Tag Archives: substance abuse

5 Reasons Doctors Are ‘Non-Standard’

Non-standard physicians and surgeons are practicing doctors who have had claims frequency or severity issues or board actions or have been previously or are currently on probation. It can often be difficult for non-standard physicians to find affordable malpractice insurance coverage because they are considered a higher risk by insurance companies. Typically, a doctor remains in the non-standard market for about five years, provided once they enter the non-standard market they have kept themselves clean. In this post, we examine the top five reasons doctors become non-standard physicians.

#1 Claims – The common reasons for claims filed against physicians include: poor communication, poor bedside manner, erroneous documentation and failure, delay or change in diagnosis. To reduce the likelihood of lawsuits and claims, physicians might take just a few minutes of extra time to answer all questions and address all concerns. Patients and their families will walk away feeling as though they had all the information, even if a bad outcome occurred. They will be much less likely to seek the counsel of an attorney. Click here to read our blog post Top 5 Reasons Doctors Get Sued.

#2 Lack of informed consent – Informed consent should occur with every patient encounter. Patients must be informed on the details of their options, especially when care involves an invasive or new, cutting-edge procedure. Top breaches in informed consent that lead a doctor to the non-standard market include the use of non-FDA approved medications, and new or innovative procedures. Physicians should engage with a risk management consultant to learn best practices and get risk management advice specific to a particular practice specialty, especially those that are considered high-risk.

#3 Substance abuse issues – While physicians are about as likely to abuse alcohol or illegal drugs as any member of the general public, they are more likely to misuse prescription drugs. The motivation for this often initially includes the relief of stress or pain or to stay alert when suffering from sleep deprivation. Physicians often work strange hours and long shifts, especially in the ER. The cycle often begins by using medication to stay awake and alert to manage the stress and the hours. These stresses combined with easy access to medications can lead to substance abuse issues.

#4 High-risk practice profile – Physicians in a practice with higher claim ratios automatically fall into the category of “high risk.” Examples of high-risk specialties include: bariatric surgery, OB/GYN, neurosurgery, plastic surgery and pain management. These specialties are either composed of high-risk and invasive procedures such as in the case of surgeons or they are prescribing medications that are new or dangerous, such as with weight-loss or pain-management clinics. Physicians in these practices will most likely have to remain in the non-standard market throughout their entire careers.

#5 Poor record keeping – Following a bad outcome or an adverse event, the first thing that the patient’s attorney will request is a copy of medical records. These will be scrutinized. Any incorrect or conflicting information contained within the medical record will prove problematic for the physician’s case. Accurate and thorough record keeping proves especially challenging for older physicians, who may have been away from practice for some time and re-enter wanting to pick up where they left off. Or perhaps they are just resistant to change. Medical clinics are now using electronic medical records (EMR), which provides a more streamlined and accurate system of record keeping; they even have informed consent forms built right in. From a risk management perspective, EMR is highly encouraged.

Bottom Line – Physicians should consult a clinical risk management expert for help in developing strategies to decrease the risk of becoming a non-standard physician. Thorough protocols covering documentation, informed consent and communication will all prove invaluable in risk reduction. It’s also important that doctors are honest about their personal bandwidth when it comes to patient load capacity, stamina for extended work hours, overall physical and emotional health and stresses that may be coming from personal circumstances. These factors are important to consider and if not tended to can lead to events that have a long and lasting impact on a doctor’s ability to practice medicine.

Reducing Substance Use in the Workplace

Mental health and substance use disorders are common in the U.S., affecting millions each year. While these illnesses are serious and often recurring, they are treatable. Prevention programs, early intervention and screenings are important and necessary parts of treatment and recovery. Workplace programs to prevent and reduce substance use among employees can be especially effective.

According to the National Council on Alcoholism and Drug Dependence, approximately 70% of drug users, binge and heavy drinkers and people with substance use disorders are employed. In 2014, about 21.5 million Americans were classified with a substance use disorder. Of those, 2.6 million had problems with both alcohol and drugs, 4.5 million had problems with drugs but not alcohol and 14.4 million had problems with alcohol only.

