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.

In making decisions about medical care, everyone should factor in cost -- patients, doctors health insurance companies and government. Consider two alternative procedures, A and B. If for each $1,000 spent on procedure A, patients gain one extra month of life whereas using procedure B costs $2,000 for the same gain, A should be preferred to B. By making the efficient choice, we free up money to meet other health and non-health needs. There remains this problem, however: What if the person who makes the decision about cost is different from the person who realizes the gain? That is what gives rise to charges of “rationing” and “death panels.” Aaron Carroll writes: "Other countries routinely use cost-effectiveness data to make decisions about health coverage. In Britain, the National Institute for Health and Care Excellence, a government agency that gives guidance about which services the National Health Service should cover, has a threshold of 20,000 to 30,000 pounds per QALY [quality-adjusted life year] -- that's about $31,000 to $47,000. The health service doesn’t make decisions on whether to cover therapies based on this number alone, but it is certainly  a factor." And because government healthcare budgets are strained everywhere in the world, you can be sure that the cost-effectiveness criterion is “considered” a lot. According to a 2002 World Health Organization report, 25,000 cancer patients die prematurely in Britain each year — often because of lack of access to drugs generally available in the U.S. and Europe. (See also this 2013 NHS estimate on all causes of premature deaths.) To use an example closer to home, in 1994 Hillary Clinton decided that as part of her own health reform, health plans would provide free mammograms only to women 50 and older — and only at two-year intervals. In contrast, the National Cancer Institute and the American Cancer Society at the time were recommending mammograms for women after 40, either annually or every other year, and yearly mammograms after 50.  Similarly, Clinton hinted that she would relax the usual recommendation of a Pap smear every year for sexually active young women. (Canada, at the time, offered the test every three years.) While these decisions were being made, a review of the literature by Tammy Tengs and her colleagues showed that:

• Annual mammograms for women age 55 to 64 were expected to cost $110,000 for every year of life saved.
• Annual mammograms for women in their 40s were expected to cost $190,000 per year of life saved.

In essence, Clinton decided that the lower number was an acceptable use of money while the higher figure was not. The review of the literature on Pap smears showed that:

• Screening young women for cervical cancer every four years costs less than $12,000 for every year of life saved -- a very good deal in the risk-avoidance business.
• The cost soars to about $220,000 per year of life saved at three-year intervals and $310,000 at two-year intervals.
• Giving Pap smears every year (as opposed to every other year) is really expensive: $1.5 million per year of life saved.

Clearly, Clinton and her advisers thought $1.5 million was way too high. These decisions are said to have turned the general public against Hillary Care and doomed the Clinton health reform effort. But we shouldn’t take the wrong lesson away from that experience. Hillary Clinton was not wrong about the cut-off choices she made. She was wrong in thinking that the White House should make this decision for all the women of America. The tests involved are relatively inexpensive. They can easily be paid for from a health savings account. If not getting a test is keeping someone awake at night, then by all means she should be encouraged to spend the money and get the test. Here are some public policy principles to guide us going forward:

1. Wherever possible, people should make their own decisions about risk -- using money from savings accounts they own and control.
2. Doctors should be encouraged to help patients make sensible decisions based on their own knowledge of the literature on cost effectiveness. That is, doctors should be financial advisers as well as health advisers when their patients have to make choices about medical procedures.
3. Insurance companies should be encouraged (and maybe even required) to reveal what standards they use in making decisions about coverage, and we should encourage an insurance market where people can pay higher premiums for more generous coverage – especially if they are unusually risk-averse.
4. Government health programs should make coverage decisions that are in line with private-sector insurance. And, like private insurance, the government should announce what monetary cut-off standard it is using. But we should encourage a secondary market for “top up” insurance -- for example, providing coverage for expensive cancer drugs the government refuses to cover.

