Once again, I’ll head out on a limb with saw firmly in hand… 1.  Aetna will NOT be able to sell the Coventry workers' comp services (CWCS) division.  I’ll double down on last year’s prediction: Even if the giant health plan wants to dump workers' comp, the network – which is where all the profit is – isn’t sellable. The rest of the operation isn’t worth much; the bill review business continues to deteriorate (and CWCS is looking for a replacement bill-review application), competitors are picking off key staff and customers continue to switch out services and network states. 2.  Workers' comp premiums will grow nicely, driven by continued improvement in employment and gradually increasing wages coupled with increases in premium rates in key states (we’re talking about you, California). 3.  Additional research will be published showing just how costly, ill-advised and expensive physician dispensing of drugs to workers’ comp patients is. Following on the excellent work done by CWCI and Accident Fund/Johns Hopkins, we can expect to learn more about the damage done to patients, employers, insurers and taxpayers by docs looking to Hoover dollars out of employers’ pocketbooks. 4.  Expect more mergers and acquisitions; there will be several $250 million-plus transactions in the workers' comp services space, with more deals won by private equity firms. Of late, most transactions have been “strategics,” where one company buys another; the financials of these have been such that private equity firms couldn’t match the prices paid. I’d expect that will change somewhat in 2015 as  “platform” companies come on the market. 5.  A bill renewing TRIA will be passed; the new GOP majorities want to show they can “govern,” and this has bipartisan support. 6.  Liberty Mutual will continue to de-emphasize workers’ comp. The company’s continued focus on personal lines and property and liability coverage stands in stark contrast to the changes in workers' comp. The sale of Summit, management shifts and the financial structuring of legacy work comp claims portend more change to come. Recent financial results show the wisdom of this strategy. 7.  After a pretty busy 2014, regulators will be even more active on the medical management front. Workers' comp regulators in several more states will adopt drug formularies or allow payers to more tightly restrict the use of Scheduled drugs via evidence-based medical guidelines and utilization review (UR). While the former is easy, the latter is better, as it enables payers to more precisely focus their clinical management on the individual patient. Expect more restrictions on physician dispensing and compounding, increased adoption of medical guidelines and UR, along with incremental changes in several key states (California, we hope) to “fix” past reform efforts. 8. There will be at least two new workers' comp medical management companies with significant mindshare by the end of 2015. These firms, pretty much unknown today, are going to be broadly known among decision-makers within the year. While they will not generate much revenue this year, they will be attracting a lot of attention. 9. Outcomes-based networks will continue to produce much heat and little real activity. After predicting for years that small, expert-physician networks will gain significant share, I’m throwing in the virtual towel. There’s just too much money being made by managed care firms, insurers and third-party administrators (TPAs) on today’s percentage-of-savings, huge generalist network/bill review business model. Yes, there will be press releases and articles and speeches; no, there won’t be more than a very few real implementations. 10.  Medical marijuana will be a non-event. Amid all the discussion of medical marijuana among workers’ comp professionals, there are very few (as in no) documented instances of prescribing/dispensing of marijuana for comp claimants. Yes, there will likely be a few breathless reports about specific claims, but just a few. And, yes, there may also be a few instances of individuals under the influence of medical marijuana incurring workers' comp claims, but these will be few indeed. There you have it – here’s hoping I’m more prescient this year than I was last. This article first appeared on Managed Care Matters on Jan. 5, 2014.

Much has been written about the promise of digital technology to change insurance. But what does this mean in practical terms? Can digital technology reshape traditional patterns of engagement between insurers and their customers that have existed for decades (or centuries)? Can technology create a value proposition that avoids a zero sum game and benefits both insureds and insurers simultaneously? This post identifies three major opportunity areas for insurance and describes what one insurer, Tokio Marine & Nichido Fire Insurance, has delivered to make the transition to a digital insurance platform. Consumer expectations are increasingly being conditioned by the best practices found on sites such as Amazon, PayPal and eBay. Compared with these experiences, the traditional insurance process presents insurers with a number of challenges. Three problematic areas are:

• Buying is periodic: In the majority of sales, insurance is purchased infrequently. In some lines of business, such as life insurance, it may only be bought once (and used only once!). In personal lines, annual or semiannual renewals are automated, and a customer may never speak with an agent or a representative of an insurer. This lack of contact limits the opportunity for a distributor or an insurance company to establish a significant relationship with a customer and personalize the buying experience.
• Risk is poorly managed: Sales may be periodic, but risks are continuous. Business conditions and lifestyles change over time, and specific products, limits and coverages should be introduced at strategic times to respond appropriately. Changes in conditions – when a contractor offers a new type of construction, or a commuter in a dense metro area begins working from home and parks his automobile – need to be identified immediately and responded to appropriately. In an ideal insurance scenario, risks are managed on a continuous basis. However, in the current model, active risk management is a high-touch, high-cost service. Low premiums on products such as small business insurance provide little incentive for agents to service the risk management needs of customers appropriately. As a result, too often, insureds unintentionally self-insure. Many a claim submission includes the comment, “I have insurance; I thought I [or my business] was covered!”
• Payment, not avoidance, is the focus: The best loss is the one that is avoided altogether. However, the core of most traditional insurance products is to compensate an insured financially for a loss caused by a covered peril. This results in an emphasis on paying claims, not avoiding losses. While insurers are very familiar with the typical causes of loss, their customers generally are not aware of how their day-to-day behavior affects their loss exposure. Consumers and business owners do not typically evaluate their behaviors, lifestyles, operations or choices in light of loss potential and, thus, participate in behaviors that expose them to loss. For example, individuals choose to post vacation pictures on public forums such as Facebook, which increases their exposure to theft at their vacant home.

