liability, D&O, E&O, cyber and medical malpractice — to name but a few product lines that will have the ability to rapidly respond to a risk and liability landscape that didn’t exist  in their wildest imaginations two to three years ago. Insurers that are not preparing themselves for this eventuality will fail.

The on-demand labor force is growing substantially and has every reason to continue to do so. Just look at these results from a survey completed in June 2016 by Burson-Marsteller, The Aspen Institute and TIME, which measured responses from 3,000 on-demand workers:

• More than 45 million Americans have worked in the on-demand economy – accounting for 22% of the total workforce.
• 42% of adult Americans, or 86.5 million people, have used at least one service offered by the on-demand workforce.
• Of the workers surveyed, 64% expect their financial future to improve, compared with only 47% of the general population.
• More than 51% on-demand workers responded that their finances have improved over the past year, compared with 34% of the general population.
• 61% of the workers surveyed believe that on-demand economy companies care about their workers.

The ability to decide when to work, what kind of work you prefer and where you work from, represents a giant carrot for many American workers. Insurance: It Affects All Consumers The changing workforce will affect insurance, especially property/casualty, where the claims process is most important to the consuming public. This process should be as uneventful as possible because an insurance claim can either make or break the relationship between the parties of an insurance contract. But ask any vehicle owner who’s had an accident to describe the claims experience in a word; too often, the word is “stressful.” Traditional insurers do not understand that time is measured differently in the 21st century because of technology. Even when this difference becomes apparent to senior staff members, most dig in their heels as they consider the additional cost of streamlining their claims process. They need to know that by inserting on-demand workers in the claims process, they can gain efficiencies and save money. Modern customers demand efficiency, choice and ease of access. This is no longer a nice-to-have in today's digital economy. You must provide this to your customers, or be at the wrong end of disruptive industries like fintech and insurtech. External Claims Resources and Modern Insurance The claims process that some insurers employ poses serious challenges because of time constraints and having to depend on a claimant to provide a significant portion of the information required. Policyholders can drag their feet on providing needed claim documentation and then rate the claim adjuster poorly because their perception is that the settlement took far too long. Insurers are learning that they can overcome these challenges by embracing the on-demand workforce that external claims resource companies like WeGoLook provide and significantly reducing the time required to adjust claims. Why hire an entire staff of highly paid claims adjusters to complete mundane tasks that can be associated with standard insurance claims. Why be subject to W2 employees having very little to do when claims are slow and then becoming overwhelmed when a catastrophe arrives? Or, why not supplement traditional workforces with external claims resource workers who are flexible, available and spread across the country. On-demand workers and external claims resources are available where and when you need them. They enable insurance carriers to reduce payroll costs, improve their bottom line and remain flexible in the new digital economy reality. And, just as importantly, leveraging external claims resources speeds up the claims process, thereby increasing customer satisfaction. In an age of immediate gratification, this is necessary for any business model to thrive.

In many insurance companies, claims and procurement departments do not work well together, even though a closer alignment could bring a number of benefits. Why do these two functions spend so much time debating their respective areas of responsibility? In part, it’s because they co-exist as uncomfortable partners, each with their own biases and interpretations. Claims, for example, is heavily influenced by the cost of procured products and services from third-party vendors, and holds tightly to the decision-making reins. Procurement, on the other hand, often misconstrues what claims wants and has its own agenda. See also: How to Avoid Common Tactic by Insurers   If, however, claims and procurement were to look beyond their siloed tactical practices to the common goal of increased competitiveness, they could make critical improvements, including:

• Strategic assessment of total cost of partnership. The two departments need to collaborate to translate qualitative claims criteria into tangible procurement measures that enable objective vendor selection and contractual terms.
• Integrated technology. By coming together on the strategic use of technology across claims and procurement value chains, insurers can achieve innovation and unlock the value currently lost due to conflicting tactical approaches.
• Globally consistent, locally optimized practices. Global claims procurement programs need to be consistent but optimized for local regulatory and economic realities.

By unifying decision-making, balancing biases and building a digital ecosystem, claims and procurement departments can strengthen their relationships with key vendors, improve efficiency, improve loss ratios and enhance customer engagement—a win-win, whichever way you look at it. See also: M&A Surges in P&C Claims, Technology   To see the full posts in this series, visit the Accenture Insurance Blog.

A couple of years ago, lots of people in insurance were looking over their shoulders, because of concerns that a tech giant such as Google, Amazon or Facebook might innovate in some shocking way and take over the industry. That threat has faded, but a recent story about Tesla from a transportation news site should make us all pay attention. It suggests a possibly major change for auto insurance, and it certainly fits much more into my mental model of how innovation will happen than a full-on invasion by Google, Amazon or Facebook ever did. 

