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ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES THE AFFORDABLE CARE ACT (ACA), THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) AND OTHER FEDERAL HEALTH BENEFIT MANDATESBy Laura Carabello By Caroline McDonald
Future-Forward Improvements in Quality Healthcare
Innovative Metrics, Payments & Plan DesignWritten By Laura Carabello
Qualityhealthcare is an evergreen topic that appears to take on new parameters year after year.
As self-insured employers face unprecedented healthcare costs in 2023 and reflect upon some uneven patient experiences and satisfaction with care during the past year, they are counting on value-based payment and direct contracting models for improved quality and better outcomes.
Employers now realize that they can use their purchasing power to negotiate arrangements that tie provider reimbursements to the quality of care -- not the quantity of services -- and get ‘healthier’ results at lower costs.
This is precisely where direct contracting is pivotal to achieving improved quality, as explained by Dr. Shane Purcell, MD, Direct Access MD who offers this perspective, “Directly contracting with a primary care physician – known as Direct Primary Care -allows for more access and time, which are critical for proper care. Primary care is about building relationships…heck, all of medicine is built on relationships. While quality like beauty is in the eye of the beholder, studies show patients do better with strong relationships with a primary care physician. The only way to build trust and relationships is time, which DPC offers.”
Fundamental to this approach is the belief that when practices draw on the expertise of a variety of provider-team members, patients are more likely to get the care they need. A large provider team that is part of an ACO or health system under direct contract might also support continuous, data-driven quality improvement through effective intra-team communication and problem solving.
When the key driver of financial success is keeping patients healthy – rather than billing for services – providers are more inclined to deploy team-based care: broadly defined by The Institute of Medicine (IOM) as “the provision of health services to individuals, families, and/or communities by at least two healthcare providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated high-quality care.”
Team-based care offers many potential advantages for employer groups that are concerned about absenteeism related to accessing care, including:
o Expanded hours of coverage, shorter wait times
o More effective and efficient delivery of additional services that are essential to high-quality care, such as patient education, behavioral health services, selfmanagement support
o Care coordination
o Increased job satisfaction
o An environment in which all medical and nonmedical professionals are encouraged to perform work that is matched to their abilities.
The voice of providers and health systems regarding direct contracting is indicative of the support and traction it is gaining in the marketplace.
To this point, Sandy Balwan, MD, chief medical officer, Northwell Direct, shares, “Direct Contracting strategically places employers in the driver’s seat by eliminating the middleman and allowing for direct negotiation of rates for health care services.
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Armed with additional dollars garnered from discounted rates, employers are empowered to improve the quality of care and health outcomes for their employees through investing in preventive services, wellness and disease management programs. Further, the current competitive healthcare landscape drives healthcare systems and provider groups to compete for patients, thereby incentivizing them to raise the ceiling on the quality of care delivered now and in the future.”
Since quality is widely perceived as a crucial aspect in provider direct contracting strategies, Mac Meadows, president 90 Degree Benefits – Houston, says it is often the central point of negotiation between parties.
“Health systems may demand steerage and exclusivity in exchange for competitive rates, while employers require the health system to demonstrate measurable quality in terms of patient experience and outcomes, in order to justify a narrowed network for members,” says Meadows.
As Ashley Rutkowsky, Independent TPA Consultant, points out, “The concept of quality can be multifaceted, depending on the specific needs of a plan. For instance, an employer-based plan might place a premium on patient experience in order to boost employee satisfaction and retention. Conversely, a plan may prioritize cost-efficiency for providers, in order to remain financially viable during leaner years. In either case, the ultimate goal is to achieve positive outcomes for all stakeholders involved.”
As employer plans often tout the importance of quality in their mission statement regarding healthcare benefits, actualizing this goal can prove challenging for a number of reasons.
Scott Bennett, senior vice president, Provider Relations, The Phia Group, explains that one issue is the lack of standardization in quality metrics for health systems, which can vary greatly depending on the factors prioritized in their assessment.
“This dynamic creates a need to seek direct contracts with providers who consistently deliver high-quality care. By doing so, all parties can be assured that their goals of costeffectiveness and optimal patient outcomes are met.”
individualized, based on factors such as patient characteristics, procedures, and staff,” says Bennett. “This makes it difficult to predict the experience of any one individual.
the goal of quality can sometimes conflict with the budget constraints that employers face, as members may expect a higher-quality, and therefore more costly, experience even when the
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“Additionally, outcomes can be highly
health outcome remains unchanged.”
Quantifying Healthcare Quality
While there are many bodies and organizations that measure healthcare quality, the regulation is fragmented between government agencies, provider, and health plan sponsored organizations.
“With this fragmentation, plan sponsors are at risk for inadequate quality of care information flows resulting in adverse patient events and increased costs,” advises Jakki Lynch RN, CCM, CMAS CCFA, director of cost containment, Sequoia Reinsurance Services, who describes these burdens further in this article.
There are many definitions of healthcare quality but the Agency for Healthcare Research and Quality (AHRQ) denotes six domains, with measures that can be combined and leveraged differently in varying value-based care arrangements. The following provides an overview of these critical areas for valuebased care success, as many employer purchasing contracts require that certain quality measures must be met before payment:
1. Effectiveness and Efficiency
A joint effort that centers around ensuring that hospital patients receive proper care and the resources to coordinate future care to reduce readmission rates. Many value-based care contracts assess whether or not the provider has taken the appropriate steps to deliver a level of care that could have prevented readmission barring extenuating circumstances.
Providing prompt patient care can positively affect patient experience and increase quality of care. Difficulty making appointments, or long wait times to get in for an appointment, can negatively affect patient experience and hinder patient care. Delays in care create challenges in fulfilling the tenants of value-based care models and can hinder the preventative aspects of the model.
Quality care means safe care. Patient safety models are incorporated into value-based care models for obvious reasons, since a major emphasis in these systems is on prevention.
Patients want to feel like they are being listened to and that their providers care about their health and well-being. Patient-centered care checks off these boxes to provide a more fulfilling patient experience. This can also come as a result of increased patient compliance and more effective coordination of care, which is rewarded by value-based care models.
A tricky quality measure to evaluate quantitatively, equitability is nonetheless critical in value-based care models. Equity quality measures encourage providers to provide care to patients from every portion of the population, regardless of demographic. An important consideration in healthcare equity includes understanding and addressing social determinants of health, such as the economic status of patients.
NEW JOINT COMMISSION REQUIREMENT: HEALTH EQUITY BECOMES A NATIONAL QUALITY & SAFETY GOAL
Increased awareness of health equity issues and their impact on quality has led business leaders and employers to ask what more can be done to address health disparities. Many have taken meaningful steps toward improving the outlook, buoyed by a recent announcement from The Joint Commission (JC).