Tokio Marine & Nichido Fire Insurance (TMNF) began addressing the periodic sales challenge in 2010 by moving to a more continuous delivery platform. Offering personal lines insurance in the Japanese market, the company found that its traditional products did not allow it to sell to clients on a frequent basis. To change this dynamic, the company combined new technology with updated insurance products to fundamentally change the traditional process of customer engagement. The company developed a series of one-time, short-term insurance solutions that addressed targeted needs such as travel, skiing and one-day automobile insurance. The company partnered with a leading telecommunication provider, NTTdocomo, to sell these on mobile telephones. The buying experience requires very little customer input of information (because the phone company has most of the required demographic information), and payment for the policy is part on the next phone bill.  Over time, the product set has expanded into health coverages and now takes advantage of continuous health tracking technology. These make wellness recommendations to users on a daily basis and has helped TMNF make the transition from a periodic insurance provider to an active participant in its customers’ lives. Leading insurers are beginning to discover how to innovate with technology and product to change traditional trade-offs and deliver higher-value solutions to their customers. In subsequent posts, some solutions to the challenges of suboptimal risk management and loss avoidance will be detailed.

Now that the implementation of the Affordable Care Act (ACA) is well underway, opportunities for insurance product innovations are emerging. The ACA, or Obamacare, has been accelerating the changes that have been occurring in the last decade in how healthcare is delivered. A large portion of this change has manifested itself in the consolidation of healthcare institutions, physician medical practices and the employment of physicians by hospitals. As a result, the ACA is contributing to blurring lines that have separated those providing, managing and coordinating care. All those changes create opportunities for innovative carriers to thrive over the next decade. As an example, look at the trend of hospitals and hospital systems directly employing physicians, which Obamacare is encouraging, to seek greater efficiency and lower costs. Healthcare organizations are adding physicians, either by hiring them or by purchasing practices that employ them, and this shift has substantially increased demand for a seldom-used feature of a product known as the extended reporting period (ERP). An ERP endorsement, as part of what is known as a claims made product, addresses medical incidents that have occurred during the period of a policy that is about to expire but that are not yet known or made as a claim. Using ERP coverage can help insulate a new employer from any lingering medical incidents that occurred before it employed the physician but that become claims during his time with the new employer. Claims of malpractice can take months or even years to surface and then resolve, and a facility employing a new physician wants to be sure it isn’t inheriting a host of problems. The ERP carries an additional premium that is sometimes 250% of the expiring annual premium. Historically, ERP was largely purchased by physicians as a last resort – if they were leaving a claims made carrier, and the new carrier wouldn’t honor the prior carrier's retroactive date (the date after which any medical incident must take place to potentially be covered under a policy). This situation requiring the purchase of ERP was relatively infrequent, and pricing the risk was a challenge, because exposure can be carried for an unlimited time under an ERP. Typically, the physician’s only option was to buy it from her incumbent carrier, which is generally required to offer an ERP endorsement. Few carriers developed a separate ERP product to compete with the incumbent carrier’s endorsement approach, so there was little competition. In 2012, though, there was an opportunity to provide a competitive stand-alone ERP policy. The ACA was accelerating consolidation in the industry and boosting interest in purchasing ERP. At the same time, ERP pricing was still based on the hard market that began in the late 1990s even though claims frequency was showing an unprecedented decline in more recent years. In other words, premiums were substantially more than adequate for the risk. For quick-acting carriers, there was a chance to offer a stand-alone policy at generally a better price, but one that was still adequate in a small but rapidly expanding market. This also opened up the opportunity to innovate on product features, including providing options of different limits, various levels of risk-sharing and a variety of durations for the ERP. The market welcomed these pricing and innovations. Here is an example of how the ERP issues play out: A physician enters into an employment contract with a hospital, coming out of private practice. She may have done most or all of her work at that very same hospital, and, as part of standard guidelines for credentials in most states, she needed to provide proof of insurance of at least $1 million/$3 million to maintain privileges there while working as an independent contractor. Options for the prospective hospital employer are:

1. Ask the physician to obtain a quote from her existing insurance carrier for an ERP. That amount could become part of negotiations about her compensation.
2. Assume the exposure for the physician’s prior acts as part of the hospital’s self-insured retention, its captive insurance program or its balance-sheet obligations. After all, the physician practiced at this hospital almost exclusively, and the hospital may consider that it has the exposure to the physician's incurred but not yet reported liability obligations anyway.

