What is pain? According to Merriam-Webster, it is "the physical feeling caused by disease, injury or something that hurts the body." Which is different than suffering: “to become worse because of being badly affected by something." Often, these words are treated as synonyms (or as a single word, "painandsuffering") when they are actually quite different. Pain is what happens to you. Suffering is how you handle it. The confusion of these two terms can create issues. The American Pain Society in 1996 described "pain as the fifth vital sign" (giving it equal status with blood pressure, heart rate, respiratory rate and temperature). The phrase created a perfect storm because it coincided with the message being delivered to medical schools and the healthcare industry that doctors had an opioid phobia and were under-treating pain. That was followed in 2000 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) establishing standards for pain assessment and management. Then the Veterans Health Administration incorporated the new emphasis into its national pain management strategy. So, regardless of where a patient was treated and by whom, the (subjective, patient-driven) assessment of pain was one of the first questions asked and often drove treatment plans. Then the new approach began to be questioned. A 2006 study by the VA found quantifying pain "did not increase the quality of pain management." In June 2016, the American Medical Association recommended removing "pain as the fifth vital sign" and connected the idea to the beginning of over-prescribing of opioids. Opponents of the change say it will "make it even more difficult for pain sufferers to have their pain properly diagnosed and treated." Proponents of the change say "pain is not a vital sign, but more of a symptom, and cannot be measured." So far, pain is still the fifth vital sign. See also: Health Startups Go After 3 Pain Points   The biggest problem is unrealistic expectations - patients often are told or come to believe they will be pain-free. When they're not, and their condition becomes chronic, it sows doubt in the mind of both the patient and clinician. The second biggest problem is that often the circumstances beyond their physical pain is ignored. I am convinced that dealing with what happens between the ears and at home is as important as what is physically wrong with the body (i.e. the biopsychosocial model). So how is "pain as the fifth vital sign" measured? Sometimes it's a scale of frowny face to smiley face. But often it's a comparative pain scale, from 0 to 10. The Health Organization for Pudendal Education (HOPE) offers the best description:

• 0 - No pain - Feeling perfectly normal.
• 1 - Very mild - Barely noticeable pain, like a mosquito bite or a poison ivy itch. Most of the time, you never think about the pain.
• 2 - Discomforting - Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails. Note that people react differently to this self-test.
• 3 - Tolerable - Very noticeable pain, like an accidental cut, a blow to the nose causing a bloody nose or a doctor giving you an injection. The pain is not so strong that you cannot get used to it. Eventually, most of the time you don't notice the pain. You have adapted to it.
• 4 - Distressing - Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe really hard. So strong you notice the pain all the time and cannot completely adapt. This pain level can be simulated by pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails and squeezing hard. Note how the simulated pain is initially piercing but becomes dull after that.
• 5 - Very distressing - Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that your normal lifestyle is curtailed. Temporary personality disorders are frequent.
• 6 - Intense - Piercing pain so strong it seems to partially dominate your senses, causing you to think somewhat unclearly. At this point, you begin to have trouble holding a job or maintaining normal social relationships. Comparable to a bad non-migraine headache combined with several bee stings, or a bad back pain.
• 7 - Very intense - Same as 6 except the pain completely dominates your senses, causing you to think unclearly about half the time. At this point, you are effectively disabled and frequently cannot live alone. Comparable to an average migraine headache.
• 8 - Utterly horrible - Pain so intense you can no longer think clearly at all, and have often undergone severe personality change if the pain has been present for a long time. Suicide is frequently contemplated and sometimes tried. Comparable to childbirth or a really bad migraine headache.
• 9 - Excruciating, unbearable - Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk. If this doesn't work, suicide is frequent because there is no more joy in life whatsoever. Comparable to throat cancer.
• 10 - Unimaginable, unspeakable - Pain so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss have experienced level 10.

How many times have people said their pain is a 9 or 10 (or a 47) when they're conscious, sitting upright and drove themselves to the doctor's office? I have seen that manifold times in hundreds of chronic pain workers' comp claims since 2003. But it's easy to succumb to that kind of self-assessment ... I had the flu in February and went to a CVS Minute Clinic. One of the initial questions the nurse practitioner asked me (having been prompted to do so by her practice management software) was my level of pain. I truly felt miserable -- body aches, high temperature, sneezing. For a brief moment, because I wanted to ensure a prescription of Tamiflu, I wanted to catastrophize ("an irrational thought a lot of us have in believing that something is far worse than it actually is") and say I was a 9 or 10. But then I remembered all the times I had argued against that approach. And I remembered exactly what a 9 or 10 meant. So I resisted the urge and gave myself a 5 rating. I still got the Tamiflu that started the journey to recovery. See also: Better Outcomes for Chronic Pain   Pain is complicated and individual, so there is not a single answer for quantifying and treating it appropriately. However, I have three high-level suggestions:

• Re-calibrate the scale. The clinician should educate patients on the true meaning of 0 through 10 and help them decide on a lower number that better describes their pain. That would require an actual dialogue between the clinician and patient. I understand that pain is unique and personal. But if patients can convince themselves their pain is a 6 instead of a 10 (or a 47), then managing it seems much more achievable.
• Be honest. If there is going to be residual, chronic pain, the patient should know it. And own it.
• Manage the pain. In my opinion, "pain management" is a term that is often misused. You can't manage your pain if you're comatose (i.e. sedated on opioids, benzos, muscle relaxants, et al.). Yet we often see "pain management" as a series of pills or injections that are passive and repetitive (in some cases, I think pain management clinics have become "addicted" to the repeat office visits). At some point, patients need to manage their pain rather than allowing the pain to manage them, and be taught how to do that. That could mean yoga, an active lifestyle, better nutrition, biofeedback, proper sleep hygiene, deep breathing exercises, mindfulness, volunteer work or any number of other methods in combination or isolation that work for the patient. The key is an internal locus of control ("he or she can influence events and their outcomes").

I'm not saying pain isn't real. For those dealing with chronic pain, it is very real. But I've chatted with and observed too many people with significant chronic pain who overcome it on a daily basis to live productive and happy lives. I know that chronic pain does not have to win. Instead, we need to re-define pain, re-define suffering and help people take back control of their lives. I will finish with this wisdom from Dr. Stephen Grinstead:

• Thoughts cause feelings
• Thoughts + feelings = urges
• Urges + decisions (choices) = actions
• Actions cause reactions
• Reactions could help or hurt management of pain

In other words, how you think about pain influences how much power pain has over you. So think differently.

Once disaster strikes, the first priorities are always safety and preservation of property, but there are priorities to consider ahead of a loss to avoid unexpected surprises. Disaster mitigation and restoration is a critical service after property damage, and how you manage it may affect the outcome of your claim. Though there are many capable firms that specialize in property damage clean-up and restoration, there are some that will make mistakes, and others may even take advantage of the situation. When it comes to recovering the cost of mitigation and restoration services for an insurance claim, any mishaps can create big problems that may leave you stuck with the bill. See also: Are You Ready for the Next Disaster?   Here are five techniques to prevent potential problems before they arise:

1. Vet your emergency response team prior to loss -- Preparation is the key in any endeavor, and with property damage claims you cannot be too prepared. Recovery service providers should be identified and interviewed. Make sure the company you choose will be able to handle your potential issues. Involve your insurer during vetting. There are “approved” vendors that insurance companies recommend; however, just because they are “approved” does not mean there will not problems. Notify the insurance company of who you plan to use, as well.
2. Clarify and document scope of work -- Be clear on scope of work with the recovery firm and make the adjuster part of that conversation. Often, emergency response does not follow the normal protocols of a typical project. There likely won’t be time for detailed estimates, so try to get the adjuster to approve work in real-time to avoid second guessing.
3. Take a hands-on approach -- Your property may still be underwater, but once access is granted you must be hands-on. No one should have access to your facility without the presence of a company representative. Assign a property supervisor to the affected site to keep track of who is there and what they are doing. It’s your property and your responsibility. The bigger the loss, the more people there will be coming in and going out, so it is vital to have a company representative onsite to observe and answer questions.
4. Audit contractor charges before approving -- The first weeks after a loss are chaotic. It’s important for policyholders to put controls in place to monitor activity and to verify that work has been completed to specifications and according to the terms of the agreement. Reimbursable insurance expenses should be separated and audited prior to payment for proper detail and accuracy. This needs to be done efficiently in real-time. If you don’t have the resources, this step can be completed by your claim preparation accountants, i.e. forensic accountants. Having forensic accountants on your team, along with your technical experts, can let you process this information in the context of insurance recovery. Don’t assume your forensic accountants will automatically audit invoices. Identifying errors or, worse, fraud is critical to avoid delays in payment or project completion.
5. Address issues immediately -- When the first invoice arrives, insurance companies may act surprised and even deny coverage, especially if the steps above have not been followed. Make sure to get the parties together to discuss the issues. Don’t procrastinate and don’t assume. It is important to be proactive with any potential discrepancies. The policyholder is responsible if there are unresolved differences. If the adjuster disagrees with the work performed and the invoices are paid, it may be difficult to recover all your expenses.

See also: A Real Checklist for Real Disasters   The immediate aftermath of a disaster is stressful and hectic. Preparation and communication can help you weather the storm and minimize unwanted surprises when you’re looking for claim payment. Having an experienced and independent forensic accounting team will reduce the stress, the workload and reimbursement issues. Per the tagline for one of the largest restoration firms, in the end you want it to be “Like it never even happened.”