JC issued new and revised requirements that upgraded health equity as a leadership standard that is included in the national patient safety goal (NPSG 16), effective January 1, 2023.
Under NPSG 16, accredited hospitals will still be required to focus on social disparities by identifying patients' needs and disparities and developing a strategic plan to improve health equity in their organizations. But the new change is significant, underscoring the importance of health equity and encouraging hospitals and health systems to view disparities as a quality and safety priority.
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points to a proven approach of
care guidance to promptly address the physical, practical, emotional, informational, cultural, spiritual and familial barriers that impact patients – issues that directly affect quality of care in direct contracting arrangements.
“We are pleased to see the Joint Commission take action to further elevate the importance of health equity,” says Craig Parker, CEO of Guideway Care. “After all, access and understanding are the foundation for safety and quality of healthcare.”
With scalable and repeatable interactions between patients and those who guide the care, supported by a structured care guidance platform, this approach captures and communicates relevant data back to the clinical team, such as those data elements that meet the new Joint Commission requirements and can potentially be shared with the employer.
The value extends to resolving barriers to accessing care that are completely distinct from clinical issues, which becomes critically important for capturing Social Determinants of Health data and disparity-related barrier resolution.
It leverages the capabilities of non-clinically trained individuals to facilitate operational improvement by seamlessly escalating clinically relevant information while delivering SDoH insights for each patient population. It also alleviates any concerns about Electronic Health Record (EHR) systems that are generally not specifically designed to facilitate the kind of resolution workflows that are needed when addressing health equity and social determinant issues.
Joint Commission president and CEO Jonathan Perlin, MD, PhD says, “By elevating the existing standard to a National Patient Safety Goal, we are emphasizing the importance for healthcare organizations to ensure oversight and accountability for healthcare
equity. The new National Patient Safety Goal will help increase the focus on improving healthcare equity, a global patient safety priority."
PROVIDER DIRECT CONTRACTING WITH CARE MODELS THAT ENSURE QUALITY
In their quest for quality healthcare and cost predictability, employers are adopting a direct contracting strategy that incorporates robust financial incentives to manage the cost of care for all parties —employers, providers and employees —while delivering enhanced clinical outcomes for patients.
This approach establishes a one-to-one relationship between a health system or a provider network and a self-insured employer, with employers assuming the financial risk and responsibility of paying their employees’ medical claims.
Typically, the employer contracts with third parties for enrollment, claims processing and provider network construction. According to a recent survey by the Business Group on Health, nearly a quarter (24%) of all employer healthcare purchasers are considering contracting directly with integrated delivery systems.
“An immediate benefit of direct contracting is the enhanced ability of the consumer to better align their aspirational goals with the capabilities of participating provider organizations,” says Brandon J. Burket, MHA, vice president, Orlando Health, Value-Based Care & Population Health. “In the traditional model,
third party involvement can frequently produce inefficiencies, thereby generating waste (effectively, increased costs to the consumer) without measurable improvements in performance, such as better quality outcomes and patient experiences.”Brandon Burket
He points to the strength of a direct relationship between the purchaser and provider of services as a key factor in removing such extraneous and, oftentimes, competing interests from the equation to allow organizations to jointly define what “value” means to them.
“Once fully aligned on this principle, organizations can turn their collective vision into reality more quickly through a direct partnership than through conventional models which tend to leverage “one size fits all” approaches for their clients,” continues Burket. “This can translate to the co-development of population-tailored clinical programs, demographically-relevant quality measures, and win-winwin economic terms to create financial advantages for the patients, employers, and providers alike.”
George Stiles, president and COO, Planned Administrators, Inc. sees direct contracting as another way to help clients customize a health plan that best meets their needs.
MODELS OF CARE FOR DIRECT CONTRACTING
Quality is at the heart of this value-based strategy, as employers are eager to move to these payment models. The Business Group on Health, which advocates for large employers in health care policy, points to several models of care that represent opportunities for quality healthcare value purchasing:
Direct Primary Care
DPC gives family physicians a meaningful alternative to fee-forservice insurance billing, typically by charging members a monthly, quarterly, or annual fee. This fee covers all or most primary care services including clinical and laboratory services, consultative services, care coordination, and comprehensive care management. Simply stated: DPC practices charge a flat recurring membership fee instead of billing insurance, eliminating the associated red tape and allowing physicians to build rapport with each member.
These DPC practices shift the focus of primary care toward quality instead of simply focusing on numbers, allowing providers to be free of traditional time constraints due to the need of seeing a high volume of patients.
In turn, this allows clinicians to spend more time with patients at the point-of-care and provide
“We are especially excited about opportunities to partner with direct primary care providers (PCP) who share our goal of providing the best care at a reasonable cost, ” says Stiles. “When the PCP ‘owns’ the patient relationship and is focused on getting them the best care both inside and outside of their clinics they can have a real impact on care quality, which should be supported through data exchanges and streamlined referral processes. This is especially important when the primary care physicians is not beholden to a single health system for that care.”
more comprehensive care to patients throughout the health care journey.
Think of the positive impact this has on quality when, for example, a patient needs to be referred to a specialist for more additional services.
DPC practices have the ability to maintain a strong, ongoing relationship with patients and ensure that the care delivered is thoroughly coordinated throughout the treatment process. The improved effectiveness of primary care at the population level not only improves quality, but also leads to substantial decreases in costs.
Because some services are not covered by a monthly fixed fee, DPC practices often suggest that members acquire a high-deductible wraparound policy to cover emergencies, or another insurance alternative option that will protect members in the case of necessary surgeries, hospitalization or a large medical claim.
John Halsey, founder and chief growth officer, Recuro Health, observes,
He notes that when employers opt for self-funding their benefits, they essentially break ties with traditional health plan payers and find themselves without access to networks for care delivery.
“Employers should be seeking value partners that provide a virtual first approach to engage the members at a lower cost while ensuring access to quality care – including preventive care to treat chronic disease on the front end and more proactively.”
Halsey points to the role of narrow networks that are isolated from traditional health plan networks and will remain with the employer regardless of any changes in the major medical network.
“Employers are seeking quality healthcare and cost predictability and are adopting a direct contracting strategy for primary care that incorporates robust financial incentives to manage the cost of care for all parties – employers, providers and employees – while delivering enhanced clinical outcomes for patients. This approach establishes a one-to-one relationship between a provider group or primary care provider network and a self-insured employer, with employers assuming
the financial risk and responsibility of paying their employees’ medical claims. Typically, the employer contracts with third parties for enrollment, claims processing and provider network construction.”John Halsey
“With this approach, when the employer changes networks, members won’t have to reestablish a relationship with a new primary care physician,” he says. “Ideally, the provider network runs outside of the hospital-owned primary care practice, further lowering costs by steering members towards higher performing services.”
