National Council on Compensation Insurance, Inc. 901 Peninsula Corporate Circle Boca Raton, FL NCCI-123 ( ) ncci.

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1 National Council on Compensation Insurance, Inc. 901 Peninsula Corporate Circle Boca Raton, FL NCCI-123 ( ) ncci.com

2 Welcome to ncci s 2012 issues report The 2012 edition of NCCI s Workers Compensation Issues Report arrives at a time of continuing economic uncertainty. But as market stakeholders continue to await a full economic recovery, we ve assembled a collection of industry experts to examine the most pressing issues, offer varying perspectives, and provide predictions for the year ahead. Among the topics examined: Updated results from NCCI s 2011 State of the Line report Two perspectives on the prospects for economic recovery from Bob Hartwig, president of the Insurance Information Institute, and Harry Shuford, NCCI chief economist An examination of how opioid overprescribing and physician dispensing are harming claimants and employers from Joseph Paduda, president of CompPharma, LLC Forecasts for state-based and federal activities that may affect workers compensation in the coming months We trust that you will find these articles both timely and insightful. And, of course, NCCI will continue to provide additional industry research, analysis, and issues overviews at ncci.com throughout the year. Please enjoy the 2012 edition of NCCI s Issues Report. Stephen J. Klingel, CPCU, WCP President and CEO NCCI NCCI is the nation s most comprehensive source of workers compensation insurance information. We gather data, analyze industry trends, and prepare objective insurance rate and loss cost recommendations. These activities, together with our research, analytical services and tools, and overall commitment to excellence, help foster a healthy workers compensation system. Visit ncci.com. 1

3 4 TABLE OF CONTENTS Workers Compensation Market Struggles to Identify a Direction Stephen J. Klingel, CPCU, WCP President and CEO, NCCI 8 Divergent Fortunes: As Labor Markets Recover, Will Workers Compensation Insurers Lag Behind? Robert P. Hartwig, PhD, CPCU President and Economist, Insurance Information Institute 11 NCCI Research Brief: Workplace Violence 12 The Economy and Workers Comp Are Stuck in the Doldrums What Will It Take to Get Us Moving Again? Harry Shuford, PhD Chief Economist, NCCI 19 Legal Brief: Claimants Duty to Cooperate with Medical or Vocational Rehabilitation NCCI S MISSION STATEMENT Legislation and Regulatory Outlook Peter Burton, CPCU, AU Senior Division Executive, State Relations NCCI Wasted Dollars, Wasted Lives How Opioid Overprescribing and Physician Dispensing Are Harming Claimants and Employers Joseph Paduda President, CompPharma, LLC 27 NCCI Research Brief: Workers Compensation Prescription Drug Study: 2011 Update is a publication of the National Council on Compensation Insurance, Inc. 901 Peninsula Corporate Circle Boca Raton, FL Published March 2012 Reprints, permissions, and reader feedback Contact Gregory Quinn, Media Relations Director gregory_quinn@ncci.com Fax: For more information or to view the electronic version of this Issues Report, visit ncci.com. includes articles written by authorities from outside of NCCI.These articles reflect the authors opinions and do not necessarily represent the views of NCCI. Copyright 2012 National Council on Compensation Insurance, Inc. All Rights Reserved Ready or Not, Here Comes Technology: A Reluctant Workers Comp System Ponders the Benefits and Risks of Change Nancy Grover Editor, Workers Compensation Report Program Director, National Workers Compensation and Disability Conference & Expo Workers Compensation and the Aging Workforce Tanya Restrepo, MBA, and Harry Shuford, PhD NCCI s Actuarial & Economic Services Division Legal Brief: Medical Marijuana No Cure-All in Workers Compensation Context The History of Rate Regulation in Workers Compensation Dennis Mealy, FCAS, MAAA, Chief Actuary, NCCI; and Karen Ayres, FCAS, MAAA, Director and Actuary, NCCI NCCI s Actuarial & Economic Services Division Legal Brief: Missouri s Exclusive Remedy for Occupational Disease Workers Compensation Claim Frequency Rise Examined Jim Davis, ACAS, MAAA; and Yair Bar-Chaim NCCI s Actuarial & Economic Services Division 48 Legal Brief: Injuries Incurred Working at Home Continue to Pose Challenges During 2012, please be sure to visit ncci.com for continual updates on the issues and articles contained in this Issues Report. 2 3

4 Workers Compensation Market Struggles to Identify a Direction By Stephen J. Klingel, CPCU, WCP President and CEO NCCI With the onset of the 2007 recession and the stumbling economic recovery that has followed, the task of forecasting the workers compensation market outlook has been fraught with uncertainty and constant adjustment. In May 2011, NCCI delivered our diagnosis that conditions in workers compensation were deteriorating. This analysis was based on observations that the line was experiencing an ever-lengthening list of challenges, including poor underwriting results, declining premiums, and a new and unwelcome uptick in claim frequency. At the beginning of 2012, however, a gradually stabilizing economy appears to have helped slow the precipitous decline in workers compensation net written premium that private carriers experienced from In fact, our current projections for 2011 show that direct written premium increased approximately 9% in So what is the current outlook for workers compensation, and what are the key issues that NCCI is tracking? In the following, we examine