International Medical Cost Containment Strategies

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INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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COST CONTAiNMENT: EXPERT INSIGHT FOR iPMI PAYORS & PROVIDERS

Although risks have changed the cost of healthcare around the world remains a key concern for the international private medical insurance industry.

Featuring Cegedim Insurance Solutions, Global Excel, Payer Fusion, MDabroad and Transworld Claims Solutions this round table defines the complex nature of international cost containment and how medical payors and providers may leverage cost containment strategies to improve the standard of care and reduce the bottom line.

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COST CONTAINMENT PROVIDER NETWORK

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ON THE FRONT COVER: Faced with the ever growing risk of the rising cost of global healthcare, for his remote and mobile work force, our intrepid traveller is pictured trying to get the best possible price with the limited choice of tools he has.

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COST CONTAINMENT PROVIDERS IN FOCUS: Turn To Page 67 for complete cost containment company business intelligence featuring Cegedim Insurance Solutions, Global Excel, Payer Fusion, MDabroad and Transworld Claims Solutions.

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EXCLUSIVE ROUNDTABLE: INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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INTERNATIONAL MEDICAL COST CONTAINMENT ROUND TABLE In a Closed Door Exclusive Round Table Business Forum iPMI Magazine Spoke with C-Suite Industry Leaders from the International Medical Cost Containment Market about International Medical Cost Containment Strategies For Global Medical Payors And Providers.

Cegedim Insurance Solutions, Global Excel, Payer Fusion, MDabroad and Transworld Claims Solutions took their seats at the table, and as always the dialogue was extremely interesting.

We hope you enjoy this industry exclusive as much as we enjoyed producing it. Turn the page to enter the discussion >>

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ROUND TABLE

Q1

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PLEASE INTRODUCE YOURSELF AND BACKGROUND IN THE INTERNATIONAL MEDICAL INSURANCE MARKET:

CEGEDIM INSURANCE SOLUTIONS: I’m Steve Westley, Director of Strategy at Cegedim Insurance Solutions (International Division). Chairman of the Association of Medical Expense Insurers (‘AMEI’), I have experience of all aspects of the healthcare and healthcare insurance markets, from business development to the manufacture, distribution and servicing of products and services.

Cegedim Insurance Solutions is a global leader in software and services across the healthcare ecosystem, from insurers and social welfare institutions to professionals, intermediaries and end users. Its endto-end solutions suite supports 230,000 professionals and 43 million beneficiaries, with €2.9 billion in benefits paid and 400 million electronic data interchanges processed annually. The business unit is part of Cegedim, whose 4,200 people generated €457m in revenue in 2017.

GLOBAL EXCEL: My name is Steve McClung and I’m the Senior VP of Innovation and Technology at Global Excel Management Inc. I’m responsible for the direct oversight of all of our organization’s cost containment functions, as well as information systems and technology.

My primary responsibility is innovation – driving new products and services for our clients.

I’ve been with Global Excel for over 17 years and have held numerous roles, most recently as Assistant VP of Operations and Director of Managed Care.

18 years later, we have grown to become the MD Group that consists of our legacy billing business plus two additional divisions that were launched in response to strong demand from payors and providers: 1) International Medical Claims Financing, and 2) Comprehensive Payer Support (TPA, Medical Assistance, Networks, Case management, Cashless Access, Audits & Cost Containment Services).

Our geographic focus remains in LATAM & Mexico.

Our corporate office is located in Miami (Aventura, Florida) and our 24/7 Assistance Centre is located in Buenos Aires.

PAYER FUSION: My name is Griselle Chernys and I am the CEO of Payer Fusion.

Payer Fusion is a technology company serving the insurance and reinsurance industries as well as assistance companies and other insurance and healthcare related companies.

TCS: My name is Doug Clement. I am CEO of Transworld Claims Solutions Inc..

“TCS” is a niche provider of cost containment solutions with a focus on ‘Loss Recovery’ in its various iterations. We are the North American partners of AVUS Worldwide Claims Service.

Together with AVUS and other service providers in our network we provide comprehensive cost containment and loss recovery services worldwide.

MDabroad: My name is Scott Rosen. I founded MDabroad in 2000 as a Latin American (LATAM) provider focused international claims billing & management platform.

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ROUND TABLE

Q2

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IN YOUR OWN WORDS, PLEASE DEFINE MEDICAL COST CONTAINMENT:

CEGEDIM INSURANCE SOLUTIONS: Medical cost containment is the identification of opportunities to reduce costs in the provision of healthcare without compromising on the quality, effectiveness or availability of care enjoyed by patients.

GLOBAL EXCEL: I think one standard definition could be the process of obtaining a discount from a medical provider’s billed charges. Unfortunately the term ‘cost containment’ isn’t the best description for that particular function. A term more commonly used in the U.S. would be repricing.

Global Excel has always understood cost containment in a much broader context. Focusing on containing costs only after a healthcare event has occurred is like closing the barn door after the horses have escaped. The damage is already done.

Global Excel wants to revolutionize the ‘cost containment’ paradigm completely. We are convinced the only way to truly manage healthcare risk is to intervene much earlier in the process. We want to improve the member journey by avoiding unnecessary costs and helping the member find the appropriate level of care. The assistance is provided in the most convenient setting with the highest quality and after the event we can address any ‘containment’ of the subsequent costs.

Cost avoidance is perhaps even more complicated than cost containment. It starts with properly designed and effectively worded insurance policies and then, when it comes to using that policy, it involves a number of different factors all centred around providing the right care at the right time in the right location at the right cost. What this provides is a very pro-active medical assistance and case management infrastructure.

You need to manage a number of different variables and tools including: policy design, wording, intent and premiums, pre-treatment risk assessment, telemedicine, visiting physicians, outpatient clinics

and urgent care centres, in addition to emergency room and inpatient care. At that point is the whole issue of repricing bills once they are received and the various methodologies used. And finally, reporting which provides more than just a bunch of numbers; it provides actionable intelligence. If you’re not closing the whole loop you’re flying blind.

If all you’re doing is repricing the bill on the back end – you’re playing a losing game.

MDabroad: Regardless of the vendor, cost containment is about optimising the claims expense to the lowest possible level. It is an equilibrium of sorts, where payors and providers agree as to what constitutes fair value. Most typically, this fair-value is reached to via a contracted network arrangement, or “network rental”. My sense is that the leading cost containment service providers share an understanding that cost containment is not an ‘event” but rather a result of a comprehensive approach to managing “all the moving parts” and adapting it to fit the unique businesscultural needs of a certain region/market. At the same time, each company has its “Magic Sauce”, or a key differentiator that sets it a part from its competitors.

Early on in our development, I decided to go “against the grain” and focus on the greatly misunderstood LATAM region. I leveraged our extensive providerbilling portfolio in LATAM and Mexico is to the region’s leading cashless hospital network. These legacy relationships have earned us the trust of both payors and providers. MDabroad’s provider relations standout.

At the end of the day, provider & payor trust, local rates, support of expert physician case managers, best-in-class providers, and an ability to solve problems in an often misunderstood region are the ingredients of our “Magic Sauce” for effective cost containment.

PAYER FUSION: The essence of cost containment is the art of keeping a healthy premium with low increases

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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for the members of the insurances while providing fair pricing and access to members to high quality providers and proper medical outcomes. The direct cost per claim which includes administrative costs affect the outcome of the annual premium.

The growing cost of healthcare costs is a worldwide phenomenon affecting everyone. The traditional cost containment practiced by most companies out there with a high percentage of savings model works against the insurance companies best interest, while driving the cost per claim higher every year.

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TCS: The term ‘medical cost containment’ is generally understood to involve the discounting of medical service provider invoices, so called ‘billed charges’.

This is the simplest definition. In reality, the process is far more involved and may include both proactive (ie: intervention in the billing process before a patient is discharged) and reactive; (ie: after a patient is discharged and invoices are generated) Other less embraced methods include the recovery of costs paid out from other insurers also on a given risk. (ie: priority on risk matters and/or losses arising out of the liability of a third party or parties.)

WHY DO INTERNATIONAL PRIVATE MEDICAL INSURERS AND ASSISTANCE PROVIDERS NEED MEDICAL COST CONTAINMENT?