Under option 1, there can only be one quote for the ERP, because there is only one existing insurance carrier. If the carrier provides ERP coverage, it is increasing the time period within which claims can be brought under its policy, which increases uncertainty and requires, in the actuarial vernacular, "risk load" or “rate load” (defined as rate needed to account for the potential adverse claims fluctuation inherent in the extended time frame for claim reporting) or, from the perspective of a cynic, increases the fat, the fudge or the cushion, which creates an opportunity in option 2. Given that ERP rates are based on historical losses and that claims frequency has declined, it’s a good bet that – with the added risk load and without the challenge of competition – the quote may be, as an actuary or a lawyer might say, “disproportionate to the risk.” Moreover, with the existing carrier, there oftentimes are no options for a deductible that has a different (lower) limit or shorter duration as a means of lowering the cost to the physician and her new employer. Option 2 introduces a wrinkle: When a hospital grants a physician privileges as an independent contractor, the hospital potentially has a stronger defense than when it employs the physician. If the physician’s prior acts as an independent contractor are covered under the hospital’s insurance program, the lines between independent contractor and employee blur, and the hospital may become more vulnerable. Additionally, the hospital’s coverage would not generally provide a specific individual limit for the physician, meaning the hospital exposes its entire tower of insurance to a claim against the physician. With an ERP covering the period before she became an employee, a $1 million policy might suffice, and the hospital could maintain its defense against claims for her time as an independent contractor. There is an opportunity for stand-alone ERP policies to provide a third option – one that can carry a better price than in Option 1 and that allows for the opportunity to provide a better defense against claims than Option 2. ERP is just one of many opportunities to innovate that ACA will provide. There could be, for example: --A blurring of the lines between different aspects of healthcare and of health insurance products. --An explosion in the power of telemedicine – and for new thinking about coverage. --A need to be far more careful about data breaches and other cyber issues – perhaps even leading to a decision to confiscate physicians’ phones. My colleagues and I will tackle these and other topics in subsequent articles.

[Editor's Note: A debate about the effectiveness of corporate wellness programs began on this site in late November, with the publication of a piece arguing that rigorous analysis showed no savings. A prominent proponent of wellness responded with a piece acknowledging some common ground but pushing back on the need to have wellness programs show a return on investment (ROI). Two of the authors of the original piece then raised 11 questions for the proponent. Now, one of them, Al Lewis, forwards an email he sent to the proponent, Ron Goetzel, that does a solid job of laying out what I see as the common ground -- including an agreement not to sell wellness based on claims of ROI. The hope is to forge an agreement on how wellness should be sold and administered. As of this writing, Lewis says Goetzel has not responded. We've attached the email, which was sent Jan. 5.] Ron, based on your posting I think we have enough common ground to stop arguing and sign a joint open letter like the one below.  Feel free to edit it. Let’s aim to have it out in a week. If people haven’t had a chance to sign it by then, they can add signatures. Eventually, we should get a lot because there isn’t really any major controversy left, if ROIs are no longer an issue and we agree on adherence to guidelines. Al   The signatories of this note, leaders in the wellness field who have previously been unable to find common ground, now agree on many key aspects of workplace wellness and would like to share that consensus. First, instead of what are known as “pry, poke, prod and punish” programs that require financial forfeitures (large penalties or loss of large incentives) by employees who refuse to (1) divulge personal health information on health risk assessments; (2) participate in overly frequently blood draws or (3) be sent to the doctor when they aren’t sick, we would encourage employers to adhere to USPSTF [U.S. Preventive Services Task Force] screening/checkup guidelines and frequencies (once every three to five years for most working-age adults). Aside from these infrequent screenings, we recommend that employers stay out of employees’ personal medical affairs unless they ask for help, because overdoctoring produces neither positive ROIs nor even healthier employees. There is also strong anecdotal and behavioral economics evidence that morale is adversely impacted by interference in employees’ personal medical affairs. Second, we also all believe that employers should respect the dignity of employees not just by no longer economically forcing these programs upon them, but also by not shaming employees who can’t lose weight. Third, we would jointly like to apologize to Penn State, Honeywell, Nebraska and others for not helping them recognize the importance of adhering to guidelines and/or of respecting employee dignity. Finally, we recommend that future programs be undertaken without regard for return-on-investment (ROIs) in medical spending since there is too much controversy surrounding the calculation of those ROIs.  Journals and consultants supporting wellness find positive ROIs from wellness whereas other journals and consultants do not, while no vendored program has ever been validated by the industry’s gold standard, the Validation Institute, for medical claims savings, though it is possible this happens in the future. Instead, we propose that wellness programs be done for employees rather than to them, in order to enhance the engagement and productivity of America’s workforce, which ultimately is what will keep America competitive in international markets for the foreseeable future.  Because of the importance to corporate America of having an engaged workforce, we urge the Business Roundtable and other wellness influencers to support us in this new direction.