some of the more critical market indicators. Challenging Conditions NCCI s annual State of the Line report for 2011 highlighted a number of cautionary trends facing the workers compensation line. Among these, the Calendar Year combined ratio for private carriers increased another 5 points in 2010, to 115. The 2010 Accident Year combined ratio was 114, also up 5 points from Accident Year While the line benefited from increased levels of investment income, it still produced a 1% pretax operating loss for 2010 the first pretax operating loss since NCCI also noted that the reserve position of private carriers continued its recent pattern of modest deterioration in We estimated the reserve deficiency to be $10 billion at year-end 2010, up $1 billion from year-end After credit for the allowable discounting of the indemnity reserves for lifetime pension cases, the reserve position remains at a relatively slight inadequacy of about $5 billion on a total carrier reserve base of more than $109 billion. And in a singularly distressing development, the countrywide lost-time claim frequency decreases for NCCI states that occurred without interruption for the last 12 years came to an abrupt halt in 2010 (more on this ahead). A gradually stabilizing economy appears to have helped slow the precipitous decline in workers compensation net written premium that private carriers experienced from NCCI is working now to collect, analyze, and publish full Year 2011 results for the line of business. But as can easily be seen from the previous statistics, a significant number of industry trends in recent months were not moving in the direction we would like to see for a healthy system. Signs of Change in Residual Markets After six consecutive years of decline in the population of workers compensation residual markets managed by NCCI, we are now seeing an increase in new application premium bound for residual market coverage. In fact, the new assigned premium for the first three quarters of 2011 is up 12% versus the same period in Equally as important, the rate of change increased in Third Quarter 2011 as new assigned premium bound for the residual market increased 27%. Residual market operating results, a key factor in the health of workers compensation markets, have remained manageable. However, the combined ratio for all residual market pools serviced by NCCI increased from 114% in 2009 to 120% in Preliminary indications show that the residual market combined ratio may be increasing slightly again in NCCI is watching this important indicator closely as full Year 2011 experience is reported. As always, we will continue to work toward self-sufficient residual markets in all states where we are responsible for residual market rate filings. Unexpected Claim Frequency Result Perhaps the most surprising and disturbing negative development in 2010 was the aforementioned increase in injury claim frequency the first in 13 years. Based on a preliminary analysis of data in NCCI states, the frequency of lost-time claims per $1 million of premium increased 9% in 2010, based on our standard measures of frequency change. It is important to note, however, that NCCI s research indicates that as the recession ended there were several distortions in the data, which resulted in an overstatement of the indicated change. Once adjustments were made for those distortions, frequency was shown to have increased a more modest 3%. The biggest distortion was the impact of premium audits on the calendar year premiums. As the recession took hold, insurers discovered that the audits, rather than producing additional premium as in most years, were resulting in significant reductions to Calendar Year 2010 premiums. Those reductions were more properly reflected in reduced exposures that really belonged in Calendar Year One leading explanation for the increase in new claims may be small lost-time claims that may have been medical-only claims in more normal times. This is apparent when noting the change in the average cost of lost-time claims from 2009 to In NCCI states, the average indemnity cost per lost-time claim declined 3% from The average medical cost per lost-time claim increased 2%, yielding a total lost-time claim cost change of 0%. We believe that the small change in average severity of lost-time claims in 2010 is probably an aberration. This is likely caused by a temporary influx of medical-only claims becoming smaller lost-time claims as the recovery firms. The numbers do not reflect an underlying reduction in medical and indemnity cost drivers. And in spite of this shift, the underlying cost drivers for both indemnity, and particularly medical, are still present. This means that medical costs, absent the claim shifts, are still likely to be increasing in excess of medical CPI as they have done for many years. Although adjustments reduce the frequency increase for 2010 to 3%, this increase still must be viewed as an area of significant concern. NCCI will be watching the frequency situation closely to determine whether the increase is a one- or two-year occurrence (as happened in the early 1980s) or a more permanent and disturbing trend. (For more detailed information on frequency, please see NCCI s Workers Compensation Claim Frequency Rise Examined research report, summarized in this Issues Report.) Notable External Forces Federal Activities Apart from economic factors, a number of external forces can also affect the continued stability and smooth operation of the overall workers compensation system. For example, the Patient Protection and Affordable Care Act (PPACA), passed by Congress in 2010, is still in its early stages of implementation. The only direct impact on workers compensation to date was changes to the Federal Black Lung program, which liberalized criteria for qualifying for direct benefits and survivor benefits. However, another PPACA provision requires that the Secretary of Health and Human Services (HHS) determine whether or not types of insurance other than health have to 4 5

