Health Wonk Review, kabuki style, and other noteworthy news briefs

Fresh HWR - Health Wonk Review, Kabuki Theater Edition is freshly posted by Brad Wright at Wright on Health. In this edition of the biweekly best of the health policy blogoshphere, Brad rounds up recaps and rounds up reactions to last week's Health Care Summit. A good edition, plus, some nice Japanese art prints!

Happening right now - On Thursday March 4 - that's today - from 9 am to 6 pm, join OSHA's live webcast, a first-ever live streamed public meeting. Over 200 people have registered to attend and more than 45 presentations will be made on to the Assistant Secretary of Labor for OSHA, Dr. David Michaels. If you can't make the event, keep up with OSHA happenings on its newly launched Twitter feed: http://twitter.com/OSHA

Google & pharma - At Health Business Blog, David Williams posts about the Google crackdown on ads for online pharmacies - only VIPPS-certified pharmacies (as selected by the National Association of Pharmacy Boards) will be allowed to post adwords. This will eliminate "rogue" pharmacies, which sounds reasonable. But it also eliminates Canadian pharmacies and some smaller outfits. Consumer protection or kowtowing to the big pharma interests? Read more about the controversy.

P&C industry: don't lump us in financial reform - have you heard about the Property & Casualty Leaders Coalition? You may yet. This is a new coalation eleven CEOs from the nation's largest property casualty insurance companies - among them State Farm Insurance, Allstate Corp., Travelers Companies Inc., Chubb Corp., ACE Group, Nationwide Insurance, Liberty Mutual, and Zurich Financial Services Group - who have banded together to urge Congress to leave them out of the financial services overhaul legislation. "There is no public policy justification for taking funds from companies in our industry, especially on a pre-event basis, to bail out other financial institutions deemed to be overexposed to failing ‘systemic’ companies."

How much risk is too much? - In Jobs to Die For, Yvonne Guilbert looks at people who risk their lives to work in jobs they love. One of the cases profiled is that of animal trainer Dawn Brancheau. Claims Journal features this related item: SeaWorld Death Raises Questions About Animal Entertainment Safety. And on the topic of high-risk endeavors with passionate participants, some are wondering if this year's winter Olympics went to extremes.

Director's cut - Here's a topic you won't see much about in the upcoming Oscar awards: Hollywood and risk. Fireman's Fund dishes up its annual list of the riskiest films it insures.

Other noteworthy briefs
At Comp Time, Roberto Ceniceros ponders Schwarzenegger's legacy and what comes next for California's workers comp.

Check out The Great Captive Shuffle, by Dave Lenckus of Risk and Insurance: Fresh blood courses through the captive regulatory veins in Vermont, Delaware, Arizona, Utah, Hawaii and Nevada, as new faces prepare to alter the captive landscape."

Joe Paduda always has the lowdown on the medical side of workers comp and this week, he has Texas covered in a recent pair of posts at Managed Care Matters: Texas' efforts to add science to the art of work comp medicine and Texas' efforts to control WC Rx.

Medicare and Physician Pay: Jim Bunning's Bean Ball

There are four things that are memorable about Jim Bunning's professional baseball career: First, tossing a perfect game for the Philadelphia Phillies against Trace Stallard and the New York Mets on the afternoon of 21 June 1964, lowering his ERA to 2.07 in the process (Phillies: 6 runs, 8 hits and no errors; Mets: Zip, Nada and Zilch); second, finishing second in the Cy Young voting in 1967 (Mike McCormick of the Giants won with 18 first place votes; Bunning got one, but, hey, it was good enough for the silver medal); third, from 1955 to 1963 while pitching for the Tigers, striking out Ted Williams more than any other pitcher Williams faced (and, as Jim Bouton's Memoir, Ball Four, tells it, Teddy Ballgame did not like it one bit); and fourth, entering the Hall of Fame compliments of the Veterans Committee in 1996.

About this time in Washington, DC, there are many Republican Senators, baseball fans all, who are wishing that the 6'3", 190 pound righthander had called it quits right there and retired to the backwoods of Kentucky. But, of course, he didn't. He had to go ruining it all by running for and winning a Senate seat from the blue grass state in 1998; and then he did it again in 2004! The political version of the Peter Principle.

Republicans politely call him "cantankerous" - at least that's what they say in public. Behind the scenes, they’re not so nice about it. Senator Bunning marches to his own drummer, and always has.

One Pitch, Three Strikes
He's retiring this year, but not before throwing one more hard-breaking slider (his best pitch back in the day). On Monday he managed something he never could in the Big Leagues - he threw three strikes with one pitch. By preventing a vote on an emergency spending bill, Senator Bunning: first, at least temporarily, killed an extension of unemployment and COBRA subsidy benefits for more than a million long-term unemployed Americans; second, shot down a short-term extension of the Highway Trust Fund, which is a federal fund set up to pay for transportation projects nationwide, after which Transportation Secretary Ray LaHood said that up to 2,000 employees at the Transportation Department will be furloughed without pay as a result; and third, insured that Medicare would immediately reduce fees to physicians by 21.3% via the Medicare Sustainable Growth Rate Factor (SGR). Wow, a "threefor!"

Strike 3 is what concerns us here. We've written often about the steep and steadily rising costs of Medicare, and now along comes Senator Bunning saying we have to lower costs and let's do it on the backs of hard-working primary care physicians. He certainly has a point that we need to lower Medicare costs, although he expressed it in a wild pitch sort of way. Here's a chart from the Centers for Medicare and Medicaid Services (CMS) that shows what will happen to Medicare costs in the future if nothing changes. The vertical axis is percentage of GDP:

And here's a summary from a Congressional Budget Office (CBO) Issue Brief on the Medicare Sustainable Growth Rate Mechanism (PDF). It's from September, 2006, but is still appropriate: The Supplemental Medical Insurance program (Part B of Medicare), which will cost about $158 billion in 2006, pays for physicians' services, outpatient hospital services, durable medical equipment, physical therapy, and certain other outpatient services. About 38 percent of those expenditures are payments for services provided by physicians, which are based on a schedule of fees that specifies the amount to be paid for each type of service. Most of Medicare’s payment rates are simply adjusted each year for inflation--but not those for physicians’ services (emphasis added). Those rates are governed by a complex formula -- the Sustainable Growth Rate (SGR) mechanism.