In case you missed it, Chris Conover has applied cost-effective analysis to the entire Obamacare program, based on results from Massachusetts. He writes: “…. even under the most wildly optimistic assumptions possible, Obamacare costs a jaw-dropping $224,000 per QALY. In the worst case, the costs would be as high as $1.3 million per QALY.” He presents this chart (green = low estimate; red = high estimate): Photo credit: Christopher Conover, Duke University

Some claims resolve unremarkably. People heal, they go back to work, they resolve their claim around permanent impairment, if any, and adapt to their post-injury circumstances. We don't focus on those claims. They simply pass through the system, without fuss and without remark. There are no water cooler conversations about the claimant who did what was expected of him or her. This group represents about 80% of our claims, but only about 20% of our resources in loss costs and processing headaches. There's another much smaller group that do attract our time, attention and concern. They are the claims, often with similar injuries to those that heal unremarkably, that fail to resolve, demand disproportionate amounts of time to administer, result in serial disputes and cost significantly more. They cause considerably more wear and tear on claims personnel and demand more time from our dispute resolution systems. They are the 20% who represent 80% of the claims costs, and most of the excess stomach acid for system administrators, claims managers and regulators. The difference is often the development of a secondary condition that focuses claimants on what they have lost, on their symptoms and on their "new identity" as injured (and often disabled) persons. Sometimes, this secondary condition is explicitly claimed as a compensable injury, but, in the U.S., psychological conditions are generally not compensable without a direct causal connection to a discernible traumatic incident. Harm that occurs as a reaction to the experience of the compensation system is often dismissed as malingering, secondary gain behavior or personal weakness, and you may thinking, "We don't compensate that." Think again. To be sure, you may not be using the words, "exacerbation of primary claims due to secondary psychological overlay," but you are still paying for it. The research evidence is now overwhelming. Psychological conditions, whether pre-existing or acquired after a claim arises, affect the physical healing as well as the probability that an injured person will return to his pre-injury life. You are paying for secondary psychological overlay, whether or not your systems are set up to detect and measure this cost driver. It is very likely your largest unmeasured cost driver. All of these conditions are attributable to secondary psychological overlay:

• Unexplained failure to thrive and return to work;
• Functional syndromes that have neither explained cause nor effective treatment;
• Unexplained chronic pain (and all the expensive treatments and addiction problems that go with it); and
• The appearance of secondary physical symptoms that complicate recovery