During my tenure at both British Petroleum and Walmart, I tried various forms of wellness, but to no avail. There were never any savings, participation was low, employees didn’t like it, and administration was complex. I’ve continued to follow the wellness industry but could never see any genuine success stories. The gratifying news is that I’m not the only one to notice any more. The Los Angeles Times called wellness a scam while Slate just recently called it a sham. And Al Lewis, my co-author on Cracking Health Costs, would say they’re being polite. Most recently, he has noted that the 2016 Koop Award is going to a vendor whose own data shows they made employees unhealthier. See also: The Yuuuuge Hidden Costs of Wellness   Speaking of Al Lewis, he has now entered the employee health field directly with Quizzify, which transforms the boring but long-overdue task of educating employees about health, healthcare and their health benefit into an entertaining trivia game. As a colleague and co-author, I have an obvious conflict of interest as I describe my impressions below, so don’t take my word for any of this. Just go play the sample short game right on the website, and ask yourself if you’re learning anything useful, right off the bat. Click here for a link to Quizzify. Do you think your employees already know this stuff? It’s doubtful. Americans vastly over-consume healthcare; it’s almost free at the point of service once the deductible is satisfied, and they are being bombarded with ads and marketing, as are their doctors. Nothing can solve this massive problem, but Quizzify can help, and is about the only vendor even trying. Backed by doctors at Harvard Medical School and a 100% savings guarantee, Quizzify provides a plethora of shock-and-awe, “counter-detailing” questions-and-answers (with full links to sources) that will educate even the savviest consumers of healthcare and entertain even the dourest CFO. Nexium? Prilosec? Prevacid? You wouldn’t believe the hazards of long-term use. Then there is the sheer waste and possible harm of annual checkups, well-woman visits, PSA tests and so on. Speaking of hazards, CT scans emit as much as 1,000 times the radiation of an X-ray. Uninformed people are going clinics that will give them a “preventive” CT scan. If a doctor suggested patients have a series of a thousand X-rays for “preventive” reasons, there would be a stampede out of the office. On the other hand, there are instances where people should go to the doctor but don’t. Swollen ankles? Painless, perhaps, but you may have a circulation problem, possibly a serious one. Blood in your urine, but it goes away before you even make an appointment? That could be a bladder tumor tearing and then re-attaching itself, especially if you smoke. And show me one health risk assessment that correctly advises people over 55 or 60 to get a shingles vaccine if they had chicken pox as a kid. Then there are the health hazards of everyday life. Those healthy-sounding granola bars are full of sugars cleverly hidden in the ingredients labels. And whoever says vaping is safer that smoking better not be pregnant, because for pregnant moms, incredibly, vaping could be worse for the unborn baby. Just as with the shingles vaccine, chances are your HRA is silent on the texting-while-driving (TWD) issue while obsessing about seat belts, but TWD is by far the more underappreciated hazard. See also: Wellness Promoters Agree: It Doesn’t Work Your HRA is probably also silent on the health risks of loneliness, poor spending habits, boredom and most of the other major health risks Robert Woods, PhD, and I describe in our book, An Illustrated Guide to Personal Health. Quizzify has many questions on spending habit, but, if I had one complaint, it would be that (at least in the questions I’ve seen) Quizzify doesn’t address these risks we’ve described in this book. One of the largest health risks that workers have is being in a job you hate. You won’t see that question on anyone’s HRA either, or in Quizzify. That issue could lead to mass resignations in some pressure cooker companies. Scores and scores of people have told me they fudge answers on HRAs, anyway. Interestingly, they feel they are on the ethical high ground to do that because of the goofy, nosy and intrusive questions they are asked to answer, e.g., asking about your pregnancy plans in the future. Quizzify, on the other hand, encourages people to cheat. Quizzify wants you to look up the answers because that’s how you learn. So instead of denying human nature, Quizzify channels it. Conclusion: if you offer old-fashioned wellness, walk, don’t run, to the nearest exit. If you want to look at something that shows huge promise, check out Quizzify.

In my post last month, I discussed why the insurtech revolution should be focusing more on addressing the protection gap, thereby growing the pool of insurable risks, rather than figuring out how best to eat the insurance incumbents' lunch. A

t a conference in February, Tom Bolt of Lloyd's noted that an increase of 1% in insurance penetration can lead to a 13% drop in uninsured losses and a 22% drop in taxpayers' share of the loss. The key to increasing penetration is lowering distribution costs to make products more affordable. That is where insurtech can come in.

Many recent startups have business models looking to tackle the excessive intermediation costs that exist in the current insurance value chain. Sadly, when a catastrophe strikes areas of low insurance penetration, those communities not only suffer from the difficulties of having to seek aid—which can take three-plus months to reach affected zones—but also face the prospect of a significant drag to economic growth.

It is unsurprising, therefore, that governments in vulnerable countries are keen to improve their “resilience” and seek solutions to better prepare themselves for catastrophes by working with the likes of the World Bank, the UN and the recently established Insurance Development Forum (IDF). Interestingly, AIR Worldwide announced recently the Global Resilience Practice, which will be led by former U.S. presidential adviser Dr. Daniel Kaniewski.

See also: InsurTech Need Not Be a Zero-Sum Game  

As well as providing low-cost distribution models in new markets, a related opportunity I see for insurtech is working together with the insurance industry in the growing field of resilience analytics. As Robert Muir-Wood recently pointed out on RMS' blog, the claims data gathered by insurers — which historically has been used for the pricing and managing of risk — have the potential to also be used to reduce the potential for damage before the event.