Tesla is bundling car insurance with its cars, albeit, thus far, just in Australia and Hong Kong. This makes perfect sense to me. Car makers have complained for decades that they make the boxes while everyone else profits from financing, insurance, repairs and so on. Why not offer to bundle insurance at an attractive price?

Tesla has powerful advantages. The article cites a study showing that Tesla's Autopilot feature reduces accidents by 40%, and Tesla's irrepressible founder and CEO, Elon Musk, believes he can boost that figure to 90%. A huge reduction in crashes lets Tesla set prices that traditional insurers might not match, because they lack Musk's confidence in the data. Tesla also has a major edge on cost because its "Do you want fries with that?" approach to selling knocks out the commission that would go to agents, if you're a State Farm, or the huge marketing budget if you're, say, Geico. Tesla has an underwriting advantage, too: It's already tracking the actions of its cars moment by moment, so it can evaluate drivers incredibly precisely, whenever they're in control.

The Tesla approach reinforces my belief that much of insurance will become invisible. Perhaps you buy a commercial building and, as part of the transaction, take out a mortgage that includes a term life policy that lasts the length of the mortgage, to be sure your heirs would be able to keep the building. Already, when you ship rice in the developing world, you may automatically have insurance included in the cost. Various forces will try to maintain the status quo, as car insurers will surely fight Tesla, but going invisible takes out a big chunk of sales costs and simplifies underwriting, because it can be done quickly and mostly based on broad demographic data about the likelihood of a claim.

Tesla's experiment may never go anywhere. The company already has a ton on its plate, ramping up production at its crucial Gigafactory for batteries and integrating its acquisition of Solar City (also founded by Musk). That integration could well pose a problem because a maker of cars and an installer of solar panels don't have a whole lot in common, because they are both gobbling up cash at this point and because any problems could lead to charges of self-dealing, as long as a Musk company bought a Musk company for $2.6 billion at a time when Musk held 22% of the acquired company's stock. Just in case he didn't have enough things going on, Musk is still CEO of another company he founded, SpaceX, which has plans in outer space at least as ambitious as what Tesla is trying to do on the planet. 

But I'd suggest you keep an eye on Tesla's foray into auto insurance—and look for other ways that insurance can be bundled like an Extra Value Meal at McDonald's.

One more quick thing before I get out of the way and turn you over to my six favorite articles from the past week: I've been mentioning The Innovator's Edge, which tracks the more than 850 insurtechs we've identified around the world. To make it easier to identify the likely winners from this pool, we're assembling a panel of distinguished judges who will identify "5 to Watch" every month, starting in mid-March. The judges will draw from the insurtech startups that have filled out our Market Maturity Review—45 and counting have done so—within Innovator's Edge. If you're an insurtech startup and want to be considered for our first list, you have about a week to go to Innovator's Edge and fill out an MMR. It only takes a few minutes and has the huge added benefit of exposing you to incumbents that are looking for sources of innovation—whether that means buying from you, partnering with you, investing in you or buying you. If you have any problems with the MMR, please contact us at info@insurancethoughtleadership.com. 