HIGH PERFORMANCE NETWORKS
Providers in a true high-performance network consistently deliver both lower costs and higher quality through care that is patientcentered, evidence-based, appropriate and coordinated – not simply lower costs. Robust data-sharing and effective quality measurement are also critical in identifying providers that deliver quality care at a lower cost.
According to the Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey, roughly 16% of larger employers have built a “high-performance” network into their health plan, a number
that is projected to grow in the coming years as these networks evolve and mature. Since these networks differ substantially in quality and cost, it’s important for employers to identify the measurement metrics used.
ACCOUNTABLE CARE ORGANIZATIONS (ACOS)
An ACO is a group of doctors, hospitals and/or other health care providers who come together voluntarily to give coordinated high-quality care that improves the care delivered to patients.
These organizations help doctors and other health care providers understand an individual’s health history and confer with one another about care and health care needs.
This model can save employers time and money by avoiding repeated tests and unneeded appointments and may make it easier to spot potential problems before they become more serious—like drug interactions that can happen if one provider isn’t aware of what another has prescribed.
The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
CENTERS OF EXCELLENCE (COE)
A COE is a hospital or healthcare facility where patients continually return to receive primary care or treatment for acute conditions, separate from the place of diagnosis. Such facilities are often epicenters of care provision for large patient populations and are thereby an example of best practices within a distinct specialty. COEs aim to reduce variation in quality and cost and increase the likelihood of optimal patient outcomes. Quality improvements and decreased costs result from improved professional care coordination, team attention to evidence-based guidelines, better discharge planning to avoid preventable readmissions, increased uniformity of practice and measurement and feedback of patient outcomes.
Early initiatives, such as the center of excellence (COE) program adopted by Lowe’s, Walmart, and others, targeted specific high-cost surgical interventions, incorporating the use of high-quality health care entities and bundled pricing to optimize outcomes while ensuring predictable case costs.
Similarly, organizations with geographically consolidated workforces, such as Boeing and Microsoft, have partnered directly with local integrated delivery networks for comprehensive care delivery.
Another example: in 2013 the Purchasers Business Group on Health established the Employers Centers of Excellence Network (ECEN) to support value-based purchasing among its members. ECEN provides employees access to demonstrated high-quality care for elective surgeries at meticulously selected COEs across the United States.
Through the ECEN, patients receive care at little or no cost, and their employers gain predictable health care costs and downstream savings. The ECEN program initially selected hospitals and surgeons throughout the nation for hip and knee replacements and later expanded to offer spine and bariatric procedures and certain oncology services.
With 96,000 members representing both individuals and organizations, the Healthcare Financial Management Association (HFMA) helps its members to achieve optimal performance by providing the practical tools and solutions, education, industry analyses, and strategic guidance needed to address the many challenges that exist within the US healthcare system.
In the COE direct contracting model, HFMA defines the responsibilities of each party:
For employers, the model offers cost savings and cost predictability via a bundled payment for a defined episode of care. For example, an employer might contractually secure a flat rate of $30,000 for knee arthroplasty at an orthopedic surgery COE. In addition to reduced costs, the employer enjoys the potential benefit of faster return to work for employees.
For providers, the future-state COE model secures additional patient volume via contractual provisions that deliver a degree of exclusive access to the employee population. Providers may also be able to earn incentive payments for meeting contractually defined quality indicators.
For employees, going to a COE provider means their out-of-pocket costs are fixed. Also, by enjoying access to a provider that performs services at or above clinical best-in-class standards and that tracks clinical quality outcomes, employees are assured of having the best opportunity to recover as quickly and fully as possible.
Further underscoring the benefits of direct contracting, Blake Allison, CEO, Employers Health Network (EHN), shares, “Direct contracting allows for the buyers, the self-funded employers, and the sellers, the providers of healthcare services, to work more directly to drive true innovation and performance. When the two parties are connected via a third party, specific rules typically accompany the relationship that are designed to value the third party, not the two key stakeholders.
Allison emphasizes that direct interaction allows for the measurement of specific, outcomebased measures, drives performance and ensures that the value of the healthcare delivery system directly impacts the employer.
REDUCING THE BURDENS OF MISDIAGNOSIS, MEDICAL ERRORS
Alerting employers to the impact of misdiagnosis on the quality of care, Jakki Lynch offers this important perspective:
“This is a timely concern for plan sponsors as errors in health care delivery lead to missed, delayed or incorrect diagnoses, higher costs and unnecessary injuries and deaths. A new report published by US Department of Health and Human Services’ Agency for Healthcare Research and Quality found that nearly 6% of the estimated 130 million people who go to US emergency rooms every year are misdiagnosed. The researchers estimate that 7.4 million misdiagnosis errors are made every year, 2.6 million
“The current system has evolved to create value for the intermediary, leading to a lack of measurable performance and overall dissatisfaction,” he concludes.
Skyrocketing prices. Administrative challenges. Shock claims. Aging workforces. At Amwins Group Benefits, we’re here to answer the call. We provide solutions to help your clients manage costs and take care of their people. So whether you need a partner for the day-to-day or a problem solver for the complex, our goal is simple: whenever you think of group benefits, you think of us.
The benefits landscape is broad and complex.
people experience a harm that could have been prevented, and another 370,000 are permanently disabled or die because of the misdiagnosis.”
She further reports on new data released by the CDC that several healthcare acquired infections (HAIs), such as central lineassociated bloodstream infections and ventilator associated pneumonias, showed increased prevalence in 2021.
“Although health plans may have payment policies that address these issues, many do not have processes to identify them and adjust claim payments,” continues Lynch.
Employers should keep in mind that charges incurred for preventable events should not be paid and hospitals will consider charge adjustments if presented with adequate documentation and clinical record support by payment integrity specialists.
explains Lynch. “According to a recent 2022 study published in the Journal of Patient Safety, “Cost of Health Care-Associated Infections in the United States” estimates for HAIs ranged from 7.2 to 14.9 billion dollars.”
Plan sponsors need visibility and a solution-oriented approach to identify, track, report, and manage costs for complex risk from quality-of-care events.
QUALITY FOR THE FUTURE
The National Committee for Quality Assurance (NCQA) offers recommendations that represent a vision for evolving the current quality measurement ecosystem while maintaining its most effective elements. A few key themes recur:
• The importance of refining and developing quality measurement to help stakeholders drive toward health equity and address social determinants of health.
• The potential to reduce burden and improve care by moving to a digital quality measurement system that captures quality data during care delivery and provides results and decision support much more rapidly.
• The essential role of data validation to ensure accurate payments in value-based models.