They may seem like curses of modern corporations, but org charts and regular reorganizations are now a fact of business life. I'm sure, as an insight leader, you will have seen your fair share. As you've risen up the hierarchy, you've probably changed your role, from recipient to author. From my experience, two major opportunities exist for organizing customer insight functions. The first is to bring together the different technical areas that can best collaborate to provide deeper insights that lead to more action. These include teams that are often located in different functional silos. In line with my definition of customer insight, I would recommend bringing together: customer data, analysis and modelling, research and database marketing teams. Suitably integrated and with a culture focused on outcomes, these teams can work together for an "insight engine" that produces not just technical output but actions that result in both commercial impact and improved customer experiences. The second opportunity tends to come later in the maturity of a customer insight function. It is the centralization challenge. Whereas I would not encourage accelerating this (my experience is that insight teams drive more value when close to the business area they serve, with shared targets and emotional engagement), there do come times when it is appropriate. This will often be driven by wider corporate changes in line with simplification and cost reduction. But centralization can also be an opportunity. Integrating into one center of excellence on customer insight that drives consistent processes and coordination of customer interactions across lines of business can also drive value. Here are some of the benefits and risks I've seen in these centralized models: Benefits of a center of excellence:

• Economies of scale in specialist technical work;
• Career paths for more technical practitioners;
• More independent overview from business partners;
• Optimization and coordination of customer interactions.

Risks of a center of excellence:

• Loss of knowledge about specific business areas (becoming an "ivory tower");
• Loss of a sense of belonging to a business area (engagement);
• Inflexibility about different local needs (one best way);
• Apparent bureaucracy -- some things take longer (common process).

Interestingly, a poll we ran on customer insight found that all the leaders answering were running or part of a center of excellence. It would be interesting to hear from any customer insight leaders who are still successfully running a more federated or localized insight model. What is your experience?

Opioids have been used for thousands of years in the treatment of pain and mental illness. Essentially everyone believes that opioids are powerful pain relievers. However, recent studies have shown that taking acetaminophen and ibuprofen together is actually more effective in treating pain. Because of this, it is helpful for medical professionals and patients to understand the history of these opioid medications and the potential benefits of using nonsteroidal anti-inflammatory drugs (NSAIDs) instead. Extracted from the seedpod of the poppy plant, opium was the first opioid compound used for medicinal purposes. The active ingredients of opium are primarily morphine, codeine and thebaine. Opium and its derivatives have had more impact on human society than any other medication. Wars have been fought and countless lives have been lost to the misuse, abuse and overdose of opioids. It is also clear, however, that many received comfort from pain when there was no other alternative. For thousands of years, opium products provided the only effective treatment of pain and were also used to treat anxiety and depression. Tolerance, dependence and addiction were identified early as a problem with opioids. In 1899, Bayer produced and introduced aspirin for wide distribution. It became the first significant alternative to opioids for treating pain. Aspirin not only relieves pain but also reduces inflammation and is in the class of NSAID medications. Aspirin was commonly used for mild pain such as headache and backache. Other NSAID medications followed with the development of ibuprofen in 1961, indomethacin in 1963 and many others over the next 20 years. While these drugs are not addictive or habit-forming, their use and effectiveness were limited by side effects and toxicity. All NSAID medications share some of the same side effects of aspirin, primarily the risk of gastrointestinal irritation and ulcer. These medications can also harm renal function. Acetaminophen was created in 1951 but not widely distributed until 1955 under the trade name Tylenol. Acetaminophen is neither an opioid nor an NSAID. Tylenol soon became another medication that was useful in the treatment of pain, offering an alternative to the opioid medications and to aspirin. Acetaminophen avoids many of the side effects of opioids and NSAIDs b­ut carries its own risk with liver toxicity. Efficacy in acute pain Since the development of acetaminophen, medical professionals have had the choice of three different classes of medications when treating pain. Those decisions are usually made by considering the perceived effectiveness of each medicine and its side effects along with the physical status of the patient. For example, acetaminophen should not be taken by someone with advanced liver damage; NSAIDs should not be given to an individual with advanced kidney disease or stomach ulcers; and opioids pose a potential risk to anyone with a personal or family history of addiction. Although many have long been believed that opioids are the strongest pain medications and should be used for more severe pain, scientific literature does not support that belief. There are many other treatments that should be utilized for treating pain. Studies have shown NSAIDs are just as strong as the opioids. Number needed to treat When considering the effectiveness or the strength of pain medications, it is important to understand one of the statistical measures used in clinical studies: the number needed to treat (NNT). NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication, and the effect is usually 50% pain relief. That is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50% pain relief (effective relief)? A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100% effective at reducing pain by 50% -- everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means two people must be treated for one to receive effective relief. Or, alternatively, one out of two, or 50%, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. Basically, the medication with the lowest NNT will be the most effective. For oral pain medications, an NNT of 1.5 is very good, and an NNT of 2.5 would be considered good. Treating chronic pain Despite the widespread use of opioid medications to treat chronic pain, there is no significant evidence to support this practice. A recent article reviewing the evidence regarding the use of opioids to treat chronic non-cancer pain concluded, “There is no high-quality evidence on the efficacy of long-term opioid treatment of chronic nonmalignant pain.” (Kissin, 2013, p. 519) A recent Cochrane review comparing opioids with placebo in the treatment of low back pain came to a similar conclusion. This review said that there may be some benefit over placebo when used for short-term treatment, but no evidence shows that opioids are helpful when used for longer than four months. There is no evidence of benefit over non-opioid medications when used for less than four months. (Chaparro et al., 2014) Several other reviews have also concluded that no evidence exists to support long-term use – longer than four months – of opioids to treat chronic pain. (Kissin, 2013; Martell et al., 2007; McNicol, Midbari, & Eisenberg, 2013; Noble et al., 2010) Epidemiologic studies have also failed to confirm the efficacy of chronic opioid therapy (COT) for chronic non-cancer pain. A large study from Denmark showed that those with chronic pain who were on COT had higher levels of pain, had poorer quality of life and were less functional than those with chronic pain who were not on COT. (Eriksen, Sj.gren, Bruera, Ekholm, & Rasmussen, 2006) In the last 20 years in the U.S., we have increased our consumption of opioids by more than 600%. (Paulozzi & Baldwin, 2012) Despite this increase, we have not decreased our suffering from pain. The Burden of Disease study in the Journal of the American Medical Association (JAMA) showed that Americans suffered as much disability from back and neck pain in 2010 as they did in 1990 before the escalation in the prescribing of opioids. (Murray, 2013) A study in JAMA in 2008 found, “Despite rapidly increasing medical expenditures from 1997 to 2005, there was no improvement over this period in self-assessed health status, functional disability, work limitations or social functioning among respondents with spine problems.” (Martin et al., 2008, p. 661) It is currently estimated that more than 9 million Americans use COT for the treatment of chronic nonmalignant pain (Boudreau et al., 2009). When we consider the proven benefits of this treatment along with the known risks, we must ask ourselves how we can ethically continue this treatment. The reality is we really don’t know if COT is effective. Anecdotal evidence and expert opinion suggest it may be beneficial in a few, select people. However, epidemiologic studies suggest that it may be doing more harm than good. Terminal care The treatment of incurable cancer, end-stage lung disease and other end-of-life situations are notable examples where opioid medications are absolutely indicated. Although opioid painkillers are not very good medications for the treatment of pain, they are very strong psychotherapeutic agents. They are excellent at relieving anxiety and treating depression for a limited time. Opioids cause beneficial changes to brain serotonin, epinephrine, norepinephrine, dopamine and endorphins. For short-term, end-of-life situations, these neuropsychiatric effects are likely beneficial. For terminal care, opioids are the medications of choice. Conclusion The opioid medications are often referred to as “powerful painkillers.” In fact, the evidence shows that they are mild to moderate painkillers and less effective than over-the-counter ibuprofen. They have, however, powerful side effects that harm hundreds of thousands of individuals every year in the U.S. Even if one disregards the public health problems created by the use of opioid painkillers, these medications still are not a good choice for the treatment of acute pain -- regardless of the severity. In some situations, limited use is appropriate. But in the majority of situations in which opioid painkillers are used today, they are not appropriate. The standard of care in the practice of medicine today is to provide the best treatment that causes the least harm. When there is a treatment that is proven to be both more effective and safer, it is the treatment of choice. The implication of this data for policymakers is critical. By implementing policy that puts restrictions on opioid prescribing to protect public health, policymakers will also improve the treatment of pain by guiding prescribers to use medications that are more effective. It is also important for the medical and dental communities to address this inadequate and unsafe treatment of pain and change practice standards to guide care that is more appropriate for what our patients need and deserve. This is an excerpt from a paper that can be downloaded in its entirety from the National Safety Council.