There are indirect repercussions, as well. Some people seem to develop the attitude that they are entitled to whatever treatment or benefits that they request, or that they deserve special treatment by the system. There is burnout, desensitization and turnover among staff, with the very significant attendant costs of recruitment and training of new personnel. These claims drive (and are driven by) lawyer behavior that enables "victimhood" and doctor behavior that "medicalizes" symptoms and sets inappropriate patient expectations.  The list of cost centers goes on and on. We haven't done a very good job of measuring this cost driver. Partly, that's because our analytics are limited by the data we've collected. If we haven't collected the right data (or haven't even asked the right questions in the first place), then it's hard to directly analyze the phenomenon. Partly, it's a matter of the complexity of the calculation. Factoring personnel costs and systemic behavior changes by lawyers and doctors makes things a lot more complicated. We avoid useful thinking about these claims. In fact, we habitually avoid thinking about anything psychological. Effective treatment is elusive, and we have too many examples of ineffective treatment stretching into lifelong periodic sessions with "the shrink." We can't see the injury associated with these claims, and tend to think that they aren't "real" in the same way as physical injuries. This outmoded approach isn't serving us well, as increasing claims severity in many jurisdictions clearly demonstrates. And there's an element of fear of the unknown -- if we acknowledge those claims, we just might have to learn different approaches to claims management and develop different substantive knowledge that we've needed in the past. Unfortunately, this avoidance of all things psychological is a holdover from "person as a machine" thinking -- the idea that we can fix the broken part, and the mechanism will go back into the production cycle. Alternatively, the thinking may presume that the difficulty with the worker is a disease, for which discovery of the right medication or treatment will restore equilibrium. Either way, it's gotten much harder to maintain these simplistic views of injury and disability, given the overwhelming evidence that people are significantly affected by factors that have to do with their biopsychosocial environment and experience. But that's the trouble. How do we deal with this relatively small cohort of expensive claims without opening the proverbial Pandora's box? On the one hand, acknowledging the biopsychosocial elements of the claims process may open the door to psychological claiming, which in the past has been a nightmare of unending expensive interventions with few or no positive outcomes. (Alternatively, focus on biopsychosocial factors exposes underlying matters about which the claim manager often has little or no control, such as the claimant’s prior history or the nature of the person's off-work relationships.) On the other hand, failure to acknowledge the biopsychosocial elements flies in the face of an avalanche of research findings associating a bewildering and seemingly inconsistent array of factors correlated with good or poor outcomes. So what are you supposed to do? First, quit pretending that the biopsychosocial flagging systems that have flooded the market are going to save you. There has never been a published properly controlled study that could show that the identification of people pursuant to a flagging system and subsequent intervention efforts had any more impact than just providing more personalized attention to claimants generally. Flagging systems have value for predicting outcomes for groups, rather than individuals. They are useful for managing reserves and initiating increased scrutiny of behavior. When misused, they also carry a potential for adverse impact through the mechanism of self-fulfilling prophesy. When you tell a well-intentioned claims manager that certain claimants have “flags,” it’s hard to predict the subtle ways in which the manager will treat the claimant differently, but it’s almost certain that the differences will be there. Identification of a person at risk, without more, has never made anyone recover faster or better. Second, acknowledge that the presence of a secondary psychological overlay is very likely to affect the worker’s physical recovery. The research findings overwhelmingly demonstrate that psychological conditions such as depression and anxiety, a sense that personal control has been transferred to others and individual expectations for recovery have significant physical impact on physical welfare and healing of the claimant and the experience of things like chronic pain. The research shows that even the way that we talk to a patient about pain can have significant impact on the clinical outcome. It’s time to stop blaming the worker or assuming that the person is out to take advantage of the system. Just as the medical profession has acknowledged “iatrogenic” (system-created) injury, the workers’ compensation world would benefit from understanding that our compensation systems actually cause additional harm to the people we are supposed to be helping. Our system design should be more focused on preventing that harm than trying to suppress the costs associated with it. Third, find a way of thinking about secondary psychological overlay to original injury that helps you understand how it all fits together. Such a conceptual model will help you to understand the relationship between findings that aren’t obviously related. For example, understanding the relationship between the positive impact of early intervention programs, the negative impact of lawyer representation and the negative impact of sleeplessness may be difficult without an overarching explanatory framework. There are several models out there, but I suggest that most everyone agrees that a very basic place to start is the understanding that the worker's loss of an internalized sense of control over one’s own life is critical to explaining what’s happening to people in the claiming environment. Finally, whatever your model of secondary psychological harm, find the places that you can control or improve the claims environment. Can you encourage early intervention or other activity that maintains the important sense of identity as a “worker” that is endangered by injury and absence from the workplace? Can you institute mechanisms that reduce the time and stress of dispute resolution and attend to the real personal needs of people in dispute? Can you arrange circumstances so that claimants get their calls returned more quickly to preserve their feeling of being valued, or minimize the repetition of their story, to prevent unnecessary entrenchment of a changed view of self? There are literally dozens of systemic changes that you can control that will have a positive impact on the worker and his recovery. It's a different orientation than mere "cost cutting," but it will have a greater long-term and sustainable impact. The complication of claims because of undiagnosed and unmitigated secondary psychological overlays threatens the integrity of workers' compensation generally. Whether you recognize it or not, it is a very significant underlying cost driver. In the absence of understanding this phenomenon, systemic attempts to control costs have led to the increasing perception of a failure of the underlying quid pro quo that is reflected in recent litigation in Florida and changes in the structure of the Oklahoma system.  Most of us have within our control some aspect of the system can lead to the reduced incidence of secondary psychological complication of a claim.  All of us can insist that our policy makers and regulators open their eyes to this hidden source of complexity and poor outcomes, and that they respond to it in a meaningful way.