See Also: Winning the War Against Opioid Addiction and Abuse

Substance use disorders can present in a number of different ways in the workplace:

  • Workers with alcohol problems were 2.7 times more likely than workers without drinking problems to have injury-related absences.
  • Large federal surveys show that 24% of workers report drinking during the workday at least once in the past year.
  • One-fifth of workers and managers across a wide range of industries and company sizes report that a coworker’s on- or off-the-job drinking jeopardized their own productivity and safety.
  • Workers who report having three or more jobs in the previous five years are about twice as likely to be current or past-year users of illegal drugs as those who have had two or fewer jobs.

Coworkers and supervisors are in a unique position to notice a developing problem. Missed days of work, increased tardiness and reduced quality of work can all be signs of substance use.

Early intervention and prevention programs can be key in slowing the move toward addiction and improving chances for recovery. Many organizations offer employee assistance programs and educational programs to increase awareness and reduce substance use problems. Anonymous online screenings are also an effective way to reach employees who underestimate the effects of their own condition and are unaware of helpful resources.

For employers looking to address substance use issues in the workplace, national awareness days can be a great starting point. The website HowDoYouScore.org, developed by the nonprofit Screening for Mental Health Inc., offers anonymous screenings for alcohol and substance use. Efforts like these help to reduce stigma and to teach employees to recognize symptoms in themselves and others. Manager trainings on substance abuse symptoms, support for employees who seek treatment (paid time off, disability leave, etc.) and health insurance (including robust mental health coverage) are also excellent ways to support employees.

Those who struggle with substance use and addiction also have higher rates of suicide. To fight this serious connection, the National Action Alliance for Suicide Prevention’s Workplace Task Force champions suicide prevention as a national priority and cultivates effective programming and resources within the workplace. The task force provides support for employers and motivates them to implement a comprehensive, public health approach to suicide prevention, intervention and postvention in the workplace. Programs like the Workplace Task Force are important sources of knowledge and assistance for employers.

When organizations make the health of their workers a priority, benefits are seen beyond the individual employee. Improved attendance, quality of work and overall morale can lead to the betterment of the entire organization. While substance use disorders are common, they are treatable. Workplace-based programs are key to recognizing symptoms early and connecting employees with the treatment they may need.

How to Help Veterans on Mental Health

The constant beat of the major media drum often paints a grim picture of veterans and suicide. Sometimes, we wonder if these messages become a self-fulfilling prophecy. Consistent headlines include data such as:

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  • Approximately 22 veterans die by suicide each day (about one every 65 minutes).
  • In 2012, suicide deaths outpaced combat deaths, with 349 active-duty suicides; on average about one per day.
  • The suicide rate among veterans (30 per 100,000) is double the civilian rate.

Listening to this regular narrative, a collective concern and urgency emerges on how best to support our veterans who are making the transition back to civilian jobs and communities. Many veterans have a number of risk factors for suicide, contributing to the dire suicide statistics, including:

  • A strong identity in a fearless, stoic, risk-taking and macho culture
  • Exposure to trauma and possible traumatic brain injury
  • Self-medication through substance abuse
  • Stigmatizing views of mental illness
  • Access to and familiarity with lethal means (firearms)

Veterans show incredible resilience and resourcefulness when facing daunting challenges and learn how to cope, but employers and others who would like to support veterans are not always clear on how to be a “military-friendly community.”

The Carson J Spencer Foundation and our Man Therapy partners Cactus and Colorado’s Office of Suicide Prevention conducted a six-month needs and strengths assessment involving two in-person focus groups and two national focus groups with representation from Army, Air Force, Navy and Marine Corps and family perspectives.