The passage of the Affordable Care Act (ACA) changed both the dialogue and dynamics of healthcare in this country. It has also brought employers a new set of challenges and opportunities. Seemingly uncontrollable medical costs have plagued virtually all businesses in recent decades. The medical component of claim costs now accounts for well over half of the total workers’ compensation cost make-up. In addition, as more individuals have signed up for coverage under the ACA legislation, the demand on the system for healthcare services is becoming increasingly strained. This demand, coupled with a projected shortage of physicians, has made access to care a more prominent workers’ compensation concern. The offshoot of such pressures and constraints is a strong and unyielding focus on healthcare technology developments and advancements. The rapidity with which such innovations are being made, and the advances planned in the healthcare treatment and delivery landscape in the coming years, are phenomenal. Undoubtedly, technology will play an increasingly important role in maintaining employees’ well-being and fostering their recovery in the future. Some of the technological advancements that are available today and on the verge of exploding onto the healthcare scene include telemedicine, Google Glass, wearable monitoring devices, Internet-connected sensors, 3D printing and robotic devices. These are designed to increase the efficiencies associated with delivering healthcare and maximize the providers’ time and talents. Below are some additional details on these innovations and the advantages they can bring to the workers’ compensation industry. Telemedicine The American Telemedicine Association defines telehealth as remote healthcare technology designed to deliver clinical services. This could include alternatives ranging from medical providers consulting patients by phone to performing robotic surgery from a remote location. Telemedicine can certainly benefit injured or ill employees in situations such as nurse triaging and clinical consultation. For example, using telehealth, a nurse at a remote location can evaluate symptoms and determine whether an injured employee needs to be seen directly or can be discharged with instructions for homecare. Telehealth can also be used to reduce or even eliminate wait times and thus, appointment costs. A patient visiting an occupational healthcare provider who needs an evaluation from an orthopedist could have it right on the spot via a conference call during which the test results are projected onto a screen visible to the specialist. Google Glass Google Glass technology is being used today to maximize the time and talents of specialty providers and bring high-level expertise to remote areas of the country. One of its most valuable applications is in surgery. For example, a surgeon in New York could assist a surgical team in rural Oregon and show them precisely where to make an incision for a given procedure. Google Glass can also increase a physician’s efficiency in seeing and assessing patient conditions. A patient’s electronic health records could be displayed on Google Glass as a physician is conducting an initial assessment. Information such as medical history or current symptoms and medications could be reviewed in real-time as the physician converses with the patient and determines ensuing treatment. Moreover, in coming years, patients may use Google Glass to assess and evaluate physicians based on available information and reviews appearing on their own display. Wearable monitoring devices A number of wearable healthcare monitoring devices have flooded the market and have become popular among a select set of consumers. They are frequently worn around the wrist and can monitor physical information, such as calories burned, steps taken, activity, blood pressure, heart rate, sleep patterns and other defined metrics. These devices help increase awareness among users. For example, if a morning run is missed and step count is down, the individual may be more inclined to take the stairs, park farther away from the building or consume fewer calories. The next step is for users to begin sharing this information with their medical providers as a way of becoming more engaged healthcare consumers. Such information would allow a physician to customize a healthcare treatment plan specifically for that individual as opposed to relying on more general treatment guidelines. Internet-connected sensors  Sensors are being used and will become more readily available in the future as a way of monitoring and communicating an individual’s condition. For example, an individual who has recently undergone surgery may have sensors in his shoes to send an alert if he becomes unstable, thereby increasing the risk of a fall. Such sensors may trigger an alert to a smartphone, dashboard or other monitoring device signaling that the individual needs assistance. With the additional capabilities of these devices, resources can be deployed where and when needed, allowing for more effective and efficient care. 3D printing 3D printing is perhaps one of the most fascinating and promising medical advancements. Using 3D printing, experts have produced replicas of human hearts, which allow surgeons to perform a procedure in advance of an actual operation, improving quality and outcomes. 3D printing is also being used to produce human skin. This technology can be a tremendous benefit to burn victims and can reduce recovery time considerably. It also shows promise in aiding back surgeries. Previously, titanium plates were inserted between disks, and bone would grow around these plates. 3D printing allows the production of cellular structures that can become part of the bone growth itself. Such advancements are expected to reduce the need for repeat surgeries. Robotic devices Robotic devices are being used now and will likely become more common. One of their current uses is to help extend the efficiency and effectiveness of nurses and allow them to focus more specifically on patient needs and priorities. For example, when a nurse is recording vital signs, a robot can be used to retrieve supplies, allowing the nurse to spend more time providing valuable patient care. Looking further into the future, robots may be used to provide more extended patient care. These types of medical technology advancements are helping to create a culture of connected health that will redefine our treatment and delivery system. While new challenges and risks will arise, technology will play a prominent role in tomorrow’s healthcare. In the not-too-distant future, the amount of real-time information and communication that can be shared instantaneously is hard to imagine. This will allow for more productive and cost-effective interactions among patients, providers, employers, payers and caretakers. A more effective and efficient healthcare system characterized by improved quality and outcomes is a win-win situation for virtually all workers’ compensation stakeholders, and one that could quickly become a reality in today’s world. Preparation breeds optimism, and employers have the opportunity to prepare for the roll-out of the new healthcare legislation using digital health advancements. The suite of health technology tools, companies offering solutions in this space and the advanced products described above are all part of the newly evolving digital health arena, and undoubtedly these advancements will be part of a broader solution. In looking ahead, the convergence of digital health solutions with evolving healthcare delivery models has the potential to significantly improve access to care, address quality concerns and assist with costs. This would enable consumers to become more engaged and active in their health and, in turn, lead to improved health and productivity for employers. This would be a workers’ compensation offshoot by which we could all stand. This article first appeared at WorkCompWire.