5 comply with the same basic procedures (e.g., numbering, tracking, billing, etc.) required for the health industry under the Health Insurance Portability and Availability Act (HIPAA). A hearing was held by the Subcommittee on Standards of the National Committee on Vital and Health Statistics during November 2011 to take testimony as the basis of recommendation to the Secretary. Clearly, PPACA is a major reorganization of the healthcare industry, which may have residual impacts on workers compensation. With court cases challenging the bill s constitutionality moving through several federal courts, the uncertainties surrounding PPACA and its implementation remain... as does the industry s commitment to respond to adverse outcomes. On another federal front, the Dodd-Frank Act mandates that the new Federal Insurance Office (FIO) complete a study about state insurance regulation, and any needed changes and/or modernization, and submit it to Congress by the end of January That date was pushed back, and in comments reported in January s National Underwriter magazine, FIO Director Michael McRaith stated that FIO will not be a regulatory authority but rather a monitor of the insurance sector. When it is issued, the FIO report and accompanying recommendations are likely to be the main topic of conversation regarding insurance issues and the federal government for some period of time. Another potential issue will be any call for data collection from insurance companies by the FIO and possibly the Office of Financial Research (OFR), which was also created by the Dodd-Frank Act. Here again, the workers compensation industry at large is paying close attention to developments at the federal level, and NCCI stands ready to respond with information and expert input as required. State Activities In 2012, elections and the economy are expected to be the main focuses in state capitals across the country, potentially leaving little room for major workers compensation reform efforts. In all, 11 states will be holding gubernatorial elections this year, with Democrats defending eight seats and Republicans defending three seats. And 44 states will be holding legislative elections in 5,979 separate races. Approximately 64% of state senate seats and 87% of state house seats are up for grabs, including 250 seats being vacated by term-limited legislators. NCCI has noted before that we are seeing a gradual shift in the number of loss cost declines compared to loss cost increases in many states. In fact, the ratio of increases to declines has doubled in just two years. And given the still-struggling economies in many states, that trend is expected to continue in In all, given the busy election year, NCCI anticipates that many states will focus on pursuing focused changes to their workers compensation systems rather than broad-based reforms. The ultimate goal will be to make state systems less expensive and more economically attractive to business. For more detailed information on the legislative outlook and key state activities, please see the 2012 Legislation and Regulatory Outlook piece in this Issues Report. Apart from economic factors, a number of external forces can also affect the continued stability and smooth operation of the overall workers compensation system. Economic Outlook The health of the economy will play a large part in how quickly the workers compensation line is able to reverse existing negative trends. Our latest economic analysis examined a number of key trends that we will be closely monitoring during Among these are: Employment Growth: Continued weakness in the economy is expected to produce slow growth in private sector employment. Slower job growth indicates that there will be limited pressure on claim frequency and exposure. Wage Growth: Changes in average weekly wages (AWW) are a key factor in determining indemnity severity. The projected weakness in the labor market suggests that pressure on indemnity severity due to wage inflation should increase only slowly. At this point, wage inflation should not be a major concern for the workers compensation industry. Premiums are also directly tied to wages, which may offset any negative effect on indemnity severity. Premium Growth: The observed premium growth in 2010 seems a bit larger given the current level of payroll increases and price increases. One possible reason is that carriers have over-compensated for the audit returns experienced in 2010 and are once again seeing additional premium booked through audits. We expect premium to more closely track the fundamentals of payroll growth and pricing in Medical Inflation: Medical price inflation is an important driver of changes in medical severity. Enhanced utilization of costly medical treatment options also adds upward pressure to medical claim costs. Medical inflation is expected to outpace general inflation for the foreseeable future and will negatively influence medical severity. NCCI Chief Economist Harry Shuford examines the reasons for the economic collapse and the resulting fallout as well as what signs workers comp stakeholders should be looking for to indicate