Reserving is an important aspects of claim handling. Whether it is a normal run of the mill lost time claim, or a claim with benefits payable over the remaining life of the injured worker, the goal is always the same: To accurately place the proper amount of money or reserves in the claim for the duration of the claim, which may be for the life of the claimant.

One method of estimating life expectancy is to use a one-size-fits all chart or table based upon historical data. This is the method set by California regulations (§10169. Commutation Tables and Instructions) when a commutation of future benefits is ordered by a WCJ. This table is based on the U.S. Decennial Life Tables for 1989-91, a metric that is outdated by about two and a half decades.

However, a rigid life expectancy chart or table may not be the best choice when a more accurate calculation is needed, such as when estimating settlement value, or a reserve estimate.

U.S. life expectancy increased for the first time in two years, according to a new report by the CDC. The report, released this week, marks a notable reversal: People born in the U.S. in 2022 can expect to live 77.5 years, an increase from 76.4 in 2021.

The data shown in this report reflect information collected by the National Center for Health Statistics for 2021 and 2022 from death certificates filed in all 50 states and the District of Columbia and compiled into national data known as the National Vital Statistics System. Differences between death rates were evaluated using a two-tailed z test.

The 10 leading causes of death in 2022 remained the same as in 2021. Heart disease was the leading cause of death, followed by cancer. Age-adjusted death rates decreased for 9 leading causes and increased for 1. Life expectancy at birth increased 1.1 years from 76.4 in 2021 to 77.5 in 2022, largely because of decreases in mortality due to COVID-19, heart disease, cancer, unintentional injuries, and homicide.

Data from the National Vital Statistics System

– – Life expectancy for the U.S. population in 2022 was 77.5 years, an increase of 1.1 years from 2021.
– – The age-adjusted death rate decreased by 9.2% from 879.7 deaths per 100,000 standard population in 2021 to 798.8 in 2022.
– – Age-specific death rates increased from 2021 to 2022 for age groups 1-4 and 5-14 years and decreased for all age groups 15 years and older.
– – The 10 leading causes of death in 2022 remained the same as in 2021, although some causes changed ranks. Heart disease and cancer remained the top 2 leading causes in 2022.
– – The infant mortality rate was 560.4 infant deaths per 100,000 live births in 2022, an increase of 3.1% from the rate in 2021 (543.6).

The rise in life expectancy comes as overdose deaths leveled out between 2021 and 2022, according to a separate CDC report also released Thursday.  According to that report, while overdose deaths nearly quadrupled over the past two decades, they did not significantly increase between 2021 and 2022. The rate of drug overdose deaths was 32.4 deaths per 100,000 people in 2021 and 32.6 deaths per 100,000 people in 2022.

And a number of other factors can make major differences. According to the latest CDC data in 2022, the difference in life expectancy between females and males was 5.4 years, a decrease of 0.4 year. from 2021.

From 2021 to 2022, age-adjusted death rates, corrected for race and ethnicity misclassification, decreased 15.4% for Hispanic males (915.6 to 774.2) and 14.5% for Hispanic females (599.8 to 512.9).

Among the non-Hispanic population, death rates decreased 15.9% for American Indian and Alaska Native males (1,717.5 to 1,444.1), 14.0% for American Indian and Alaska Native females (1,236.6 to 1,063.6), 9.7% for Asian males (578.1 to 522.2), 9.3% for Asian females (391.1 to 354.9), 8.5% for Black males (1,380.2 to 1,263.3), 11.8% for Black females (921.9 to 813.2), 7.9% for White males (1,055.3 to 971.9), and 7.8% for White females (750.6 to 691.9).

Key California health care players are divided over whether the state should impose new regulations on pharmaceutical middlemen to bring down spiraling drug prices in the largest market in the nation.

Those middlemen, the pharmacy benefit managers, came under the microscope Tuesday at “Corrective Action: How to address prescription drug costs,” a POLITICO Live event. And according to the report by Politico “It was somewhat hostile territory for the industry, featuring its chief antagonist in Sacramento: State Sen. Scott Wiener.”

