Tag Archives: standards

What Is Wrong With Our Industry?

While there has been a lot written over the years regarding the “brain drain” in the insurance industry, I think the industry as a whole has done a fairly good job of educating the next generation (no, this is not an article about millennials).

The problem our industry now faces is even more insidious, as it is very apparent to me that we are losing sight of long-standing business relationships and, most importantly, the standards that all insurance professionals are required to apply in everyday practice. This is true for all insurance professionals, including agents, brokers, adjusters, underwriters, middle management and senior executives.

It used to be that insurance companies always stood behind their agents (remember the phrase “agency accommodation”?). But I have been dismayed over the last number of years by a growing “us versus them” mentality in the agent-insurer relationship. I have seen many overzealous adjusters denying claims based on what they say is a late report and attempting to blame the agent for not promptly reporting the claim, while the agent was merely trying to balance the interests of the client and the insurer. I have also seen clerical errors resulting in coverage denials; rather than doing the right thing, the insurer took a scorched-earth approach and hung the agent out to dry. That never used to happen.

See also: The Insurer of the Future – Part 12  

I worry that civility in our industry is disappearing. It may be that a younger, less experienced, yet more aggressive work force is the cause. But I hope we can return to the days when we were “all in this together,” when the overriding consideration was the welfare of the insured/client.

These are industry standards that all of you reading this have heard many times, include:

  • Coverage should be evaluated with an eye toward providing coverage, not in an effort to exclude coverage
  • The insurer must prove that an exclusion applies, to exclude coverage for a claim
  • The insured should be given the benefit of the doubt when there is an ambiguity in the policy
  • Any undefined term in an insurance policy should be given broad meaning (as long as it does not lead to an absurd result) in an effort to provide coverage, not a narrow interpretation to preclude coverage (“read in, read out”)
  • All coverage available to an insured must be disclosed and the claim process clearly explained

All too often, overzealous adjusters attemp to manufacture claim denials. When I ask which particular policy provision they feel excludes coverage, I am many times met with the mantra: “We have sought a coverage opinion, and our attorneys feel the claim is not covered.” When asked to reconsider, their silence is deafening. When there is a response, all too often the response reflects that no real consideration was given to the request.

We need to keep in mind that attorneys are trained to be “zealous advocates for clients” (here, the insurance company), and they therefore take an entirely different approach to coverage interpretation than that required of an insurance adjuster, which is to try to find a way to cover the claim. Therefore, adjusters need to make coverage counsel understand that the adjuster is actually looking to provide coverage, not looking to deny the claim. How many times do you think an adjuster has had that conversation with coverage counsel?

Even when asking simple questions regarding pending claims, I am confronted by the adjuster, and sometimes the adjuster’s superior, as if I am the enemy and have no business asking questions about my client’s claim. At times, I have even been accused of crossing some non-existent line that somehow prevents me from trying to assist my client, even receiving a cease-and-desist letter on one such occasion. This is just the opposite of what should happen.

We as agents have an obligation to our clients to advocate for their best interests. Likewise, the insurer has collected premium in exchange for a “promise to pay” because “in buying insurance an insured usually does not seek to realize a commercial advantage but, instead, seeks protection and security from economic catastrophe.” We are all in this together, and we should be working to explore ways to find coverage or resolve the claim with the best possible outcome. Likewise, we as agents are the insurance company’s sales force, and they should stand behind us. What has happened to our industry?

Not to be completely gloom and doom: There are many very capable, well-trained and right-minded insurance adjusters out there. In fact, my interaction with one such adjuster at Travelers (to give credit where credit is due) this past week is what really prompted me to write this article. He and I have been working together in an attempt to find coverage for one of my clients’ claims. That is the way it is supposed to be. While we may or may not succeed, the experience has been invigorating and given me hope.

See also: Innovation: ‘Where Do We Start?’  

I also know that there are very few (if any) insurance company executives who give standing orders that their adjusters should look to deny claims. Most executives will attempt to do the right thing if a contested claim is brought to their attention. I’m sure most would be appalled at the way some claims are handled by overzealous adjusters, if they ever became aware of what was really going on.

I guess what I am trying to say through all of this is that we need to work as a team, and our overriding concern should be for the welfare of our client/insured. We need to recite our industry standards often, and they should be every adjuster’s mantra. Middle management needs to be our watchdog and make sure the adjusters working for them apply these standards to every claim. Senior management needs to ensure these standards are supported from the top down and should be available and visible should things go south.

Here’s to a kinder gentler agent-insurer relationship in the years ahead.

When Is It Right to Prescribe Opioids?

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.

