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Rx Roulette

Patient risk versus pharmacy productivity.
By: | March 3, 2017 • 4 min read

A flurry of prescription pills – all different colors, shapes and sizes – pass across white counters. It almost looks like a blur of betting chips thrown across the slick surface. The click-clacking and pinging sounds they make as they ricochet off the sides of the metal pill counting tray create a white noise similar to that of a casino.

While it may appear to be a scene from the Vegas strip, it’s actually the high speed processing that takes place behind the counter of your neighborhood pharmacy.

A gamble, yes, but there is more than just money at stake. High speed dispensing too often comes at a risky price of compromised patient safety in exchange for maximized productivity and profits. With risks of potentially fatal drug interactions resulting from dangerous combinations, the winners and losers are differentiated by more than just a jackpot.

Risk versus Reward

As evidenced by the Chicago Tribune’s recent study, many of today’s medication dispensing practices exemplify the need for speed to satisfy corporate productivity pressures. With success and compensation bonuses based primarily on high volume dispensing, pharmacists and staff may cut corners and compromise patient safety standards in order to meet targets.

While these targets are the focus behind the counter, the consequences for a missed alert can be staggering. Priority one should be protecting the patient, including identifying potential drug interactions. In a day-to-day battle that seems to constantly pit speed against safety, pharmacists are caught in the middle and patients are unknowingly playing a risky game of prescription roulette.

The pharmacists’ plight is not a new one. Fast paced and management free dispensing to facilitate consumer convenience and corporate production expectations fuel the multibillion-dollar pharmacy industry.

Pharmacies value high volume dispensing, and as found by the Chicago Tribune article, more than 50 percent of the time the tested pharmacies were in such a rush to dispense that they did not tell patients about potential interactions.

The Safe Bet

With patient safety being an industry priority, models that promote management, pharmacy accountability and compliance are in high demand.

A more cautious approach may be viewed as “slowing” the dispensing process, but if we apply the tortoise and the hare fable to the return to work race, safe and steady always wins. Prospectively managed medication dispensing improves compliance and patient safety and lowers pharmacy risk.

The pharmacies in the Tribune study were processing medications outside of prospective and concurrent pharmacy benefits manager (PBM) management. While internal alerts are built into pharmacy processing systems to warn pharmacists, they do not require any action. And, after so many endless, seemingly meaningless warnings, it is common for pharmacists to become desensitized. PBMs on the other hand add a second layer of safety to the dispensing process. PBM alerts require edits via overrides and phone calls. This requirement for an affirmative response disrupts the anesthetized alert fatigue and dramatically increasing pharmacist compliance.

In a prospectively managed PBM model, Drug Utilization Review (DUR) edits scan patients’ medication histories and flag unsafe drug interactions. These contraindications alert pharmacists to review each flagged medication to determine the clinical significance. Unlike the episodes detailed in the article, where the medications were processed and dispensed by the referenced pharmacies outside of PBM management, the PBM requires concurrent reviews to be performed by the pharmacist for payment.

A Sure Thing

CorVel delivers the resources to support accountable and safe medication dispensing. In addition to call centers fully staffed with CorVel associates that assist pharmacists nationwide, CorVel’s Certified Pharmacy Technicians work with pharmacies and share information with adjusters to improve decision-making, combatting the slowness that may mistakenly be associated with safety. By addressing key indicators at the front end through alerts and actionable data, prospective management promotes accuracy in concurrent interventions, ultimately driving safe pharmacy utilization practices.

At a time where risks stemming from the overuse and abuse of narcotic pain medications, and unmanaged prescription medications top payors’ lists of concerns, CorVel’s managed dispensing model holds a unique position within industry. CorVel’s process disrupts unmanaged dispensing and holds pharmacies accountable to PBM contracts.

CorVel’s program reduces risk of overdose, no risk of interacting medications and lowers the risks of opioid addiction, all of which contribute to significant savings and better care for patients. Everyone wins.