The SGR is pegged against a target originally established in the 1997 Deficit Reduction Act. Its aim is to hold down Medicare costs. It's calculated every year, and every year since 2004 this complex and nearly Byzantine calculation has called for an annual reduction of physician reimbursement rates by an average of 3% to 4%.

Nonetheless, every year since 2004 Congress, yielding to the medical lobby, has voted to override it by delaying the triggering of it. The trouble is, the law is cumulative. So, what Congress has done in a typically heroic display of moral courage, is to dig itself into an ever-deepening hole by not facing up to yet another looming catastrophe. Sound familiar?

Docs Rush the Mound
The AMA is nearly apoplectic about the SGR and the prospect of Senator Bunning causing it to be finally triggered. Monday, the organization was out in force in DC making its views known. The current President, Dr. James Rohack, went on Bloomberg and, later, CNN with Larry King. President-Elect Dr. Cecil Wilson even did an hour on Washington Journal C-Span answering questions from Democrats, Republicans and Independents, and, generally making his case.

And his case was that for a while now, physicians have been abandoning the Medicare ship, because, even though their Medicare fees have remained steady due to the congressional overrides, they claim they're losing money with Medicare patients because their costs have been inexorably rising. Moreover, it's no secret that there is an ever-increasing shortage of primary care physicians, and CMS reports that, while 92% of primary care physicians participate in Medicare, only 73% are accepting new patients. If nothing changes, that will surely drop precipitously.

Case in point – the Mayo Clinic, President Obama's iconic national model of high-quality health care efficiency, lost $840 million on Medicare in 2008, and, as of January 1, 2010, stopped seeing Medicare patients at its Glendale, AZ, clinic. The Mayo claims Medicare covers only 50% of its costs every time it sees a Medicare Patient.

So, we’re left with another one of those rock and hard place things. Medicare could bankrupt the nation, but physicians don’t get paid enough from it.

Yesterday, Congress stole second base on Bunning by extending unemployment and COBRA benefits for another month and by delaying the 21.3% Medicare physician pay cut until the end of March, at which time we'll probably have to go through this whole thing all over again. (Yogi Berra’s “déjà vu?)

Perhaps Senator Bunning's out of left field move will actually cause Congress to do something it has thus far been absolutely incapable of doing regarding our nation's health care. That is, fix it.

Right. And tomorrow 78 year old Jim Bunning will quit the Senate and to great expectations accept a $100 million free-agent contract to rejoin the Phillies as their Pitching Ace.

Noe Go: Con Man in a Corner

Four years ago (time flies when you're having fun!) we blogged the saga of Thomas Noe, the power broker who parlayed his relationships with highly-place politicos into lucrative contracts with the Ohio workers comp bureau. The state invested $50 million of comp funds in his coin business. Unfortunately, Noe's inventory of coins and his tracking of the funds fell short of bookkeeping standards. He was convicted on both federal and state charges. The "Coingate" scandal brought down some heavy hitters, including the governor.

In an article in the Columbus Dispatch by Mark Niquette and Joe Hallet, Noe outlines his next moves.

"God has a plan for me, and what I'm going to do (is) I'm going to make the best of my time in Hocking {Correctional Facility]," he says. Much of his time is tied up in his appeal, which is wending its way to the Ohio Supreme Court, where he subliminally hopes the judges remember him fondly: last time around, five of the seven judges removed themselves from a previous case because they had taken campaign contributions from the ever-generous Noe.

His appeal appears to be based upon a technicality: "Believe me, I'm not sitting here saying I didn't make mistakes. I made a lot of mistakes. I'm just saying I'm not guilty, in my opinion, of what they said I'm guilty of."

To put it mildly, the prosecutors aren't buying Noe's claiming of innocence.

Assistant Lucas County Prosecutor John Weglian says: "He's a liar."

"There isn't a single embezzler in the history of embezzling, I think, who has not intended to pay the money back," Weglian said. "They all say that. ... He's a salesman; he's trying to market himself." (With all due respect, Mr. Weglian, Bernie Madoff knew all along he was never going to pay people back.)

Accentuate the Positive
For the disgraced Noe, the marketing options from a jail cell are clearly limited. But Noe prides himself on being a positive person.

"I've always said a negative thought's a down payment on failure. I'm not going to fail. I'm not going to fail on the outside. I'm not going to fail as a prisoner."

One might argue that Noe's conviction on multiple charges of corruption was a failure on the outside, and that his prospects for success from the "inside" are remote. But as Noe says, it's just part of God's plan - a plan, at the moment, that calls for another decade or so in Hocking. The former high roller used to enjoy steaks and cabernet at the best restaurants in Ohio. His current fare falls rather dramatically short of that standard, but, heck, it's free and there's no tipping.

It would be nice to think that if he ever gets another opportunity to make business decisions on the outside, Noe will have learned how to say "no way" to the Noe Way. I'm not exactly holding my breath.

On redefining disability

When is a worker disabled and unable to do his or her job? This is an issue that surfaced in a recent post about an employer that was reluctant to make workplace accommodations for employees who had been injured on the job but who wanted to return to work. This case came to mind again after viewing a presentation by record breaking athlete Aimee Mullins. In her most recent appearance at the TED conference, Aimee delivers an outstanding talk that properly redefines the word 'disabled.' The video clip is about 22 minutes, but it's guaranteed to be one of the best things you see this week. Here are a few excerpts that we liked:

"It's not just about the words, it's what we believe about people when we name them with these words - it's about the values behind the words and how we construct those values. Our language affects our thinking and how we view the world and how we view other people."

"...we have to make sure that we don't put the first brick in a wall that will actually disable someone. Perhaps the existing model of only looking at what is broken in you and how do we fix it serves to be more disabling to the individual than the pathology itself. By not treating the wholeness of a person, by not acknowledging their potency we are creating another ill on top of whatever natural struggle they may have."

More about Aimee Mullins
TED profile - with links to additional presentations she has made
Aimee Mullins website
Aimee Mullins on Wikipedia

Chronic pain management in workers' comp

Recently, I attended the 2010 Health and Productivity Forum jointly sponsored by the Integrated Benefits Institute (IBI) and the National Business Coalition on Health (NBCH) in San Antonio. I had been invited to participate in a panel discussion by Gary Anderberg, of Broadspire, who, as I have written previously, is one of the smartest people I'm fortunate to know.