CEGEDIM INSURANCE SOLUTIONS: Life expectancy, the financial impact of chronic diseases, the cost of new technologies…all are on the rise. For IPMI insurers and assistance providers, these bring financial pressures, in the face of which cost containment represents a welcome avenue to financial success. It will require bold decisions and the support of innovative revenuedriving offerings: but ignoring its potential is not an option.

By managing risk, insurers can protect their members from unwarranted increases in premiums or personal liability.

GLOBAL EXCEL: Healthcare costs continue to rise at a rate that far outpaces general inflation. It used to be the USA was their primary concern from a financial perspective. Then we started seeing spikes in costs at a few individual international healthcare providers.

Then it was international ‘areas’ of concern – often in tourist zones. Now it’s evolving again to include larger expat, student and iPMI destinations, and even entire countries.

None of our data or the market studies we view

shows a downward trend for healthcare costs. In fact, as concerned as we are about the high costs we’re seeing in the USA, it’s other countries around the world that are showing larger relative price increases… particularly developing nations. Our feeling is that as long as the USA continues to be the beacon for comparison, many providers around the world will use those U.S. prices as a benchmark. That’s why the assistance, case management and cost containment industries need to evolve with new strategies to combat these ever increasing costs.

Why do private medical insurers and assistance providers need medical cost containment? Using the traditional definition it would be to manage the financial risk of an insurance product or portfolio by attempting to discount healthcare provider bills after the treatment has been provided. Using our definition it would be to improve the customer journey in order to more effectively manage healthcare risk.

MDabroad: While in general, over utilization and unreasonable charges are the leading drivers for cost containment; we find that in Latin America it’s more

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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about effective medical case management and understanding the practice culture on a facility-byfacility basis. Mind you, we know our providers very well from the billing side. To this end, we can connect the dots more effectively, ensuring transparent medical care and billing at local rates, where possible.

PAYER FUSION: Prices continue to inflate, and populations get older, people live longer. The ability of a company to charge fair pricing to the clients while producing TRUE cost savings is a challenge to all insurance companies. If the so called “discounts” are still driving the cost per claim of the insurance company, then such cost containment has been ineffective if

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the cost per claim exceeds the healthcare inflation of the region where the cost containment is being performed.

TCS: An effective cost containment strategy is essential in order to remain competitive in an environment where the other players routinely employ strategies of their own. That said, the days of gaining a competitive edge by paying fees for discounts seem largely gone.

As insurers demand better results cost containers are responding with solutions which may be tailored to a specific client’s unique needs. By and large these employ a more proactive approach and by their nature come at additional cost.

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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ROUND TABLE

Q4

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IN-HOUSE OR OUT SOURCED MEDICAL COST CONTAINMENT, WHAT WORKS BEST AND WHY?

CEGEDIM INSURANCE SOLUTIONS: We believe that a combination of both generally delivers the best results. Supplementing the in-house team’s core knowledge and skills with regional knowledge of best practices and regulations enables the most appropriate use of local provider networks, clinical expertise and specific case and cost management.

To facilitate this combination, IPMI providers can benefit from deploying a “Commercial Off-The-Shelf” (‘COTS’) solution and aligning it with their strategy and processes. This allows them to better support their ecosystem, typically achieving payback faster than with internally-developed systems. Specialist systems designed to address the complexities and opportunities of managing products, policies and claims throughout the IPMI lifecycle allow insurers and providers to enhance efficiency and deploy internal resources more effectively.

GLOBAL EXCEL: There’s no right answer to this question. If you have all the tools and the expertise, you can definitely do it in-house. For many years our parent company was a large MGU and we managed our own risk in-house. It took us years to develop the proper tools and even then most of our risk was focused on the U.S. market – the most expensive healthcare system in the world.

Unfortunately many risk takers don’t have all the tools necessary or the expertise in-house to be able to do this effectively on a global scale. They may be experts in certain geographic areas, but not everywhere.

For the vast majority of our clients the U.S. remains their primary focus. Although they may have more claims in other parts of the world, their healthcare spend in the U.S. is disproportionally high. To complicate matters further the U.S. healthcare system is unique in the world. As I mentioned it is by far the most expensive, but also the most complicated. It’s also perhaps the least transparent in that as a general

rule, what gets billed is very seldom what gets paid.

All this to say, if you’re going to do it in-house you need to know what you’re doing.

MDabroad: The models of the larger and more successful insurers has proven time and time again to work. There is nothing like a regional expertise.

Our experience has shown that we are used in the Americas for a reason: we are based in the region, we get the region and we specialise in the region.

You can’t expect to have access and offer a strong member experience unless you work as a payor with a strong aggregator, such as MDabroad.

PAYER FUSION: This depends on the business model of the insurance company, the type of insurance they produce. The company must design the model it needs to adhere to. In the U.S.A insurance companies do not use cost containment companies and rather develop, manage and carry their cost containment functions consistent with not only cost, but medical necessity and evidence based medicine. This process allows them to control the entire episode and life cycle of the claims. In other parts of the world it is preferred that the insurance outsource the claims to a cost containment company or a third- party administrator. For me cost containment is only one of the tools and techniques of claims administration.

Most companies put a discount on a claim and that is called cost containment for which they charge a high percentage of savings not affecting in the long run the cost per claim and the premium.

TCS: This is a bit of a loaded question. If an entity has amassed the considerable expertise required, trained staff, and network contacts to do it well, in house is probably best. For others, however, outsourcing works perfectly well. And, of course, a third option is some combination of the two.

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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Q5

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LOCAL OR INTERNATIONAL – WHAT ARE THE ADVANTAGES OF A LOCALIZED MEDICAL COST CONTAINMENT SERVICE?

CEGEDIM INSURANCE SOLUTIONS: Local requirements have to be met: it’s the law. However, only through a holistic approach can providers avoid gaps in their operational infrastructure through which profits can slip: and this means taking an international approach.

The ideal scenario is therefore a ‘glocalised’ one, leveraging the economies of scale of a global strategy whilst complying with all local requirements. The value of truly local knowledge in addressing the delivery of care, and therefore cost, cannot be underestimated, be those requirements regulatory and enshrined in law or market-driven and subtly woven into the fabric of the local ecosystem.

GLOBAL EXCEL: Local knowledge is key. Whether it is feet on the ground, extensive local knowledge or the use of experienced partners, it helps to have that local expertise. In 2017 we processed approximately $1.7B USD in billed charges – slightly over 500K bills – in over 70 countries around the world. We have locations in 8 countries and we have extensive knowledge and volume in many others, but we couldn’t have done the rest without excellent local knowledge.

standards of cost containment but each geographic area has its problems and must be a process that follows the practice of medicine in that market, the morbidity and mortality of the geographic area, the main diseases that affect that population.

Expats become exposed to those environments and can be affected with these situations. You need to have the cooperation of a local on ground support that comes from knowledgeable staff for cost containment and cost management. You can do some of the work from remote but you still need to have that knowledge. Today’s cost containment companies need to do more, they need to health population management, disease management and most of all react properly when there are specific needs or epidemics.

TCS: A knowledgeable localized cost containment service is well positioned to ensure the best possible result. They will have a reputation, local contacts, and will know the local etiquette and rules. Working within that framework will minimize risk and outlay thus saving both time and money.

MDabroad: Our business exists because we have local knowledge. On large cases, we send our commercial managers or medical director to the facilities. We need to understand the protocols being applied for the treatment to make sure that utilisation is consistent with the treatment approach of the medical team.

When you operate in an environment with different practices and norms, local expertise, specifically in medical case management, can be performed fairly and credibly. Additionally, a local presence and command of local knowledge creates a feeling of good faith and typically results in a collaborative relationship between us and the provider.

PAYER FUSION: I believe that there are general iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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Q6

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DOES USUAL, CUSTOMARY AND REASONABLE EXIST IN MARKETS WHERE QUALITY IS VARIABLE FROM PROVIDER TO PROVIDER?

CEGEDIM INSURANCE SOLUTIONS: “Reasonable and customary” represent standards that can be witnessed, at least in how initial treatments are administered. For example, mending a broken finger is a straightforward procedure, one from which most patients walk away in a seemingly similar state. The difference in the quality of such an operation often only truly manifests itself over time, perhaps in unnecessarily long recovery times or, worse still, in side-effects such as arthritis. That’s why ‘value’ can only be measured over a lifetime. That’s why Prof.