When asked how we could best reach them, what issues they’d like to see addressed and what resources they need, here is what veterans and their advocates told us:

  • “I think that when you reach out to the vets, do it with humor and compassion…Give them something to talk about in the humor; they will come back when no one is looking for the compassion.” People often mentioned they preferred a straightforward approach that wasn’t overly statistical, clinical or wordy.
  • Make seeking help easy. A few veterans mentioned they liked an anonymous opportunity to check out their mental health from the privacy of their own home. Additionally, a concern exists among veterans, who assume some other service member would need a resource more. They hesitate to seek help, in part, because they don’t want to take away a resource from “someone who may really need it.” Having universal access through the Internet gets around this issue.
  • “We need to honor the warrior in transition. The loss of identity is a big deal, along with camaraderie and cohesion. Who I was, who I am now, who I am going to be…” The top request for content was about how to manage the transition from military life to civilian life. The loss of identity and not knowing who “has your back” is significant. Several veterans were incredibly concerned about being judged for PTS (no “D,” for disorder – as the stress they experience is a normal response to an abnormal situation). Veterans also requested content about: post-traumatic stress and growth, traumatic brain injury, military sexual trauma and fatherhood and relationships, especially during deployment.
  • The best ways to reach veterans: trusted peers, family members and leaders with “vicarious credibility.”

Because of these needs and suggestions, an innovative online tool called “Man Therapy” now offers male military/veterans a new way to self-assess for mental health challenges and link to resources.

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In addition to mental health support, many other things can be done to support veterans:

We owe it to our service members to provide them with resources and support and to listen carefully to the challenges and barriers that prevent them from fully thriving. Learn how you can be part of the solution instead of just focusing on the problem.

Working From Home Poses Tricky Issues

There’s no shortage of evidence that homeworkers appear to make happy employees, because of, among other things, flexibility, empowerment and better time management. According to experts (http://globalworkplaceanalytics.com/resources/people-telecommute), an estimated three million American professionals never set foot in an office outside of their own home, and 54% say they are happier that way. But what about the 46% who aren’t happier?

Almost 12 months ago, I wrote (http://www.riskandinsurance.com/struggling-stress/) on the topic of stress, and how the increased use of homeworking might be good for productivity, but not necessarily so good for the employee. Isolation, work insecurity and lack of personal contact are good ingredients for increased work-related anxiety. Beyond this are the issues of poor working conditions, bad posture, working through sickness and substance abuse (which may be as simple as excessive caffeine but could be worse, much worse).

Employers usually seek to discharge their obligations by providing guidelines to homeworkers, and the better ones also encourage self-appraisals, which are shared with managers. But to what degree are these processes merely lip service? Isn’t self-appraisal a dodgy process at the best of times? To what extent would a homeworker be candid about a medical or emotional condition, which might hurt their bosses’ view of them? Are homeworkers really best placed to comment on their own posture? What other risks might emerge from homeworking, which don’t feature in a self-appraisal, such as tripping over the dog?

Legislation places a duty of care on employers. Losses arising because of failure in discharging that duty of care give rise to liabilities that may be covered under an insurance policy. It’s a fine balance between an organization empowering its employees, and leaving itself open to liability, and there’s little doubt that homeworking carries with it a significant amount of trust.

There’s no clear answer. Some suggest that answers might rest in site visits, furniture provided by the employer, enforced breaks, fixed working hours and wellness programs as an integral part of an employment contract. But don’t options like these create other issues?

How does the idea of fixed working hours apply to individuals working across multiple time-zones, which often result in exceptionally long days? In the absence of fixed working hours, could an employee successfully argue that almost any injury in the home has occurred during the course of their work?

How proactive can and should employers be? Providing office furniture that allows an employee to sit, stand or even walk brings new risks, especially where ergonomic experts cite potential injury problems. Wellness programs can compensate for sedentary lifestyles, and normally injuries that occur through work-funded wellness programs are not a matter for insurers as they have occurred outside normal working hours – but what if the wellness program has been mandated by the employer as part of an employment contract?