With me on the panel were Dan Shaughnessy, Director of Disability Programs, Textron, Inc., and Mike Machanich, Chief Executive Officer, Workers' Comp Solutions. Gary’s charge to us was to discuss the effect of national health care reform on workers' compensation. Thanks a bunch, Gary. But we had a stimulating discussion as we opened that colossal can of worms. I'll write more about this in another post. One of the issues our panel tossed around was chronic pain. We've written about chronic pain many times over the last few years. Here are links to a couple of the relevant posts:Workers Comp Drugs: Paying too much...For the Wrong Medicines!; The Pain Conundrum.

Our concern is that the treatment of chronic pain often involves what is to us a highly problematic overutilization of narcotics. So, I was a bit surprised to learn of Broadspire's well thought out and relatively holistic approach to treating this debilitating and often times life-changing medical condition. With that in mind, I invited Broadspire's medical team to submit a guest blog post for the Insider. Our one requirement was that it be informative to our readers, but not a self-serving advertisement for Broadspire. The company accepted our invitation, and what follows is Broadspire's approach to the treatment of chronic pain. I’d be remiss if I didn't add that Broadspire is not a client of Lynch Ryan's and our publication of this guest blog post does not constitute an endorsement of the company's products or services.

Chronic Pain Management Matters
Candy Raphan RN, BSN, ARNP, MAOM and Dr Jacob Lazarovic, MD, FAAFP, Broadspire

In 2006, The Center for Disease Control and Prevention (CDC) released its 30th annual report on the health status of America, "Health, United States, 2006" which found that the overall health of the nation seemed to be improving or holding steady, but highlighted one particular condition as needing further attention: pain.

Pain is a common and troubling condition around the world. In a 2005 European study, it was estimated that 20% of the world’s population deals with some form of chronic pain. In Europe, chronic pain accounts for over 30 billion euros in lost productivity. In 2002, an American study found common pain conditions caused 13% of workers to experience a loss of productivity over a two-week period. The estimated cost to corporate America was $61.2 billion dollars that year. In fact, pain has been such a prominent health care issue that the 106th U.S. Congress passed Title VI, Sec. 1603, of H.R. 3244, declaring the period between January 1, 2001 and December 31, 2010 the "Decade of Pain Control and Research."

Solutions
Conventional treatment of chronic pain is time-consuming and often very expensive, particularly for those claims that continue without resolution over the course of several years. For this reason, it is important that employers and payers understand the dynamics and drivers of the costs associated with chronic pain. By employing a focused, multi-disciplinary clinical approach very costly segments can be targeted. It is then possible to effectively manage chronic pain from the overall costs associated with medical care and treatment as well as loss of a productive workforce.
Using evidence-based medicine to create a plan of action for those individuals with inadequately managed chronic pain promotes optimum results. Medical management programs can provide information and resources to the claimant's current treating doctors, clinics and hospitals. These types of consultations with providers help achieve the following objectives:

• Safe, rational and effective management of the chronic pain population
• Maximized functionality and return to work
• Management of medical costs
• Focused and designated processes/people to reduce internal duplication of effort
• Documented and measurable results and ROI metrics

The key to the program is the expertise clinical and claim professionals bring to each claim. A highly experienced staff performs the data analysis, oversight and management of the process. An expert panel of specialized pain physicians (anesthesiologists, physiatrists, orthopedists, and psychologists or psychiatrists) provides guidance. Other contracted resources such as selected, accredited pain management facilities and urine drug monitoring labs help ensure that patients are compliant with prescribed regimens.

A Chronic Pain Program has the power to make a sizable difference. With proven methods, resources, and expertise it can provide the support and control to help employees beat pain back and return to productivity.

Cavalcade of Risk and News You Can Use

New Cavalcade of Risk - David Williams of Health Business Blog is this week's host of Cavalcade of Risk. He offers a concise array of postings, including one method of improving immune response that you absolutely do not want to miss. While stopping by, check out his other posts - he always has the scoop on interesting new issues and trends in healthcare. Also, follow his Twitter feed.

Healthcare reform - The latest Kaiser Tracking Poll on attitudes to healthcare reform shows that while Americans are evenly split on health care reform legislation (43% for; 43% against), but agree on certain provisions. The poll also shows that if Congress decides to stop working on healthcare, 58 percent of Americans say they will be either disappointed or angry, with 38% saying they will feel happy or relieved.

There is support for several key provisions of reform that cuts across all political persuasions. Percent saying that it is extremely or very important:
76% - reforming the way health insurance works
72% providing tax credits to small businesses
71% Creating a health insurance exchange / marketplace
71% Helping to close the Medicare doughnut hole
70% Expanding high risk insurance pools
68% Providing financial help for low / middle income

Property-casualty trends - At the Insurance Information Institute's Blog, Claire Wilkinson posts that the U.S. property-casualty rating trends are stable. She reports on the A.M. Best 2009 Rating Trend Review, which says that although the industry’s results are likely to be pressured in 2010, rating actions are not expected to move profoundly in one direction and the number of upgrades/positive outlooks and downgrades/negative outlooks will be fairly balanced over the next year.

California agriculture - According to a study conducted by the California Workers' Compensation Institute, the state's agriculture industry accounted for 5.5 percent of all injury claims and 5.9 percent of all workers' compensation benefit payments over an eight-year study period. The three most common injury categories for these workers were medical back problems without spinal cord involvement; minor wounds and injuries to the skin; and shoulder, arm, knee and lower leg sprains.

Colorado Fraud surveillance - Pending legislation in Colorado would put new restrictions on insurers and employers use of surveillance of employees with workers comp claims. Before surveillance can be conducted, the insurer or employer must have a reasonable basis to suspect fraud, and employees would have the right to a hearing to learn why they are being investigated. Critics of the law say that, if passed, it would be the nation's most restrictive surveillance law related to workers comp. At Comp Time, Roberto Ceniceros examines the issue of the dollar value of surveillance.

Medicare Second Payer deadline - The Centers for Medicare/Medicaid Services (CMS) advises that the deadline for non-group health mandatory reporting for secondary payer has been delayed from April 1, 2010 to January 1, 2011. "Medicare Secondary Payer reporting requirements are intended to ensure that Medicare remains the secondary payer when a Medicare beneficiary has medical expenses that should be paid primarily by a liability, no-fault or workers compensation plan."