Michael Porter of Harvard Business School says that “value cannot be understood at the level of a hospital, a care site, a speciality, an intervention, a primary care practice or a broad population” and that “value is created in caring for a patient’s medical condition (acute, chronic) of the full cycle of care”.1 GLOBAL EXCEL: Unfortunately not – there is no definition of ‘usual, reasonable and customary’ that is legally binding, regardless of which market we review. What it’s come to mean in the industry is simply ‘what everyone around us charges or accepts as payment’.

That’s not good enough. We always move the discussion away from this artificial amount to something more concrete. We prefer to deal in hard numbers – costs. We want to establish what the provider’s costs were and then use that as the basis for discussion.

Using ‘usual, reasonable and customary’ just leads you down an illusionary rabbit hole.

MDabroad: UCR exists when care is standard across the board. In the US, yes, of course. In Latin America, you typically do get what you pay for, although there are exceptions. In a public/private system, private hospitals exist to treat the overflow of patients for some market demographic segments, while other segments cater towards a range of insured or self-

pay members, with quality (in terms of technology, training and other clinically significant investments) varying by segment. There is a direct correlation between cost of delivering service and quality of care, period. Healthcare exists in an environment that has free-market forces at work, meaning that you typically get what you pay for. Outcomes may not be measured in all cases and, therefore, quality may not be confirmed by recorded outcomes, but the service experience and perception typically ranges and is commensurate with price. So, UCR is a function of segment, which varies but is also limited by “like” facilities.

PAYER FUSION: It doesn’t, and this is a problem.

There is no law that grants hard numbers to what should be charged and by who, so it is left to what everyone is generally doing. There is no structure of uniformity to control what a provider will charge.

Few places really have price control and normally those are in countries with public health system whereby a cost containment company does not have very much need to act. An effective company must know how to address UCR in any markets and the intricacy of the markets. There are markets where it is acceptable to charge differently for insured versus non-insured clients. The standards of medicine in those markets also affect how the medicine is delivered, clients are invoiced and ultimately how a UCR is reached that will be agreeable to the providers and acceptable to the members if there is to be any responsibility due from the member after the UCR is applied. The company needs to make sure their pricing will stand the fairness and acceptance of the market.

Case management guidelines for the different markets go in hand with the UCR principle. We manage and keep a high number of those guidelines where available and utilized. Immature insurance markets present other problems in quality but often those markets can be perceived as still inexpensive as

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compared to other developed markets and the claims may be easier to manage.

TCS: Of course the terms ‘usual, reasonable, and customary’ can exist even in markets where service quality varies from provider to provider. The more

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salient question is whether those terms carry any actual weight in the event of a dispute. The answer to that question is; these terms are not legally binding, so unless the other party in a negotiation perceives weight in them, there is none.

WHAT ROLE IS TECHNOLOGY PLAYING IN MEDICAL COST CONTAINMENT?

CEGEDIM INSURANCE SOLUTIONS: Amongst the opportunities for cost containment enabled by technology, four stand out: 1. Digital empowers policyholders to take the lead in their relationship with insurers, alleviating the administrative burden by directly providing data, booking appointments and selecting care providers.

This delivers value to both insurers and members in the planning and delivery of elective care, providing the added benefit of speed and response when expatriates are exposed to a medical emergency.

2. Telemedicine has been around for over two decades.

Yet only now are we experiencing the perfect storm that will allow practitioners to maximise its potential, with an ecosystem of connected devices and sensors continuously expanding upon the broad and solid foundations of connectivity and video capabilities.

This will allow telemedicine to finally deliver upon its promise of time savings for all the players in the healthcare ecosystem, helping insurers and practitioners contain costs and drive customer retention without compromising on care quality.

3. These digital developments can already impact the next P&L statement. But digital also has a key longterm role to play, enabling IPMI insurers and providers to engage with policyholders and guide them towards healthier lifestyles, thereby reducing the cost of care in years to come.

4. Focusing on claims management, “Straight-Through

Processing” (‘STP’) technology allows IPMI providers to automate up to 70% of claims. The savings can be dramatic: the cost of processing a claim manually in the US is estimated at 74 cents, whereas STP can drive it down to 26 – a 63% improvement.

GLOBAL EXCEL: Technology is the great enabler. That is one of the main reasons why we combined cost containment (our definition) and our information systems and technology into a single responsibility at Global Excel. Those functions are most critical for a successful healthcare risk management strategy, and include proactive case management, medical triage and even policy design. These are the very functions that can deliver the greatest impact if supported through an innovative use of technology.

Our StandbyMD platform – whether embedded in a client’s system, accessed through a client app with our APIs or used by our team in house – is based on some very sophisticated artificial intelligence and steerage data. Without those systems, it would have been very difficult to analyse different data points from telemedicine, visiting physicians, clinics and hospitals around the world, and then make an informed recommendation for treatment.

The important thing to realize is this – although technology is the great enabler – we work in an industry where the human touch is essential. There are times where people want and need to hear a

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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human voice on the other end of the line. The key is knowing when to employ that essential human element and when to let technology do its work!

MDabroad: My colleagues have provided excellent responses. We can say that the future is bright in Latin America as they are in the late-adopter category and have the chance to choose on the basis of what has worked. There are some great legislative developments in many countries and we have seen the use of technology that we don’t even see in the US deployed in public systems to deal with enhanced primary care access, appointment scheduling, reducing the cost of delivering care and in bringing scalability to these countries with growing populations demanding more and more care. In the private system, our client hospitals seem to be on par with the rest of the world.

PAYER FUSION: Well, technology is pivotal, whether we like it or not. You have to keep up with the industry and the evolution of big data. Our platforms and algorithms are constantly challenging the data, the relationship of the costs, the services rendered, billed and the reimbursement due to the provider. We must

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connect and analyse all data to understand any variation by geographic reason and by the same providers for similar age groups, diagnoses, types of services and apply it to cost containment situations.

Our medical claims processing system analyses and evaluates millions of compiled claim transactions to generate accurate reports and reliable informatics which allow our clients to compare their healthcare policy performance. The process must follow confidentiality and must strip all data segments from any member information but, permits us to know trends and allow us to negotiate with providers and demonstrate to clients our work. Makes no sense for an insurer to pay a cost containment company that charges high fees because they may report high savings, but, at the end year after year the cost per claim goes up beyond the inflation factors of the market.

TCS: Technology facilitates the movement of more data in less time. The benefits include more effective oversight of all aspects of insured/patient needs and expectations, better communication and thus decision making.

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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Q8

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HOW CAN PROVIDER NETWORKS HELP MANAGE THE COST OF INTERNATIONAL MEDICAL CLAIMS?

CEGEDIM INSURANCE SOLUTIONS: Effective provider network management is critical to successful cost containment.

Insurers can establish network assessment programs that will drive down the cost of international medical claims. For example, by monitoring the delta between pre-agreed tariffs and actual charges, measuring the quality of partners’ equipment and care and assessing their level of patient-centricity and transparency, insurers can set in motion a virtuous cycle that rewards those partners who meet or exceed contractual standards and customer expectations, containing costs in the process.

The insurer or local TPA can also improve the customer experience by becoming patient advocates and directing members towards the right provider, so that they’ll be seen by the right specialist and receive the right treatment at the right cost.

GLOBAL EXCEL: They can help and we partner with many of them. Of the $1.7B USD in billed charges we processed in 2017, approximately 40% was processed through leased provider networks. The challenge is knowing and understanding the value of each network and the quality of their providers for each client and situation presented.

These days you have to be able to match a client’s varying needs with custom solutions. Even for single clients we use multiple solutions depending on the product, the sub-client, the policy intent, the claim demographics, etc. Unfortunately there are still many ‘cost containers’ (old definition) who still advocate a single solution, a cookie-cutter approach for everything.

Why? Very simple – it’s cheaper and easier to manage.

That’s not our philosophy. Tailoring solutions to fit the very specific needs of our clients is always our approach. From a network aspect alone we work with over 150 national, regional and local PPO and HMO networks in the U.S. The secret is knowing what

solution to use when!!