Now that your efforts have made some Millennials flock toward working in the insurance industry, you need to start recruiting them for your open positions. (If they aren't yet flocking, read my past article to get some ideas on how to get them to do so: Thoughts From an Insurance Millennial.) But if you are waiting to recruit Millennials until you have a job opening, this may be too late. Let’s face it, unless you’re a well-known, direct personal lines carrier with a lizard mascot or a catchy jingle to make your agents magically appear when your clients need them, most young people won’t know who you are. This is one reason to reinforce continuous, conversational efforts in recruiting high-potential Millennials. Your first contact with your possible candidate can’t be advertising to apply for your full-time position. It is essential to build relationships with these potential employees before they hit the full-time job market. You can do this through a variety of ways: 1.      Temporary Employment (Internships, Part-Time Jobs, Summer Employment) This isn’t a revolutionary idea by any means. Employers have been using young people for temporary work for decades. But internships can be a great way to build relationships with high school and college students looking to reinforce their learning with real-world responsibilities. This is a great way for employers to teach these students about their business practices and products and services. It is low risk and a way to evaluate the skills of an applicant before the company is tied to a full-time position. If handled right, interns can blossom into top candidates for future job openings. But this is also a chance for employers to ruin their brand with the youth population. I’ll expand on the do’s and do not’s of internships in a future article. 2.      'Externships' (Job Shadowing, Career Days, Seminars) If you don’t have the work, budget or resources to employ people in temporary positions, you can host job shadowing opportunities or travel places for “career days” and seminars. These opportunities are usually called "externships" because they look at careers and the industry from an external and broad view. Interested students could be paired with professionals in your company to ask questions, observe daily workflow and build a relationship for the day. Trusted, intelligent employees could speak at seminars or career days to give insight to an audience. Externships are another great way to market your company to interested students and begin connecting with potential employees. Many college career centers could help you link up with students interested in learning more about the industry or instructors who teach classes related to the business. 3.      Challenges and Projects As discussed in my past article, challenges and projects could help spark some curiosity in students pursuing careers in the industry. You can continue advanced challenges and projects for young Millennials to evaluate skills and maintain a relationship. Partner with professors teaching risk management and insurance classes to develop real-world projects. Many professors would be more than willing to help with this. Get creative, and make it a valuable learning exercise. 4.      Strategic Social Media Usage Interacting with students via social media is no longer a competitive advantage; it’s a must for companies and an effective way to continuously connect with Millennials. Companies can have accounts on Facebook, Twitter, YouTube, LinkedIn, etc. that have material relevant to young, interested users. Many businesses have created separate accounts just for Millennials. The key is to provide material this generation wants to read. Millennials don’t need more bland product marketing shoved down their throats. We’ve gotten pretty good at being able to skim over ads. Potential posts could include:

• Entry-level job openings
• Scholarship opportunities
• Articles and blogs tailored to youthful thinking and professional development (Example: 8 Things Today's College Student Must Invest in to Get Hired)
• Philanthropic activities and community involvement (Example: Insurance Industry Gives Back)
• Videos and readings relevant to the industry (Example: Crop Insurance - An Idea Worth Seeding)

But with great power comes great responsibility. Make sure all accounts are up to date, complete and responsive. Put a face to the account, and make it easy to navigate. But don’t overdo the activity with insignificant post, tweets, videos and blog articles. It is time to stop being reactive to job openings and start being proactive. Human Resources should have a handful of potential candidates for the start of each career ladder in the organization. Fill the talent pipeline by building the relationships early with this generation. “The single biggest problem in communication is the illusion that it has already taken place.” – George Bernard Shaw

California's 2^nd District Court of Appeal has reversed a Workers' Compensation Appeals Board (WCAB) decision, which had in turn reversed a decision by a workers' compensation judge (WCJ) on a "going and coming rule" case. In Shultz v WCAB (Joint Test Tactics and Training (JT3)), the court ultimately determined that the employee was operating his motor vehicle within the course and scope of employment. So, the going and coming rule, which defines the ordinary commute as not being part of the work day, was inapplicable. Craig Schulz was a civilian employee working on a secure U.S. Air Force base not open to the public. On the day in question, he drove his personal vehicle to the base and passed through the secure gate using the security pass issued by his employer. Approximately one mile past the gate, he was involved in a motor vehicle accident (MVA) and sustained injuries. He claimed they were in the course and scope of employment. His employer denied the claim, saying he had not yet reached the employer’s premises. The employer also argued that the applicant had sustained injuries because of an idiopathic seizure related to his diabetes, so the injuries did not arise from his employment. Extensive testimony was taken at trial as to the employee’s duties, his need to travel to various locations on the base during the course of the day and whether his employer expected him to use his personal vehicle. The employee testified that he commonly used his own vehicle to travel from location to location on the base. The employer presented testimony that it provided vehicles for employees to travel around the base and that it did not require the employee to use his own car. Multiple witnesses, however, confirmed that Schulz did, in fact, use is own vehicle on multiple occasions. Schulz provided compelling documentation from his own log (kept for tax purposes) of his vehicle usage. There was also general agreement that, while vehicles were typically available, on occasion they were not. Schulz's side argued both that he had entered the employer’s “premises” when he went through the secured gate and that his vehicle was used in the course of his employment, based on custom and practice. The WCJ ruled in Schulz's favor, relying principally on the use of his personal vehicle on the job site. The judge did not address the premises issue raised by Schultz, nor was there any compelling evidence (at least according to the court) to support the claim of idiopathic causation. On appeal, the WCAB reversed, based on the employer’s evidence of availability of its vehicles and the policy that work could be postponed until a vehicle was available. The WCAB held that the injury was outside the course and scope of employment. The WCAB did not address the applicant’s argument that he was on the employer’s premises at the time of injury. The appeals court did not focus on either the WCJ’s line of thought nor that of the WCAB but instead focused on the premises argument. The court noted: “Although Schultz was assigned to a particular building on Edwards, it is undisputed that he and other employees of JT3 performed work at multiple locations at the base at various times. Edwards is a secure location, and JT3 controlled Schultz’s access to the base, which he could only enter with a security pass issued by JT3 and approved by the Air Force. Because JT3 controlled Schultz’s access to Edwards, and Schultz worked throughout the base on assignments, he was on the premises of his employer once Schultz entered Edwards, and his injury therefore occurred during the course of that employment for purposes of the workers’ compensation law. “ The court cited Smith v IAC, a California Supreme Court case, as support for the concept of an understanding of the expanded-workplace concept. The court found that the Schulz case was even “more compelling” than Smith on defining the premises of the employer as beyond the actual buildings where the work was performed. The court found that the discussion as to whether Schultz was required to provide his vehicle was irrelevant once it was determined he was on the premises: “For purposes of the premises line rule, it does not matter whether Schultz was permitted to use his own car to perform work, as he contended, or if that was not permitted, as maintained by JT3, as the record clearly shows that Schultz was required to work throughout Edwards at times, and his work was not confined merely to Building No. 1440. Schultz was on JT3’s premises for purposes of employment when injured.” The court summarized as follows: “We hold that the premises line rule applies to an employee injured in a single-car traffic accident where (1) the employee was a civilian working on a secure U.S. Air Force base not generally open to the public, (2) the employee entered the base in his personal vehicle after passing a guard gate using a security pass issued by his employer with the approval of the Air Force, (3) the employee had traveled one mile inside the base when the accident occurred and (4) the undisputed evidence established although the employee worked out of a fixed location, the employer had multiple locations on the Air Force base and the employee traveled sometimes in his own vehicle, as needed, throughout the base to perform work assigned by his employer.” Comments and Conclusions: If we were ever under the illusion that the “going and coming” rule was an inflexible legal concept, this case should certainly dispel the notion. It is interesting that neither the WCJ nor the WCAB seemed to focus on the ultimate legal issue relied upon by the appellate court, namely whether the employee had entered the employer’s premises once he had passed through the secured gate. Some understanding as to why that may have occurred can be found in some of the court’s discussion as to whether the applicant had raised this issue in proceedings below the appellate level. One of the arguments raised by the defense included the assertion that the applicant was raising the premises rule for the first time on appeal and therefore had forfeited the right to raise the argument. The appellate court rejected that argument, finding the applicant had included a discussion of the issue in the trial brief, thereby preserving it for consideration on appeal. However, it is certainly possible that, with all the testimony on whether and how often the applicant used his vehicle, the parties may have simply overlooked the premises issue. The court certainly found enough evidence in the testimony to make a finding on the issue, so the factual basis was available for everyone to see. In the grand scheme of things, this case does not increase exposure very much. The number of cases where an employee enters a third party’s premises that will also be considered the employer’s premises and then continues to drive several miles will likely be very limited. The fact that the court relied upon the secured nature of the location also makes expansion of this concept somewhat questionable.