Just like beauty, quality healthcare may well be in the eyes of the beholder. Employers need to be the final arbiters of quality, how it will be measured and how they can access care that meets these expectations.
“Preventable hospital acquired conditions continue to have a huge economic burden on the healthcare system and they negatively impact overall healthcare expenditures,”
“Plans can successfully implement a comprehensive payment integrity program to identify and mitigate significant charges associated with unexpected hospital acquired conditions and quality of care events,” advises Lynch.
RE-ENERGIZE YOUR FOCUS ON QUALITY
“Quality” will be a key focus of a spectacular line-up of speakers at the SIIA Spring Forum, March 29-31, 2023 in Orlando Florida.
Expected to participate at the largest gathering of senior-level self-insurance industry professionals for the first half of 2023. You will have the opportunity to attend and participate in sessions focused specifically on what self-insured payers and their business partners need to know about how to better assess and leverage health care quality for the benefit of plan participants and plan sponsors.
Register Now: https://siiaconferences.org/springforum/2023/register_now.cfm
Session: Cost, Quality, and Acuity in Negotiations and Navigation
Moderator: Scott Bennett -- Phia Group
Speakers: Mac Meadows -- 90 Degree Benefits; Ashley Rutkowski -- Borislow
Session: Direct Primary Care – Connecting the Dots for Quality Care
Moderator: George Stiles -- PAI
Speakers: Jeffrey Gold – Gold Direct Care; John Collier – Proactive MD; Shane Purcell -- Direct Access MD
Session: Health Systems, Direct Contracting and Quality of Care Considerations
Moderator: Blake Allison -- Employers Health Network
Speakers: Sandy Balwan – Northwell Health; Brandon Burket – Orlando Health; Thomas Caven –Ascension
Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel, and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com
How ESG is Impacting Captives
UWritten By Caroline McDonald
Upuntil now, quality, style and value were the main drivers of the consumer economy. But consumer-driven attention is propelling another component to the forefront: Environmental, Social and Governance (ESG).
Once on the fringe, ESG has acquired more significance for consumers, which makes it more important to businesses for a number of reasons. It also adds new considerations and opportunities for captives.
EFFECTS OF ESG ON BUSINESSES
Dawn Hiestand, head of group captives for Zurich North America noted that before doing business with a company, vendors, suppliers and consumers are increasingly examining that company’s ESG commitments and actions. Regulators and shareholders, too, are looking beyond financial considerations to a company’s ESG record.
These are some of the reasons for a recently created group captive by Zurich, Hiestand said. The captive, Envision Re., Ltd., “brings together companies from diverse industries that share a common interest in not only optimizing their risk management programs but also in advancing environmentally sustainable business practices.”
Nancy Gray, regional managing director, captive & insurance management, commercial risk solutions at Aon, notes, “There are four ways we’ve identified how captives can help with ESG initiatives:
--Deducting captives’ assets in an ESG aligned portfolio. A lot of captives tend to have more fixed income, shorter duration portfolios. If they take a portion of their assets and invest in an ESG-aligned portfolio, it helps to support the ESG goals at a corporate level.
--Funding initiatives that improve ESG risk management in an organization by using some of the surplus it has built over time, to help improve ESG risk management initiatives.
--Aligning underwriting by adding ESG objectives. Certain risks, such as wildfire and climate change, are difficult to insure, and aligning underwriting for those objectives and using the captive to help support that can be beneficial.
“They are asking companies to demonstrate stronger environmental stewardship, social responsibility and integrity in their leadership,” she said. “And if those consumers make buying decisions based on what they see in that regard, that will impact the bottom line.”
Another impact is on employees.
“Many job seekers want to work for companies that are proactive role models on ESG considerations such as carbon reduction,” Hiestand said.
--And providing employee-based initiatives. For example, if you are a food producer, it would involve taking some of the company profit of the captive and providing weather insurance to farmers in developing countries. This is about helping in terms of an ESG initiative perspective,” she said.
A looming risk worldwide is environmental degradation which means that every organization needs to plan for an escalation of risks from natural disasters.
A new study by Aon, The 2023 Weather, Climate and Catastrophe Insight report, looks at the cost of natural disasters in 2022 and how these losses were insured globally. Findings include:
• Natural disasters caused a $313 billion global economic loss in 2022, with only 42 percent covered by insurance.
• Much of this was driven by the impact of Hurricane Ian, which was the second costliest natural disaster for insurers on record globally.
• 75 percent of all insured losses were recorded in the U.S. alone.
Captive insurers are taking heed and becoming more important in bridging the widening insurance gap caused by these losses.
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This example is illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.
How ESG is Impacting Captives
Adriana Scherzinger, head of captives sales & execution for Zurich North America.
“For example, as climate risks grow, companies in certain industries or regions may find it difficult to secure the desired amount of property coverage in the traditional market.”
CAPTIVES AND CARBON CREDITS
John R. Capasso, president & chief executive officer of Captive Planning Associates LLC, said that what they are seeing is increased attention for one specific sector of clients.
“From an insurance perspective, as captive managers we have a large book in the agribusiness world,” he said “So, we are very involved from an environmental, social and governance perspective.”
From an environmental perspective, “What we’re seeing in the farming sector are carbon credits,” he said. “We’ve created a venture-like structure using captives to backstop the value of carbon credits coming from farming bio charge – which eliminates the source for forest fires and hog waste.”
What is a carbon credit?
According to the Department of Agriculture and Consumer Economics:
“A carbon credit is a tradeable certificate representing the right to emit one metric ton of carbon dioxide or the equivalent amount of another greenhouse gas, such as methane or nitrous oxide, called a carbon dioxide equivalent. There are two types of carbon markets: compliance and voluntary.”
Capasso noted that, “Carbon can be thought of like a crop produced on a farm. A carbon credit – also known as a carbon offset – represents either greenhouse gases removed from the atmosphere or greenhouse gas emissions that are reduced.”
Agricultural carbon markets, he explained, exist through privately and publicly owned companies with the aim of reducing carbon emissions through trade of carbon units gained at the farm level. “The
sale of carbon credits presents an opportunity for farmers to receive financial benefits from changing to more environmentally beneficial agricultural practices,” he said.
This is being seen globally, Capasso added, “Even among coffee growers in foreign countries. We have many growers using captives for carbon credits in farming, bio charge and hog waste.”
The goal, he said, is “assurance that the value of these credits doesn’t depreciate in the future. The people selling the credits are providing a backstop.”
For example, he explained, if an airline’s fleet “can’t reduce their carbon footprint, they have to buy credits to offset that.“ Because these credits depreciate, “the companies that are providing them are ensuring they will maintain their value. If not, the captive insurer will pay a claim for any depreciation, based on a certain benchmark.”