Headlines can have direct bearing on the world of data and insight —and this has been even more frequent in recent years. This, increasingly, including topics like data monetization. One such story was the news that Facebook was preventing Admiral Insurance (in the U.K.) from using social-media-activity data as a means of assessing risk. Admiral planned to enable Facebook users to not only log on with their Facebook ID but to also opt in to giving Admiral access to their data in return for potentially lower car insurance premiums. Given the higher cost of car insurance for younger drivers, the idea had real appeal. However, it appears that, at the last minute, Facebook announced that it is not willing to allow such data from its users to be shared with Admiral, citing data privacy concerns. (If you missed it, the full BBC news report is here.) Why should such news matter to customer insight leaders? This dispute gets to the heart of a new battleground for both service providers and those collecting significant amounts of user-provided and user-generated data/content. See also: 5 Predictions for the IoT in 2017   The issue at stake Sadly, this appears to be another example of today’s data barons relying on an old-style command-and-control mindset. To reach the potential for greater data democracy, we need to see a move in corporate culture toward greater collaboration and transparency. We may never know the rights and wrongs of Admiral’s negotiations — like whether or not it was naive in failing to contractually lock down access to the required APIs. However, Facebook’s behavior still appears to be heavy-handed and conveys an arrogance in regard to data ownership that is disappointing. But then, perhaps, the leopard, which thought it was fair to experiment on users without permission, has not really changed its spots. It is an interesting object lesson for other firms aiming to create value from social data and data sharing between businesses. Customers should own their own data The core of my concern, however, comes from a customer perspective. As more and more firms — from Admiral to TripAdviser — are looking at data-monetization plans, firms should remember whose data it is. Hiding behind fine words about protecting privacy does not mask how consumers are being denied decision-making power about their own data. It is my hope that truly customer-centric organizations can learn from this bad example. People deserve to be educated about the reality of data monetization in our changing world. Many applications, with permission, will have the potential to make peoples' lives easier or to save them money (for the price of their data). Infantilizing customers by deciding what is to be allowed is “Nanny State” thinking. What our industry and our society needs, instead, is clear communication that gives people the opportunities and choices of what should happen with their data. I suspect many young drivers would have chosen to share their Facebook data with Admiral in return for cheaper premiums. Changing mindsets, thinking in terms of customers as more active data owners, also happens to be the best mindset to adopt in preparing for GDPR. A controversial issue It has been interesting to see how this Facebook-Admiral item has divided opinion. The active hub My Customer promptly ran an opinion piece (to which I contributed toward the end of the article). As you can see, there are strong views on both sides. See also: How to Turbocharge a Marketing Budget   I see the need to raise awareness about social media data being used by other companies. Too many conferences laud the potential of big data without an equal emphasis on data protection and permission-based marketing. But I still come down on the side of giving the customer the choice. Closing reflections Let’s just reflect on the fact that this might be an example where a U.S. tech giant is not embracing the free market and the U.K. insurer could be the customer's champion. Strange times, indeed… Let us know if there are other news stories that have grabbed your attention or on which you’d like to know the Customer Insight Leader view.

Everyone knows the bulk of workers’ comp costs now are medical. Claims reps and nurse case managers handle injured workers and their medical costs with utmost care. Anecdotes show that their work saves time and money. The problem is that concrete evidence of their value has been elusive—until now. How can costs avoided and time saved be measured? The measurements are like rabbits pulled from a magician’s hat. What really happened? Quantifying what did not happen is usually impossible. However, quantifying and measuring savings is completely feasible through a different approach, using predictive analytics. The workers’ comp industry does not readily embrace change or innovation. That is changing as pressure increases to become more efficient to sustain profitability as resources shrink. The best approach to meeting this challenge is incorporating advanced technical strategies such as predictive analytics that are designed to support and streamline the business process and make workers smarter. The collateral benefit is being able to objectively measure and report savings. The solution is to extensively analyze the organization’s historic data using predictive analytics and deliver the insights in the form of actionable information to all the stakeholders, including claims reps, medical managers and other decision-makers. Just a few steps are needed, including data analysis, data monitoring, informing and integrating the efforts of stakeholders and measuring the savings. The first and most critical initiative is analyzing an organization's historic data using predictive analytics methodologies -- because each organization has unique internal and culture processes regarding claims handling and medical management, using others’ data, regardless of how large the database, can mislead. See also: 2017 Issues to Watch in Workers’ Comp Situations and conditions found in the past are likely to recur. Once the risks are identified in historic data, they can be searched programmatically in current data through continuous data monitoring. When problematic situations occur in the data, appropriate responses and interventions are mobilized immediately. The insights are delivered to medical management stakeholders, including claims reps, medical case managers, senior management and others as appropriate. The knowledge delivered is structured to assist them in decision support and coordinating efforts. Risk information in claims is delivered concurrently to stakeholders so they can make early and sound decisions, then initiate appropriate action. Importantly, all medical management participants receive similar information so initiatives are coordinated and integrated, thereby implementing strong, multi-disciplinary approaches. When risk conditions in claims are identified in this manner, reserves in that claim need attention, as well.  When events and conditions in claims change, indicating a need for more intense medical management, reserving should also be addressed. Based on predictive analytics, the probable ultimate medical costs are projected and portrayed for claims reps, thereby providing key knowledge to support appropriate action. Data monitoring identifies claims with risk conditions concurrently and informs the stakeholders immediately. Intervention efforts are coordinated among claims reps, medical case managers and others, providing broad-based, integrated initiatives leading to improved results. Savings are gained through proactive, coordinated intervention by professionals who are offered key information for decision support making them accurate, efficient, and effective. See also: On-Demand Workers: the Implications When claims are closed, objective savings are measured by comparing projected performance based on predictive analytics with what was accomplished through active, integrated initiatives across all medical management participants. The calculations are quantifiable and objective. The simplest and most rewarding approach is to outsource this process to a knowledgeable medical analytics company. Internal processes need not change, but professionals and business processes are made more accurate and efficient—a win for the organization, its employees and its clients. Technology is far less expensive than people. When it is designed to assist professional workers by making them more accurate and efficient, the return on investment is profound.

