Perspective |The Opioid Crisis: Why This Is Our Defining Moment

For every person who dies from opioid overdose, 50 more individuals have an opioid use disorder and 272 misuse prescription opioids in some way. The time to change is now.

By: Robert Goldberg, Silvia Sacalis | October 23, 2018

Our country is being threatened. And in many ways, the enemy is us. The numbers paint a bleak picture for our priorities as a society as they relate to the opioid crisis. Statistics from the Centers for Disease & Prevention (CDC) report more than 42,000 people died from opioid-related drug overdose in 2016, and provisional data for 2017 currently put overdose fatality rates over 62,000.¹

As clinical leaders in the workers’ compensation space, we bring a unique point of view to this conversation. Managing the care of injured employee populations, where pain and its management are prevalent, we are positioned on the front line of preventive efforts against prescription opioid addiction.

We have seen firsthand the tremendous negative impact that opioids have on the recovery, health and quality of life for the patient. We have critical insight into why this problem is not just about street drugs — that prescription opioids play a definitive role in the larger crisis.

For every fatality counted, there are exponentially more people out there suffering from the impacts of opioids at the individual, family and community levels. For every one person who dies from opioid overdose, 50 more individuals have an opioid use disorder, and 272 misuse prescription opioids in some way.²

Most importantly, we know that change is possible. But it doesn’t happen without a committed effort.

Public Health Approach

The opioid epidemic was declared a national public health emergency in October 2017. A full year later, we are seeing perhaps the first sweeping action on a federal level that rises to the urgency of this declaration, with Congress passing the SUPPORT (Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment) for Patients and Communities Act.

Silvia Sacalis, PharmD, VP, clinical services, Healthesystems

The legislation — which aims to advance treatment and recovery initiatives, boost abuse prevention efforts, and increase policy and enforcement initiatives — is a good start, albeit a delayed one. And there are still other opportunities for increased effort.

Despite increased allotments to the CDC, NIH and FDA in 2018, these agencies remain the David-versus-Goliath that is the opioid crisis when comparing from a cost perspective. The crisis causes the U.S. an estimated $500 billion per year inclusive of health care, criminal justice and lost productivity costs.² U.S. opioid sales are projected to hit $18.4 billion annually by 2020.

In 2001, Purdue Pharmaceuticals spent $200 million alone on the promotion of OxyContin — a financial amount nearly twofold what the National Institutes of Health (NIH) have traditionally been allotted in previous years to research opioid use disorder and alternative pain treatments. Stack all of that up to the $500 million directed to the NIH this year, and it’s still like bringing a slingshot to a gunfight.

A continued emphasis on providing financial support to these entities will allow them to better address knowledge gaps and research treatment options for opioid use disorder, as well as new, safer pain therapies, both pharmacological and non-pharmacological. Is this a significant investment? Of course. But here is the more pertinent question: Aren’t our people and our country worth the investment?

A Responsibility for Action

Opioid use disorder — and its related fatalities — is nearly 100 percent preventable. On one hand, the needlessness of this crisis renders it even more tragic. On the other hand, it gives us our best chance at attacking the epidemic head-on with preventive strategies.

Public education: Despite recent high-profile media coverage of opioids, many people remain unaware that the pain medications they are prescribed present serious risk for addiction and other adverse effects. This is not only a significant failure of the prescriber, but there also exists responsibility from a public health perspective.

As a society, we are failing to provide the right context around the opioid crisis in a manner that enables Americans to equate it with other serious health concerns impacting our population. In 2016, the incidence of opioid overdose deaths surpassed the annual number of breast cancer deaths for the first time in history.

Unlike breast cancer, there are no nationally recognized walks, no advocacy organizations that have become a household name. We don’t pin ribbons to our lapels in support of overcoming this disease that continues to claim more lives year upon year.

A better-informed public makes better-informed patients. And this in turn must be supported by doctors who are willing to engage in dialogue with patients that will shift attitudes and expectations toward pain management — moving away from the “pill for every ill” mindset toward components of treatment emphasized in workers’ compensation populations, such as self-care and non-pharmacologic approaches, in addition to non-opioid medications.

Physician education: The extent of pain management and opioid training most physicians receive is severely inadequate. Pharmaceutical companies have capitalized, filling this void with heavy advertising, detailing and “continuing education” to promote opioid products.

Addressing this enormous gap will take a two-pronged approach: Banning or severely limiting pharmaceutical advertising and rapidly increasing training and education about opioid risks and responsible management.

Education and control measures aren’t enough. As long as opioids are in available in unyielding supply, they will find a way through. Opioids must become a less prevalent and less visible option.

State medical and pharmacy boards play an influential role in modifying, prescribing and dispensing behaviors through practitioner education, stricter board regulations around the dispensing of opioids and other controlled substances with addiction potential, prescribing limitations on dose, quantity and duration, and implementing stronger and more frequent disciplinary actions in response to violations.