He added, however, that liquidity in a captive is a director’s first concern. “So, if you become too ESG sensitive, are you derelict in your responsibility of managing? Trying to segregate and invest could be a detriment to the liquidity of the insurance company.” In addition, he said, “All of these captives must have an investment policy statement and be approved by regulators.”
"Captives can help parent organizations fund coverage gaps and enhance resilience to climate-related risks," said
ESG growing worldwide
In European locations and increasingly in the U.S., “Regulatory bodies are requiring disclosures and so, are pushing companies to embrace ESG,” Gray said.
Regulators want disclosures of what organizations are doing, “and that will continue to increase: how they are embracing ESG objectives and how they are benchmarking in terms of their ESG initiatives, and how they are reducing their carbon footprints.”
She added, “We can learn from European captive use, and this will become more prevalent in the U.S.”
Overall, companies that are proactive in assessing their ESG risks will be in a better position to take action to mitigate those risks, Scherzinger noted. While this kind of assessment is not currently required for many companies, “It may be in the not-too-distant future, based on regulations and other actions by various stakeholders. So, companies would be wise to start acting now,” she said.
How ESG is Impacting Captives
What is ESG?
ESG in general refers to a broad range of environmental, social and governance concerns that are gaining attention from executives, investors, regulators, employees and consumers.
ESG issues were first mentioned in the 2006 United Nation’s Principles for Responsible Investment (PRI) report. For the first time, ESG criteria were required to be incorporated in companies’ financial evaluations for the purpose of developing sustainable investments.
According to Forbes, “The emphasis on ESG is increasingly growing as major institutional investors are making it clear they expect the companies they hold to commit strongly to ESG criteria.”
This has meant increased risks for corporate directors and officers, said Adriana Scherzinger, head of captives sales & execution for Zurich North America. One example, she said, is that “ESG-related litigation is sometimes triggered by headlines reporting negative facts or allegations about a company’s business practices.”
To monitor the risks related to environmental sustainability, the Securities and Exchange Commission formed an ESG task force in 2021, she said. Within a year the task force had issued its first enforcement action, “challenging statements in a company’s sustainability reports after a dam operated by the company collapsed, releasing toxic waste into surrounding areas.”
Caroline McDonald is an awardwinning journalist who has reported on a wide variety of insurance topics. Her beat has included in-depth coverage of risk management and captives.
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ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:
PRACTICAL Q & A
Q & A
TheAffordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Women’s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other federal benefit mandates.
Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, Ken Johnson, Amy Heppner, and Laurie Kirkwood provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley, Carolyn, Ken, Amy, and Laurie are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at firstname.lastname@example.org.
ACA PROPOSED §1557 REGULATIONS: "BACK TO THE FUTURE”
More than 10 years after enactment, much remains unsettled with regard to prohibited discrimination for health plans under the Affordable Care Act (ACA). Now, the third set of “final” rules for §1557 of the ACA are on the horizon, but the controversies surrounding its nondiscrimination provision show no signs of slowing down this year.
Generally, §1557 prohibits health plans or activities that receive Federal funds from discriminating against certain protected classes. Ever since the first set of §1557 final regulations were announced in 2016, and the second set in 2020, the scope of the prohibition against health plan discrimination has been challenged. If current litigation is any indicator, those challenges will not when the 2022 proposed rules are finalized.
In addition to changes in scope for sex discrimination, the 2022 proposed rules expand the types of entities covered under §1557 to include insurers that receive federal funds—even when acting as thirdparty administrator to self-insured plans.
This restores the 2016 rules’ expansive application of “covered entity” status on insurers, which the 2020 rules had removed. A recent case (discussed below) underscores the potential risks for TPAs.
Because of numerous court orders enjoining and invalidating certain portions of both the 2016 and 2020 rules, the current state of §1557 regulations has been called “unworkable” by at least one court.
One key issue in §1557 litigation is how the Supreme Court’s 2020 opinion in Bostock v. Clayton County fits into determining the scope of prohibited sex discrimination for ACA §1557 covered entities and health plans. In that case, the issue was whether an employer could terminate an employee based on sexual orientation or gender identity.
The Court sided with the terminated employees to say that such termination was prohibited discrimination on the basis of sex.
However, Bostock was decided under Title VII of the Civil Rights Act as an employment discrimination case, and §1557 incorporates the prohibition against sex discrimination through Title IX of the Education Amendments--not Title VII.
This is significant because although the Bostock court specifically cautioned that the holding was limited to Title VII employment discrimination, many courts have looked to Title VII when analyzing Title IX cases.
Some courts that have taken a very strict reading of
Bostock and §1557 maintain that Bostock’s expansion to include sexual orientation and gender identity do not apply, while other courts have reached the opposite conclusion.
These competing interpretations of Bostock may result in a circuit split, taking the issue back to the Supreme Court at some point. We are already seeing two cases—one in the 4th Circuit and one in the 11th— that have the potential to do just that.
The first case, Fain v. Crouch, involves the West Virginia Medicaid program, which covers hormone treatments for gender dysphoria but excludes surgical treatments for gender dysphoria. The plaintiffs claim that the exclusion was not allowed under §1557, as well as the equal protection clause of the 14th Amendment and certain requirements under Medicaid.
The U.S. district court agreed and enjoined the West Virginia Department of Health and Human Services from enforcing the exclusion. The court’s discussion of the ACA issue under §1557 was simple and direct: the ACA incorporates Title IX, and the 4th Circuit looks to Title VII to evaluate Title IX claims, and therefore Bostock is the appropriate test.
The discussion did not address the Supreme Court’s limitation of Bostock to Title VII employment
discrimination cases only. West Virginia appealed the case to the Fourth Circuit, and several amicus briefs have been filed. Oral argument before the 4th Circuit is scheduled for March 2023.
The second case, also a state Medicaid program case, was filed in September 2022 in Florida’s Northern District (11th circuit). Dekker v. Marstiller is strikingly similar to the West Virginia case in that it also involves a state Medicaid plan that has exclusions for treatment for gender dysphoria, and Plaintiffs also claim violations of §1557, as well as the 14th Amendment, and portions of the Medicaid Act.
Whether the Florida district court will take a different approach in the ACA analysis for applying Bostock to §1557 remains to be seen. The trial is set for May 2023. There are several other cases in other districts that also touch on the Bostock issue, but the similarity of the facts in these two cases is what makes these interesting to watch for a possible circuit split.
Another important development relates to the reach of ACA §1557 as applied to a TPA that is also an insurer that receives Federal funds for unrelated business activities. In a case out of Washington state that was decided late last year, a plaintiff sued the TPA that denied his claims for gender dysphoria-related treatment (C.P. v. Blue Cross Blue Shield of Illinois).