Health & Safety - Most employers know that good health & safety resources are avaiable from OSHA and the CDC. Don't forget out neighbor to the north. The Canadian Center for Occupational Health and Safety has a wealth of information also. A few recent finds:
Vibration Exposure
Tips on handling negative interactions at work
Substitution of Chemicals: Considerations for Selection
Excavations: A guide to safe work practices - a 6 part video

(Uncompensable) Nightmare at Work

In December we blogged the horrendous case of Carla Nash, a lovely woman who was mauled by a chimpanzee owned by Sandra Herold, a friend. The 200 pound chimp literally ripped her face apart. Nash, who lacks health insurance, has been hospitalized for over a year at the Cleveland Clinic. The attack destroyed her vision and rendered her face unrecognizable (and unviewable). Doctors have determined that she is not ready for a facial transplant. She has sued Herold for $50 million. Her medical bills will easily run to 7 figures; who will pay has yet to be determined.In our prior blog, we noted that Herold was trying to limit the exposure to her workers comp policy.

A little lost in Nash's tragedy is the fate of Frank Chiafari, the Stamford, Connecticut police officer who came to Nash's aid. The raging, blood-covered chimp approached Chiafari's cruiser, tore off the mirror, ripped open the door and tried to attack the policeman. Chiafari shot and killed the chimp.

In the weeks and months following the incident, Chiafari suffered from post-traumatic stress disorder (PTSD); he experienced anxiety, flashbacks, mood swings and nightmares. He underwent counseling. (It's not clear how much time, if any, he was away from work.) Chiafari's workers comp claim was denied: under Connecticut law, public safety officers are eligible for PTSD benefits only when they shoot people - not animals.

Compensating for the Uncompensated
The good news is that Stamford has been covering Chiafari's medical bills, although they did require him to switch to a therapist of the city's choosing. The even better news is that Chiafari has literally been working his way through this work-related nightmare. He is still on the job.

There is movement in the Connecticut legislature to amend the workers comp statute so that public safety officers are covered for PTSD resulting from the use of deadly force involving animals. As is so often the case, the law will be adjusted long after the incident that exposed the gap in coverage. Fortunately for officer Chiafari, the city, despite the comp denial, recognized the legitimacy of his claim and paid for the needed counseling. They did the right thing for an officer who did the right thing. Nothing will erase the horrible images from that fateful day last February. But life for Chiafari can go on in all its ordinary splendor - more than we can say, alas, for the ill-fated Carla Nash.

Independent Contractors and the (Deadly) Spirit of 1706

Joseph Stack set his house on fire and then piloted a small plane into a building housing the IRS in Austin, Texas. His daughter calls him a hero. Most of us would call him a terrorist. But whatever you call him, he was motivated in part by section 1706 of the 1986 Tax Reforms. Stack was a software engineer, and thus was directly impacted by the following language in the statute, which forbids the hiring of software engineers as independent contractors:

(d) EXCEPTION. - This section shall not apply in the case of an individual who pursuant to an arrangement between the taxpayer and another person, provides services for such other person as an engineer, designer, drafter, computer programmer, systems analyst, or other similarly skilled worker engaged in a similar line of work.

As a result of this unusual and highly specific language, programmers are almost always compelled to work as employees. Unlike the situation for most workers - who may or may not meet the criteria for independence - there is virtually no wriggle room for engineers.

Stack's self-identity as a tax protester goes deeper and taps a rich pathological vein. Envious of the tax exempt status granted to religious organizations, he tried to establish his own church, in his own home. Ten years and $40,000 in tax liabilities later, he gave it up. But he surely did not forget, nor did his daughter, Samantha Bell, who appears to be the last remaining worshipper at the defunct church.

Bell concedes that her father's actions were "inappropriate." Nonetheless, she considers him a hero for taking a stand for "justice." Some stand, some notion of justice! In addition to his own life, Stack's violent act took the life of IRS manager Vernon Hunter and had the potential for killing many more innocent people.

Ironically, the national consensus building around independent contractors is quite the opposite of what Stack envisioned. There is a concerted effort at the federal and state levels to view most working relationships as employer/employee. The burden of proof has shifted onto the companies (most notoriously, FedEx) that try to avoid taxes by calling people "independent contractors."

Joseph Stack might have thought himself a martyr for the cause of tax reform. He is surely something else: a symbol of the violence, fanaticism and rage that threatens to destabilize the most enduring democracy the world has ever known. Not exactly my idea of a hero.

Obscenity Laced Latte

Robert Friedman went to his local Starbucks in Boca Raton and ordered a coffee. He sat at a table and began swearing loudly while punching the wall with his fist. Alarmed by this behavior, the baristas called the cops and had Friedman removed. They asked that he not return to the store or he would be arrested for trespassing. End of story?

Not quite. Friedman suffers from Tourette's Syndrome, which leads to uncontrollable actions in his body and, on rare occasions, a stream of obscenities. Friedman, in other words, suffers from a recognized disability.

In its initial review of the case, the Florida Commission on Discrimination ruled in Starbuck's favor, determining that the baristas had no way of knowing that Friedman was disabled. The commission's own lawyer, however, over-ruled the investigators and found that Friedman had been a regular customer and was thus known to the baristas as a disabled person. As his behavior did not constitute an immediate threat to Starbucks staff or customers, the store had an obligation to accommodate him.

Ah, there's the rub. How exactly do you accommodate an individual who is swearing loudly and smashing walls with his fist? The commission wanted Starbucks to at least ask Friedman to stop behaving in an unruly manner before calling the cops. The commission noted that Friedman did offer an apology at the time of incident, before the police removed him from the premises.

Starbucks disagrees with the commission's findings and believes that its personnel took appropriate action to remove a disruptive customer from the store.

Outside the Comfort Zone
It is easy, perhaps too easy, to side with Starbucks in this situation. It's difficult enough to run a coffee house without worrying about accommodating unruly customers. But before you allow your distaste for bad behavior to slam the door in Friedman's tormented face, take a moment to view this video of children who suffer from Tourette's. They are victims of a cruel and random process that robs them of their dignity and compromises their ability to function in a challenging world. They deserve our sympathy.

As for Friedman, it is admittedly difficult to empathize with an adult who appears simply to behave badly. If we met him as a stranger, we would distance ourselves immediately. But once we know the source of his disruptive actions, he deserves at least a chance to re-establish his tenuous equilibrium. Tourette's puts us all outside our comfort zones - not necessarily a bad place to be. Friedman has to live with this problem every waking moment of his life; he has few, if any, comfort zones. We can accommodate Friedman for a few random moments, while enloying our lattes or going about the many tasks that comprise our hectic days. If nothing else, Friedman's situation reminds us that it is a great gift to be masters of our movements and of our words.