We have written several articles on the topic of baseline testing and demonstrated some substantial results. Today, with more than three years of baseline data, we are still asked the question: Is baseline testing really worth the effort? That's the question we address in this article. First, some background on baseline testing: Often called a bookend solution, it is a non-discriminatory way for an employer to ascertain if a work-related injury arises out of the course and scope of employment (AOECEO). For a baseline test to be valid for musculoskeletal disorders (soft-tissue injuries), it has to assess the specific function of the nerves and muscles of  the spine or other body part in question. In the case of soft-tissue injuries, the test should include electromyography (EMG), range of motion and functional assessment for some of the essential functions of the job. The test should be noninvasive. The baseline test data is stored unread until there is a work-related injury and then compared with a post-incident test to determine a change in condition or AOECOE status. A baseline test is not designed to see if somebody can perform the essential functions of their job and therefore differs from the post-offer, preplacement evaluation (POET). Another major difference between a POET and a baseline test is that baseline testing can be done on the existing workforce. According to the ADA, post-employment medical inquiries and exams can only be done when they are job-related and consistent with business necessity. 42 U.S.C. § 12112(d)(4)(A).  Two recent cases from the Sixth Circuit (Bates v. DuraAuto Systems and Kroll v. White Lake Ambulance Authority) can assist employers with questions. It is our opinion, consistent with Bates, that a medical exam is not prohibited as long as it does not identify or single out a disability. Therefore, baseline testing is permissible, because the data is never evaluated unless a post-loss event occurs and at that time becomes subject to workers’ compensation requirements. At no point does the baseline testing determine or identify disability or an individual's inability to perform their job functions. According to Kroll, an employer that requires medical examination of an employee has to have a reasonable belief, based on objective evidence, that the test will satisfy  a vital function of the business. The keys are objective evidence and vital business function. Accepting AOECOE claims, and getting the employee the best care for the work-related injury, will fulfill this obligation. With recent case law, and a basic understanding of the differences between POET and baseline testing, let's evaluate a case study: A national concrete manufacturer and supplier conducted POETs on all new hires. The employees use heavy equipment, and POET had proven to be a valuable tool to ensure that people could handle the equipment and to increase safety in the workplace. However, in the event of an injury, the POET test could not determine if there was an AOECOE condition and could not assist in identifying better treatment for the condition. To better help employees in the event of a work-related injury, the company decided to do baseline testing for existing employees and new hires. Mr. Smith, a 48-year-old driver who was an existing employee, felt a sharp pain in his back after lifting at work. When he reported the incident, he stated that he  was injured before his EFA baseline evaluation and that even no change from the baseline still meant he had a work-related injury. As part of the  EFA-STM program, he was referred for evaluation and sent for post-injury assessment. Based on the EFA comparisons, chronic unrelated pathology and no acute pathology were noted on both evaluations. Furthermore, no change of condition was noted, and the comparison testing revealed that he was improved on the post-loss test. He subsequently pursued a surgical opinion on his own, without authorization  from the workers’ compensation carrier. The surgeon who evaluated him recommended a lumbar surgery, and this was performed, again without authorization. After the surgery, the court commissioner found the injury to Mr. Smith’s back not to be work-related, based on the EFA-STM results. Therefore, surgery was not compensable. Furthermore, the post-incident EFA testing found surgery wouldn't have been indicated even if there were a change in condition. Mr. Smith has still not been able to return to work following his back surgery. This case demonstrates that the EFA-STM program enables determination of AOECOE conditions. In Mr. Smith’s case, the baseline testing program was not only instrumental in determining there was no AOECOE, nothing OSHA-recordable and no mandatory reporting but, most importantly, was able to determine that Mr. Smith was not a surgical candidate. Thousands of dollars for unnecessary medical care was avoided by the company for an injury that was not work-related, according to an objective determination by the EFA testing. Is baseline testing worth the effort? You be the judge.

The new year already feels well under way. The pressure is on to accelerate progress and increase business impact on all things digital. You’ve locked down the budget, and goals are in place. Now it’s time to reset the results meter and build momentum. If one of your goals is to make digital matter more to employees, customers and shareholders, and you want to shake that feeling of being left out or left behind by the torrid pace of technological change, consider taking on these eight “to-do’s.”