It’s clear that employers cannot contract out of their obligations, and, with the number of homeworkers predicted to rise by 63% in the next five years, doesn’t the insurance industry need to think more about this particular aspect of the future? Is there a role for technology as part of the solution? Perhaps some form of workforce analytics has a part to play – maybe even telematics for teleworkers – but were such a thing to emerge, wouldn’t the concept of “home” and “work” as two separate entities disappear completely?

Progress on Opioids — but Now Heroin?

You’ve probably noticed recent reports, within the workers’ comp pharmacy benefits manager (PBM) industry and elsewhere, that prescription opioid use and overdoses are on the decline. It is a long journey, and we cannot yet see the destination, but progress is being made. One of the goals has been to make it more difficult to secure clinically inappropriate prescription opioids through legitimate (physician, dentist) and illegitimate (pill mills, street sales) means. Abuse deterrent formulations have also helped, creating a hassle factor for those who want to abuse them. The increase in focus on the subject in the media and government has made it more top-of-mind. Although even one death or the creation of one addict is too many, and we have lots of cleanup to do today on the damage already done to individuals and communities, the trends are heartening.

However, for every intended consequence, there are also unpredictable unintended consequences. And one of those that I’ve been following for some time, that two recent clinical studies have codified as accurate, is the dramatic increase in the abuse and misuse of heroin. A good amount of that increase is theorized to be coming from those who may have become addicted or highly dependent upon the euphoric effect or dulling of the pain from opioids. Because today’s heroin is “pharma quality” and less expensive than opioids on the street, heroin has become the primary alternative choice. If you think this is a recent issue, this USA Today article titled “OxyContin a gateway to heroin for upper-income addicts” was my initial warning, on June 28, 2013.

The reasons for this switch are multiple and complicated. An excellent article on this issue was published in the June 2015 edition of “Pain Medicine News.”

Three quotes that struck me the most:

  • “Fewer than 20% of chronic pain patients benefit from opioids.”
  • “The prolific normalization of opioid use for chronic pain within primary care has seeded the epidemic of heroin addiction.”
  • “We are going to see the biggest explosion of heroin addiction ever in the next five years.”

Obviously, heroin is an illegal drug and therefore cannot be tracked or managed within a PBM. But everyone needs to be watching. While heroin use may not be a “workers’ comp problem,” it is a societal problem, which ultimately always rebounds as an issue for everyone (and everything) else.

The CDC just published (or at least publicized on Twitter) a “Vital Signs” report specifically on the subject. This should be required reading for everyone concerned with the epidemic of substance abuse in the U.S. Note that I said “substance abuse,” because as has been clearly stated the issue is not specific to prescription drugs or heroin or cocaine or alcohol binge drinking — it is a cultural issue of people either wanting to have a good time or just to check out from life or pain. According to this CDC report, more than 8,200 people died from heroin overdoses in 2013. When you add that to the more than 175,000 people who have died from prescription drug overdoses since 1999, the people affected is staggering. Not just those who lost their lives, but friends and family left behind and communities (and, in some cases, employers) dealing with the aftermath.

While there is a treasure trove of information included in the CDC’s report, the most important point for me (given my focus since 2003) was the advice to states:

  • Address the strongest risk factor for heroin addiction: addiction to prescription opioid painkillers

If you still don’t believe that opioid use and the abuse of heroin (and other drugs) are related, you just aren’t paying attention. Or you don’t want to connect the dots. I will let the CDC prove my point …

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The use of heroin is no respecter of income level, age, gender, education or geographic location. However, the CDC did outline those most at risk for use:

  • People who are addicted to prescription opioid painkillers
  • People who are addicted to cocaine
  • People without insurance or enrolled in Medicaid
  • Non-Hispanic whites
  • Males
  • People who are addicted to marijuana and alcohol
  • People living in a large metropolitan area
  • 18- to 25-year-olds

Do yourself a favor. Take 10 minutes and read the report from the CDC. It will only be wasted time if the information does not influence you to action.