MDabroad: Networks are important, however in LATAM and Mexico it does not necessarily mean discounts. We aim for effective case management, quality standards, InterQual guidelines and local C&U charges. Where not possible, we make every effort to leverage our keen understanding of provider practice and business culture to attain the desired fiscal outcomes. As a matter of policy, we never take a hostile position against the provider. It would be fair to say that our method has yielded more WINS than losses for our clients and providers. Both of whom see us as an honest broker of the valueequilibrium I had previously mentioned.

PAYER FUSION: By basing our medical claims pricing on the actual cost of appropriate care, not a percentage reduction of an inflated retail price. Our negotiations with providers are based on a clear understanding of their costs - by type and size of facility, type of treatment and by actual share of unfunded or underfunded care that requires them to cost shift.

This knowledge empowers us and our clients, with a unique advantage in negotiating fair reimbursement for quality care. Building a healthy provider network that allows us to base the payment in other than a percentage of savings is key to the success of claims cost control, we have achieved this model and thus part of our extreme success especially in the most difficult markets.

TCS: Provider networks typically provide access to a broad range of service options and pricing. Understanding those options and how best to choose amongst them to ensure the best possible result for the insured while minimizing the financial bite to the insurer is the job of the insurer’s claim administrator. A well informed administrator is key.

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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WHY IS PROPER CASE MANAGEMENT CRITICAL TO MEDICAL COST CONTAINMENT?

CEGEDIM INSURANCE SOLUTIONS: With an everbroadening spectrum of treatment options, insurers can look after their policyholders better than ever.

However, if not managed correctly, this variety can lead to confusion, inappropriate care and, ultimately, uncontrolled costs.

By ensuring policyholders receive the right care, case management can contribute to containing costs throughout the treatment lifecycle. This allows case managers to identify the best course of action, avoiding unnecessary diagnostics and reducing convalescence periods for policyholders, which ultimately delivers savings to the IPMI provider.

Furthermore, by optimising case management IPMI providers can lower the long-term financial burden of chronic diseases. By its nature, case management only comes into play once a claim has been submitted.

Always necessary, it is no longer sufficient. Insurers must implement proactive strategies to contain the number of claims. The number of people living with diabetes, for example, currently stands at 371 million globally: however, estimates by the International Diabetes Federation expect it to hit 552 million by 2030.2 This represents a 48.8% increase: whilst it cannot be avoided in full, it can be limited. And insurers have a key role to play here: unable to turn back the clock once chronic diseases have set in, they must seize the day and embrace their role as care partners to guide their members towards simple, effective lifestyle changes that will help them improve their health, potentially enjoy lower premiums, thus containing costs in the long run.

GLOBAL EXCEL: Very simply, what would you prefer, saving 50 percent off a bill of $200,000 or saving 20 percent off a bill of $30,000?

Traditional cost containment simply reduces a bill after it has been incurred. Our case management makes sure the bill is smaller to start with.

Proactive assistance and case management has an impact on both the financial outcome of a claim and the customer experience. Ensuring the patient has the right care at the right time in the right place and at the right cost needs to be organised up front. All of those elements have a very direct impact on the costs and experience of the claimant. I mentioned this earlier, insurers, assistance companies and traditional cost containers need to start working towards pro-active cost avoidance rather than reactive discounts.

MDabroad: I agree with my colleagues. We employ top notch physician case managers to ensure that InterQual & best practice guidelines are maintained.

Where necessary, we will offer constructive suggestions in ensuring that optimal care plans are utilized. As such, our medical and surgical case managers are in cell-phone contact with the attending physicians. My sense is that the patient is the ultimate beneficiary of our excellent provider relations and case management services. A doctor who has a good relationship with our physician case manager, tends to be more attentive and have better bedside manners. At the end of the day, he/she know that we seek rational explanations and reasonable charges. Good case management is a WIN-WIN-WIN to all stakeholders PAYER FUSION: To us it is the same, Cost containment must start with Medical Case Management services are necessary to ensure appropriate care. If the proper care is rendered the proper bill should be generated by the provider eliminating unnecessary charges or over utilisation of services. In our practice of medical case management we ensure that patients receive the appropriate care while increasing opportunities for cost savings. Our case management team coordinates medical care for pre-planned procedures, suggests treatment options and monitors ongoing medical

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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treatment while directing patients toward high-quality providers. We evaluate each case using evidencebased medicine and best practice guidelines ensuring that patients are receiving the right care, in the right setting, at the right time. Most companies claim to practice Case Management but they don’t sometimes they do some utilization review.

The incentive of companies that charge a percentage of savings is contradictory to that of the insurance company. The larger the claim, the bigger the fee for the Cost Containment Company but the higher the cost to the insurance, so the model is totally unaligned with the insurance. We align our model with the insurance company to keep a healthy loss ratio and

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good costs results.

TCS: Any insurer will be aware of cases where their insured has undergone unnecessary or inappropriate treatment. Proper case management helps ensure the claimant qualified for the cover he treatments rendered are medically necessary and meet clinical norms. Proper case management can also play an important role in such things as bill review and auditing including verifying the timing of certain treatments, bundling or unbundling of treatment codes, repatriating a pt where appropriate, etc..Failure of any or all of which tend to lead to inflated charges.

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HOW ACTIVE ARE COST CONTAINMENT FIRMS IN DELIVERING PROPER, PROACTIVE CLINICAL CASE MANAGEMENT?

CEGEDIM INSURANCE SOLUTIONS: When it comes to cost containment, we need to draw a clear demarcation between ‘active’ and ‘effective’. Most firms are busy with cost containment strategies: and, the lesser the scope they can identify to reduce internal costs, either by optimising processes or failing to spot opportunities to do so, the tighter the squeeze they place on network partners. Whilst this may deliver short-term savings, it is unlikely to represent a sustainable strategy, nor one that delivers value to the customer.

For effective, proactive cost containment, firms must partner with their insureds to reduce the likelihood of clinical cases arising in the first place.

We are beginning to see evidence of such strategies, for example with wellness programs: but, when we look back in a few years’ time, having driven true value out of the Internet Of Things and the real-time predictive analytics it enables, as well as AI, we’ll realise that we were only really seeing the tip of the iceberg.

minimal and explanations like “we just couldn’t get the treating doctor on the phone” are common. The traditional cost container is simply reacting to an over inflated bill with ”we know its twice as much as last year but look, we still got you a 50 percent discount”.

The positive take away is when those service providers actually work closely together, the financial outcome improves considerably AND the member has a better customer journey!

TCS: Much depends on the service or suite of services the insurer contracts for with their chosen cost container. Ie: Is the agreement for ‘first call’ full case management? Or, just paying a fee for discount? A fee for discount after the fact is obviously less proactive.

GLOBAL EXCEL: From what we see in the market – not very active. In the continuum of services (policy design and wording, assistance, case management and traditional cost containment) there seems to be very minimal interaction when these services are provided by different organizations. Each one has its focus and its challenges. Rarely are they able to seamlessly coordinate services and as a result each group tends to do what’s in their best interest.

The assistance company tries to minimize costs by reducing customer interaction times because they’re only being paid a flat case fee. They want to provide the quickest solution and tell their members to “just go to the nearest emergency room”. The medical case management company may not have experience in the geographic area where the claim is occurring and so actual medical management or intervention is

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HOW CAN A MEDICAL COST CONTAINMENT STRATEGY HELP COMBAT MEDICAL INSURANCE FRAUD?

CEGEDIM INSURANCE SOLUTIONS: Combating fraud is a cornerstone of any cost containment strategy.

In the US, the National Health Care Anti-Fraud Association estimates health care fraud at $68bn.

That’s 3% of healthcare spend; other estimates have it as high as 10%.3 Those costs translate into higher premiums for customers and higher costs for insurers. With specialised case and network provider management devoted to identifying fraudulent claims, inappropriate care, duplicate invoices and charges that breach contractual agreements, insurers can contain costs and market their offerings more competitively.