Insurtech companies could work with government authorities to pool this claims data, leveraging it with other key data from external sources and then using the results to influence urban resilience strategies. There are inevitable doubts over the willingness of insurers to share their data, but agile and thoughtful startups are likely better placed to be able to find insights in a world of abundant unstructured data than the more technologically challenged incumbents.

The current size of the protection gap is a failure of the insurance industry, and any companies that can help address it will not only be first movers in new markets but will also be adding social value and much-needed resilience to vulnerable communities all over the world.

Building on T.J. Geelen’s blog post about the thriving fintech ecosystems in Asia, I’d like to share with you some insights relating to the emerging insurtech ecosystem in the region. Although insurtech in Asia is in its infancy, since 2015 we’ve seen a surge of interest. By the way, I’m a big believer that Asia has a real potential to power the next wave of global insurance innovation.

[The other three parts of this series can be found here and here.] “Power is the ability to define reality and to have other people respond to your definition as if it were their own.” – Wade Nobles “Words are powerful. Old and inaccurate descriptors, and the inappropriate use of these descriptors, perpetuate negative stereotypes and reinforce an incredibly powerful attitudinal barrier.” – Kathie Snow Workplaces are microcosms of society and can be powerful change agents when they create caring cultures through attention to how suicide and mental health are discussed. It is difficult for us to write about language and mental health in a simple “Say this” and “Don’t say this” way, but we must strive to do better. Generally, clinicians dominate the discussion, but thoughtful language about mental health and suicide does not rest on diagnostic categories. Rather, it tries to communicate more clearly, accurately, individually and holistically about the experience. We must constantly look to find language that is dignified, empowering and inclusive as well as being as descriptive as possible. See also: The Daily Grind Is Good for the Mind   It is not easy to find “the best” language, but we can do better. 1. The terms that are used are often clinically based and clinically biased. The term “mental illness” puts the descriptor of a person in medical language, even though the person may not always wish to be identified based on a medical perspective. The medical model contributes to rampant oversimplification that looks like this: “All that has to be done is to get these ill people to seek treatment; they take a pill, and they are fixed!” Diagnosis serves the medical practitioner in treatment planning, but it does not provide good information or understanding about the whole person and encourages us to see a person only in terms of a medical condition. And diagnosis is often incorrect, so it should not be the focus of how we educate. Although it is very common for people who have received a label regarding mental health or substance use to have a significant history of trauma, the correlation is ignored in the language, and often in treatment too. Only the set of “symptoms” currently seen is addressed. The trauma is not. 2. The choice of words is not mindful. The word “suffering” is used often, as in “people who suffer from depression.” This paints a pathetic picture of nothing but suffering, which is a fallacy, while suggesting passive inaction. Another common term is “the stigma of mental health.” In fact, the stigma is an attitude of prejudice toward a group of people. See below for suggested alternatives to the term. 3. Terms promote “other than” thinking. The words “disorder” and “disability” inform us that those who fall into these categories are other than “ordered” or “able.” “Order” and “able” are the givens, the desirable things. “Dis” implies that a person described this way falls short. Consider this: the term “non-white” is not used to name a person who is other than Caucasian, because it would be deemed to be disrespectful. Unfortunately, we do not have a wording solution for mental health. 4. Better terms require more words. We are forced to use terms that represent dominant culture mindsets, even though they are just labels, not the “truth.” For example, a better way of saying “a person who has a mental illness” could be to say: “a person who has the experience of having been assigned a medical label in the category called ‘mental illness.’“ But this makes writing and speaking very cumbersome. 5. We do not have consensus around best language. Inside what is known as the recovery movement, we do not have consensus on best language, and that is okay. Let’s all keep thinking about this, talking to each other and pushing collectively toward better communication. The chart below provides some principles of progressive language. The suggestions that appear in the right-hand column are far from perfect, and we hope that they will continue to adapt and improve. To fulfill our desire to support self-determination, please note that if a person with the lived experience of a mental health challenge wishes to identify himself using language from the left-hand side of the chart below, we support that choice. (This is not an exhaustive list, and for reasons of space does not hold all the terms and usage that we wish would change.) Portions of this chart have been adapted with permission from Each Mind Matters, California’s Mental Health Movement, funded by counties through the Mental Health Services Act (Prop 63). See also: Why Mental Health Matters in Work Comp Words matter, especially where there is such a long history of marginalization, misinformation and mystery around daunting topics. When it comes to language related to mental health, we may not have all the right answers, but many of us are in the struggle to do better.