The TPA was an insurance company, and presumably not a covered entity in its role as TPA under the 2020 rules. The employer, which
is part of the Catholic Health Initiatives Franciscan Health System, controlled the design of its self-insured group health plan, and the TPA believed that ERISA required the plan to be administered according to this design. The TPA made the following arguments in its defense, but the district court was not persuaded by any of them:
• The TPA claimed that it was not a covered entity under the 2020 rules, which distinguish insurers as entities principally engaged in the business of providing “insurance”, rather than the business of providing health “healthcare” (the latter category would be a “covered entity” under the 2020 rules, but the former is not). The district court refused to defer to the 2020 rules, calling the rules arbitrary and capricious and contrary to the statutory language, which was not ambiguous.
• The TPA said that it received no Federal funds for its TPA business, but the court took the company’s activities as an insurance company into account as a whole and said that the statute covers such entities, “any part of which” receives Federal funds.
• The TPA did not design the plan exclusions —the religious-based employer did. Also, the TPA is required under ERISA to administer the plan according to its terms. Notably, the preambles to the 2016 rules and 2022 proposed rules suggest that whether the discriminatory provision in a plan design originates with the TPA will be taken into consideration when processing complaints. Even so, the court refused to apply deference to this guidance because statutory text contains no
exclusion for TPAs that did not design the plan. Nor was the ERISA argument persuasive, because ERISA 1144(d) states that ERISA will not be construed to alter/invalidate/impair/ supersede any other U.S. law.
• The TPA argued that there is no medical consensus on gender affirming treatment, which the court also denied as immaterial to the issue.
• Lastly, the TPA claimed that the employer/plan sponsor has sincerely held religious beliefs that are protected under the Religious Freedom Restoration Act (RFRA). The court pointed out that RFRA is not a defense for the TPA, and that RFRA provides relief only when the government is a party. Neither the government nor the employer/plan sponsor were parties here.
The outcome of the case is significant for TPAs that may be part of an entity that receives Federal funds because neither the exclusion for insurers under the 2020 rules (which are technically still in effect) nor the plan design defense saved the TPA on summary judgement.
The proposed 2022 rules clearly bring insurer/TPAs back under the §1557 covered entity umbrella, so these TPAs will need to evaluate exposure when administering plan designs that discriminate under §1557.
Included below is a brief, highlevel summary of the evolution of the §1557 regulations with regard to how they apply to insurers and TPAs:
2016 Final Regulations (“2016 Rules”)
• Defined the term “on the basis of sex” to include (among other things) “gender identity” and “sex stereotypes,” which included transgender individuals.
• Applied to insurers that received Federal funds, even when acting as a TPA for a self-insured plan.
• Key challenges: the Franciscan Alliance line of decisions ultimately resulted in limitations on the application of the ACA §1557 rules for the prohibition against discrimination on the basis of "gender identity" (and "termination of pregnancy”).
2020 Regulations (“2020 Rules”)
• Repealed and replaced parts of 2016 Rules, deleting the definitions for “on the basis of sex” and “gender identity” and incorporated Title IX’s religious exemption.
• Distinguished insurers as entities principally engaged in the “business of providing insurance”, thereby excluding insurers
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from entities engaged in “the business of providing health healthcare.”
• Key challenges: Whitman-Walker Clinic v. HHS and Walker v. Azar collectively resulted in injunction against HHS from enforcing the 2020 Rule’s repeal of the 2016 Rule’s definition for “on the basis of sex” and incorporation of Title IX’s religious exemption.
2022 Proposed Regulations
• Effectively (though not in an identical manner) re-instates 2016 “on the basis of sex” definition by incorporating sex stereotypes, sex characteristics, and gender identity (as well as pregnancy and sexual orientation) into the term “sex.”
• Allows entities to notify OCR if the entity believes it is exempt under Federal consciences or religious freedom laws. OCR will “promptly” consider the views in responding to complaints.
• Applies to insurance issuers and TPAs administering selfinsured plans but does not categorically include group health plans. A fact-specific inquiry may be required to determine if the plan or the plan sponsor is the recipient of Federal funds.
“But for” the authority of the Bostock opinion to buttress HHS’s interpretation of “sex”, the 2022 proposed rule is not fundamentally different from the 2016 rules. Whether Bostock is appropriately applied to §1557 will be something for plan sponsors and TPAs to watch in the coming months.
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At Vālenz® Health, our culture of innovation encourages us to “get comfortable being uncomfortable.” With healthcare constantly evolving, we thrive in the face of change - always prepared to deliver the right solutions for our customers.
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See how Valenz delivers smarter, better, faster healthcare that moves your company forward to what’s next: visit valenzhealth.com or call (866) 762-4455.
Proud to be a Diamond Member
SIIA ENDEAVORS J
The SIIA Spring Forum is expected to be the largest gathering of senior-level self-insurance industry
This year’s educational program will incorporate a track of sessions focused specifically on what self-insurer payers and their business partners need to know about how to better assess and leverage health care quality for the benefit of plan participants as well as plan sponsors.
The educational program will be combined with multiple networking functions, including one event specifically for you younger attendees. Finally, companies will have the opportunity to showcase their products and services by participating as part of table-top exhibitor program.
Cost, Quality, and Acuity in Negotiations and Navigation
Networking and Program highlights include:
SIIA Future Leaders Meet-Up Mixer
Join other younger attendees for an after-dinner networking event.
SIPAC Fund-Raising Dinner
Event details will be provided separately to SIIA members.
State of the Industry – Live Audience Polling
Get off to a fast and fun start this morning by offering your anonymous opinions on the hottest industry issues for 2023 and see aggregated audience results in real time via SIIA’s attendee polling technology. Be sure to bring a fully-charged mobile device to this session.
While the cost of health care is obviously important to plan sponsors (and sometimes participants), don’t overlook quality when considering provider options and negotiations. While up until recently, quality has been hard to quantify, that is starting to change with the greater availability of quality metrics and the requirement to consider quality in surprise billing negotiations and IDR. This session will provide practical guidance on how to incorporate such metrics as part of holistic plan management strategy and include case studies of real-world success stories.
Vice President, Provider Relations
The Phia Group
90 Degree Benefits – Houston
Ashley RutkowskiVice President
Planning for the Future – Positioning Younger Members for Success
The SIIA Future Leaders Committee has been hard at work helping the association accelerate its support for younger members. This session will provide a report of what has been done, preview what to expect going forward and invite input and questions from the audience. If you are current industry leader who has been wondering what and who comes next, this is a must-attend session.
President & COO
Planned Administrators, Inc.