GLOBAL EXCEL: Traditional cost containment can combat medical fraud. Every payer should be asking their cost containment company about bill editing, bill scrubbing, no pay lists, complex claims analysis, etc. That being said, a true medical cost containment strategy can go a step further. It starts with directing a patient to a reputable provider that has been vetted and will deliver the most appropriate level of care, be that a telemedicine consult, a house call, a retail clinic or an emergency room. Further concurrent and utilization review management can ensure the level of care is appropriate and acts as further validation against billing when it is received to ensure that all services billed were actually those rendered.

MDabroad: I believe that good case management results in professional trust with the physicians and a more honest relationship with the hospital. As such, I see an inverse relationship between good providerrelations and billing fraud.

PAYER FUSION: Medical cost containment strategies can be key to combat insurance fraud. Using techniques such as auditing, monitoring, verification and data analysis. Verifying providers and key players in the

claims process helps to ensure quality and trust through provider agreements and oversight. Ongoing case management can help avoid some fraud, but the fraud identification process needs to be performed as separate line of defense to the insurance company.

We have a separate process to determine the authenticity of the entire episode and protect the companies from fraud.

We use totally different technologies for the detection and prevention of fraud with state of the art analytics tools for this process, TCS: Medical insurance fraud comes in many forms but most often leaves a distinct ‘footprint’ in the claim documentation. This can come in the form of charges that are inappropriate; services rendered that are excessive or otherwise inconsistent with the stated reasons for seeking treatment; up to and including spontaneous admissions from or heated exchanges involving an insured when they are communicating with their insurer’s administrator.

An effective cost containment strategy takes all ‘red flags’ into account and acts to confirm or rule out any indicators that a claim is not progressing as it normally should. Being proactive is key and insurers are well served to ensure their administrator is mandated and does in fact pursue all indicators of fraud with vigor. To do anything less is complacency and fraud thrives on that.

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Q12

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CAN INTERNATIONAL MEDICAL CENTRES OF EXCELLENCE PLAY A ROLE IN MANAGING MEDICAL CLAIMS AND COSTS?

CEGEDIM INSURANCE SOLUTIONS: Absolutely.

International medical centres of excellence are critical in ensuring that members receive the right care, whether for planned or emergency treatment. Even when requiring repatriation by, say, air ambulance, this strategy optimises cost management, delivering a level of care that enhances member advocacy.

GLOBAL EXCEL: Absolutely, however this can be a complicated landscape to cross. Any medical centre and any medical provider can claim they’re a Centre of Excellence. There is absolutely no regulation around that assertion and it seems to be the latest provider buzzword.

You need to look past the advertising and the slick internet sites. You need to look around the unverified glorious quotations from patients. Get the facts. Read actual independent quality assessments. Question their costs and how much they bill over costs.

Global Excel has long been the market leader in combining the concepts of quality and cost of care.

Global Excel identifies true provider value as a combination of cost and quality. Unfortunately, consideration for both quality and true cost elements in the payment of hospital services is virtually nonexistent in the market today and the two concepts tend to remain separate.

Our experience has shown, time and again, that some of the lowest ranked facilities on a quality scale are at the same time some of the highest billing providers in the country. For this reason, Global Excel has developed our FairChex product to align a facility’s quality (per DRG by percentiles) with its charges (per DRG by percentiles).

As a cost-containment partner we use this tool to offer direction and in our case management, bill review and settlement processes. For our clients whose policies specifically involve planned treatment (rather than pure emergency), being able to offer

information based on quality AND financial ratings allows them to enter into more informed discussions with the patients about the best place for treatment.

It provides a comprehensive evaluation of all components of medical quality, including processes, outcomes, and patient experience, and then links this with actual billing and discount information.

You need to be vigilant. Look at the facts and not the advertising. Some of the highest ranked providers in our system are the smaller little known specialists who deliver outstanding quality service for a reasonable price. These are the ones we prefer steering patients to!

MDabroad: Our colleagues responded well on these.

I couldn’t have said it better than Global Excel. We do prefer working based on our experience with certain facilities and not on market perception solely.

PAYER FUSION: International medical centres of excellence can definitely play a role in managing medical claims and costs. By being a centre of excellence, their claims should be cleaner accurate and services less costly as they should be more efficient and should not make many mistakes that may extend the length of stay and cost to the insurance. They can established protocols to deal with insurance companies and members in competitive care and fair pricing. Because of the conflict I expressed above where cost containment companies charging on percentage of the savings make a lot do money, providers in general and international centre of excellence are not very keen to deal competitively with these cost containment companies. These know there have been not steerage of the member by the cost containment company and that part of the discount being issues goes to the cost containment company fees. In some markets where the costs and the fraud are not as extensive the relationship with

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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the cost containment company is effective and rates are pre-established under contract.

TCS: Indeed, international medical centers of excellence can play a critical role. It is important to recognise,

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however, that there is no real standard of ‘excellence’ and that the quality of claims management will vary from one center to another. It falls to the administrator to assess the promises made VS the results obtained and utilise the most cost effective solution.

HOW SERIOUS ARE INTERNATIONAL MEDICAL PROVIDERS ABOUT MEDICAL COST CONTAINMENT?

CEGEDIM INSURANCE SOLUTIONS: Every international medical provider is desperately trying to contain costs, but many have yet to equip themselves with the appropriate tools. Most insurers are incurring costs before even becoming aware of the claim, their policyholders undergoing pre-authorised treatments that leave them with nothing to do but settle the bill.

How can providers be partners unless they enjoy full visibility – potentially enabling them to avoid treatments being required, saving them money and their customers time, pain and discomfort?

GLOBAL EXCEL: In our opinion it varies considerably.

Some international providers seem to be focused on providing good quality care at reasonable prices and we love them. Other international providers (and we even have them here in Canada) seem entirely focused on U.S. prices without the accompanying ‘discount’ philosophy and little regard for quality. We actively steer away from those providers.

MDabroad: Many providers, regardless of geography see cost containment as an effort to deny them much deserved fees and charges. As a trusted relationship managers, our role is to educate our dedicated providers that the care continuum includes good medical outcomes AND reasonable prices.

just like any other industry in today’s world. I believe international medical providers are serious about cost containment it is important on all fronts if indeed the cost containment is appropriate and real. However, the proliferation of diseases around the world and especially in developing countries make it difficult for inexperienced companies to establish the real cost containment being achieved and to engage with the insurances in a model that will give better results.

Transparency on the part of the providers must be achieved and pursued in the contractual model adopted to make sure that the mark up over the cost of the service is fair and appropriate, Cost containment companies need to get away from the traditional repricing and the superficial case management and get involved with providers in disease management, emphasis on out-patient services and work to keep the inflation of medicine from continuing to escalate.

TCS: No doubt each views their mandate very seriously.

More importantly perhaps is what results they achieve for their clients. Unfortunately not all live by the mantra to ‘promise less and deliver more. As above, it falls to administrators to employ the center most suitable to the matter at hand.

PAYER FUSION: Medical providers must keep up with technology and new developments and drugs

iPMI MAGAZINE | INTERNATIONAL MEDICAL COST CONTAINMENT STRATEGIES

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IN A WORLD OF NEW APPROACHES WHAT ROLE DOES A PPO PLAY IN COST CONTAINMENT?

CEGEDIM INSURANCE SOLUTIONS: PPOs are playing a traditional role. If we’re truly talking about new approaches, we need insurers to focus on the value of care rather than its mere cost, so that long-term implications are taken into account. Prof. Michael Porter defines the Value equation as “Health outcomes that matter to patients: Costs of delivering these outcomes”, stating that “value is the only goal that can unite the interests of all system participants”.4In a world of new approaches, it’s this Value equation that stands to allow insurers to solve the “Health Care Problem” emerging out of the perfect storm of demographic, economic, social and medical changes that we are currently witnessing.

GLOBAL EXCEL: In our opinion, you always need to go back to the basics and ask ‘what value do they truly provide’. Many PPOs these days are content to lock in provider contracts that are strictly based on a percentage off billed charges discount. There is often little value there. The PPOs who offer case rates, per diems, or best of all, cost-plus contracts are the ones providing true value. We like them and partner often.

We always tell our clients that ‘if you don’t know what the cost of treatment was, you have no clue whether the savings percentage you achieved was good or bad’. Clients still make the mistake of judging a traditional cost container on the discount percentage (either on individual bills or in the aggregate) rather than how much they paid above cost.