Wiener has authored legislation, Senate Bill 966, that would impose new rules on PBMs, represented on the panel by industry advocate Caitlin Berry.

Anthony Wright, executive director of Health Access California, a consumer advocacy organization, supported the goal of the legislation though not its specifics while a third panelist, UC Law San Francisco professor Robin Feldman argued that California can in fact act more boldly to bring down drug prices in the state.

Here are five takeaways from the event:

1) A chief antagonist of pharmacy benefit managers does not want to eliminate them. Wiener did not go as far as others nationally who seek to abolish the middlemen who negotiate with manufacturers over drug prices. He’s carrying legislation that would, among other things, require PBMs to be licensed with the California State Board of Pharmacy and to pass down drug rebates to consumers. The proposal is expected to dominate health care regulation discussions in Sacramento this legislative year.

Caitlin Berry, a senior principal with Prime Therapeutics, opposes the bill and argued her industry bolsters competition through negotiations and actually helps limit prices. “We build networks that stoke competition in between pharmacies to capture business from the insurance members in order to lower costs for the payer,” she said.

2) States have been limited in their ability to regulate the drug industry. That could be changing. UC Law San Francisco professor Robin Feldman argued a 2023 Supreme Court ruling allowing California to set rules for pork ranchers has reframed the Constitution’s Commerce Clause in a way that would allow states to regulate pharmaceuticals, too.

3) A group representing consumers didn’t back one proposed regulation of PBMs.Wiener’s SB 966 does not yet have the approval of Health Access California. Anthony Wright, it’s executive director said “we agree that there should be regulation of the industry,” but did not sound sure of which entity should license PBMs.

4) Drug pricing remains the elephant in the room. Pharmaceutical prices have risen faster than inflation, prompting finger-pointing between industry players and skeptics in government over who’s to blame.

5) Artificial intelligence could bring down drug costs. Wiener pointed to an antibiotic developed by artificial intelligence as evidence that the technology presents major promise for drug development. And using AI to help design treatment could help bring down the costs of doing so, including speeding the designing of generics, said Feldman.

The United States filed a complaint alleging that six health plans participating in the Uniformed Services Family Health Plan (USFHP) program, as well as their trade group, the US Family Health Plan Alliance, violated the False Claims Act by knowingly retaining erroneously inflated payments for healthcare services the health plans contracted to provide to retired military members and their families. The United States has also reached a settlement with Department of Defense (DOD) contractor Kennell & Associates Inc., a consulting firm, related to the conduct.

The USFHP program is one of the healthcare options available to military personnel, retirees and their families. Six health plans are eligible to participate in this program, each of which is a defendant in the government’s complaint: Brighton Marine Health Center, CHRISTUS Health Services, Johns Hopkins Medical Services Corporation, Martin’s Point Health Care, Pacific Medical Center and St. Vincent’s Catholic Medical Centers of New York.

Through the USFHP program, the DOD pays the plans capitated rates to provide healthcare services to their enrollees. According to the complaint, in June 2012, the plans learned of calculation errors that had inflated the rates they had been paid in prior years. Nevertheless, the plans took steps to conceal the existence of the overpayments from the government and continued to submit invoices at the inflated payment rates. The complaint alleges that during discussions about rates for the subsequent year, some of the plans even asked the government to continue paying them at the prior, inflated rates even though, by that time, those plans knew the rates were inflated by the errors.

“Contractors have an obligation to return overpayments, and we will hold accountable contractors that knowingly and improperly retain such funds,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “We are committed to ensuring that taxpayer funds for healthcare services to military members and their families are actually used for that purpose, not to enrich those charged with administering the program.”

“Protecting the integrity of the healthcare system for our military members and their families, is a top priority of the Defense Criminal Investigative Service (DCIS), the law enforcement arm of the Department of Defense Office of Inspector General,” said Acting Special Agent in Charge Brian J. Solecki of the DCIS Northeast Field Office. “The DOD expects companies to adhere to contract requirements and DCIS will continue to work with our law enforcement partners and the Justice Department to hold DOD contractors who engage in fraudulent activity at the expense of the U.S. military accountable for their actions.”

