Managing Outcomes

Injured Worker Voice Lacking in Treatment Guidelines

Without input from injured workers it's unclear whether the treatment of occupational illnesses and injuries achieves the most favorable outcomes possible.
By: | October 3, 2017 • 4 min read

Injured worker input is missing from the development of treatment guidelines widely used for medical and case management of workers’ compensation claims.

Expert clinician researchers working to produce a RAND Corp. report found the shortcoming when analyzing the technical quality and clinical acceptability of the Official Disability Guidelines (ODG). Workers’ comp payers widely use ODG’s products, published by MCG Health, for claims adjusting and medical management purposes, such as utilization review.


ODG is not the only medical treatment guideline that has lacked the injured worker perspective, and it’s not the first time researchers have cited lacking injured worker input into guideline development.

Overall, RAND’s report gave ODG favorable ratings, “despite notable limitations to the methods used to develop the guidelines.” The report addressed claims payers, policymakers and clinicians considering implementation of ODG. It states that the U.S. and Australian clinical experts who evaluated ODG’s work found that “most of the guideline content related to common occupational disorders was valid.”

Forty-one of 47 topics RAND researchers reviewed were ruled to be clinically valid with a high degree of confidence, said Phil LeFevre, managing director at ODG. The other six topics were neither positive nor negative, he added.

Teryl K. Nuckols, M.D., health services researcher, RAND

“So they were overwhelmingly positive and the conclusion of the RAND Corp. was that they recommended adopting ODG.”

Researchers conducted the report for a large Australian workers’ comp insurer. Following the results, the insurer adopted the use of ODG, LeFevre said.

U.S. insurers, third party administrators and managed care organizations use the same ODG guidelines.

Without input from injured workers, however, it remains uncertain whether patients suffering occupational illnesses and injuries achieve the most favorable clinical and occupation outcomes possible.

“A really good guideline is going to hear people out,” including workers’ perspectives, said Teryl K. Nuckols, M.D., health services researcher at RAND.

“The voice of the person getting the care is absolutely fundamental,” she said. “Imagine if you were sick or injured and people were developing guidelines about how to take care of people like you and they never talked to anybody like you.”

A 2011 study cited by RAND and conducted by the National Academies of Sciences, Engineering and Medicine recommended improving medical guidelines by including a current or former patient and a patient advocacy group representative in the guideline development process.

“Imagine if you were sick or injured and people were developing guidelines about how to take care of people like you and they never talked to anybody like you.” — Teryl K. Nuckols, M.D., health services researcher, RAND

Obtaining the advice of individual workers is difficult, LeFevre said. They typically are not educated on medical literature and medical evidence, and their interest is often limited to their specific injury claim. It’s a challenge faced by all guideline developers, not just ODG, he said.

“While we are open and encourage [public input, including feedback from injured workers] it just doesn’t come in,” LeFevre said. “That was one of the things RAND felt might be a good way to improve ODG going forward, perhaps not understanding the reality of the situation that patients don’t typically have the knowledge base with respect to evidence-based medicine or the interest to submit qualified feedback.”

Phil LeFevre, managing director, ODG

ODG reaches out to medical organizations for feedback but does not actively solicit worker input.

ODG does, however, encourage case managers and claims adjusters to share its evidence-based treatment guideline recommendations with injured workers so they understand the expected interventions for their specific injuries and the length of expected recovery time.

“That really sets the claim up for success from the start,” and provides opportunity for worker input at the claim level, LeFevre said. “Realistically, that is the only place you are going to find they are interested and want to play a role.”

ODG also believes data on time away from work provides a good proxy for injured worker input. The data offers an objective, numeric measure reflecting the effectiveness of treatment regimens called for by the guidelines, LeFevre said.

“So we think we incorporate what is best for the injured worker by getting them back to pre-injury status and function and using return to work as a proxy for that,” LeFevre said

ODG does not intend to change its current practice of mostly reaching out to medical organizations for public feedback on its guidelines, LeFevre said.


Finding an interested workers’ comp patient to participate on a guideline development committee should not be difficult, Nuckols said. It would be best to find one who is thoughtful and experienced a significant medical condition.

“There is no reason that various guideline developers in workers’ compensation can’t do that,” she said.

That does not mean patients should have their way in guideline development when their suggestions are not appropriate, Nuckols added.

“But we should hear their voices,” she said. “The purpose of health care is to make people better, so we should be listening to what peoples’ definition of better is.”

Another ODG weakness RAND’s report cited is inadequate information about the methodology applied to identify and synthesize evidence. Strengths, on the other hand, included an expansive scope, clearly documented recommendations, frequent updating and extensive clinician input.

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

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Risk Report: Marine

Crewless Ships Raise Questions

Is a remote operator legally a master? New technology confounds old terms.
By: | March 5, 2018 • 6 min read

For many developers, the accelerating development of remote-controlled and autonomous ships represents what could be the dawn of a new era. For underwriters and brokers, however, such vessels could represent the end of thousands of years of maritime law and risk management.

Rod Johnson, director of marine risk management, RSA Global Risk

While crewless vessels have yet to breach commercial service, there are active testing programs. Most brokers and underwriters expect small-scale commercial operations to be feasible in a few years, but that outlook only considers technical feasibility. How such operations will be insured remains unclear.

“I have been giving this a great deal of thought, this sits on my desk every day,” said Rod Johnson, director of marine risk management, RSA Global Risk, a major UK underwriter. Johnson sits on the loss-prevention committee of the International Union of Maritime Insurers.