12 Issues Inhibiting the Internet of Things

While the Internet of Things (IoT) accounts for approximately 1.9 billion devices today, it is expected to be more than 9 billion devices by 2018—roughly equal to the number of smartphones, smart TVs, tablets, wearable computers and PCs combined. But, for the IoT to scale beyond early adopters, it must overcome specific challenges within three main categories: technology, privacy/security and measurement.

Following are 12 hurdles that are hampering the growth of the IoT:

1. Basic Infrastructure Immaturity

IoT technology is still being explored, and the required infrastructure must be developed before it can gain widespread adoption. This is a broad topic, but advancement is needed across the board in sensors themselves, sensor interfaces, sensor-specific micro controllers, data management, communication protocols and targeted application tools, platforms and interfaces. The cost of sensors, especially more sophisticated multi-media sensors, also needs to shrink for usage to expand into mid-market companies.

2. Few Standards

Connections between platforms are now only starting to emerge. (E.g., I want to turn my lights on when I walk in the house and turn down the temperature, turn on some music and lock all my doors – that’s four different ecosystems, from four different manufacturers.) Competing protocols will create demand for bridge devices. Some progress is emerging in the connected home with Apple and Google announcements, but the same must happen in the enterprise space.

3. Security Immaturity

Many products are built by smaller companies or leverage open source environments that do not have the resources or time to implement the proper security models. A recent study shows that 70% of consumer-oriented IoT devices are vulnerable to hacking. No IoT-specific security framework exists yet; however, the PCI Data Security Standard may find applicability with IoT, or the National Institute of Standards and Technology (NIST) Risk Management Guide for ITS may.

4. Physical Security Tampering

IoT endpoints are often physically accessible by the very people who would want to meddle with their results: customers interfering with their smart meter, for example, to reduce their energy bill or re-enable a terminated supply.

5. Privacy Pitfalls

Privacy risks will arise as data is collected and aggregated. The collation of multiple points of data can swiftly become personal information as events are reviewed in the context of location, time, recurrence, etc.

6. Data Islands

If you thought big data was big, you haven’t see anything yet. The real value of the IoT is when you overlay data from different things — but right now you can’t because devices are operating on different platforms (see #2). Consider that the connected house generates more than 200 megabytes of data a day, and that it’s all contained within data silos.

7. Information, but Not Insights

All the data processed will create information, eventually intelligence – but we aren’t there yet. Big data tools will be used to collect, store, analyze and distribute these large data sets to generate valuable insights, create new products and services, optimize scenarios and so on. Sensing data accurately and in timely ways is only half of the battle. Data needs to be funneled into existing back-end systems, fused with other data sources, analytics and mobile devices and made available to partners, customers and employees.

8. Power Consumption and Batteries

50 billion things are expected to be connected to the Internet by 2020 – how will all of it be powered? Battery life and consumption of energy to power sensors and actuators needs to be managed more effectively. Wireless protocols and technologies optimized for low data rates and low power consumption are important. Three categories of wireless networking technologies are either available or under development that are better suited for IoT, including personal area networks, longer-range sensors and mesh networks and application-specific networks.

9. New Platforms with New Languages and Technologies

Many companies lack the skills to capitalize on the IoT. IoT requires a loosely coupled, modular software environment based on application programming interfaces (APIs) to enable endpoint data collection and interaction. Emerging Web platforms using RESTful APIs can simplify programming, deliver event-driven processes in real time, provide a common set of patterns and abstractions and enable scale. New tools, search engines and APIs are emerging to facilitate rapid prototyping and development of IoT applications.

10. Enterprise Network Incompatibility

Many IoT devices aren’t manageable as part of the enterprise network infrastructure. Enterprise-class network management will need to extend into the IoT-connected endpoints to understand basic availability of the devices as well as manage software and security updates. While we don’t need the same level of management access as we do to more sophisticated servers, we do need basic, reliable ways to observe, manage and troubleshoot. Right now, we have to deal with manual and runaway software updates. Either there’s limited or no automated software updates or there are automatic updates with no way to stop them.

11. Device Overload

Another issue is scale. Enterprises are used to managing networks of hundreds or thousands of devices. The IoT has the potential to increase these numbers exponentially. So the ways we currently procure, monitor, manage and maintain will need to be revisited.

12. New Communications and Data Architectures

To preserve power consumption and drive down overall cost, IoT endpoints are often limited in storage, processing and communications capabilities. Endpoints that push raw data to the cloud allow for additional processing as well as richer analytics by aggregating data across several endpoints. In the cloud, a “context computer” can combine endpoint data with data from other services via APIs to smartly update, reconfigure and expand the capabilities of IoT devices.

The IoT will be a multi-trillion industry by 2020. But entrepreneurs need to clear the hurdles that threaten to keep the IoT from reaching its full potential.

This article was co-written with Daniel Eckert. The article draws on PwC’s 6th Annual Data IQ Survey. The article first appeared on LinkedIn.