Fresh Health Wonk Review; also - the power of pink, the bunkhouse rule, and more

Clear the decks - it's Health Wonk Review day and Brady Augustine has posted Health Wonk Review: "The Relationship Rescue" edition over at medicaidfirstaid. It's a Dr. Phil-themed issue replete with art, videos, and commentary on some of the best of the health policy blogosphere. Check it out.

The Power of Pink - Sometimes those of us who work in workers comp are so focused on the process, the insurance issues, and following the dollars that we lose sight of the fact that we are actually in the people business. Our friends at the Work Comp Complex Care blog have a refreshing post that demonstrates the difference one person can make: A little pink goes a long way.

The Bunkhouse Rule - Can an injury that occurs at home be compensable? Yes, if your home is your employer's property, according to the South Carolina Supreme Court. Read more details on the ruling in Roberto Ceniceros' article in Business Insurance, Migrant worker's injury in company housing ruled compensable.

Misclassification - The L.A. Times features an article by Dave Gram on a topic that is near and dear to our heart (search for "FedEx"): how companies are slashing payrolls by calling workers independent contractors. The Internal Revenue Service and 37 states are cracking down on this practice, which resulted in an estimated underpayment of $2.72 billion in lost Social Security taxes, unemployment insurance taxes, and income taxes just in the year 2006, according to the Government Accountability Office. Many experts think that the economic downturn has exacerbated the problem of employee misclassification.

Good PT and bad PT - At Managed care Matters, Joe Paduda asks How many dollars are wasted on physical therapy?. He suggests that while he's a believer in the benefits of physical therapy, but advocates for clinical guidelines to separate the wheat from the chaff.

More on the Toyota mess - At Claims Magazine, Mary Anne Median writes that . Her article focuses on issues associated with claim-handling, subrogation, and litigation. It's a fascinating read - here's just a sampling:
"To break it down; damages, subrogation, and settlements will all be affected, not only for current, but also past and future accidents involving Toyotas.

Record workers comp-related ADA payout

An employer's failure to to accommodate an injured worker to return to the workplace can be costly - just ask Sears Roebuck & Co., who learned the hard way. The U.S. Equal Employment Opportunity Commission (EEOC) just announced that Sears will distribute $6.2 million to 235 former employees, the result of Americans With Disabilities Act (ADA)-related litigation. The monetary distribution stems from a September 2009 consent decree which resolved a class lawsuit against the retail giant. It is the largest ADA settlement in a single lawsuit in EEOC history.

This case began in 2001, when appliance technician John Bava injured his knees, wrist, and back after falling down the stairs while on a service call at a customer's home. The injuries required two surgeries and physical therapy.

"Afterward, he tried to go back to work under restricted conditions in which he would not be required to kneel or squat for a prolonged period. “They wouldn’t let me come back,” he said.

Bava, 58, said he applied for several other jobs at Sears, including a service manager position that he claims went to someone younger and less qualified. He said he learned he had lost his job when his wife tried to use his employee discount card and found it had been canceled.

Bava obtained a copy of his personnel file from Sears, and found a memo saying he had been fired for medical reasons.

Bava said he now works as a repairman for another employer and stays busy despite the restricted conditions that his injuries make necessary."

The average award is approximately $26,300. According to reports in the National Law Journal via Law.com, employees will receive between $2,500 and $122,500 each, depending on their individual circumstances. As with all EEOC litigation, none of the settlement fund will retained by the EEOC; all of it will be distributed.

Employers would do well to examine their own return-to-work policies and programs in light of the other provisions that the three-year consent decree prescribes beyond monetary relief: an injunction against violation of the ADA and retaliation, a requirement that Sears amend its workers' compensation leave policy, and train its employees regarding the ADA. Sears must also provide written reports to the EEOC detailing its workers’ compensation practices' compliance with the ADA and post a notice of the decree at all Sears locations.

Besides compliance with the ADA, there are several other lessons to be learned by the stunning lack of communications evidenced in this case:

• When an employee is out on disability, stay in frequent communication to monitor their recovery progress
• Have a return-to-work goal and plan for all injured workers
• If you fire employees, tell them! They shouldn't have to learn about it through canceled benefit cards.

Risk Management, Family Style

We have been following with increasing amazement the saga of Amy Bishop, the Harvard-educated biology professor who certainly is in touch with her rage, if not much else. She was involved in a year-long conflict with the University of Alabama-Huntsville over tenure. Sometime after receiving the final denial, she calmly taught a class and then attended a faculty meeting with 13 colleagues. Forty-five minutes into the meeting, she took out an unregistered automatic pistol and methodically shot six colleagues in the head, three of whom died. Had her gun not jammed, she might have succeeded in executing the remaining 7 people. After being forced out of the room, she calmly called her husband and asked for a ride home.

The astonishing part of this story is that she had apparently already committed a cold-blooded murder. In 1986 she killed her younger brother with a blast from a shotgun. In what now wreaks as a coverup, the incident was classified as an accident: she claimed that she was attempting to remove the shells from the shotgun and accidentally drilled her brother. Sounds reasonable, except that she had already discharged the gun in her bedroom - no one in the family heard the blast (just Amy being Amy?). She was, coincidentally, in the middle of an argument with her brother. As we have now all learned, you definitely do not want to get on Amy's bad side.

Her mother, claiming to have witnessed the shooting, upheld Amy's version of the event. Mom, conveniently, was a politically connected official in the local town. Amy was released into the custody of her parents (enjoying, we presume, her new status as an only child). The investigative report ignored the utter implausibility of the entire story: the incoherent sequence of events, Amy's evident rage, her fleeing the house with the gun and subsequent threatening of people on the street.

Defending the Indefensible Self
Here's the risk management part: Amy's father bought the shotgun after someone allegedly broke into the house. (There is no mention of any police record of this earlier incident.) Dear old dad kept the shotgun in the bedroom, with the shells conveniently laid out on top of a dresser. Amy, a brilliant scientist, but, she would have us believe, mechanically inept, took down the gun and put in the ammunition. (Why? no one bothered to ask.) She "accidentally" discharged the gun into the ceiling. Oops, how did that happen? Then she carries the gun downstairs and asks for help in unloading it. Her brother walks into the kitchen. The rest, as they say, is history as written by the (cruel) victors.