“The agreed uncertainty that underpins marine insurance is falling away, but we are pretending that it isn’t. The contractual framework is being made less relevant all the time.”

Defining Autonomous Vessels

Two types of crewless vessels are being contemplated. First up is a drone with no one on board but actively controlled by a human at a remote command post on land or even on another vessel.

While some debate whether the controllers of drone aircrafts are pilots or operators, the very real question yet to be addressed is if a vessel controller is legally a “master” under maritime law.


The other type of crewless vessel would be completely autonomous, with the onboard systems making decisions about navigation, weather and operations.

Advocates tout the benefits of larger cargo capacity without crew spaces, including radically different hull designs without decks people can walk on. Doubters note a crew can fix things at sea while a ship cannot.

Rolls-Royce is one of the major proponents and designers. The company tested a remote-controlled tug in Copenhagen in June 2017.

“We think the initial early adopters will be vessels operating on fixed routes within coastal waters under the jurisdiction of flag states,” the company said.

“We expect to see the first autonomous vessel in commercial operation by the end of the decade. Further out, around 2025, we expect autonomous vessels to operate further from shore — perhaps coastal cargo ships. For ocean-going vessels to be autonomous, it will require a change in international regulations, so this will take longer.”

Once autonomous ships are a reality, “the entire current legal framework for maritime law and insurance is done,” said Johnson. “The master has not been replaced; he is just gone. Commodity ships (bulk carriers) would be most amenable to that technology. I’m not overly bothered by fully automated ships, but I am extremely bothered by heavily automated ones.”

He cited two risks specifically: hacking and fire.

“We expect to see the first autonomous vessel in commercial operation by the end of the decade. Further out, around 2025, we expect autonomous vessels to operate further from shore — perhaps coastal cargo ships. For ocean-going vessels to be autonomous, it will require a change in international regulations, so this will take longer.” — Rolls-Royce Holdings study

Andrew Kinsey, senior marine risk consultant, Allianz Global Corporate & Specialty, asked an even more existential question: “From an insurance standpoint, are we even still talking about a vessel as it is under law? Starting with the legal framework, the duty of a flag state is ‘manning of ships.’ What about the duty to render assistance? There cannot be insurance coverage of an illegal contract.”

Several sources noted that the technological development of crewless ships, while impressive, seems to be a solution in search of a problem. There is no known need in the market; no shippers, operators, owners or mariners advocate that crewless ships will solve their problems.

Kinsey takes umbrage at the suggestion that promotional material on crewless vessels cherry picks his company’s data, which found 75 percent to 90 percent of marine losses are caused by human error.


“Removing the humans from the vessels does not eliminate the human error. It just moves the human error from the helm to the coder. The reports on development by the companies with a vested interest [in crewless vessels] tend to read a lot like advertisements. The pressure for this is not coming from the end users.”

To be sure, Kinsey is a proponent of automation and technology when applied prudently, believing automation can make strides in areas of the supply chains. Much of the talk about automation is trying to bury the serious shortage of qualified crews. It also overshadows the very real potential for blockchain technology to overhaul the backend of marine insurance.

As a marine surveyor, Kinsey said he can go down to the wharf, inspect cranes, vessels and securements, and supervise loading and unloading — but he can’t inspect computer code or cyber security.

New Times, New Risks

In all fairness, insurance language has changed since the 17th century, especially as technology races ahead in the 21st.

“If you read any hull form, it’s practically Shakespearean,” said Stephen J. Harris, senior vice president of marine protection UK, Marsh. “The language is no longer fit for purpose. Our concern specifically to this topic is that the antiquated language talks about crew being on board. If they are not on board, do they still legally count as crew?”

Harris further questioned, “Under hull insurance, and provided that the ship owner has acted diligently, cover is extended to negligence of the master or crew. Does that still apply if the captain is not on board but sitting at a desk in an office?”

Andrew Kinsey, senior marine risk consultant, Allianz Global Corporate & Specialty

Several sources noted that a few international organizations, notably the Comite Maritime International and the International Maritime Organization, “have been very active in asking the legal profession around the world about their thoughts. The interpretations vary greatly. The legal complications of crewless vessels are actually more complicated than the technology.”

For example, if the operational, insurance and regulatory entities in two countries agree on the voyage of a crewless vessel across the ocean, a mishap or storm could drive the vessel into port or on shore of a third country that does not recognize those agreements.

“What worries insurers is legal uncertainty,” said Harris.

“If an operator did everything fine but a system went down, then most likely the designer would be responsible. But even if a designer explicitly accepted responsibility, what matters would be the flag state’s law in international waters and the local state’s law in territorial waters.


“We see the way ahead for this technology as local and short-sea operations. The law has to catch up with the technology, and it is showing no signs of doing so.”

Thomas M. Boudreau, head of specialty insurance, The Hartford, suggested that remote ferry operations could be the most appropriate use: “They travel fixed routes, all within one country’s waters.”

There could also be environmental and operational benefits from using battery power rather than conventional fuels.

“In terms of underwriting, the burden would shift to the manufacturer and designer of the operating systems,” Boudreau added.

It may just be, he suggested, that crewless ships are merely replacing old risks with new ones. Crews can deal with small repairs, fires or leaks at sea, but small conditions such as those can go unchecked and endanger the whole ship and cargo.

“The cyber risk is also concerning. The vessel may be safe from physical piracy, but what about hacking?” &

Gregory DL Morris is an independent business journalist based in New York with 25 years’ experience in industry, energy, finance and transportation. He can be reached at [email protected]