a turnaround in his article The Economy and Workers Comp Are Stuck in the Doldrums What Will It Take to Get Us Moving Again? in this Issues Report. Summing Up As noted at the outset, last year NCCI described the condition of the workers compensation market as deteriorating. Since then, we have continued to compile and analyze the most recent data, and we will offer a new prognosis for the state of the line in May. In the interim, we do know that some indicators have showed signs of improvement particularly the growth in premium and for now at least, the outlook appears to be slightly more positive. Clearly, the economy continues to be a negative drag and any new signs of recession or poor developments in Europe or elsewhere could quickly erode existing gains. But at this moment, we are more optimistic about the outlook for workers compensation than we were six months ago. Despite our tenuous optimism, the line continues to face a daunting list of challenges. Despite our tenuous optimism, the line continues to face a daunting list of challenges, including: Deteriorating Underwriting Results: With investment yields at historic lows, the current levels of underwriting losses are not sustainable. Even with what appears to be a temporary increase in investment gains, the combined ratio needs to decline substantially to earn a reasonable return on capital. Uncertain Claim Frequency Results: It remains unclear whether 2010 s frequency increase is a new normal or a one- or two-year phenomenon coming on the heels of the Great Recession. The Political Environment: At both the state and federal levels, 2012 will be an active electoral year. In addition, NCCI will be joining other industry stakeholders in closely monitoring legislation surrounding national healthcare and financial reform. Like every other industry in America, workers compensation continues to stand at a crossroads, awaiting a more robust economic recovery. During 2012, we expect to see a number of meaningful developments in our industry. Among these: Election results at both the state and federal levels that could signal yet another significant political shift in governing philosophies NCCI s analysis and reportage on full Year 2011 workers compensation results delivered in our annual State of the Line report in May A more definitive economic direction with a more stable long-term outlook As we await new developments, NCCI will remain active in analyzing and reporting on industry trends, data, and direction for the coming months. Our emphasis will continue to be focused on maintaining rate and loss cost adequacy in the face of potentially increasing trends in claim frequencies and severities; evaluating the cost implications of legislative reform efforts; and providing timely research that helps in understanding the changing dynamics surrounding the workers compensation system. We will also continue to monitor legislative activity at both the state and federal levels, and inform decision makers on the cost consequence of policy choices to best ensure the continuing health of the workers compensation system in America. Stephen J. Klingel, CPCU, WCP, was appointed president and chief executive officer of NCCI in Before joining NCCI, Mr. Klingel was a leader with the St. Paul Companies for more than 25 years. 6 7

6 Divergent Fortunes: As Labor Markets Recover, Will Workers Compensation Insurers Lag Behind? By Robert P. Hartwig, PhD, CPCU President and Economist Insurance Information Institute The agonizingly slow recovery of labor markets from the Great Recession that began in late 2007 and ended in mid-2009 has caused enormous and indelible pain for millions of American workers for more than four years. No recession since the Great Depression itself has done more damage to worker incomes, caused greater atrophy of worker skills, or discouraged participation in the workforce to such a degree. Throughout all of the misery, workers compensation insurers were along for the nauseating ride. Payroll exposure plunged as mass layoffs and business failures soared. Insurers slashed rates to retain as much of the rapidly shrinking payroll pie as possible, all the while watching their underwriting margins run deeper into the red. By the time the carnage had run its course, 8.4 million American workers had lost their jobs, payroll exposures had plunged by $350 billion, and workers compensation premium written had plummeted by one-third. By 2011, workers compensation insurers were paying out nearly $1.20 for every dollar they earned in premium, earning workers compensation the dubious distinction as the least profitable of all major property/casualty insurance lines. The Great Recession and its aftermath were nothing short of an economic apocalypse to those who lost their jobs, homes, and businesses. Many of these losses are permanent. But brighter days are ahead, and the healing process has begun. Employers are hiring again, and consumer and business confidence are on the rise, fueling steadier economic growth in Workers compensation insurers stand to be among the principle beneficiaries of renewed vigor in the American economy if and only if they can quickly turn their underwriting performance around amid the new reality of ultra-low interest rates while simultaneously seizing the opportunities that the newly restructured American economy brings. Proof of Life: Overview of Labor Market Conditions There s no question that labor market conditions remain far from ideal. After all, the national unemployment rate at yearend 2011 was 8.5%, nearly double the 4.4% trough in