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Uptick Charted in Telemedicine Cyberrisk

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Advances in telemedicine have benefited patients, but, as with any emerging technology, they also create exposure to cybersecurity risk.

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In addition to patients’ data, monitoring and diagnostic devices that can provide treatment from a distance can be compromised due to a variety of causes—from hackers to employee error.

Because of a drastic increase in internal threats, cyber events have become a prevalent threat—with alarming consequences for employers and patients. While malicious actors are perceived as a major threat, 43% of healthcare cyber events are the result of internal threats, according to The Identity Theft Resource Center’s 2017 Annual Data Breach Year-End Review.

The study found that hacking continues to rank highest in the type of attack, at 59.

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4 % of breaches—an increase of 3.2% over 2016 figures. Overall, the Review indicates a drastic upturn, with a 44.7% increase over the record high figures reported for 2016.

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Here’s more information on cyber breaches and other potentially damaging threats:

Workforce Drug Positivity Rate Still Peaking

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Workforce use of illicit drugs across the board—including cocaine, marijuana and methamphetamine—remains at its highest rate in a decade, a new study by Quest Diagnostics found.

Overall positivity in urine drug testing among the combined U.S. workforce in 2017 continued to hold at 4.2%, which is still 0.7% higher than the positivity rate from 2012, which represented a 30-year low. The findings were made from analysis of more than 10 million workforce drug test results.

“It’s unfortunate that we mark 30 years of the Drug-Free Workplace Act with clear evidence that drugs continue to invade the country’s workplaces. Not only have declines appeared to have bottomed out, but also in some drug classes and areas of the country drug positivity rates are increasing,” Barry Sample, senior director of science and technology at Quest Diagnostics, said in a statement.

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“These changing patterns and geographical variations may challenge the ability of employers to anticipate the ‘drug of choice’ for their workforce or where to best focus their drug prevention efforts to ensure a safe and healthy work environment.”

The new data indicates shifting patterns of drug use, with cocaine and amphetamines positivity surging in some areas of the country and marijuana positivity rising sharply in states with newer recreational use statutes.

Opioids
The one bit of good news is that prescription opiate positivity rates declined dramatically on a national basis. Quest reported that the positivity rate for opiates in the general U.S. workforce in urine drug testing declined 17% between 2016 and 2017 (0.47% versus 0.39%). More notably, oxycodones (oxycodone and/or oxymorphone) positivity declined 12% between 2016 and 2017 (0.69% vs. 0.61%), hydrocodone positivity declined 17% (0.81% vs. 0.67%); and hydromorphone positivity declined 22% (0.59% vs. 0.46%). Opiates other than codeine were at their lowest positivity rate in more than a decade.

This data is supported by the Centers for Disease Control and Prevention (CDC), which shows that the overall national opioid prescribing rate in 2017 fell to the lowest it had been in more than 10 years, although rates vary by state and are high in some areas of the country.

The topic was explored during an educational session at RIMS 2018, where it was noted that the decrease in opioid use may be attributed to corporate initiatives like prescription drug monitoring policies (PDMP), which can limit employees’ ability to refill scripts, in addition to states that had comprehensive reforms.

“This shows that the more queries there are, the bigger the drop in opioid prescribing,” said John Ruser, president and CEO of the Workers Compensation Research Institute (WCRI), last month in San Antonio. He said WCRI used Kentucky as an example of a successful PDMP. Kentucky’s HB1 law mandated the use of the PDMP and between 2011 and 2013, WCRI information indicated a 10% decline in prescriptions in the state, whereas prescription levels were flat in others that did not have similar reforms.

Methamphetamine
Methamphetamine positivity, however, is increasing. An analysis of trends in the general U.S. workforce based on the four U.S. Census regions identified large increases of methamphetamine positivity rates. Between 2013 and 2017, methamphetamine positivity increased: 167% in the East North Central division of the Midwest (Illinois, Indiana, Michigan, Ohio, Wisconsin); 160% in the East South Central division of the South (Alabama, Kentucky, Mississippi, Tennessee); 150% in the Middle Atlantic division of the Northeast (New Jersey, New York, Pennsylvania); and 140% in the South Atlantic division of the South (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia). The percentage increase in these four divisions ranged between 9% and 25% between 2016 and 2017.

Marijuana
Overall, marijuana positivity continued its five-year upward climb for both the general U.S. workforce and the federally-mandated, safety-sensitive workforce. Marijuana positivity increased 4% in the general U.S. workforce (2.5% in 2016 versus 2.6% in 2017) and nearly 8% in the safety-sensitive workforce (0.78% versus 0.84%).

