Column: Workers' Comp

Worker Pharma Choice Debatable

By: | October 12, 2017 • 2 min read
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.

This is a tale of two pharmacy models, although we can’t say it’s the best of times or the worst of times for either.


Thanks to court records, we can say each tallied a win and suffered a loss in two state supreme court battles. The disputes were over whether workers’ compensation claimants can select prescription drug providers, bypassing typical insurer pharmacy utilization and cost-control arrangements.

That should interest most claims payers who build their workers’ comp pharmacy cost-containment programs around directing injured workers to contracted prescription distribution systems, often involving PBMs.

In one case, the Kentucky Supreme Court ruled that five claimants with similar cases can select their pharmacy under a state law allowing injured workers to choose medical providers.

The decision in Steel Creations v. Injured Workers Pharmacy resulted from medical fee disputes, which pitted five employers and their insurer, the Kentucky Employers’ Safety Assn., against employees using the services of the IWP. Plaintiffs’ attorneys referred the claimants to IWP after they complained of delays in receiving prescriptions under KESA’s existing arrangement.

According to the court decision, IWP, (which recently hired PBM veteran Michael Gavin to bolster payer relations), markets to plaintiffs’ attorneys and takes prescription orders from doctors rather than adjusters. It is a mail-order pharmacy offering next-day delivery.

By contrast, insurer KESA provides injured workers with medical cards for purchasing prescriptions. It does so through a “handshake agreement” with service provider M. Joseph.

I don’t think these two court decisions mark the end of this story. Legislative battles continue to be fought over whether workers can bypass insurer-selected pharmacies.

While the case involved drug pricing, the ruling reveals difficulties in unraveling prescription charges under such arrangements. Witnesses could not or would not testify about upcharges added to drug pricing by both pharmacy benefit management companies and “middle-man” M. Joseph.

However, the court cited evidence submitted by KESA showing significant price differences between M. Joseph and IWP on some medications. On others their prices were similar.

The second ruling, handed down by Louisiana’s Supreme Court, involved IWP and a claimant seeking $13,110, an amount the claimant’s employer refused to pay for IWP prescriptions.


Following review, Louisiana’s Supreme Court held in Burgess v. Sewerage & Water Board of New Orleans that under its state law, pharmacy choice in a workers’ comp case belongs to the employer.

I don’t think these two court decisions mark the end of this story. Legislative battles continue to be fought over whether workers can bypass insurer-selected pharmacies.

With the increased role of drug expenses in workers’ comp, you can bet entities in the pharmacy business will keep fighting, hoping to make it the best of times for their operations. &

More from Risk & Insurance

More from Risk & Insurance

Risk Management

The Profession

Janet Sheiner, VP of risk management and real estate at AMN Healthcare Services Inc., sees innovation as an answer to fast-evolving and emerging risks.
By: | March 5, 2018 • 4 min read

R&I: What was your first job?

As a kid, bagging groceries. My first job out of school, part-time temp secretary.

R&I: How did you come to work in risk management?

Risk management picks you; you don’t necessarily pick it. I came into it from a regulatory compliance angle. There’s a natural evolution because a lot of your compliance activities also have the effect of managing your risk.

R&I: What is the risk management community doing right?


There’s much benefit to grounding strategic planning in an ERM framework. That’s a great innovation in the industry, to have more emphasis on ERM. I also think that risk management thought leaders are casting themselves more as enablers of business, not deterrents, a move in the right direction.

R&I: What could the risk management community be doing a better job of?

Justified or not, risk management functions are often viewed as the “Department of No.” We’ve worked hard to cultivate a reputation as the “Department of Maybe,” so partners across the organization see us as business enablers. That reputation has meant entertaining some pretty crazy ideas, but our willingness to try and find a way to “yes” tempered with good risk management has made all the difference.

Janet Sheiner, VP, Risk Management & Real Estate, AMN Healthcare Services Inc.

R&I: What was the best location and year for the RIMS conference and why?

San Diego, of course!  America’s Finest City has the infrastructure, Convention Center, hotels, airport and public transportation — plus you can’t beat our great weather! The restaurant scene is great, not to mention those beautiful coastal views.

R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?

The emergence of risk management as a distinct profession, with four-year degree programs and specific academic curriculum. Now I have people on my team who say their goal is to be a risk manager. I said before that risk management picks you, but we’re getting to a point where people pick it.

R&I: What emerging commercial risk most concerns you?


The commercial insurance market’s ability to innovate to meet customer demand. Businesses need to innovate to stay relevant, and the commercial market needs to innovate with us.  Carriers have to be willing to take on more risk and potentially take a loss to meet the unique and evolving risks companies are facing.

R&I: Of which insurance carrier do you have the highest opinion?

Beazley. They have been an outstanding partner to AMN. They are responsive, flexible and reasonable.  They have evolved with us. They have an appreciation for risk management practices we’ve organically woven into our business, and by extension, this makes them more comfortable with taking on new risks with us.

R&I: Are you optimistic or pessimistic about the U.S. health care industry and why?

I am very optimistic about the health care industry. We have an aging population with burgeoning health care needs, coupled with a decreasing supply of health care providers — that means we have to get smarter about how we manage health care. There’s a lot of opportunity for thought leaders to fill that gap.

R&I: Who is your mentor and why?

Professionally, AMN Healthcare General Counsel, Denise Jackson, has enabled me to do the best work I’ve ever done, and better than I thought I could do.  Personally, my husband Andrew, a second-grade teacher, who has a way of putting things into a human perspective.

R&I: What have you accomplished that you are proudest of?

In my early 20s, I set a goal for the “corner office.” I achieved that when I became vice president.  I received a ‘Values in Practice’ award for trust at AMN. The nomination came from team members I work with every day, and I was incredibly humbled and honored.

R&I: What is your favorite book or movie?

The noir genre, so anything by Raymond Chandler in books. For movies,  “Double Indemnity,” the 1944 Billy Wilder classic, with insurance at the heart of it!

R&I: What is your favorite drink?


Clean water. Check out for how to help people enjoy clean, safe water.

R&I: What’s the best restaurant at which you’ve eaten?

Liqun Roast Duck Restaurant in Beijing.

R&I: What is the most unusual/interesting place you have ever visited?

China. See favorite restaurant above. This restaurant had been open for 100 years in that location. It didn’t exactly have an “A” rating, and it was probably not a place most risk managers would go to.

R&I: What is the riskiest activity you ever engaged in?

Eating that duck at Liqun!

R&I: If the world has a modern hero, who is it and why?

Dr. Seuss who, in response to a 1954 report in Life magazine, worked to reduce illiteracy among school children by making children’s books more interesting. His work continues to educate and entertain children worldwide.

R&I: What do your friends and family think you do?

They’re not really sure!

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]