Twenty four years later, Amy practices shooting at a firing range. Her husband does not ask where she got the gun or why she wants to learn how to shoot it. He apparently has no clue what she is planning to do. He claims that he is "no psychologist" - and who could possibly argue with that? When he finally gets to talk to his homicidal wife, secure in a jail cell, she asks if the kids have all done their homework. From executing colleagues to worrying about homework. Who could possibly know what is going on in the mind of this brilliant, demented woman? And how could you possibly hold her parents accountable for enabling this monster and letting her loose upon an unsuspecting world?

Toyota: Success is Dangerous

It will be years before we know the full implications of Toyota's recall problem, but a few things are already evident. In its relentless push to become the world's number one car manufacturer, Toyota lost its corporate soul (to the extent, of course, that any corporation has a soul). As with any business, performance measurement is a month to month, year by year priority. At this point, it appears that Toyota's primary measurement involved gross sales. Since 2003 the company has ignored alarming signs that their quality control was slipping dramatically. Long known as the producer of reliable, if somewhat pedestrian, cars, Toyota tried to become all things to all drivers. They expanded production capacity across the world as their market share grew. They buried the competition, but in doing so, dug a rather big hole for themselves. They will surely survive, but what form will the survival take?

The old adage "be careful what you wish for" should be engraved over every Toyota plant. They wanted to dominate the market and now they dominate the market. Alas, their cars are prone to uncontrollable accelation and compromised braking. A rather unfortunate combination, to say the least.

Acceleration and Stopping
As evidence of the acceleration problem accumulated - going back to the mid-2000s - Toyota entrenched itself in a denial stance. Finally, they acknowledged a problem with the floor mats. They fixed that. Then they admitted to a defect in brake pedal design, which is the subject of the current recall: they are attaching a small plastic shim to the brake pedal to fix that. Now there are indications that a problem may exist in the computers that determine gas feed. To date, Toyota has not conceded on this last potential source of the acceleration problem. If they are wrong on this one, it's virtually three strikes and you're out.

The braking issues in the Prius involve a sophisticated mechanism which seeks to transform the natural friction in braking into energy to charge the car's battery. The good news is that the battery runs longer. The bad news, of course, is that you might not be able to stop the car.

From a risk management perspective, rapid growth is frought with dangers. On the employment side, you are bringing in (thousands of) strangers to make your product. On the management side, your lines of communication are stretched to the breaking point (no pun intended): a work culture that was successful for a relatively small company might prove inefficient and even disastrous for a world-wide organization. Toyota executives may think that today's company is simply an extension of the modest, diligent operation that entered the world market some decades ago, but size matters. Toyota the Giant is no longer "the little engine that could."

Blame the Media?
One dealer thinks the media has created the problem. Tammy Darvish, who operates 4 dealerships in the Washington, D.C. area, thinks Toyota's commitment to safety is equal to that of other manufacturers. "I don’t want to minimize importance of any safety matter. But I think the media has made a sport out of sensationalizing something that is very common: a recall. I sell Chryslers, and they had 18 recalls last year. Did you read about any of those?"

So Toyota's commitment to safety is no different from any other manufacturer. That's a comforting thought! True, the whole problem has been sensationalized. The image of 3,000 pound vehicles hurtling out of control is, well, sensational. It would be nice to think that Toyota will do a little soul searching and re-commit to the values that made them successful: producing a safe, high quality vehicle that accelerates when you want it to and stops when you press the brake. Anything less from Toyota at this point would be, to put it bluntly, criminal.

Fresh Cavalcade of risk; new sidebar resources

A new issue of Cavalcade of Risk has just been posted at John Leppard's blog, Healthcare Manumission. Check it out!

Check out our sidebar resources
In other matters, we'd like to direct your attention to our sidebar of resources, which you can find over in the right hand column of this blog. If you haven't checked it out in awhile, you may find some handy resources. Over the past few weeks, we've double checked all links, deleted a few broken ones, added a few news ones, and generally tidied things up.

Here are a few of the newest resources we've added:

• National Crash Statistics - stats for large trucks and buses involved in fatal and non-fatal crashes that occurred in the United States. These statistics are derived from two sources: the Fatality Analysis Reporting System (FARS) and the Motor Carrier Management Information System (MCMIS). Crash Statistics contain information that can be used to identify safety problems in specific geographical areas or to compare state statistics to the national crash figures.
• Workers Comp Matters - legal podcasts on a variety of workers' comp topics hosted by Massachusetts plaintiff attorney Alan S. Pierce at the Legal Talk Network.
• Workplace Safety - safety articles from Reliable Plant, a publication which focuses on manufacturing processes and plant operations.
• City Data - If need to research any city, zip code, or neighborhood for any reason, this is is a good starting place. It compiles and presents a wide variety of data, stats, photos, maps, news, and reports.
• American Agent & Broker - magazine aimed at property & casualty agents and brokers. Related: editor Laura Mazzuca Toops' blog, Agent for Change.
• Mashable - Whether you're a newbie just venturing a toe in the Web 2.0 water or an early adapter wanting to stay up on the latest Twitter and Facebook news, this site has a lot to offer - from "how to" guides and tips to breaking news and technology trends.
• Communicating With and About People with Disabilities - the Office of Disability and Employment Policy offers a chart with affirmative and negative phrases when speaking about people with disabilities, as well as general communication tips when interacting with people with disabilities.
• Legistalker - Wanting to follow your congressperson during key issues? Try Legistalker, a site that makes it easy to stay on top of what your elected officials say and how they vote. The database is updated every 20 seconds, and relies on data from Twitter, YouTube, Capitol Words, literally hundreds of different news sources, and others.
• Dictionary Of Occupational Titles - This is the complete Dictionary of Occupational Titles (DOT) revised fourth edition, as supplied electronically by the US Dept. of Labor, provided as a public service by
  Information Technology Associates.
• Work Matters- a good blog on labor and employment law by Texas attorney Michael P. Maslanka.
• eLCOSH images - a collection of images intended to educate and promote safety and health in construction. The searchable collection includes images that may illustrate good practices or bad practices. Images are available for free use (with some restrictions) in print publications, training presentations, videos, websites, etc. and can be downloaded in resolutions appropriate for both print use and screen use.
• U.S. Chemical Safety and Hazard Investigation Board - independent federal agency charged with conducting root cause investigations of chemical accidents at fixed industrial facilities. Root causes are usually deficiencies in safety management systems, but can be any factor that would have prevented the accident if that factor had not occurred. The agency does not issue fines or citations, but does make recommendations to plants, regulatory agencies such as OSHA and the EPA, industry organizations, and labor groups. Congress designed the CSB to be non-regulatory and independent of other agencies so that its investigations might, where appropriate, review the effectiveness of regulations and regulatory enforcement.