This article was produced by CorVel Corporation and not the Risk & Insurance® editorial team.



CorVel is a national provider of risk management solutions for employers, third party administrators, insurance companies and government agencies seeking to control costs and promote positive outcomes.

More from Risk & Insurance

More from Risk & Insurance

Cyber Resilience

No, Seriously. You Need a Comprehensive Cyber Incident Response Plan Before It’s Too Late.

Awareness of cyber risk is increasing, but some companies may be neglecting to prepare adequate response plans that could save them millions. 
By: | June 1, 2018 • 7 min read

To minimize the financial and reputational damage from a cyber attack, it is absolutely critical that businesses have a cyber incident response plan.

“Sadly, not all yet do,” said David Legassick, head of life sciences, tech and cyber, CNA Hardy.

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In the event of a breach, a company must be able to quickly identify and contain the problem, assess the level of impact, communicate internally and externally, recover where possible any lost data or functionality needed to resume business operations and act quickly to manage potential reputational risk.

This can only be achieved with help from the right external experts and the design and practice of a well-honed internal response.

The first step a company must take, said Legassick, is to understand its cyber exposures through asset identification, classification, risk assessment and protection measures, both technological and human.

According to Raf Sanchez, international breach response manager, Beazley, cyber-response plans should be flexible and applicable to a wide range of incidents, “not just a list of consecutive steps.”

They also should bring together key stakeholders and specify end goals.

Jason J. Hogg, CEO, Aon Cyber Solutions

With bad actors becoming increasingly sophisticated and often acting in groups, attack vectors can hit companies from multiple angles simultaneously, meaning a holistic approach is essential, agreed Jason J. Hogg, CEO, Aon Cyber Solutions.

“Collaboration is key — you have to take silos down and work in a cross-functional manner.”

This means assembling a response team including individuals from IT, legal, operations, risk management, HR, finance and the board — each of whom must be well drilled in their responsibilities in the event of a breach.

“You can’t pick your players on the day of the game,” said Hogg. “Response times are critical, so speed and timing are of the essence. You should also have a very clear communication plan to keep the CEO and board of directors informed of recommended courses of action and timing expectations.”

People on the incident response team must have sufficient technical skills and access to critical third parties to be able to make decisions and move to contain incidents fast. Knowledge of the company’s data and network topology is also key, said Legassick.

“Perhaps most important of all,” he added, “is to capture in detail how, when, where and why an incident occurred so there is a feedback loop that ensures each threat makes the cyber defense stronger.”

Cyber insurance can play a key role by providing a range of experts such as forensic analysts to help manage a cyber breach quickly and effectively (as well as PR and legal help). However, the learning process should begin before a breach occurs.

Practice Makes Perfect

“Any incident response plan is only as strong as the practice that goes into it,” explained Mike Peters, vice president, IT, RIMS — who also conducts stress testing through his firm Sentinel Cyber Defense Advisors.

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Unless companies have an ethical hacker or certified information security officer on board who can conduct sophisticated simulated attacks, Peters recommended they hire third-party experts to test their networks for weaknesses, remediate these issues and retest again for vulnerabilities that haven’t been patched or have newly appeared.

“You need to plan for every type of threat that’s out there,” he added.

Hogg agreed that bringing third parties in to conduct tests brings “fresh thinking, best practice and cross-pollination of learnings from testing plans across a multitude of industries and enterprises.”

“Collaboration is key — you have to take silos down and work in a cross-functional manner.” — Jason J. Hogg, CEO, Aon Cyber Solutions

Legassick added that companies should test their plans at least annually, updating procedures whenever there is a significant change in business activity, technology or location.

“As companies expand, cyber security is not always front of mind, but new operations and territories all expose a company to new risks.”

For smaller companies that might not have the resources or the expertise to develop an internal cyber response plan from whole cloth, some carriers offer their own cyber risk resources online.