March 2007 (Figure 1). Still, the figure is much improved from the October 2009 peak of 10.1%. Likewise, as 2011 drew to a close, some 13.1 million people remained without jobs a big number but meaningfully down from the 14.4 million jobless at the end of Many other indicators suggest that 2012 will be a better year for American workers. Initial claims for unemployment insurance fell steeply in 2011, to 1.8 million from 2.8 million in 2009 and monthly figures continue to trend generally downward. Another encouraging sign was that the unemployment rate fell to 8.3% in January Sources: US Bureau of Labor Statistics; Insurance Information Institute. Employment opportunities, of course, continue to vary substantially across the country, with unemployment rates in December 2011 ranging from 12.6% in Nevada to just 3.3% in North Dakota. That being said, unemployment rates fell in all 50 states last year, a trend that is likely to continue in So what does all this mean in terms of jobs? The good news, as shown in Figure 2, is that 2.09 million private-sector jobs were created in the United States in 2011, nearly 700,000 more than the 1.42 million created in Yet, the gain of 3.51 million private-sector jobs in 2010 and 2011 still pales in comparison to the 8.44 million jobs lost from December 2007 at the onset of the Great Recession through December 2009, six months after its official end. Figure 3 suggests that with a net deficit of 4.7 million jobs as of January 2012, it will likely take another two years before employment surpasses its 2007 peak. Strong employment growth is the harbinger of accelerating payroll exposures. Figure 4 confirms that the half-decade growth drought in workers compensation is finally over, with net written premium up an estimated 6% last year after suffering five consecutive years of declines and a cumulative shrinkage in premium of nearly 30%. Growth in 2012 is likely to be even stronger, the beneficiary of a potent combination of accelerating job growth, wage gains, and rate increases. Where Are the Jobs? While the national unemployment rate has declined significantly over the past year, job growth (and, therefore, payroll exposure growth) has been very uneven. As mentioned earlier, unemployment varies widely across the country. Indeed, as of year-end 2011, four states (California, Rhode Island, Mississippi, and Nevada) and the District of Columbia were still plagued with doubledigit jobless rates. As the economy continues its tortured emergence from the Great Recession, it is clear that American workers and employers are forever transformed by the experience. The same must be said of the nation s workers compensation insurers. The escape velocity necessary to achieve a selfsustaining recovery has radically altered the trajectory of the American economy today in ways that could not have been Sources: US Bureau of Labor Statistics: Insurance Information Institute Source: Insurance Information Institute calculations from US Bureau of Labor Statistics data. foreseen just a few years ago. Insurers must carefully consider the implications in order to capitalize on new opportunities. In the section that follows, I provide discussions on several industries likely to provide new opportunities for strong growth for workers compensation insurers over the next five years. Health: Spending on healthcare in the United States is expected to increase by $2 trillion, from $2.6 trillion in 2010 to $4.6 trillion in 2020, according to the Centers for Medicare and Medicaid Services. Over this period, healthcare spending is expected to increase at an average annual pace of 5.8%, exceeding growth 8 9

7 $7000 $6000 $5000 $4000 $3000 $2000 * Private employment; shaded areas indicate recessions. Payroll and WC premium for 2011 are I.I.I. estimates. Sources: NBER (recessions); Federal Reserve Bank of St. Louis (wage and salary disbursements); NCCI; I.I.I. overall by 1.1 percentage points. By 2020, healthcare spending will account for 19.8% of GDP, up from 17.6% in Implications for Workers Comp Insurers: The rapid escalation in healthcare spending will require enormous investments in health facilities, infrastructure, and human resources. Workers compensation insurers can be among the primary beneficiaries of rapid growth in this labor-intensive, recession-resistant industry. The US Bureau of Labor Statistics (BLS) estimates that more than 3.1 million new jobs for hospital workers, clinicians, and home health aides will be created between 2010 and 2020, generating hundreds of billions of dollars in payroll exposures. Construction of healthcare facilities and growth in ancillary support services will create many thousands of additional jobs. Traditional Energy: While alternative or so-called green energy has received most of the attention in recent years, the oil and natural gas industry in the United States is poised for significant growth and already supports some 9.2 million jobs, according to the American Petroleum Institute. Numerous oil and gas discoveries and the development of new extraction technologies, including hydraulic fracturing (often referred to as fracking ), are boosting employment of high-wage jobs in many states, including Pennsylvania, West Virginia, and Texas. States such as New York could follow. At least a half million jobs are likely to be created. Implications for Workers Comp Insurers: Many insurers that write workers compensation insurance have little or no exposure to oil and gas extraction for one of two reasons. First, some insurers regard oil and gas extraction as akin to