The United States filed its complaint in a lawsuit originally brought under the qui tam or whistleblower provisions of the False Claims Act by Jane Rollinson and Daniel Gregorie in the District of Maine. From 2007 to 2015, Rollinson worked at Martin’s Point Health Care, including as its Interim Chief Financial Officer. Gregorie was a consultant to the CEO and Board of Martin’s Point Health Care and later served on its Board of Trustees. The False Claims Act permits a private party to file an action on behalf of the United States and receive a portion of any recovery. The United States has the ability to intervene in such lawsuits, as it has in this case. The qui tam case is captioned United States ex rel. Rollinson v. Martin’s Point Health Care Inc., No. 2:16-cv-00447-NT.

The United States entered into a settlement agreement with Kennell and Associates Inc., a research and consulting firm located in Falls Church, Virginia, that provides actuarial consulting services to the Defense Health Agency (DHA) in connection with the USFHP program. The settlement resolves allegations that Kennell & Associates failed to notify DHA about errors in executing the rate-setting methodology that caused the USFHP rates to be overstated and their impact on DHA’s payments made to the plans. Under the terms of the settlement agreement, Kennell & Associates has agreed to pay the United States $779,951, plus interest, as well as contingent payments based on its annual contract revenue and cash reserves through the year 2025. The settlement amount is based on Kennell and Associates’ ability to pay.

The Civil Division’s Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the District of Maine investigated the case, with assistance from DHA.

Attorneys Diana Cieslak, Evan Ballan and Amy Kossak of the Civil Division’s Fraud Section and Assistant U.S. Attorneys Andrew Lizotte and Sheila Sawyer for the District of Maine are handling this case.

The claims in the complaint and settlement agreement are allegations only. There has been no determination of liability.

In 2021 Ahmad Zaki Noori, who lived in Sacramento, was arraigned on two felony counts of workers’ compensation insurance fraud, after allegedly misrepresenting symptoms following a work-related injury, in order to receive $21,000 in undeserved benefits.

On July 16, 2019, Noori, while working as a welder, sustained a head injury and contusions on multiple parts of his body.

Following his injury, a workers’ compensation claim was filed with his employer’s insurance company and Noori began receiving workers’ compensation benefits. He presented himself as someone with severe amnesia and as someone who had difficulty performing daily functions of living, like speaking, walking or driving.

An investigation by the California Department of Insurance found Noori misrepresented his symptoms to medical professionals and those handling his claim.

Undercover surveillance showed Noori speaking, walking, and driving – all functions he claimed not to be able to do as a result of the injury. The surveillance also showed him performing duties at an automobile dismantling yard, like loading items onto a flatbed trailer and changing a spare tire.

In addition, two of his former co-workers reported they saw him out and about acting normally. One co-worker reported seeing Noori inside a retail store and that he was walking unassisted, laughing, and speaking on the phone. The second co-worker reported seeing Noori at another retail store and that he drove a vehicle into the parking lot, exited the vehicle and was able to walk with no walking aids.

After watching the video surveillance, his doctor reported the actions Noori was performing in the video were drastically different than the actions he was performing during his office visits. The doctor also reported that Noori showed no evidence of neurocognitive or orthopedic deficits during the entirety of this claim period.

Due to Noori’s misrepresentations, he received $21,000 in undeserved workers’ compensation payments and his employers’ insurance company lost an additional $80,679 in medical, legal and investigation costs.

Noori was arrested at his residence on April 13, 2021.

On March 23, 2023, Ahmad Zaki Noori was convicted of workers’ compensation insurance fraud. The amount of restitution requested by the victim, Sentry Insurance, was contested by Noori.

On March 12, 2024, a restitution hearing was conducted. The evidence proved the victim sustained losses totaling $139,130.97 in temporary disability pay and medical expenses due to Noori’s fraudulent workers’ compensation insurance claim. The Court ordered Noori to pay the victim $139,130.97 in restitution.