The Medicare Secondary Payer Statute: In Search of Ariadne’s Thread

In Greek mythology, Daedalus built the Labyrinth for King Minos of Knossos to contain the awful half bull/half man Minotaur. Theseus eventually killed the Minotaur, but only found his way out of the Labyrinth because Ariadne had given him a magic thread to mark his way in and out of the maze. I’m beginning to think that American health care makes the Labyrinth look like an easy walk across Boston Common on a sunny day. And, so far at least, no one seems to have found the magic thread.

Workers’ compensation medical care is now getting whipsawed by two powerful and unstoppable forces: the Medicare Secondary Payer Statute (MSP) and the inexorable aging of the baby boomer generation.

We’ve written about these two looming catastrophes in the past. Seventy-eight million baby boomers are hard to ignore, and the MSP issue is starting to remind me of the 1958 horror movie, The Blob , wherein a gelatinous creature grew gargantuan by eating everything in its path. Two things have already occurred in the new year that bode well for continued growth of the MSP Blob.

The insurance industry goes a-begging
Last week the American Insurance Association, the National Association of Mutual Insurance Companies and the Self-Insurance Institute of America wrote to the Department of Health and Human Services Secretary Kathleen Sibelius asking her to delay the 1 April 2010 implementation of MSP mandatory reporting requirements. You can find the reporting requirements here.

The new regs lay a heavy burden on the comp insurance industry, referred to in the regs as Responsible Reporting Entities (RREs). (Such unfortunate acronyms bring me back, alas, to my days in the military.) RREs must report to the Centers for Medicare and Medicaid Services (CMS) any workers’ compensation claims that involve ongoing medical payments, with the exception of most medical only claims. In their letter, the organizations list five reasons they believe an implementation delay is necessary. The first items are all about process: security protection, a lack of guidance from the CMS and an insufficient period for testing the proposed reporting procedures. The fifth reason, which is really the first reason, is the economic big stick which, when deadlines are missed, will slap fines of up to $1,000 per day per claim upside the heads of RREs. Ouch!

There’s a lot more to it, and we’ll be writing more about it in the coming months, but for now it’s enough to know that the insurance industry is on its collective knees asking for a delay in the implementation of reporting requirements that have already been delayed and extended once.

Inedible Maryland Crabcake?
The second thing affecting MSP that happened in the new year may or may not turn out to be a big deal. On 4 January 2010, the Maryland Workers’ Compensation Commission issued emergency regulations that require CMS approval for all workers’ compensation settlements, not just the ones that meet the review thresholds in the CMS User Guide, version 2.0. The commission is requiring CMS review of virtually every claim up for settlement.

The new procedures require that every settlement pass through CMS before the Commission will approve it. Here is an excerpt from Maryland’s emergency regulations:

A settlement that falls within the Medicare thresholds must be approved by CMS before it will be approved by the Commission.

A settlement the falls outside the Medicare thresholds may be approved by the Commission provided that the settlement agreement:

1. Contains a statement confirming that the interests of Medicare have been considered in reaching the settlement; and

2. Identifies the amount of the proposed settlement:

a. Apportioned to future medical expenses;or

b. Set-aside for future medical expenses through a formal set-aside allocation

3. The apportionment of the amount of the settlement associated with future medical expenses shall be supported by medical evidence such as a medical opinion or evaluation.

While it remains to be seen if the Commission’s action will significantly delay settlements or increase costs in Maryland, it's reasonable to assume that it will. As any workers’ compensation professional knows, the longer a claim stays open, the more it costs. As a result, the Maryland approach to Medicare set asides is not a good candidate for replication in other states.

A Magic Thread
As I write this, I’m about to leave for San Antonio for the 2010 Health and Productivity Forum, sponsored by the Integrated Benefits Institute and the National Business Coalition on Health. I’ll be participating in a panel discussion organized and led by Broadspire’s Gary Anderberg, one of the smartest people I know. Our panel will be addressing workers’ compensation medical care and costs and the effect health care reform may have on both. I sure hope that Gary has brought a few spools of Ariadne’s thread. We're going to need some magic to guide us through this formidable labyrinth.

Posted by Tom Lynch at 10:25 AM Link to, Comment (1), or E-mail this post

Health Wonk Review and other news briefs

Get the latest scoop from the health policy blogosphere at this week's excellent "Health Wonk Review - so what do we do now?" edition. Joe Paduda at Managed Care Matters is our most capable host this week. Kudos to Joe, who is the visionary and founder of Health Wonk Review, a biweekly compendium of best posts from more than 80 participating health policy bloggers, journalists, and organizations. It's been a particularly useful guidepost to the health care reform efforts.

Happy birthday to RIMS - RIMS is celebrating its 60th anniversary as an organization this year. You can look back at the 60 year-history in the current issue of Risk Management, which now is available in digital editions. The current January/February issue also includes articles on the the soft property/casualty market continuing in 2010, a multi-generational perspective on communication, steps to avoid when investigating an employee for fraud, and steps to reduce stress.

Mea culpa, medical style - What happens when doctors who err say they are sorry to their patients? Kevin O'Reilly examines the issues surrounding medical disclosure and apologies when things go wrong in an article in American Medical News. Thirty-five states have laws offering some kind of legal protection for physicians who express regret or empathy to patients who experience an adverse event, and some hospitals that have adopted "I'm sorry" policies have experienced drops in both the numbers and costs of claims. But in looking at some of the legal issues, some attorneys counsel caution. Thanks to David Harlow of HealthBlawg for pointing us to this interesting article, in which he is quoted.

Social networking - At the LinkedIn Workers' Compensation Forum, there have been some lively discussions this week . One on an Illinois Supreme Court ruling which found that an employer is liable for continued TTD benefits to an employee who was accommodated on light duty and terminated for cause, and another on proposed Colorado legislation that would put limits on an employer's ability to spy on employees in workers' comp cases.

Preventing retail fatalities - There has been a decade-long drop in the number of retail workers who died as a result of workplace violence - from 286 in 1998 to 167 in 2007. Of that number, nearly half were employed in late-night establishments: 39 in convenience stores, 32 in gas stations, and 7 in liquor stores. OSHA has updated its guidance for prevention: Recommendations for Workplace Violence Prevention Programs in Late-Night Retail Establishments.