The definition of insanity is doing the same thing over and over and expecting different results, right? The reality behind, and perhaps even the origin of, this statement is the simple fact that change is hard. This is especially true in the antiquated, paper- and process-laden insurance industry, which has resisted any kind of fundamental upgrade for decades. In the meantime, other industries have raised the bar of consumer expectations to a level where it is now unreasonable for the insurance industry to not respond. In identifying what is needed to improve self-service opportunities, access, prices, personalized product variations and, in turn, the entire customer experience overall, insurers inadvertently shone a spotlight on the industry’s enormous technology gap. And, having made significant money in fintech, the investment community is driving considerable interest in insurtech. See also: The Formula for Getting Growth Results   Insurers are ramping up to take back control from the mentality of the “way it’s always been done” and “if it ain’t broke don’t fix it.” There are three things that insurers can do to change the insurtech definition of insanity, including evaluating and overhauling processes, establishing a transformation team and doing a little mythbusting. Reinventing the Wheel First things first. Take a good hard look at your processes, keeping in mind that, without a change in process, there will be no change in results. It’s time to reject, revamp and reinvent processes that were created as workarounds for things legacy systems can’t and won’t do. The insurance industry has accepted changes already in the last several years that no one could have predicted 10, 15 or 20 years ago. And, the on-demand economy is pushing further changes in product definition – what is billable and in what increments, who owns information, where it should be stored and who should have access. The processes that drove the insurance industry yesterday do not have a carte blanche license for tomorrow. Rubber, meet road. Empowered AND Accountable Second, choose the right transformation team. This may be made up of internal insurance domain subject matter experts (SMEs), of IT professionals with a working knowledge of the existing infrastructure and even of external insurtech vendor partners offering expertise with emerging technologies. But be aware that, as important as the makeup of the team is the mandate of the team; the transformation team must be both empowered and accountable for decisions and results. The right people will rise to this challenge instead of shying away from it. The insurance industry must collectively do a better job of creating an innovation environment where failure is a learning experience and not a cause for dismissal. Shiny Bubbles? Third, insurers must become futurists, fortune tellers and mythbusters. Sound unlikely? Admittedly, this is probably not going to happen, but in the absence of true foresight (or ownership of a Ouija board), insurers must avoid getting enamored of the next big thing or shiny object. In the past, technology vendors have been criticized heavily for throwing big advertising and marketing dollars behind vaporware, or going to market with half-finished products and using insurer customers as unsuspecting development partners. This trend is no less prevalent in the new insurtech revolution or among startups, as opposed to incumbent insurance technology vendors. Desire to take advantage of the latest technology trend or to jump on the insurtech bandwagon should not outweigh prioritization of technology initiatives with tangible business value, or due diligence to determine if a product is actually present behind the marketing and advertising curtain. See also: Matching Game for InsurTech, Insurers Resistance is Futile Maybe the industry is taking the first step in a recovery program. Insurance has recognized there is a problem to be solved, and, by and large, there is acceptance that “resistance is futile.” Few insurers will maintain that the status quo must stand, technology advances must not be incorporated, products must not be made more flexible and processes must not be changed. Technology can help the industry meet the demands of modern consumers, attract new talent, protect policyholder data, provide mobile access and on-demand products and relate better to Millennials but only if evaluated and implemented quickly and responsibly, and in conjunction with substantive process change. Those who don’t believe this to be true, and who are insistent on continuing to resist change, are likely to be victims of their own insanity.