Medicare Set Asides (MSAs) are a critical component of many settlements. After settlement, the injured party must spend, track and report the MSA carefully according to guidelines provided by the Centers for Medicare and Medicaid (CMS):

1. Funds will be deposited in a separate interest-bearing account.
2. All treatments and prescriptions need to be verified as being related to the injury and covered by Medicare.
3. All expenses, treatments, dates of service and related ICD- 9/10 codes must be tracked annually; reporting must be sent to CMS.
4. Bills must be paid according to the specific state workers’ compensation fee schedule or “usual and customary” pricing.

Reporting is complex, and, if the injured party fails to report properly, he runs the risk of having Medicare benefits denied. Additionally, paying retail rates for medical treatment can mean he is not abiding by the guidelines and will quickly run out of funds. For this reason and more, many rely on professional administration services, like Ametros’ CareGuard service, to help manage their medical bills and reporting. Additionally, these services help save the MSA money by securing discounted rates for medical treatments. Let us describe some of the most common mistakes, so your injured party can make an informed decision about how to best manage settlement funds. 1. Overpaying When an injured party handles MSA funds on her own, she pays retail prices on drugs, doctor visits, procedures and medical equipment. In most states, Medicare guidelines indicate that the injured person should pay the lower state fee schedule for treatments — even after settlement. However, doctors and providers do not know how to bill at the correct rates. If the injured party does not demand to be billed accurately, she will be overpaying! We find that, on average, the fee schedule is 55% below what doctors actually bill. Why should someone pay $100 for a doctor visit instead of $45? A professional administrator ensures that the injured person pays the required price on the fee schedule — and, often times, even less. 2. Assuming that, when funds run out, Medicare or private insurance will automatically cover 100% of healthcare costs The settlement process has many moving parts. Often, we find that injured parties are told that, when their MSA funds exhaust, Medicare or private insurance will kick in and pay for everything. This is a huge misunderstanding. The injured party is responsible for copays and deductibles after funds exhaust. The injured party also needs to be enrolled in Medicare or private insurance and pay the premiums. If she is enrolled in a plan when funds run out, insurance/Medicare will begin picking up the bills, but she will still need to contribute copays, deductibles or coinsurance. Typically, she is expected to contribute around 20% of medical costs. It is important to have a professional administrator to ensure that an injured party does not overpay on medical expenses and never has to use personal funds once MSA funds are exhausted. See also: How Medicare Can Heal Workers’ Comp   3. Failure to enroll in Medicare or personal insurance altogether Many injured individuals assume that having an MSA means they are on Medicare automatically. This is not the case. The injured individuals still need to enroll in Medicare or private insurance to have coverage if their funds run out. While Medicare Part A (emergency visits) does not require enrollment, parts B (regular doctor visits), C (private Medicare plans) and D (prescription drugs) all have monthly premiums. Medicare requires that they enroll in plans B, C or D. If they do not enroll in a plan, when their MSA funds exhaust, they will have to pay 100% of their healthcare costs. At Ametros, we also offer extra insurance protection with Medicare supplement plans. 4. Believing that Medicare will play some part in managing the billing of the MSA After settlement, Medicare will not receive the injured person's bills and verify information. A professional administrator will do this, but, if the person is managing his funds on his own, it is his responsibility. Many injured individuals wrongly assume their medical bills will go directly to Medicare after settlement, and the MSA is used for copays or deductibles. This is a dangerous misunderstanding, as Medicare will most likely reject paying for these treatments, and injured parties may be underestimating the true cost. As long as they have funds in their MSA, they are responsible for collecting bills and paying for them IN FULL. Medicare will rely on their annual reporting to see that they did the right thing. Only once their MSA is exhausted will Medicare contribute, and they will be responsible for just the copays. 5. Using MSA funds to pay for medical expenses that are unrelated to the injury or not covered by Medicare Many view their MSA as a pool of funds they can use for their general medical care related to their injury. In reality, Medicare’s guidelines are very specific. Medicare requires they only use the funds to pay for the entire cost of medical treatments that are 1) related to the injury and 2) would be covered under Medicare. A professional administrator verifies that each medical expense is eligible and will go the extra mile with doctors to document that each treatment and prescription is related to the injury. Our team receives constant questions about whether medical treatments meet both requirements. It is important that the injured party’s doctor verifies that medical treatments are causally related to their injury — for instance, a knee injury may trigger a hip problem that requires surgery. When the problem is related to the injury and Medicare would cover the treatment, it should be paid for with the MSA. It’s best to document this chain reaction so that, if Medicare has questions, the patient has all records on hand. It’s equally important to verify that Medicare would cover the expense. Oftentimes, injured individuals are caught off guard that expenses such as transportation and long-term care facilities are not covered by Medicare. 