Increases in positivity rates for marijuana were most striking in states that have enacted recreational use statues since 2016. Those states include: Nevada (43%), Massachusetts (14%) and California (11%). These three states also saw significant increases in marijuana positivity in federally-mandated, safety-sensitive workers: Nevada (39%), California (20%), and Massachusetts (11%). Federally-mandated, safety-sensitive workers include pilots, rail, bus and truck drivers, and workers in nuclear power plants, for whom routine drug testing is required by the Department of Transportation.

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“These increases are similar to the increases we observed after recreational marijuana use statues were passed in Washington and Colorado,” Sample said. “While it is too early to tell if this is a trend, our data suggest that the recreational use of marijuana is spilling into the workforce, including among individuals most responsible for keeping our communities safe.”

Prescription Opioid Risks to the Workplace Explored at RIMS 2018

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SAN ANTONIO – When the White House declared opioid use a national Public Health Emergency under federal law in 2017, businesses began reviewing their policies and making efforts to curb their employees’ abuse of the drug in its prescribed form. This escalating risk to organizations is why the business impact of prescription opioid use was such a hot topic at RIMS 2018, where a session on April 17 focused on the practical and bottom-line costs of workforce use of prescription opioids. In a session the next day, attendees learned how liability policies are responding to government-led lawsuits against opioid manufacturers, and how to prepare for similar suits brought against other industries.

New Insights into the Impact of Opioid Prescribing to Injured Workers
Data displayed on Tuesday explored opioid-related correlations between worker, industry and employer. Presenters John Ruser, president and CEO of the Workers Compensation Research Institute (WCRI) and Michael Fenlon, senior director of corporate risk management for United Parcel Service (UPS) discussed opioid-related claims and suggested evidence-based information that can encourage a return to work without the prescriptions.

The effectiveness of prescription drug monitoring policies (PDMP) was explored, and Ruser explained that a reactive shift among prescribers has meant that states obligated to adhere to these policies have fewer prescriptions written.

“This shows that the more queries there are, the bigger the drop in opioid prescribing,” he said, using Kentucky as an example of a successful PDMP. He added that Kentucky’s HB1 law mandated the use of the PDMP and has set a standard among states since it was enacted in July 2012. Between 2011 and 2013, WCRI information indicated a 10% decline in prescriptions in the state, whereas prescription levels were flat in others that did not have comprehensive opioid reforms.

Fenlon said that when he learned in recent years that opioid overdoses—almost half of which arise from prescriptions—surpassed car accidents as the number one cause of accidental death, he realized the severity of the issue and its impact on the UPS workforce.

“Once someone gets to that third or fourth script, you can see how it leads to a vicious cycle,” he said. “We need to take ownership of this—in the workers comp space as well as the healthcare side.”

He noted that UPS’ overall pharmacy spend is about 7% of its total medical costs per year for lost-time (LT) patients, with opioids comprising about 22% of that amount. UPS employs more than 454,000 workers, and Fenlon said the company continually pays close attention to the LT patients who are the higher-risk group, with three or more scripts. He added that the collaboration of drug formularies, third-party administrators and UPS case supervisors has contributed to the 44% decrease of the higher-risk group between 2013 and 2017.

Both presenters conceded, however, that injured workers will likely get the medication they need, even if it is not in the form of opioids. “Those who are worried about pain management are noticing the trend in the decline of opioid prescriptions in some areas and ask: ‘What’s the alternative?’” Ruser said. “While there was a drop in that drug, there was an increase in the amount of NSAIDs [nonsteroidal anti-inflammatory drugs]. Clearly, that’s what these prescribers are shifting to, so it’s not that these injured workers are not receiving pain meds.”

Members may access this PowerPoint presentation by logging in at the RIMS 2018 session handout page.

Opioid Lawsuits: A Tsunami of Litigation and Associated Coverage Issues
The topic shifted from boardrooms to courtrooms the next day, as current and pending multidistrict litigations filed by various governments (local, city and state) were examined. Covington & Burling LLP Partner Anna Engh and Marsh Managing Director John Denton (pictured below) discussed insurance policies’ responses to lawsuits and provided insight as to how to prepare should similar suits be brought against other industries.
Manufacturers, distributors, retailers, prescription benefit managers, doctors and clinics are all seemingly in the crosshairs of local municipalities and governmental entities, Engh noted.