MDabroad: The primary function of the PPO is direct access to a network of professionally reliable providers.

Quality is a non-negotiable requirement and need.

Pricing is the last consideration. In Latin America, there is a huge gap in quality between 1st tier providers and the rest of the market, as such, our foremost concern is access to a high quality facility. Discounts

are negotiated on factors such as payment speed and, maybe, some volume. Facilities typically operate at normal margins and do not inflate bills like in the US, so the PPO paradigm doesn’t apply.

PAYER FUSION: PPO’s still contain costs by negotiating discounts for services with hospitals and physicians as condition for remaining within the organization.

These discounts continue to allow the PPO to reduce health insurance premiums and expenditures. In turn, the patients receive a greater percentage of cost covered by the insurance company if they stay with the healthcare providers within the PPO. However the PPO contract needs to be properly negotiated in other than a percentage of the charges as costs in most part of the world has been increasing faster than inflation.

TCS: In a world where new approaches are envisioned regularly, PPO’s continue to provide real and quantifiable discounts without the risk of exposing insurers and their insureds to collection action or litigation. They remain an important resource but perhaps no longer play such a pivotal role as administrators continue their drive towards ever more effective discounting solutions.

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COST CONTAINMENT, IN THE FORM OF DISCOUNTS, IN THE U.S. IS DELIVERED THROUGH LEASING MAJOR CARRIER DISCOUNTS THAT ARE ACCESSIBLE BY MOST COST CONTAINMENT AGENCIES. WHAT OTHER VALUE-ADDED SERVICES SHOULD BE OFFERED TO PREVENT COST CONTAINMENT FROM BECOMING A COMMODITISED INDUSTRY WITH COMPETITION BASED ON SMALL DIFFERENCES IN PRICE ALONE?

CEGEDIM INSURANCE SOLUTIONS: Whenever we use a complex product or a service, it is value that matters to us. We may make price-based decisions on the most basic of items, but beyond those we’re likely to prioritise the value we get for our money.

Insurance products differ from most other items we purchase in that we buy them hoping to never have to use them. This has always raised challenges for providers looking to differentiate their offering.

Fortunately for insurers, there are now tools designed specifically to allow policyholders to appreciate some value even without undergoing treatment.

A clear example comes in the shape of digital wellness apps, whereby insurers can guide their insureds with knowledge and support to achieve and maintain optimum health levels. Not long ago, such advice would have been generic and uninspiring; today, with data-sharing and analytics, it can be delivered in a personal, relevant and motivating manner.

When treatment is required, insurers can empower their insureds to select the practitioner that best suits their needs, both in terms of skills and convenience, and to manage their hospital stay, regularly reviewing their entitlement. This engenders Porter’s “Virtuous Circle of Value”, 5 as it improves outcomes for all stakeholders: insurers improve processes and reduce costs, and insureds take charge of processes that traditionally have only added to the stress of difficult times. This spirit of cooperation can be leveraged for continuous network optimisation, as insurers and patients contribute to the assessment of medical providers, with scores being made available at the point of selection to inform a better choice and ensuring value is delivered throughout a relationship that, for many, often lives in the background until becoming critical.

GLOBAL EXCEL: The discounts are, with certain

regional or local exceptions, very similar at least on the aggregate. Individual provider discounts can vary quite a bit, but overall the results are fairly even.

Once again international payers need to look far beyond the traditional cost containment ‘reactive discount’ philosophy. Providing true differentiated value begins much earlier in the process. How is treatment risk evaluated in real time? What are your triage factors? How can the member easily access your services? Do you offer steerage? Do you offer telemedicine? Can you arrange for house calls? What alternatives do you offer to the emergency rooms?

What is your case management philosophy? Which treatment protocols are you using? How are you evaluating repat and rehab options? Can you direct bill? How can we protect our plans against rising pharma costs? What other network options can you offer? What happens if the ‘in-network’ discount is still unreasonable? How are all these things linked seamlessly together so they most effectively work together to impact the financial outcome and the member experience.

MDabroad: While discounts have certainly been commoditised in the USA by the leasing of major payor networks; these discounts are stratified based on claims volume, and not universally available. In the USA, the Cost Containment efforts of international payors have been capped at the highest discount level available to major US payor networks. I believe that the cost containment paradigm in Mexico and LATAM is different than in the USA because provider margins are much smaller than in the USA. Additionally, in many markets, physician fees rival, or exceed, hospital charges. These conditions make for natural barrier to deep discounts.

PAYER FUSION: The notion that cost containment is applying a discount to claims is not a way to contain

THE HEALTHCARE EXPERTS OF THE AMERICAS COST CONTAINMENT | CLAIMS MANAGEMENT | CLAIMS CLEARING HOUSE SOLUTIONS | PROVIDER SOLUTIONS | PAYER SOLUTIONS | CLAIMS FUNDING | 24/7 ASSISTANCE |

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cost it is a way of reducing that claim for a better price to be paid. There are many other things to be done such as concurrent review of the charges for appropriateness of case, checking for the appropriate length of stay upon admission, reviewing that the case is based in evidence based medicine. Using tools that aligns payers and providers with actionable, evidence-based clinical intelligence to support appropriate care and foster optimal utilization of medical resources. Properly refer the members to the proper site of service so that services that can be performed and managed in one setting are not rendered in another setting. Avoiding ER visits for other forms of alternative site of care like urgent care.

Unfortunately many cost containment companies

Q16

| iPMIM

want the bill to be as large as possible and do not practice these techniques because the larger the bill the larger their fee.

TCS: It is natural when seeking a discount via these networks that administrators gravitate to the deepest discount at the best price. Accordingly, it can be argued that this is already a commoditised industry with success rooted in providing a better discount than their competitors. As to the question of what value added services might be provided to increase competitiveness, perhaps in house bill scrubbing/ auditing type services; fraud detection and prevention.

WHAT ARE THE BIGGEST CHALLENGES FACING THE GLOBAL COST CONTAINMENT INDUSTRY?

CEGEDIM INSURANCE SOLUTIONS: Focusing on insurance, the healthcare ecosystem’s growing complexity and sophistication offers the industry both the greatest challenges and the greatest opportunities. Insurers and providers who equip themselves with the right assets to manage these developments will be able to take better care of their members, improve retention rates and contain costs; those looking to solve today’s challenges with yesterday’s tools are at risk of stagnating and falling behind.

Good news: we are faring better at curing pathological diseases. We are living longer. For insurers, this equates to a constant increase in treatment options and the need to be proactive in their engagement with policyholders, helping them look after themselves and not just coming to their rescue when something needs fixing.

IPMI providers cannot afford to counter rising costs by cutting the quality of their offering. Digital empowers

them to improve loyalty and retention rates by identifying operational cost containment opportunities and provide a greater customer experience. Digital also enables data collection on a greater and faster scale than ever, enabling IPMI providers to partner with their members to prevent illnesses and diseases and improving their health rather than act as simple payers, reducing costs in the process.

GLOBAL EXCEL: As the world becomes smaller through increased mobility and travel, many of the same problems remain in health care. The top items on our list of challenges are the rapidly rising healthcare costs, not only in the U.S. but even more dramatically in other countries, particularly in the developing world. Faced with a more complex world our clients are coming to us for increasing international solutions – they want the Global Excel experience in more locations around the world. Consumer demands are changing as well – as technology quickly evolves they

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“THE INTERNATIONAL PRIVATE MEDICAL INSURANCE MAGAZINE HAS GREAT MARKET KNOWLEDGE AND EXPERIENCE IN THE IPMI SECTOR AND THEY PRODUCE EXCELLENT MARKET UPDATES. WE ARE DELIGHTED TO BE ASSOCIATED WITH CHRISTOPHER KNIGHT AND HIS TEAM.” CHRISTOPHER PERCIVAL BOARD DIRECTOR HEALTHCARE INTERNATIONAL

ROUND TABLE

want more sophisticated health care, and they want solutions around the world.

The healthcare world continues to evolve and change – quicker than ever. Those of us who supply risk management services to the industry are having to change and adapt quickly. Our challenge is not only supplying relevant value-add services today and tomorrow, but in determining what our clients will need 5 and 10 years from now.