1. Expand your personal presence on social media. As a C-level executive, you carry the flag for your brand and for your company’s reputation. Your authentic and routine presence on social media will have high return on investment (ROI). Being part of the conversation has moved beyond “cool” or “nice-to-have.” It’s a must-do as part of your personal engagement with internal and external audiences. Your personal participation will also help you to internalize the profound impact the medium is having on everyone’s lives.
2. Put mobile first. Feel you may be lagging on web-based development? The good news is you have the opportunity to leapfrog straight to a mobile-first user experience as you execute your digital road map. Invest in responsive design technology to align all screens to a consistent experience. Mobile devices are fast-becoming the “main screen” for an expanding range of purchases, transactions, inquiries and information sharing. If you don’t believe that, observe your own behavior, and you will surely be convinced.
3. Recognize and reward team behaviors that foster innovation. It’s easy to pay lip service to the need for openness, diversity, transparency, creativity, exploration and collaboration and to be able to see failure as learning… all characteristics of an innovation culture. While you may not be able to project the bottom-line impact with anything approaching actuarial precision, increased digital effectiveness will be one of the payoffs of implementing a real plan that recognizes and rewards the people in your organization who live these attributes.
4. Modernize your key metrics. The metrics that have worked really well to measure traditional financial drivers of traditional businesses may fall short in exposing the full impacts of digital. Dedicate the right analytics talent to set up a rigorous but flexible test-and-control framework that allows you to read accurately the cause-and-effect relationships of each digital enhancement.  This is not about perfection; seek sufficient precision to reveal when it makes sense to scale your digital experiments, and to inform business cases for further investments.
5. Discourage “cutting and pasting” digital solutions from the physical world. Your organization has been at digital long enough to know that picking up what worked in the physical world and dropping it online does not even qualify these days as “version 1.0” status. The unique properties of digital experiences and the different results they generate will only be within your reach when products, service delivery, sales and other core processes are re-imagined for digital, not brought to market as re-casts of potentially obsolete approaches.
6. Align your executives’ goals and incentives to drive digital performance. We’ve moved well beyond a world where digital is the domain of IT, the marketing department or a digital head or any other functional or business silo. Digital is everywhere in your company and requires cross-everyone support to implement. Single points of accountability are powerful to get results. But the more significant the changes digital brings to your business, the more important it will be to create “skin in the game” across your team. Digital execution at the required speed will depend more and more on full team alignment to make it happen.
7. If you don’t have a social media command center, this is the year to commit to having one. More and more Fortune 500 companies are implementing command centers. This enterprise-level capability aggregates information from listening, publishing, engagement, analytics and routing tools to enable a comprehensive view and appropriate action on defined topics through a holistic social media lens. This is essential to affect a brand’s social media presence and understand and manage reputation, customer and broader feedback in a borderless public square. Step one is to have a well-articulated social media strategy so that your team can deliver a pragmatic and action-oriented capability, not a “shiny toy” reflecting the latest fad.
8. Leverage open sourcing. Expense pressure won’t abate, including the pressure to manage staffing levels. But it takes talented people to get things done. Expand your talent pool without adding headcount to include people potentially any place in the world willing and able to contribute ideas and answers to business challenges. Companies like Procter & Gamble and IBM pioneered global open-sourcing and co-creation initiatives years ago and have made them integral to how they conduct business. Your approach can be as small as a time-bound contest where you award a prize to graduate students for the best approach to formulating a new model, or a weekend hack-a-thon sponsored by your brand where you can engage outside developers to build apps for your business.

This is a headline in an LA Times article: "Why 'Wellness' Program Scams Cost Employers and Harm Employees." The article, written by Michael Hiltzik, is yet another major mainstream media hit on corporate-sponsored wellness. Hiltzik writes, “Perhaps the most popular fad at large today in the employee health benefit world is the ‘wellness’ program.” Doubts about the efficacy of wellness are popping up left and right. “Now there’s more evidence that the programs don’t save companies money….” Hiltzik says,  “Despite these emerging data, the Kaiser Family Foundation has calculated that more than half of all companies with more than 200 workers offer health screening programs; 8% of those offer an incentive to participate or a penalty for refusing.” Wellness can even backfire and harm employees through false positives, etc. Corporate sponsors of wellness had the noblest of intentions. However, now it’s high time for corporations to take a good, hard, steely-eyed look at their wellness programs. This is my mea culpa. In my career in managing benefits for large companies, I implemented programs that looked promising but didn’t work. When the facts showed they didn’t work, though, I simply stopped them. The only thing worse than implementing a flawed program is keeping it around when the facts show it is a failure.