Manufacturing declines - At Comp Time, Roberto Ceniceros looks at the the steep downward slope of manufacturing jobs in California and in the nation, and raises the question of this decline's long term impact on workers comp premium production and services.

Workplace wellness - The Health Affairs blog recently featured a pair of posts on workplace wellness programs. Jaan Sidorov makes the case for why wellness incentives belong in the workplace. In response, Alec Balch examines more issues surrounding incentives: whether financial rewards and penalties should be tied to an employee's coinsurance premiums, and to what extent incentives should be based on the employees ability to meet certain health standards vs wellness program participation.

Regulatory forecast - A rundown of the U.S. Department of Labor’s (DOL) regulatory agenda for 2010 is available on Human Resources News. There's a strong emphasis on safety. Thanks to HRhero for the pointer.

Case law - Featured on the LexisNexis Workers' Compensation Law Center - The Top 10 Bizarre Workers’ Comp Cases for 2009 makes for a fascinating read.

Bad employee of the month - we offer our nominee. She will just have to try harder if she wants to earn a slot in the Insurance Fraud Hall of Shame - the class of 2009 features some rather egregious offenders.

Toyota: Hands Off!

Toyota, the world's largest automaker, is in the midst of a public relations nightmare. Over two million vehicles have been recalled for a problem with acceleration: gas pedals are prone to sticking, which leads to unstoppable cars hurtling along at high speeds. For months, Toyota denied that there was a problem. Well, there is no denying it now. U.S. Transportation Secretary Ray Lahood has advised owners of the vehicles not to drive them. [Update: he is backpedaling from his statement.]That's over two million people who are not supposed to drive for the foreseeable future. With all due respect, Mr. Secretary, in this culture where the automobile is less a luxury than an essential, what are these millions of drivers supposed to do?

For the sake of clarity, here are the specific vehicles with a pedal problem:

2007-10 Camry
2009-10 RAV4
2009-10 Corolla
2009-10 Matrix
2005-10 Avalon
2010 Highlander
2007-10 Tundra
2008-10 Sequoia
2004-09 Prius
2007-10 Tacoma
2009-10 Venza

We frequently blog the compelling issue of personal risk management: the myriad decisions we all make in mitigating risk and prolonging the chances of living to see another day. Well, we have here a crisis of huge proportions that confronts Toyota drivers with some very difficult decisions. In keeping with our usual mandate, we will try to focus primarily, but not exclusively, on the implications for workers comp.

At the head of the line are companies that operate Toyota fleets, or that have employees operating Toyotas leased by the employer. At this moment there are irrevocably immense liabilities in allowing employees to continue to drive the vehicles listed above. Of course, the usual "to and fro" issues prevail in determining whether employees injured in an accident are covered by workers comp. (Astute readers will recall that in California, anyone driving a company car is covered by comp 24/7.) But even where comp should be the "exclusive remedy," employers are vulnerable to suits alleging "wilful intent" should they insist that Toyota drivers stay behind the wheel. Prudent risk managers will rent alternative vehicles until the Toyotas have been repaired.

For employees driving their own Toyotas, the "to and fro" rule prevails. However, what happens when an employee is "in the course and scope" of employment and gas pedal lock leads to an accident? Will the employer be held liable for the injuries to third parties? Should employers prohibit employees from driving the compromised Toyotas while working? If yes, how are these employees supposed to do their jobs? Who pays for the replacement vehicles?

Secretary Lahood has accelerated the risks associated with the Toyota recall. He has put the nation on notice than any use of the above vehicles entails unreasonable risk.

This all brings to mind a Toyota ad campaign from an earlier decade. The slogan was: "Get your hands on a Toyota. You'll never let go." I remember thinking at the time that there was a gruesome ambiguity to the wording. The image of a dead driver behind the wheel of a crushed vehicle rose up in my (admittedly hyper-active) imagination. Well, that slogan has come back to haunt the automotive giant. This is no time to put your hands on the wheel of a Toyota. Until this immanent hazard is addressed, it's definitely time to let go.

Addendum:
We just noticed that Renaissance Alliance's Consumer Insurance Blog has a post on what to do if you experience sudden acceleration - it includes a video and some tips from Consumer Reports - whether you own a Toyota or not, it's a good safety skill to learn

Twitter feeds we recommend

For workers' comp news and other links in between blog posts, we encourage you to follow @workcompinsider on Twitter. If you aren't yet on Twitter, you may want to think about it. Even if you aren't ready to engage, it can be a great way to follow industry buzz. You may already be following many blogs and news sources through RSS (syndicated) feeds via news readers - we do, too. But Twitter feeds add diversity and immediacy as well as the potential for engagement. You don't have to have messages fed to your mobile devices, you can choose to follow folks on your Twitter home page or via a service like TweetDeck.

Here are just a few of the interesting Twitter feeds that we follow - most are insurance- or work-related:

@AIADC - The American Insurance Association "represents approximately 350 major insurance companies that provide all lines of property and casualty insurance"

@sthomas_eea - by Stephanie R Thomas, "economic/statistical expert & consultant specializing in employment issues"

@ijournal - daily insurance news headlines for the Property Casualty industry

@mashable - "The hottest Twitter news, Twitter tips and Twitter help"

@TheClaimsSPOT - Snippets from the blog of Marc Lanzkowsky, founder of Lanzko Consulting "Spotting process improvements & cost savings for claims & related orgs"

@ClaimsMagazine - by Eric Gilkey, Editor-in-Chief of Claims magazine

@safetycommunity - "the first online community created exclusively for the workplace safety industry," hosted and maintained by the folks at Ansell Occupational Health

@HRHero - by Tony Kessler, Group Publisher at HRHero. Information on employment law for HR and business pros from law firms in all 50 states, D.C., and Canada

@MWConsultingLLC - a company that focuses on OSHA compliance through employee training and proficiency

@NIOSH - The National Institute for Occupational Safety and Health

@hpandpsafety - "Specialists in workplace safety with emphasis on maintaining OSHA compliance"

@OccHealthSafety - Occupational Health & Safety Magazine; Carla Saavedra, Jr. Web Editor

@Health_Affairs - "The Policy Journal of the Health Sphere"

@workforcenews - News about workforce management and HR issues from Workforce Management magazine

@fastompany - "empowers innovators to challenge convention and create the future of business"