Jeffrey Gold, MD
Gold Direct Care PC
Shane Purcell, MD
Direct Access MD
Health Systems, Direct Contracting and Quality of
Representatives of SIIA’s Future Leaders Committee -
Direct Primary Care – Connecting the Dots for Quality Care
While there are obvious advantages to high quality primary care, Direct Primary Care (DPC) practices have capabilities to help ensure quality health care delivery “downstream” by serving as navigators and advocates for their patients. A panel of DPC representatives will share examples and scenarios where they are uniquely positioned to help ensure high-quality health care beyond the first stop of primary care services.
A panel representing leading health systems that have direct contracts with self-insured payers discuss how these arrangements allow them to leverage their capabilities to improve quality outcomes for plan participants and how these outcomes can lower the total cost of care.
Blake Allison CEO
Employers Health Network
SPEAKERS:Dr. Sandy Balwan Chief Medical Officer Northwell Brandon J. Burket, MHA Vice President Orlando Health Network Thomas Caven, MD Chief Medical Officer Seton Health Alliance
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Competitive Advantages/ Disadvantages in the Broker/ Advisor
Space Over the last few years, broker/advisers of all sizes have been angling to grow their books of business with self-insured employers. Larger brokers tout their resources and experience, while smaller brokers promote more customized capabilities. So, who is wining now and who is better positioned to gain market share in 2023? Don’t miss this lively panel discussion where representatives of larger and smaller brokerage shops make their case and engage in a friendly debate.
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Eugenie GuillotVice President
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Updates – What Senior Executives Need to Know in 60 Minutes
This will be a perfect opportunity for senior executives to receive an “at-a-glance” briefing of the evolving regulatory and business environment related to health transparency to help them ensure that their businesses are properly positioned now and in the coming years.
Vice President, Sales and Account Management
General Counsel/ Director of Compliance
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SIIA’s government relations team will provide the latest legislative/ regulatory updates at both the state and federal level affecting selfinsured employers and their business partners.
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SVP, Government Relations
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For more information including registration and sponsorship opportunities, visit www.siia.org.
We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world.
The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984.
Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ sipconline.net
The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ sipconline.net for advertising information.
NEWS FROM SIIA MEMBERS
2023 MARCH MEMBER NEWS
SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to email@example.com.
All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org.
If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at firstname.lastname@example.org.
THE PHIA GROUP NAMES JOANIE VERINDER AS SERVICE STRATEGIST
CANTON, MA—The Phia Group continues to demonstrate its commitment to provide the industry’s best cost containment services, by proudly announcing the hiring of Joanie Verinder as its Service Strategist.
As The Phia Group’s Service Strategist, Joanie will serve as a client liaison and achieve a new level of collaboration, regarding everything from service updates to current regulatory news.
Advocating for the company’s clients, Joanie will communicate the industry’s needs to The Phia Group’s leaders and monitor the company to ensure it is always excelling on behalf of its clientele. When a new issue, rule, or development creates need, Joanie Verinder will ensure The Phia Group takes action on the industry’s behalf.
Ms. Verinder is no stranger to The Phia Group, having previously served as the Compliance Officer for Group and Pension Administrators (GPA) TPA. There, Joanie routinely interacted with The Phia Group as a client. Additionally, Ms. Verinder served as a leader and President of Health Care Administrators Association (“HCAA”), and in that and other industry roles often worked with The Phia Group to ensure association members were receiving important industry news, updates, and education from Phia.
“After working as a client with the Phia team for 20 years, and witnessing firsthand their passion and commitment to helping our industry, I’m excited to become a member of that team. I look forward to evolving from a ‘Phia Phriend’ to becoming a member of the ‘Phia Phamily’ … and assisting all of our loyal clients.”
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THE PHIA GROUP ANNOUNCES UJWAL SHRESTHA, VP BUSINESS ANALYTICS & DATA SERVICES AND CAITLIN LANKSTON, SENIOR DATA SCIENTIST
CANTON, MA —The Phia Group continues to reinforce its commitment to offering elite technology and advanced analytics by recently hiring Ujwal Shrestha, VP, Business Analytics and Data Services, and Caitlin Lankston, Senior Data Scientist.
With an impressive track record leading data analysis and data strategy work in the self-funded industry as well as in management consulting firms, Ujwal will expand Phia’s data-driven decision algorithms that optimize business process efficiencies, data identifications and client results.
He will serve as a conduit to executive leaders by applying techniques such as Artificial Intelligence (AI), Machine Learning (ML) and predictive analytics to present data insights in a digestible and actionable format.
As Phia is poised for considerable growth, Ujwal will channel his data analysis skills toward pushing technical boundaries to spur innovation while spearheading analytics geared toward optimizing recovery opportunities.
The company’s CEO, Adam Russo, added, “I have personally known Joanie for decades… longer than most of our own team members. For most of my career, I’ve looked to her as a friend, advisor, innovator, and voice of the industry. Adding her to our roster takes us to a new level. I couldn’t be happier – not only for myself and The Phia Group, but for our clients… all of whom are going to benefit from her presence.”
“We are thrilled to welcome Joanie to the Phia team!
In her new role Joanie will be working tirelessly to continue to build relationships while ensuring our teams deliver the highest levels of value and quality for our partners and clients.
We look forward to this new year with Joanie on the team.”
Adds Chief Operating Officer Joe Montalto, “We are delighted to welcome Ujwal to The Phia Group. With his diverse background in the self-funded space and his experience at D2Hawkeye, Inc., Ujwal will be an invaluable resource to our company as we look to take our Data Services Group to the next level. I am very excited to see Ujwal grow into this role and continue to help Phia make a positive impact for our clients.”
As Phia’s Senior Data Scientist, Caitlin, a graduate of the University of Montana, where she received her master’s degree in Statistics, will be engaging in hands-on data analysis work relying heavily on Python and Tableau reporting as a means of optimally aggregating data, streamlining internal processes, and leveraging Predictive Analytics and advanced algorithms. Prior to joining Phia, Caitlin handled case prioritization work for DataSmart Health Solutions.
“Advanced and predictive analytics offer extremely exciting potential at Phia in our recovery efforts allowing us to look at our data in a new prescriptive and proactive way,” says Caitlin. “Until now, Phia relied on strong industry knowledge and robust logic to prioritize case workflow. Predictive analytics, however, leverages machine learning to discover hidden patterns and trends. Identifying these patterns
“The main reason I joined Phia is I wanted to be in a growing company in the healthcare industry,” states Ujwal. “I believe I can help the company make better business decisions that are data-driven, based on the expansive healthcare claims data we have.”
will help Phia find new business opportunities and answer complex questions.”
To learn more about The Phia Group, what it is doing to empower plans, and to learn more about its Provider Relations solutions, please contact Garrick Hunt by email at email@example.com or by phone at 781-535-5644.
About The Phia Group
The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Contact Garrick Hunt at firstname.lastname@example.org or 781-535-5644 and visit www.phphiagroup.com.