Physicians, and the care they provide, would also benefit from increased exposure to the biopsychosocial model — a care model that looks beyond the traditional medical/pharmacologic approach to address the overall physical, mental and emotional health of a patient. These are critical factors when considering that adults with mental health conditions receive 51 percent of total opioid prescriptions in the U.S.³

Dr. Robert Goldberg, chief medical officer, senior vice president, Healthesystems

State regulation: While regulation alone isn’t the solution, it provides important guardrails and controls. The last year has produced a volume of state-based regulation around opioid prescribing, including limits on quantity, dose and duration.

More can be done. Prescribers should be required to check prescription data monitoring programs (PDMPs) prior to prescribing in every state — states with these mandatory rules in place are seeing the impact on prescription rates.

Taking this a step further, interoperability of PDMPs across all 50 states and expanded access to PDMP data to third-party health care entities would help provided much-needed visibility into a patient’s history of controlled substance use. In the workers’ comp space especially, insurance carriers and pharmacy benefit managers (PBMs) play a central role in supporting and upholding opioid prescribing limits through strategic formulary implementation and the tools, alerts and guardrails they set in place to drive adherence to these rules at the claims adjuster, prescriber, pharmacy and patient touch points.

Education and control measures aren’t enough. As long as opioids are available in unyielding supply, they will find a way through. Opioids must become a less prevalent and less visible option. It is incumbent upon federal agencies to tighten controls in their respective areas.

The FDA is beginning to tighten measures around the development and approval of opioids but in the same breath continues to push new products through. The DEA can play a powerful role by helping to control both prescription and illicit opioid sources, which includes increased enforcement of pill mills, distributors and high-volume dispensing pharmacies and physicians.

Stemming the flow of illicit fentanyl from overseas also becomes a top priority with the explosion of abuse and related fatalities over the last several years. The SUPPORT Act can play a role here, as it will require the U.S. Postal Service to screen packages shipped from abroad, primarily China, a primary source for illicit fentanyl.

The Third Wave

For many, it is too late for primary prevention efforts. More than 11 million people in this country misuse prescription pain medications, and 2.1 suffer from an opioid use disorder.³ Even as we tackle the crisis from the front end, we must clean up the current mess. Measures include:

Fully funding treatment of opioid use disorder through workers’ compensation, commercial, Medicaid and Medicare programs, with an emphasis on medication-assisted treatment with buprenorphine, and expansion on the number and geographic distribution of qualified physicians;
More effective use of medication contracts, urine drug screens and opioid weaning strategies;
Mandatory legislated interoperability of PDMPs to effectively counter abuse and enable routine use for a complete picture of concurrent prescribing and dispensing across all pharmacies and prescribers.

Most importantly, we must be continually critical of ourselves, acknowledging where we are failing — as a health care system, as a government, as a society — and implementing new and better solutions to address these failures.

Ad Astra Per Aspera

Modern U.S. history is marked by moments and movements that have defined the generations in which they have occurred and reshaped the attitudes and policies of our country — for better or for worse. Arguably, the opioid epidemic has become one of the most significant crises in this decade to impact our nation. But we have hope that what will ultimately define us are not the far-reaching and devastating impacts of the crisis itself, but instead the actions we take to overcome it. &

References
¹Centers for Disease Control and Prevention. Opioid Overdose. www.cdc.gov/drugoverdose/index.html
²Key substance use and mental health indicators in the United States: results from the 2016 National Survey on Drug Use and Health
³The Council of Economic Advisers. The Underestimated Cost of the Opioid Crisis. November 2017

Dr. Robert Goldberg is chief medical officer and senior vice president with Healthesystems. Silvia Sacalis, PharmD, is vice president, Clinical Services, with Healthesystems. Robert and Silvia can be reached at [email protected].

How a Carrier Partner Can Help Navigate a Challenging Management and Professional Liability Market

A combination of a choppy economy with increased claims frequency and severity could lead to rate increases in the Management & Professional Liability market.

By: Risk & Insurance | April 3, 2024

Rates in the management & professional liability (M&PL) markets were on the rise from 2020 to early 2023 and are now falling rapidly.

M&PL divisions manage a number of different insurance products including management liability (D&O), professional liability (E&O), employment practices liability (EPL), fiduciary liability policies, cyber, etc. In 2023 and into 2024, a big influence on the marketplace has been the extremely aggressive and softening public company D&O market.

Though these rates have been softening for management liability, that may change over the next few years as companies continue to adjust their business models motivated by economic uncertainty. Layoffs were up nearly 200% last year, Forbes reported, even as other recession indicators, like the inflation rate, improved. A recession could lead to an increased claim activity and force carriers to raise rates.

“Whenever there is a meaningful downturn in the economy, we tend to see claim frequency pop up,” said George Schalick, Jr., senior vice president of the Management and Professional Liability Division at Philadelphia Insurance Companies (PHLY).