high-hazard mining risks and beyond their underwriting capabilities and experience. Second, many local and regional insurers operating in the Northeast have never had the opportunity to underwrite such risks and may remain reluctant to do so. Workers compensation insurers seeking to capitalize on America s domestic energy production boom will need to invest in experienced underwriters and claims managers but will see strong growth as a result. Manufacturing: Generations of American workers and politicians have lamented the decades-long decline in manufacturing employment. That may be about to end halftime in America, as Clint Eastwood might say. Numerous factors are coalescing for what is likely to become a modest renaissance of manufacturing in the United States with potentially enormous benefits for the American economy, workers, and insurers. Implications for Workers Comp Insurers: The US BLS projects that manufacturing employment in the United States will actually decline slightly between 2010 and But these projections do not fully consider the rapidly changing dynamics that influence manufacturing investment and location decisions on a global scale. Cheap and abundant energy in the form of natural gas, huge productivity gains, supply chain vulnerability concerns abroad, rising foreign labor costs, and a low dollar are among the many factors likely to transform the landscape of American manufacturing over the next decade. Workers compensation insurers will need to be prepared to underwrite more manufacturing risks both large and small particularly in energy-rich states. Final Thoughts The year ahead will present an array of opportunities and challenges for workers compensation insurers. In 2012, that challenge involves arresting the deterioration in the line s underwriting performance. Indeed, A.M. Best is projecting that the 2012 combined ratio for the workers compensation line will top 120 up about two points from Yet at the same time, the recovering economy, continued improvements in labor market conditions, and the associated expansion in payrolls mean that growth opportunities will be more abundant than at any time since Robert P. Hartwig, PhD, CPCU, is the president of the Insurance Information Institute. Dr. Hartwig previously served as director of economic research and senior economist with NCCI. He has also worked as a senior economist for the Swiss Reinsurance Group and as senior statistician for the US Consumer Product Commission. NCCI 2012 RESEARCH BRIEF Read the full report on ncci.com Workplace Violence The reality of workplace violence is markedly different from popular opinion. Workplace homicides are not crimes of passion committed by disgruntled coworkers and spouses, but rather result from robberies. The majority of workplace assaults are committed by healthcare patients. This report examines the many aspects of work-related homicides and injuries due to assaults, and extends a series of studies published by NCCI on workplace violence with three years of additional data, through For the most part, previously observed patterns and key findings are largely unchanged. The section immediately below describes the most notable highlights. KEY FINDINGS Work-related homicides and injuries due to workplace assaults remain well below levels observed in the mid-1990s. Homicides account for 11% of workplace fatalities. Nonfatal assaults make up less than 2% of total nonfatal lost work-time (LWT) injuries and illnesses, but that share has been increasing. Homicides due to robberies and similar criminal acts fell markedly over the late 1990s (but still make up 69% of all homicides), due largely to the decline in the homicide incidence rate for taxi drivers. The work-related homicide rates for these workers are now comparable to those for high-risk retail workers such as service station attendants and barbers. In contrast, homicides committed by work associates (a Bureau of Labor Statistics [BLS] category made up of both coworkers and customers) have increased to about 21%. Interestingly, this reflects an increase in violent acts by customers to 9%. Despite the headlines, the share of workplace homicides due to coworkers has remained steady at about 12%, and the actual number of such homicides has been in the 50 to 60 range in recent years. The decline in the rate of workplace assaults has lagged the steady decline in the rate for all lost work-time injuries and illnesses. This reflects a notable change in the composition of the US workforce and, in particular, the ongoing increase in the share of healthcare workers, who experience remarkably high rates of injuries due to assaults by patients. This is especially common in nursing homes and other long-term care facilities. In fact, 61% of all workplace assaults are committed by healthcare patients. For healthcare assaults, coworkers make up just 7%, and someone other than a healthcare patient or coworker comprises 23%. The remainder is unspecified. Based on NCCI data, injuries resulting from a crime are more severe than injuries resulting from other causes and are more likely to involve a fatality. In contrast, severity for injuries resulting from being struck by a fellow worker or patient is below average. Risk factors linked to an increased likelihood of workplace violence published by the National Institute for Occupational Safety and Health (NIOSH) in 1996 are still consistent with the types of occupations and industries at highest risk for workplace violence today. To read the full NCCI Research Brief, Violence in the Workplace, please visit ncci.com