6. Using MSA funds to pay for copays, deductibles, premiums or administrative fees Medicare guidelines state that MSA funds are not to be used for copays, deductibles, premiums or administrative fees. Some injured individuals purchase Medicare supplement plans for coverage gaps they may run into if their MSA funds exhaust. While this can be a good idea, Medicare does not allow the use of MSA funds to pay premiums for Medicare supplement plans — nor premiums for any other plan (including Medicare Part B, C or D). Medicare also does not allow the use of MSA funds to pay investment advisers or other administrative services. At Ametros, our fee for professional administration always comes from funds that are separate from the MSA funds. 7. Failure to coordinate with providers and pharmacists on which items to bill to the MSA vs. Medicare or private insurance plan Staff at most pharmacies and doctors offices have never heard of an MSA, so there is often confusion about billing. An individual managing her MSA is responsible for making sure each bill is paid properly with the MSA funds and for routing unrelated bills to Medicare or an insurance plan. It may sound simple, but often the injured person will visit the pharmacy to pick up medications that should be covered by the MSA, as well as medications that should go to the health insurance company or Medicare. It’s important to be very specific with healthcare providers and staff to make sure they are separating bills. If the injured person is doing bill administration himself, tracking can be a huge hassle; it’s a challenge to request that the insurance plan reverse bills or try to secure a refund from doctors if bills are routed improperly. See also: Top 10 Mistakes to Avoid as a New Risk Manager   8. Mingling MSA funds with other accounts or investments Medicare requires that funds be placed in a separate, interest-bearing bank account. Oftentimes, injured individuals skip this step. This may not seem like a big deal at first, but, as the account is used for other expenses, it can be a challenge to separate items and produce reporting for Medicare. In addition, depositing MSA funds into a personal checking account means the injured party may use the money incorrectly by accident. Likewise, while Medicare has not given specific guidance on placing MSA funds into investment vehicles, industry experts agree that Medicare will not step in to cover any losses incurred from placing funds into the stock market. 9. Failing to notify Medicare properly when funds exhaust or replenish (if someone has an annuity) Medicare must hear from the injured party every time her MSA funds run out and every time she receives another annuity check to replenish the account. If not, Medicare will not be prepared to cover healthcare if she has exhausted her funds and continues to be treated. Medicare’s self-administration guide has a letter template for every time funds run out and another letter template for every time funds are replenished. Some injured individuals find themselves running out of MSA funds frequently. This means they need to send two letters a year to Medicare (not counting the annual reporting). Another frequent confusion of MSA holders who have annuities is whether they technically “exhausted” their funds because they spent more than their annuity check for that one year. They only need to report exhaustion to Medicare when their aggregate account balance reaches zero. When their account is out of money entirely, they are required to notify CMS. A professional administrator verifies reporting for fund exhaustion and replenishment; this way, the hassle of keeping Medicare up-to-date is taken care of. 10. Failing to report MSA spending to Medicare annually The annual attestation is the most basic requirement of the MSA: Medicare expects to hear from the injured party on the anniversary of the injury, every year for the rest of his life. The only exception is if he has notified Medicare that he has no funds remaining and no future annuity checks. As long as he has MSA funds or expected future annuity checks coming, Medicare will count on the report. Annual reporting to Medicare is the fundamental requirement that MSA holders need to fulfill to ensure their Medicare benefits are protected. Unfortunately, many injured individuals forget the date of their settlement and file their reports late, and some do not file at all. When we take on administering MSAs where injured individuals did not complete their reporting, we usually have to make multiple phone calls, and, often, the injured individual is left waiting for approval for a medical treatment or prescription that Medicare needs to help cover. At Ametros, we’re constantly encountering new issues with MSA accounts, and our team is always adapting to take the burden off the shoulders of the injured individual. After all, injured parties with MSAs have been through enough; they deserve help so they can settle well and remain on the path to better health.