Evan Fenaroli, an underwriting product manager with the Philadelphia Insurance Companies (PHLY), said his company hosts an eRiskHub, which gives PHLY clients a place to start looking for cyber event response answers.

That includes access to a pool of attorneys who can guide company executives in creating a plan.

“It’s something at the highest level that needs to be a priority,” Fenaroli said. For those just getting started, Fenaroli provided a checklist for consideration:

  • Purchase cyber insurance, read the policy and understand its notice requirements.
  • Work with an attorney to develop a cyber event response plan that you can customize to your business.
  • Identify stakeholders within the company who will own the plan and its execution.
  • Find outside forensics experts that the company can call in an emergency.
  • Identify a public relations expert who can be called in the case of an event that could be leaked to the press or otherwise become newsworthy.

“When all of these things fall into place, the outcome is far better in that there isn’t a panic,” said Fenaroli, who, like others, recommends the plan be tested at least annually.

Cyber’s Physical Threat

With the digital and physical worlds converging due to the rise of the Internet of Things, Hogg reminded companies: “You can’t just test in the virtual world — testing physical end-point security is critical too.”

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How that testing is communicated to underwriters should also be a key focus, said Rich DePiero, head of cyber, North America, Swiss Re Corporate Solutions.

Don’t just report on what went well; it’s far more believable for an underwriter to hear what didn’t go well, he said.

“If I hear a client say it is perfect and then I look at some of the results of the responses to breaches last year, there is a disconnect. Help us understand what you learned and what you worked out. You want things to fail during these incident response tests, because that is how we learn,” he explained.

“Bringing in these outside firms, detailing what they learned and defining roles and responsibilities in the event of an incident is really the best practice, and we are seeing more and more companies do that.”

Support from the Board

Good cyber protection is built around a combination of process, technology, learning and people. While not every cyber incident needs to be reported to the boardroom, senior management has a key role in creating a culture of planning and risk awareness.

David Legassick, head of life sciences, tech and cyber, CNA Hardy

“Cyber is a boardroom risk. If it is not taken seriously at boardroom level, you are more than likely to suffer a network breach,” Legassick said.

However, getting board buy-in or buy-in from the C-suite is not always easy.

“C-suite executives often put off testing crisis plans as they get in the way of the day job. The irony here is obvious given how disruptive an incident can be,” said Sanchez.

“The C-suite must demonstrate its support for incident response planning and that it expects staff at all levels of the organization to play their part in recovering from serious incidents.”

“What these people need from the board is support,” said Jill Salmon, New York-based vice president, head of cyber/tech/MPL, Berkshire Hathaway Specialty Insurance.

“I don’t know that the information security folks are looking for direction from the board as much as they are looking for support from a resources standpoint and a visibility standpoint.

“They’ve got to be aware of what they need and they need to have the money to be able to build it up to that level,” she said.

Without that support, according to Legassick, failure to empower and encourage the IT team to manage cyber threats holistically through integration with the rest of the organization, particularly risk managers, becomes a common mistake.

He also warned that “blame culture” can prevent staff from escalating problems to management in a timely manner.

Collaboration and Communication

Given that cyber incident response truly is a team effort, it is therefore essential that a culture of collaboration, preparation and practice is embedded from the top down.

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One of the biggest tripping points for companies — and an area that has done the most damage from a reputational perspective — is in how quickly and effectively the company communicates to the public in the aftermath of a cyber event.

Salmon said of all the cyber incident response plans she has seen, the companies that have impressed her most are those that have written mock press releases and rehearsed how they are going to respond to the media in the aftermath of an event.

“We have seen so many companies trip up in that regard,” she said. “There have been examples of companies taking too long and then not explaining why it took them so long. It’s like any other crisis — the way that you are communicating it to the public is really important.” &

Antony Ireland is a London-based financial journalist. He can be reached at [email protected] Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]