“Workplace Wellness Programs Are a Sham“ is a good article in Slate by L.V. Anderson. This is a must read for people who remain true believers that workplace wellness will improve worker health. “The idea behind wellness programs sounds like a win-win," Anderson writes. Alas, history is full of “win-win” ideas that were destructive, costly or ineffective. She describes the infamous “doublespeak” of Safeway CEO Stephen Burd’s description of success with Safeway’s wellness program. Anderson writes, “As it turns out, almost none of Burd’s story was true.” (Regular readers of my blog will know I’ve written about the Safeway nonsense before.) For decades, everyone knew that an annual physical was a great way to stay healthy, but various studies, including the famous New England Centenarian Study, have exposed that as a myth, too. See also: A Proposed Code of Conduct on Wellness   Antibacterial soap, anyone? Sounded like a great win-win, no? The FDA finally outlawed it. In my book, An Illustrated Guide to Personal Health, written in 2015 with UNLV Professor Robert Woods, Chapter 4 was titled, “Avoid Antibacterial Soaps and Gels.” Why? “Overuse of antibacterial soaps and gels can reduce the effectiveness of antibiotics you may need someday…. They are helping create antibiotic-resistant germs.” Back to wellness failures. Companies in the U.S. have spent huge dollars trying to keep employees healthy through methods that are shams. It’s time to move on. I immodestly include the following quote from Anderson’s article: “You might think of Al Lewis, Vik Khanna and Tom Emerick as the Three Musketeers in the fight against wellness programs.“* Al and I are co-authors of the Amazon best seller, Cracking Health Costs. It describes flaws in typical corporate wellness schemes, which while profitable to wellness vendors are useless at best and can actually be harmful to workers health at worst, not to mention the inconvenience and costs of going to doctors for all that screening. Concerns about wasted productivity, anyone? How can wellness programs harm worker health? One way is by promoting gross over-testing and excessive screening by tools that have very high error rates and rates of false positives, e.g., PSA screens. One good byproduct of dumping your wellness program is to avoid all the costly and burdensome reporting ACA requires. Yet another good byproduct is letting your employees do their work at work instead of spending non-productive time every year in wellness lectures, filling out health risk assessments, reading wellness-related emails and brochures, etc., etc., ad nauseum. How can “wellnessophiles” in companies truly believe that their employees don’t already know that smoking, overeating, lack of exercise and excessive consumption of concentrated sugars are not good for them? Do wellness proponents truly believe that the employees’ doctors haven’t already addressed those issues…not to mention public service announcements, health classes in high school and so on? Do proponents think their employees who smoke have never noticed warning labels on cigarette packs? I meet a lot of people from various walks of life. Occasionally, I ask them if their employer has a wellness program and, if so, what do they think about it. The typical first reaction is they roll their eyes. The most common comment is that the company’s wellness program is “just another [insert unflattering adjective here] HR program.” That’s usually followed by comments best described as lampooning the programs, as in “you’re not gonna believe this but…” type of comments. Interestingly, I meet HR executives who admit their wellness program are ineffective and costly, yet they cling to them. They usually give one of two reasons. One is that they don’t want to admit that their program is a big waste of money. Another common rational is some version of “Too many of our employees are unhealthy; we gotta do something.” (I put that in roughly the same category as, “the beatings will continue until morale improves.”) That line of thinking is bureaucracy at its worst. You would never spend your own money that way…or maybe they would?  Hmm. I get asked, if not wellness then what? My reply is anything that might actually save money or get better care for your workers, e.g., centers of excellence and direct contracting with providers. There is some promising work on reference-based pricing and better pharmacy management. Also, I believe we may have a surge of international medical travel in the future, too, especially to places like Health City Cayman Island (HCCI), about an hour’s flight from Miami and one of the best-quality hospitals and clinics in this hemisphere. I have visited HCCI a number of times and met a number of their surgeons. They are excellent. See also: EEOC Caves on Wellness Programs   I tried various forms of wellness in my career of running large sell-insured plans. I tried to make them work, but in the end none of them were effective, and some actually drove up health costs in a way a steely-eyed CFO would quickly understand. For about half my career, I reported through the CFO chain, not HR. CFOs really get the numbers and ask the tough ROI questions. HR executives, take note: You can increase your status and respect if you just get out of wellness. Again, it’s time to move on. While wellness at work was a noble notion and one that made sense to many on the surface, it’s time to “fess” up to your bosses. They will appreciate your message and appreciate the reduction of wasteful spending. Tom Emerick’s latest book is An Illustrated Guide to Personal Health. For further information on this topic, see the They Said What blog by Al Lewis and Vik Khanna.

Lately, everyone from government agencies to regulators to corporate board members seem to be talking about the need for more effective risk management. The challenging part is that, despite the guidance provided in ISO 31000:2009, the concept of risk management effectiveness remains vague. This article attempts to summarize the basic components of effective risk management, which should help risk managers to respond to the challenges set by regulators and shareholders. The team at Institute for Strategic Risk Analysis in Decision Making (ISAR) and www.risk-academy.ru has been studying risk management for more than 15 years, and we firmly believe that effective risk management is only possible when all four criteria below are met. Each of these criteria is based on ISO31000:2009, the most widely used risk management standard in the world (translated and officially adopted in 44 of the 50 biggest countries based on the GDP). 1. Integrating Risk Into Decision Making One of the most important tests of true risk management effectiveness is the level of risk management integration into decision making. ISAR research shows that companies achieve long-term advantage if they are capable of systematically integrating risk management into planning and budgeting decisions, investment decisions, core operational business processes and key supporting functions. Just consider an example of a large investment fund, which makes investment decisions only after an independent risks analysis and does simulations to test the effect of uncertainty on key project assumptions and forecasts. Another example is a large airline, which makes strategic decisions based on several quality alternatives with a risk assessment performed for each alternative.

For us it's very important that risks are taken into account when investment decisions are made. That's why risk assessments are mandatory for all investment decisions. Risks are identified and evaluated by both the project team and the back-office departments, including legal, finance, scientists, strategy and others. This ensures a more objective and independent risk analysis when making investment decisions.

--Konstantin Dozhdikov, Head of Risk, RUSNANO

 2. Strong Risk Management Culture

Human psychology and the ability of business managers to make decisions in situations of great uncertainty have a huge impact on risk management effectiveness. Nobel laureates D. Kahneman and A. Tversky, have conducted some exceptional research in the field of risk perception, showing that most people, consciously or subconsciously, choose to be ignorant to risks. Robust risk management culture is therefore fundamental to effective risk management. Take for example a large petrochemical company, which used online and face-to-face training to raise risk management awareness and competencies across all staff levels. The company also allocated resources to integrating risk management principles into the overall company culture. Another example is a government agency, which documented transparent discussion and sharing information about risks as one of the corporate values, which were later communicated to all employees. See also: Risk Management, in Plain English

Training is one of the most important factors in the development of a risk management culture. Risk management can become an effective tool as soon as every employee understands what is it and how it applies to their personal area of responsibility. There are many different kinds of risk management training. It could be risk induction training offered to all new employees. Induction training should include a short explanation of the risks that might arise, information about a useful tool risk management and how to use it when making day-to-day business decisions. It is also useful to conduct separate specialized risk management training for department heads and key managers in order to help them integrate risk analysis into key business processes. The main thing is to remember that training is not supposed to be a one-time measure and, on the contrary, should be offered on a regular basis. Training sessions can be led by your company's own risk manager or an external party, but either way the trainers must possess relevant competencies and qualifications.