“The main focus against the manufacturers is of alleged misrepresentation of the addictive nature of opioids. With respect to the distributors, it is the failure to report and detect suspicious orders, or failing to have controls in place for their diversions,” Engh said. “You’ll see negligence pled in different ways, like common-law negligence, and also pled as violations of states’ controlled substance acts.” She added that public nuisance and RICO claims (Racketeer Influenced and Corrupt Organizations Act) also appear on the dockets.

With nearly 500 claims against pharmaceutical companies, distributors and pharmacies consolidated in Ohio alone, Denton said that the volume of work involved is daunting for insurance, risk and legal professionals.

“That’s thousands of pages of pleadings coming in every month. It’s a very difficult burden,” he said. “I think a lot of companies are tendering them to as many policies as possible. Hopefully, a lot of insurance carriers will be understanding of this. And a lot of this will be sorted out later, either through discussions with the carriers or litigation.”

Denton added that because there is no federal judicial precedent on insurance suits, the progress on such matters will continue to be slow.

“Insurance coverage issues are typically an issue of state law. And with lawsuits in nearly every state, it would be nice to have a [United States] Supreme Court decision on some of these coverage issues, and that would bind everybody,” he said. “But the reality is that’s not going to happen. There will be decisions in multiple states so it may take some time before these issues get sorted out.”

Risk Manager of the Year: Q&A with Rebecca Cady

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Rebecca Cady, vice president and chief risk officer of Children’s National Medical Center (CNMC) in Washington, D.C. was named the RIMS 2018 Risk Manager of the Year today. CNMC is the largest freestanding pediatric academic medical center and health system in the greater D.C. area., with annual revenues of nearly $1.2 billion.

She was praised by her peers for her success in elevating CNMC’s culture of safety, addressing risk on an enterprise basis and lowering the system’s total cost of risk. Under her leadership, programs continually seek to benefit the system’s 6,000-plus employees, and ultimately, the services they provide to children and their families. Cady spoke with Risk Management Monitor about her journey to the profession and the combination of challenges she faces as a health care risk manager.

Risk Management Monitor: Your professional career began as a labor and delivery nurse. How did you make your way into risk management?

Rebecca Cady: I was a staff nurse at a small, rural hospital in Kingsville, Texas. During a shift, several co-workers were gathered at the nurse’s station, discussing a lawsuit that many senior nurses were anxious about having to take part in.

They didn’t understand what was going on. I remember thinking: ‘What if lawyers knew what it was like to be a health care provider or practice medicine and nursing?’ It would help them do a better job of guiding the nurses and doctors through the legal process. I thought, ‘I could go to law school.’ And I did. It turned out to be a great idea because it has made for a fulfilling and interesting career.

RMM: After becoming a lawyer—and eventually partner—at a law firm, what drew you to CNMC?

RC: I saw this as an opportunity to get in the practice of avoiding litigation in the first place. I was attracted to the idea of working more closely with providers and in a hospital environment where I felt I could have a greater impact on the organization and manage its risk.

RMM: What is one of CNMC’s top challenges?

RC: Recruitment is up there. Pediatric neurosurgeons are not working at Starbucks while they’re looking for a job.

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In some of the specialties, there are very few qualified people. Being able to recruit and hire the best and the brightest, which we think our kids deserve, is hard because we’re competing with pediatric hospitals that are part of other systems.

RMM: In 2014, you updated the reporting systems to include reporting from mobile phones. What inspired that change?

RC: Being able to report an incident and have it instantly make its way up the chains of command was more of a way to cut past the tediousness of logging a report on paper, or even on a computer. I’m not a techie but I recognize that technology has the ability to make us more efficient and effective. We really do believe that more reports are better, because knowing about the low-level events that don’t reach patients or cause immediate problems can still be useful. You can then identify latent issues that need correcting and prevent something serious. Plus, it was embraced by our employees.

RMM: You are widely regarded by peers and co-workers as a relationship-builder and a strong communicator. What is your management style?

RC: My office is in the hospital and I make it a point to be visible. I go to meetings wherever possible and am present wherever possible, I administer our calls and speak at staff meetings as well and to the new residents and nurses as they come on board. The whole risk team is also out and about among the organization constantly, because having relationships builds trust and makes your job easier.

We’re not the department of ‘No.’ We’re the department of ‘Yes, If…’ Helping folks solve their problems – even if they seem small to you – is huge for them. And once they stop seeing you as the policeman, they see you as a business partner.

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Then they’ll start to call you earlier in the game when they are strategizing. That applies no matter what industry you’re in.

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