Since the Industrial Revolution, pursuing automation has been a worthwhile endeavor. The microprocessor has accelerated automation to the point that doing things like keeping a Rolodex or paper calendar seem quaint. Automation and microprocessors have had a profound impact on people’s ability to plan and invest for their retirement, too. If you Google “online retirement calculator,” you find a plethora of websites devoted to helping people figure out how much they need to save for retirement. Technology doesn’t just help figure out the right amount, either;  technology is beginning to determine what assets to buy and when to purchase them. However, despite all this progress, people in the U.S. continue to woefully under-save for near-term expenditures, let alone their retirement. According to a recent survey by the Economic Policy Institute, 45% of work-age Americans do not have any retirement savings. As the old saying goes, "You can lead a horse to water, but you can’t make it drink." Our human brains are great at reacting to immediate threats but terrible at evaluating long-term risk. The risk of not having enough to live on once you stop working is one of our greatest long-term risks. The reason that most people don’t start saving for retirement has little to do with their income or age but rather the inertia of signing up for their employer-sponsored retirement plan. Behavioral finance dictates humans like to do the default. In other words, people will not participate in their 401(k) if that is the default. Alternatively, employees will participate in their 401(k) if that is the default. Unfortunately, most employer retirement plans still require participants to recognize their need to save for retirement, overcome inertia, overcome the default and sign up to participate. A client I recently worked with had a large hourly paid workforce. The 401(k) participation rate hovered around 30% (which is actually high for that industry) for about a decade. The employer did all the right things -- matched contributions, had education meetings and made an adviser available to speak with employees about the importance of saving and how to use the 401(k) plan. Nevertheless, more than two-thirds of employees would not overcome inertia and participate in the plan. The mere act of filling out a piece of paper to help them save for a long-term risk was too great. After we banged our collective heads against the wall, the employer decided to switch its 401(k) plan over to automatic enrollment at 3% of wages, with an annual increase of one percentage point, to a maximum of 5%. We all held our breath to see how many people would call human resources and ask to be taken out of the plan. But something surprising happened. HR’s phone didn’t ring. Eventually, a few employees did realize that money was coming out of their paychecks and opted out. However, today, the participation rate is 98% and has been for more than a year. There is already talk among lawmakers about instituting a national mandatory IRA, and some states are looking into similar programs. It’s not outside the realm of possibility to see something like an automatic retirement savings program pushed through the halls of Congress within our lifetime. Until then, I encourage you to look into the merits of implementing an auto-enrollment feature on your retirement plan.