With continued fiscal uncertainty, businesses potentially already burdened with pandemic-related claims should seek a carrier with a long history in M&PL products. They will provide much-needed risk management guidance and be better positioned to support their insureds during market fluctuations.

Why Insureds Might See an Uptick in M&PL Claims

George Schalick, Jr., Senior Vice President of the Management and Professional Liability Division, Philadelphia Insurance Companies

The current soft market might come as a bit of a surprise as it does not track with previous underwriting cycles and economic conditions. Afterall, many privately held and non-profit organizations struggled during the early days of the pandemic with shutdowns and rapidly declining revenues. But the Government assistance programs, like the Paycheck Protection Program loans, helped keep many afloat during the tough times.

“During COVID many organizations stopped doing business until they were able to sort out all of the health and safety challenges,” Schalick said. “They were forced to lock down, but then all the government assistance programs allowed them to keep people employed. The increased volume of claims we anticipated we would see coming from the lockdowns and restrictions that were imposed upon businesses in the U.S. didn’t manifest at first.”

“Just because there wasn’t an onslaught of reported claims at the beginning of the pandemic, doesn’t mean the circumstances that would give rise to a claim being reported didn’t occur. Courts and the judicial system were closed or slowed and now that they are back open, we’re starting to see the circumstances that occurred during the COVID lockdowns becoming claims today,” Schalick said. “Litigation is progressing.”

Added to the delayed pandemic litigation is a concern over newer claims that might be filed as the country inches toward an economic downturn. Though a recession was avoided in 2023, experts think a soft dip could occur in 2024, with 76% of economists saying there’s a 50% or less chance of an economic downturn this year — that almost always results in more management liability claims.

“During the Great Recession in 2008, we saw an almost immediate spike in claims because of the economic conditions and the pressure it placed on organizations. They were making personnel changes with significant belt tightening almost immediately.” Schalick said.

What’s in Store for M&PL Policy Rates in 2024?

Despite an uptick in claims and increased economic uncertainty, management liability rates haven’t increased, resulting in market-wide pricing levels that may not meet the increased pressure of rising settlements and jury verdicts.

“Rates are going the other direction and settlement values are not falling,” Schalick said.

The mismatch between rates, claim frequency and severity is, in part, because carriers experiencing the dramatic soft market in the public D&O market are seeking premium gain in the private and non-profit market.

“In the public company market, the rates have been decreasing significantly. The rates were increasing in the private, not-for-profit market, and rightfully so, but there’s a desire to supplement overall mid-size D&O for carriers who also write private not-for-profit, and they see that as an opportunity to aggregate premium,” Schalick said. “So the always competitive landscape in the private, not-for-profit market has dramatically increased in the last 18 to 24 months.”

Still, companies of all sizes and types should be concerned about management liability rates in the future. Legal system abuse is resulting in increases in both the amount of litigation and the size of verdicts plaintiffs are receiving.

Certain areas of the country are particularly vulnerable to this type of legal system abuse. As a result, insureds in these localities are likely to be vulnerable to rate increases.

“The environment is so positive for the plaintiff that forces premium increases so carriers are able to stay in that market long term,” Schalick said.

Why a Tenured Carrier Partner Can Help Insureds Navigate An Uncertain Market

It’s clear that insureds are facing an uncertain M&PL market over the next few years. Fortunately, carriers with a long history in the M&PL space will be there to offer stability.

Philadelphia Insurance Companies has been supporting this market for 35 years. PHLY is committed to offering long-term rate stability, even as economic and claims trends start to push premiums upwards. They have an appetite for all sorts of companies, large and small, for-profit and nonprofit alike.

“We’ve been at this game for a long time and are one of the most tenured underwriters in this space,” Schalick said. “We like to stay very consistent.”

PHLY has worked with both for-profit and non-profit on management liability policies. With dedicated M&PL teams throughout the company’s 13 regions, PHLY provides the support agents and brokers are looking for on behalf of their clients. The teams know their regions well and can respond to local trends. They’re also dedicated to making the renewal process as easy as possible for their partners and policyholders.

“We have real confidence in our results, so we focus a lot on making the renewal experience as painless as possible for all agents and insureds,” Schalick said.

The company is also investing in tools to help insureds avoid losses. Earlier this year, they launched a new online risk management platform, PHLYGateway, which offers resources for insureds on how to create an employee handbook and trainings on issues such as recognizing workplace sexual harassment and discrimination.

If insureds have questions, they can consult a Best Practices Help Line, provided via the platform. That way, they can get on the spot risk management guidance to help them prevent claims.

To learn more, visit: https://www.phly.com/mplDivision/managementLiability/default.aspx.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Philadelphia Insurance Companies. The editorial staff of Risk & Insurance had no role in its preparation.