MDabroad: I agree with my colleagues regarding the challenges in the USA. In LATAM and Mexico we see a different dynamic. The demand for first world clinical quality in emerging nations is rapidly pushing claims expense upward. Good providers in LATAM and Mexico are islands of excellence that face disproportionately higher cost of doing business compared to their US counterparts. Although labor and legal expenses are lower than in the USA, the cost of quality in emerging

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countries is relatively higher than in the USA and Canada. This is because of the high cost of imported capital equipment, technical service, supplies, implantable, and pharmaceuticals. To this end, providers expect to recover the cost of quality and innovation via higher charges and greater interest in disproportionate charges of the very segment that leads the demand for better quality standards. Simply put “there are no free lunches”. Given these conditions, trusted relationships with payors and providers remain the cornerstone of cost containment efforts in LATAM and Mexico.

PAYER FUSION: The growing cost of healthcare is at the front lines of the problem. This culminates with lack of coordination and a great need for global data sharing. There is still a substantial lack of oversight, reporting and measuring. Additionally, working with consultants, multinationals and local healthcare providers around the world can be tedious, all the

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ROUND TABLE

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pieces must be put together and analysed on a global level.

| iPMIM

presents itself.

TCS: Information is moving faster than ever now and in ways that are both exciting and concerning. In my view, the biggest challenge for cost containers will be to stay at the forefront of this evolution responding to each new challenge and opportunity as it

Q17

HOW HAS THE COST CONTAINMENT LANDSCAPE DEVELOPED IN THE PAST DECADE?

CEGEDIM INSURANCE SOLUTIONS: The principles of cost containment haven’t changed. In the main, insurers are confronted with the same pressures as a decade ago.

What has fundamentally changed is the landscape of tools designed to empower insurers to tackle these pressures effectively, be it by identifying fraudulent claims and abuse or by optimising their provider network management.

Moving forward, technology will continuously evolve, accelerating the collection of data to better inform care and treatment whilst reducing costs.

Artificial Intelligence (‘AI’) is gathering and mining structured and unstructured data in a way never previously possible; Virtual Reality (‘VR’) is providing new treatment options for mental illnesses; Robotics are improving efficiencies and diagnostic accuracy.

We saw earlier that the growth in options represents both a challenge and an opportunity for IPMI providers.

This is why managing this growth through specialist, integrated systems, capable of improving processes and decision-making by converting unprecedented volumes of data into optimal courses of action, is key to greater health for members and providers alike.

Two developments over the past decade require new cost containment strategies: Firstly, chronic diseases have become the main

cause of mortality, accounting for 86% in the European Union,6 as well as the greatest cost factor. This “epidemiologic transition” fundamentally changes what IPMI providers must offer and the structures and systems required to do so.

For perspective, “life expectancy is projected to increase by one year by 2020, which will increase the aging population (over 65 years old) by 8%, from 559 million in 2015 to 604 million in 2020.”7 Zooming in on the UK, according to the Office for National Statistics, between 1960 and 2010 alone “the average life span increased by around 10 years for a man and 8 years for a woman”. 8 This is no passing trend, rather a fundamental change in our social make-up impacting all of us in all that we do. And this is why, more than ever, IPMI providers need to manage the cost of caring for chronic diseases beyond the initial treatment. In their new role as “Care Partners”, they can provide policyholders with support for the self-management of diseases and treatments, improvements in life habits and shared decision-making.

Secondly, one reason for rising life expectancies lies in the amazing strides made by healthcare technology. Such improvements come at a cost; and it is one that providers have to bear, prior to the switch to covering the post-treatment costs outlined above.

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ROUND TABLE

GLOBAL EXCEL: For many traditional cost containment companies it has become a very transactional costbased initiative. The push was how to streamline the flow of bills from provider to network and back with absolute minimal effort in a drive to push prices lower and lower. They still use the same methodologies, the same focus on percentage of savings, and pricing that’s based on savings. There is no attention to detail, no passion for ensuring that a fair amount is paid for an appropriate level of service and this creates mediocre patient experience.

For organizations like Global Excel, the change has been constant and dramatic. We’re not the same organization we were 10 years or even 2 years ago.

Due to our roots as an MGU we have kept our traditional focus on fair payment for appropriate services and continued to push our pro-active healthcare risk management approach even further.

MDabroad: In our legacy markets, we have seen the proliferation of quality providers, and resistance to discounts due to late payment of claims. We capitalized on late payments as a new business opportunity, and launched a funding company that bridges the 45-60 day gap in the claims payment cycle. Our funding vehicle helps providers’ cash flow and encourages discounting. Additionally it helps TPA/Networks preserve their goodwill with Providers.

Finally, it helps payors by removing pressure to deviate from established claims management practices.

In summary, like every business, the cost containment segment is multi- dimensional and requires agility to adjust to dynamic changes.

TCS: The term ‘medical cost containment’ is generally understood to involve the discounting of medical service provider invoices, so called ‘billed charges’.

This is the simplest definition. In reality, the process is far more involved and may include both proactive (ie: intervention in the billing process before a patient is discharged) and reactive; (ie: after a patient is discharged and invoices are generated) Other less embraced methods include the recovery of costs paid out from other insurers also on a given risk. (ie: priority on risk matters and/or losses arising out of the liability of a third party or parties.)

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LEARN MORE ABOUT COST CONTAINMENT COMPANIES Turn the page to enter the iPMI Magazince cost containment provider network directory, a definitive guide to leading cost containment service providers.

ROUND TABLE REFERENCES Value-Based Health Care Delivery: Core Concepts”, by Professor Michael E. Porter, Harvard Business School – “Value Measurement for Health Care”, Boston, MA. (USA), 29/11/2017 2 https://www.diabetes.co.uk/global-diabetes/ index.html 3 http://www.bcbsm.com/health-care-fraud/ fraud-statistics.html 4“ Value-Based Health Care Delivery: Core Concepts”, by Professor Michael E. Porter, Harvard Business School – “Value Measurement for Health Care”, Boston, MA. (USA), 29/11/2017 5 Value-Based Health Care Delivery: Core Concepts”,

by Professor Michael E. Porter, Harvard Business School – “Value Measurement for Health Care”, Boston, MA. (USA), 29/11/2017 6 EU committed to action on chronic diseases” http://ec.europa.eu/health/newsletter/127/focus_ newsletter_en.htm 7 “2017 Global Health Care Outlook”, Deloitte https://www2.deloitte.com/uk/en/pages/lifesciences-and-healthcare/articles/global-healthcare-sector-outlook.html 8 https://www.ons.gov.uk/ peoplepopulationandcommunity birthsdeathsandmarriages/deaths/articles/ mortalityinenglandandwales/2012-12-17 1 “

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INTERNATIONAL MEDICAL COST CONTAINMENT PROVIDER NETWORK DIRECTORY A GUIDE TO LEADING PROVIDERS OF INTERNATIONAL MEDICAL COST CONTAINMENT SERVICES FOR INTERNATIONAL MEDICAL PAYORS AND PROVIDERS.

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Actisure’s Provider and Network Management module enables the comprehensive definition of individual providers through to complex network.

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Insurance Solutions

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INTERNATIONAL MEDICAL COST CONTAINMENT | CEGEDIM INSURANCE SOLUTIONS

CEGEDIM INSURANCE SOLUTIONS GEOGRAPHY: GLOBAL

Cegedim Insurance Solutions provides high value software and services across the health value chain to 200+ leading healthcare insurers across the globe.

HQ: FRANCE SECTOR: Healthcare Insurance Management

For more than 30 years, Cegedim Insurance Solutions has been breaking new ground in order to provide insurance companies, mutual funds, contingency funds and brokers in France and overseas with software packages and services covering the whole of the healthcare value chain:

+44 117 316 9094

• • • • • •

contactcegediminsurancesolutions@ cegedim.com2000

cegedim-insurance.com

Development of back office software Digital solutions for illness prevention Facilities management Delegated authority Healthcare flow assembly Third-party payment operator

We bring together all Cegedim Group’s software packages and services for the life and health insurance industry through our subsidiaries Cegedim Activ, Activus, Cetip, and iGestion. With our solutions, we cover 40 million policyholders, along with almost 20 million via our third-party payment services through our SP Santé and iSanté brands.