--Lubov Frolova, Head of Risk , Tekhnodinamika

3. Disclosing Risk Information Another criterion for effective risk management is willingness and ability of an organization to document and disclose risk-related information both internally and externally. A mature company not only documents the results of risk analysis in the internal decision making processes but also discloses information about risks and their mitigation to relevant stakeholders, where appropriate, in external reporting or on the company website. Because actual risk information may be sensitive and contain commercial secrets, the focus of disclosure should not be  on the risks themselves but rather on risk management framework, executive commitment to managing risks and culture of the organization. Many organizations tend to treat this formally, often copying and pasting risk management information in external reporting from year to year without any update. Remember that disclosure of risk management information allows companies to both make and save money. For example, the insurance market reacts positively to a company's ability to disclose information about the effectiveness of its risk management and control environment, offering a reduction in insurance premiums. Banks and investors also see risk disclosure in a positive light, allowing companies to lower their financing costs. One large mobile network operator takes risk reporting particularly seriously. Its approach changed after an IPO. To this day, risk reporting as part of the annual report is not just a recount of the typical risks within their industry sector, but a reflection of key risk management changes and achievements over the last period. Risk reporting is composed of two parts: 1) A general description of events linked to risk management within the company; and 2) A description of key risks facing the company over the year. In the first part, risk managers give a detailed description of significant risk management events that occurred within the company that year. For example, there could be a description of how closely the company is aligned with the ISO 31000:2009 principles, or how the company has strengthened its risk culture. The second part describes common risk categories facing the company. This should point out the typical risks in the industry sector as well as the most significant risks identified over the past year. Additionally, the description of each risk should include the status of mitigation actions taken to manage the risk, their effectiveness and the anticipatory measures that the company intends to take in the future.  4. Continuously Improving Risk Management The final criterion for effective risk management has to do with the continuous improvement of the risk management framework and the risk team itself. One investment fund was able to do this with the help of regular assessment of the quality and timeliness of its risk analysis, annual risk management culture assessments and periodic review of risk management team competencies. For example, professional risk management certification helps to boost risk team competencies. One of the reasons behind the need for constant risk management improvement is rapid development of risk management discipline. The ISO 31000:2009 standard is currently being reviewed by more than 200 specialists from 30 different countries, including experts from Russia and members of ISAR. Some of the suggestions for the new version of the standard include the greater need for integration of risk management into business activities, including decision making, and the need to explicitly take into account human and cultural factors. These changes could have a significant impact on many modern non-financial organizations, raising questions about their risk management effectiveness. See also: Risk Management: Off the Rails?   Risk management, just like any other element of corporate governance, must be integrated into the overall management system of the organization. The ISO 31000:2009 international standard explicitly talks about the need for risk management to be adaptive, dynamic and iterative. As organizational risk maturity improves, so will the tools used by the organization to manage risks in decision making. Professional risk managers should not only develop risk management processes for the organizations but also improve their own risk management competencies. As I am writing this, work is being undertaken on the update of both of the most widely adopted risk management standards (ISO 31000:2009 and COSO:ERM 2004). New versions are expected to be available in 2017 and promise to revolutionize our current understanding of risk management, not necessarily in a positive way. My experience shows that participating in international conferences, training sessions and certification programs constitutes a good way for risk managers to keep themselves in top professional shape. I hope I will see you at the G31000 conference in Dubai on Oct. 12-13, 2016:www.g31000conference2016.org, where I will be presenting on the topic of risk management maturity. We recommend executives and risk managers evaluate the current level of risk management maturity using the criteria for effective risk management presented in this article. If at least one of the puzzle pieces is missing, it is probably a bit premature to talk about effective risk management.

In my last post, I outlined the four dimensions that are defining the opportunities for health insurtech innovation: the health of the American people, marketplace trends, the role of regulation and the players. Incumbent health insurers are pursuing legacy tactics to compete in the ACA world. There are big M&A approved (Centene/Healthnet) and facing regulatory challenges (both Aetna/Humana and Anthem/Cigna). Many are increasing premiums. Others are leaving the public exchanges (notably, United Healthcare withdrew earlier this year, and Aetna just announced its withdrawal from 11 of the 15 exchanges). Innovators addressing the root of user pain points can influence how plans are selected and healthcare is consumed. The levers are not easy to move. Success requires compliant ways of combining big data analytics and personalization with user-centric digital experiences. The headline of a recently published New York Times article, Cost, Not Choice, Is Top Concern of Health Insurance Customers, would seem to state the obvious. Yet insurers have expressed surprise at the policy mix and which plans are proving to be most popular. Carriers participating in the public exchanges report poorer actual performance than anticipated in premiums (lower) and claims (higher). Users are gravitating toward lower-cost plan options and show a trend to self-select into higher-cost plans when they know a big health care expense looms. This is not just an issue for incumbents. Oscar, among the most visible innovators in the US health insurance marketplace, reported a $105 million loss in 2015. Lack of scale is a challenge, but the company has also been affected by the user decision-making dynamics affecting established carriers. See also: Matching Game for InsurTech, Insurers   The results suggest (at least) three pain points: 1. People don’t see value because they don’t understand what they are buying.