In August 2022 Cal/OSHA opened an investigation, and later issued 18 citations, including six citations for willful-serious violations, to Parter Medical Products, Inc. in Carson California for failing to protect its employees from overexposure to ethylene oxide (EtO), a toxic chemical. The proposed penalties totaled $838,800. It’s inspection showed “this was not an isolated incident of chemical overexposure to workers. Parter Medical Products, Inc. dba Parter Sterilization Services was founded in 1984, and uses ethylene oxide gas to sterilize medical devices.

The Carson City Council unanimously voted in early 2022 to request air monitors be placed in various locations of the city to monitor air quality. South Coast AQMD was further investigating EtO emissions in the nearby residential communities and the agency was working with the City of Carson to identify additional locations to collect 24-hour samples in the nearest community and school. So far, data from residential monitors show EtO levels to be within typical background levels.

And now on March 14, 2024 the U.S. Environmental Protection Agency announced a rule that will reduce lifetime cancer risks for people living near commercial sterilization facilities across the country. The final amendments to the air toxics standards for ethylene oxide commercial sterilization facilities put in place the strongest measures in U.S. history to reduce emissions of EtO, one of the most potent cancer-causing chemicals. Through the installation of proven and achievable air pollution controls, commercial sterilizers will reduce emissions by more than 90%.

In finalizing this rule, EPA considered the latest data and science, while taking into account the importance of a safe and reliable supply of medical sterilization devices for patients and hospitals. EPA worked closely with partners  including at the Department of Health and Human Services, to develop a final rule that centers on public health. The EPA claims that this final rule provides sufficient time and flexibility for facilities to come into compliance, simultaneously affording strong public health protection for nearby communities while minimizing any potential impacts to the medical device supply chain.

In developing the final rule, EPA conducted extensive outreach to communities and stakeholders to ensure meaningful and extensive participation during the public comment period. EPA conducted public hearings, national webinars, and public meetings hosted by regional EPA offices. The considerable feedback received from the three days of public hearings, as well as the more than 40,000 comments submitted to the rulemaking docket, both informed the final rule and demonstrated the strong need to issue these vital health protections. Based on this input, EPA improved the risk assessment and strengthened the standards to ensure risk reductions for surrounding communities.

The final rule will address emissions at nearly 90 commercial sterilization facilities that are owned and operated by approximately 50 companies. Based on extensive input and review, EPA is finalizing the following amendments to the National Emission Standards for Hazardous Air Pollutants that:

• Establish standards for currently unregulated emissions, such as building leaks (“room air emissions”) and chamber exhaust vents, to reduce cancer risk and account for technological developments in pollution control.
• Strengthen standards that are on the books for sources such as sterilization chamber vents and aeration room vents.
• Require continuous emissions monitoring and quarterly reporting for most commercial sterilizers that will provide communities, states, Tribes, and local governments, and EPA with data to ensure EtO emissions are not entering the outdoor air.
• Ensure that sterilizers are subject to emission standards during periods of startup, shutdown, and malfunction so there is continuous clean air protection.
• Other clarifying items including electronic reporting and technical revisions.

This final rule for commercial sterilizers is one of a series of coordinated actions that EPA is taking to reduce exposure to EtO. Under the Federal Insecticide, Fungicide, and Rodenticide Act, EPA’s Office of Pesticide Programs is also working on a comprehensive set of new mitigation measures for EtO to reduce exposure for workers who use EtO to sterilize products. EPA has been working to support alignment of today’s Clean Air Act rule with the action being taken under FIFRA.

EPA is also working to strengthen standards to reduce EtO and other toxic pollutants from chemical plants. Other actions to address EtO emissions and advance EtO research include:

• Investigating additional sources of EtO (e.g., stand-alone warehouses) and opportunities for emissions controls.
• Enforcing existing regulations as appropriate.
• Conducting research to better understand and measure EtO.

For more information, visit EPA’s Final Amendments to Strengthen Air Toxics Standards for Ethylene Oxide Commercial Sterilizers webpage.