25 Great George Street, Bristol, BS1 5QT, UK.

SERVICE FEATURES 4 4 4 4

INTERNATIONAL INSURANCE MANAGEMENT DOMESTIC INSURANCE MANAGEMENT TRAVEL INSURANCE MANAGEMENT PROVIDER NETWORK MANAGEMENT

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TPA MANAGEMENT DIGITAL PORTALS MOBILE APPLICATIONS CLOUD SERVICES

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77

INTERNATIONAL MEDICAL COST CONTAINMENT | GLOBAL EXCEL

GLOBAL EXCEL GEOGRAPHY: GLOBAL

Global Excel is a worldwide premium healthcare risk management company, providing services to a broad range of market segments. Our partners trust our expertise in controlling healthcare costs for the management of their claims dollars as well as our ability to provide a superior member experience.

HQ: CANADA SECTOR: COST CONTAINMENT

Global Excel is a privately owned company that services a wide range of clients, including insurers, reinsurers, assistance providers, and third party administrators (TPA). Through these types of clients, we provide services to travellers (leisure and corporate), expatriates, students, major medical / critical care patients and U.S. domestic clients (including private health care, worker’s compensation and occupational health).

+1 819 566 8833

corpinfo@globalexcel.com

globalexcel.com

Our clients come from many different countries and cultures, so we realize the importance of developing true business relationships with them. It’s why we view all of our business relationships from a longterm perspective, as opposed to seeing them as short-term profit centres.

73 Queen Street, Sherbrooke, Quebec, Canada, J1M 0C9.

SERVICE FEATURES 4 4 4 4

INTERNATIONAL HEALTH RISK MANAGEMENT PRO-ACTIVE ASSISTANCE INNOVATIVE DIRECTIONAL CARE PRODUCTS PROVIDER AND NETWORK MANAGEMENT

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4 4 4 4

MEDICAL CASE MANAGEMENT CLAIMS ADMINISTRATION AND ADJUDICATION REPRICING AND COST CONTAINMENT REPORTING AND CONSULTING

CONTACT US

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THE HEALTHCARE EXPERTS OF THE AMERICAS COST CONTAINMENT | CLAIMS MANAGEMENT | CLAIMS CLEARING HOUSE SOLUTIONS | PROVIDER SOLUTIONS | PAYER SOLUTIONS | CLAIMS FUNDING | 24/7 ASSISTANCE |

Phone: +1 786 618 1080 Fax: + 1 718 847 0533 Website: www.mdabroad.com Email: info@mdabroad.com

79

INTERNATIONAL MEDICAL COST CONTAINMENT | MD ABROAD

4 MDABROAD GEOGRAPHY: GLOBAL HQ: USA SECTOR: COST CONTAINMENT

MDabroad was established in 2000. We developed a role of unquestionable leadership in the health care industry as the first facilitator for the financial needs of hospitals, providers, and other international health industry payers.

In just over 15 years, we have managed over 500 million dollars worldwide in settlements of medical claims between healthcare providers and insurers with full recognition and satisfaction between both segments.

+ 1 786 618 1080

Our formula is very simple: We act as a claims clearinghouse that ensures that provider and payor expectations are met.

The approach to settling claims is transparent and collaborative and ensures that value is given to all parties involved.

info@mdabroad.com

mdabroad.com 2999 NE 191st Street, Suite 608 · Aventura, FL 33180, USA.

Payors, hospitals, and physicians work mainly with local healthcare clients with the same languages and cultural norms. But, significant differences can arise when dealing with foreign hospitals. For instance, a patient claim from Latin America and an insurance company from Germany. These differences may hinder a proper understanding between each party which can result in a compromised payment settlement.

SERVICE FEATURES 4 4 4 4

INTERNATIONAL COST CONTAINMENT INTERNATIONAL CLAIMS MANAGEMENT MEDICAL CASE MANAGEMENT PROVIDER NETWORKS

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4 4 INTERNATIONAL CLAIMS MANAGEMENT 4 COMPLETE HEALTH PLAN ADMINISTRATION 4 INTERNATIONAL CLAIMS MANAGEMENT

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81

INTERNATIONAL MEDICAL COST CONTAINMENT | PAYER FUSION

PAYER FUSION GEOGRAPHY: GLOBAL

PayerFusion’s innovative TPA services utilize the latest medical claim processing technology coupled with our unique healthcare cost containment methodologies to provide you with the sharpest advantage possible.

HQ: USA SECTOR: TPA

Our rules-driven medical claim administration tools enable you to remain competitive and compliant in an environment of everincreasing costs and regulations.

+1 305 760 8739

Inflated and fraudulent bills result in $250 billion in unrecovered over payments each year. These over payments are calculated after supposed “discounts” have been applied to retail rates on medical provider bills. The results of such practices are needlessly high per claim costs, which are detrimental to the healthcare system as a whole.

info@payerfusion.comT: 2000

payerfusion.com

As regulation in the U.S. increases providers are rapidly becoming less willing to agree to blanket or routine discounts – traditional methods of medical claims processing can no longer deliver acceptable results.

5200 Blue Lagoon Dr #100 Miami FL 33126 USA

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INTERNATIONAL COST CONTAINMENT INTERNATIONAL CLAIMS MANAGEMENT MEDICAL CASE MANAGEMENT PROVIDER NETWORKS

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HIPAA COMPLIANT INTERNATIONAL CLAIMS MANAGEMENT COMPLETE HEALTH PLAN ADMINISTRATION INTERNATIONAL CLAIMS MANAGEMENT

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Transworld Claims Solutions Inc. 151 Queen Sherbrooke, QC J1M 1J8 Tel: 802-880-9026 Fax: 802-880-9027 Web: www.tcsinc.ca

Cost Effective Claims Solutions in a Competitive Environment Increasingly, insurers have begun to recognize the benefits of a thorough recovery program. For most, however, real challenges lay in the implementation of an effective 'Global' solution. TCS has that solution.

We maintain a worldwide network of legal and recovery specialists. Regardless of the jurisdiction, our associates will pursue each matter assigned to them with professional vigor.

Proud North American partners of AVUS Worldwide Claims Services Rechbauerstrasse 4, 8010 Graz, Austria office@avus-group.com

COST CONTAINMENT | LOSS RECOVERY | ADR AND MEDIATION | ATTORNEY REFERRAL | FRAUD CHECK | INVESTIGATIONS

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INTERNATIONAL MEDICAL COST CONTAINMENT | TRANSWORLD CLAIMS SOLUTIONS

TRANSWORLD CLAIMS SOLUTIONS GEOGRAPHY: GLOBAL

Loss Recovery

HQ: CANADA

Increasingly, insurers have begun to recognize the benefits of a thorough recovery program.

For most, however, real challenges lay in the implementation of an effective ‘Global’ solution. TCS has that solution. We maintain a worldwide network of legal and recovery specialists. Regardless of the jurisdiction, our associates will pursue each matter assigned to them with professional vigor.

SECTOR: COST CONTAINMENT

+1 802-880-9026

Cost Containment

tcsinc.ca

tcsinc.ca

TCS offers a range of Cost Containment solutions. From Bill Review through ‘secured’ discounting of charges, and on to final payment, we can assist with a plan tailored to your needs.

Other Services

151 Queen Sherbrooke, QC J1M 1J8 Canada

TCS’s services are multifaceted and include the areas of invoice recovery for service providers; damage assessment, contract research, and the like. Areas of concentration include the Automotive, Marine, and Heavy Industry sectors. For more information on how we can assist, contact us with your questions.

SERVICE FEATURES 4 4 4 4

INTERNATIONAL COST CONTAINMENT INTERNATIONAL CLAIMS MANAGEMENT MEDICAL CASE MANAGEMENT PROVIDER NETWORKS

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Call us today to learn more at

+44 (0)20 3907 4922 UnitedHealthcare Insurance dac trading as UnitedHealthcare Global is regulated by the Central Bank of Ireland. Registered in Ireland with registration number 601860.

Registered Office: 70 Sir John Rogerson’s Quay, Dublin 2, Ireland.