• When people think something is too expensive, it is because either they cannot afford it (i.e., it really is too expensive) or the perception of value does not justify the price.
• Reportedly one in seven employees do not understand the benefits being offered by employers, of which health insurance is by far the biggest piece.

2. People are being held accountable for health decisions that they are not equipped to handle.

• Faced with a complex set of choices and opaque information, it is no surprise that many go for the easy option: saving money now.

3. People don’t always make rational decisions.

• A basic primer in behavioral economics will tell you that emotion, bias and other limitations -- not rational analysis -- drive decisions and that people discount perceived upside relative to downside. There is not enough upside to pay more in the short term.

Players who manage to affect these behavioral drivers stand to gain. Here are examples of companies working the issues. Connecting disparate sources of data PokitDok creates “APIs that power every health care transaction.” They aim to enable data connectivity across the silos that in today’s world require manual navigation. They define an ecosystem including Private Label Marketplaces, Insurance Connectivity, Payment Optimization and Identity Management. The company closed a $35 million B round last year. PokitDok is a pure technology play. Achieving their vision could be the “holy grail”: better economics and better patient experiences and outcomes without owning underwriting risk. Helping employers It hasn’t been lost on the startup world that 150 million employees purchase health care via employers, which is why many companies are focused on improving the benefits buying experience and promising to help employers lower costs. The ACA requires that all companies with more than 50 employees offer health insurance. This aspect of the regulation, coupled with the fact that health benefits expense has risen steadily, provides a specific and large innovation space. Competitors include: Lumity, who reported raising $14 million last fall, acting as an insurance broker. The company claims to be “the world’s first data-driven benefits platform for growing businesses” promising to simplify benefits selection for employers and employees. Employees are asked to provide health data, which are compared with aggregate profiles using proprietary algorithms. The big question: Will employees see enough benefit to share potentially sensitive information? Zenefits, recovering from widely publicized regulatory issues, has new leadership. The company acts a broker, and focuses on small businesses. Collective Health is targeting a wide range of businesses via “ready-to-go,” “configurable,” and “advanced” solutions. The employee experience components of the offering are aimed at helping users make better-informed decisions with less hassle. SimplyInsured aggregates health insurance plan options for small businesses to make comparisons easier, and aims to automate processes presumably essential to creating a viable cost structure for serving this segment. See also: InsurTech Need Not Be a Zero-Sum Game   A number of benefits consultants including Aon and Towers Watson (the latter via their acquisition of Liazon in 2013) offer larger employers private exchange capabilities – these include portals for employee benefits enrollment enabled by data analytics and a friendly user interface. They act as or engage brokers to create benefits plans tailored to employers’ goals. Such portals can be helpful to employees, and check a box for employers seeking to improve the benefits experience, not just reduce expenses. Health Advocate, founded in 2002, is the largest example of a relatively new industry positioned to help patients navigate an increasingly complex system towards the right care and reimbursement. The question being raised around these solutions – although as the de facto advocate within my own family I’d love to have a professional advocate to whom I could outsource – is whether they are a workaround adding yet another layer of expense to an industry that earns among the worst customer satisfaction scores of any. As an employer, however, it’s a benefits option that could be valuable given the stress of managing the health care process many employees undergo. Motivating people to adopt healthier habits Vitality, reported on in an earlier post, is a cobranded platform offering deals and rewards designed to motivate people who take steps towards better health. Hancock offers the HumanaVitality program, integrating Vitality’s rewards program into the insurance relationship. If people see near-term benefit to behavior change this could be a good use case upon which to build. Facilitating patient payments to providers Patientco is a “payments hub” supporting “every payment type,” “every payment method,” “every payment location.” Focus is on efficiently increasing revenue for providers, secondarily to improve the payments experience for patients. The company provides the ability to integrate its solution with other health technology solutions. Providing better experience capabilities to carriers Zipari is a customer experience and CRM platform providing a product suite including enrollment, billing, and a 360-view of members across engagement channels. The company targets is product line at insurers, both direct-to-consumer and group or employer channels. See also: Be Afraid of These 4 Startups The multiple miracles that would have to occur for a quick fix make it unlikely that we will see a simple, logical health insurance experience any time soon. We are relatively early in what is likely to be a long game. But, insurtech innovators and even more mature companies operating within and around the sector are demonstrating the capacity to go after the possibilities that data, technology and the ability to see creative solutions offer to mitigate the pain.