VĀLENZ® HEALTH PROMOTES
KEVIN O’DONNELL TO SENIOR VICE PRESIDENT, PRODUCT & MARKETING
PHOENIX, AZ — Vālenz® Health is pleased to announce that Kevin O’Donnell, MPA, has been promoted to Senior Vice President, Product & Marketing. In his new role, O’Donnell will lead Valenz marketing initiatives to fuel growth and visibility for the organization. He also will continue to work with Chief Product Officer Maurice
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“Kevin has brought a tremendous vision and creative mindset to Valenz, and we are thrilled that his role is expanding,”
O’Donnell, who lives in Newark, Del., joined Valenz in 2022 as Vice President, Enterprise Solutions. He has been highly involved in expanding and integrating how Valenz delivers solutions for providers and payers that assure the validation, integrity and accuracy of reimbursement and claims, as well as care and member advocacy program enhancements.
Previously, O’Donnell was Managing Director of Operations for Evolent Health and held other leadership positions there in operations, claims quality and payment integrity. He earned a master’s degree in Public Administration with an emphasis in health and human services from the University of Arizona’s Eller College of Management.
“Through his ongoing leadership efforts, we look forward to developing new strategies
and further underscoring our ability to change the trajectory of rising plan costs, enhance member experiences, and drive better health outcomes.”
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TALON WELCOMES JOE TORINA AS VP OF STRATEGIC PARTNERSHIPS
Portsmouth, NH – TALON, a leader in providing innovative technology solutions for the rapidly evolving healthcare industry, announced that Joe Torina has joined its quickly expanding team as Vice President of Strategic Partnerships.
With a robust range of professional experience in account management, marketing, and business development, Torina comes to TALON from WLT Software Enterprises, where he spent 3 1/2 years serving as Marketing Director/Business Partner Relations, and, most recently, Director of Business Development.
“Hitting the ground running with TALON has already been exceptionally rewarding.” Torina said in a statement. “The healthcare industry is undergoing monumental changes that not only demand a dynamic, end-toend technology solution, but also the right strategic approach. I look forward to building strong, lasting relationships to better sever both current and future TALON clients, as well as the broader industry as a whole.”
TALON NAMES CATHERINE KLEHM AS VICE PRESIDENT OF PROFESSIONAL SERVICES
Portsmouth, NH – TALON, a leader in providing innovative, scalable technology solutions for the rapidly evolving healthcare industry, announced that Catherine Klehm has joined its growing team to serve as Vice President of Professional Services.
With more than two decades of diverse experience, Klehm has a proven track record of success in leading client services operations to increase customer loyalty, expanding solution footprints within accounts, turning around projects or departments,
“As the industry continues to adapt and evolve around the requirements and implications of Transparency in Coverage requirements and a new participantdriven ecosystem, TALON will evolve right along with it, ” said TALON
and CEO Mark Galvin. “Essential to this evolution, Joe’s range of experience and proven track record in business development will be invaluable to fostering and growing our strategic partnerships in the months and
years to come. We’re thrilled to have him on the TALON team.”
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Klehm comes to TALON from Uptake, where she served as Senior Director of Professional Services and was responsible for leading the development of project management, staffing/ utilization, implementation processes, and approach to identify measurable targeted outcomes for customers.
“I’m excited to join such a talented and dynamic team and
look forward to expanding TALON’s already stellar reputation as a leader and pioneer in the healthcare technology space,” Klehm said in a statement. “Essential to this mission will be driving continued innovation, addressing critical business needs, increasing client satisfaction, and further building on the tremendous value that TALON brings to the table for every customer.”
TALON’s mission is to educate, empower, and incentivize the American healthcare consumer to meaningfully reduce costs and create a healthier ecosystem. We’ve built the ultimate suite of software services designed to fulfill the requirements of the Transparency in Coverage Rule and No Surprises Act. Simply put, TALON protects healthcare stakeholders from overpaying for care while enabling seamless integration into the Payer’s existing architecture, all without disruption or distraction. Our tools create free-market dynamics, starting with our ability to ensure full compliance with all mandates and extending through our consumer-driven MyMedicalShopper platform. Visit www.talonhealthtech.com
Experience More Than Just Benefits Administration
Planned Administrators, Inc. partners with clients to improve quality and lower costs while providing exceptional customer service, pharmacy benefits, stop loss, benefit ad ins, and additional perks.
Contact us today to learn more: paisc.com/contact-us
Depend on Sun Life to help you manage risk and help your employees live healthier lives
By supporting people in the moments that matter, we can improve health outcomes and help employers manage costs.
For over 40 years, self-funded employers have trusted Sun Life to help them manage financial risk. But we know that behind every claim is a person facing a health challenge and we are ready to do more to help people navigate complicated healthcare decisions and achieve better health outcomes. Sun Life now offers care navigation and health advocacy services through Health Navigator, to help your employees and their families get the right care at the right time – and help you save money. Let us support you with innovative health and risk solutions for your business. It is time to rethink what you expect from your stop-loss partner.
Ask your Sun Life Stop-Loss Specialist about what is new at Sun Life.
The content on this page is not approved for use in New Mexico. For current financial ratings of underwriting companies by independent rating agencies, visit our corporate website at www.sunlife.com. For more information about Sun Life products, visit www.sunlife.com/us. Stop-Loss policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states except New York, under Policy Form Series 07-SL REV 7-12. In New York, Stop-Loss policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2023 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503-y SLPC 29427 01/22 (exp. 01/24)
HEALTHCARE MANAGEMENT ADMINISTRATORS (HMA) NAMED BEST PLACES TO WORK
BELLEVUE, WA -- Built In announced that HMA was honored in its 2023 Best Places To Work Awards. Specifically, HMA earned a place on Seattle's Best Places to Work list. The annual awards program includes companies of all sizes, from startups to those in the enterprise, and honors both remote-first employers as well as companies in large tech markets across the U.S.
"We are thrilled to be receiving this award for the second year in a row. This award is a testament to the value we place on empowering our people to bring their best selves to work. Our people come to HMA from diverse backgrounds and experiences, and together we achieve great results. Being in the company of the other winners on this list is an honor," says Lindsay Harris, President and CEO of HMA.
Built In determines the winners of Best Places to Work based on an algorithm, using company data about compensation and benefits. To reflect the benefits candidates are searching for more frequently on Built In, the program also weighs criteria like remote and flexible work opportunities, programs for DEI and other people-first cultural offerings.
"It's my honor to congratulate this year's Best Places to Work winners," says Sheridan Orr, Chief Marketing Officer, Built In.
"These exemplary companies understand their people are their most valuable asset, and they've stepped up to meet the modern professional's new expectations, including the desire to work for companies that deliver purpose, growth and inclusion. These winners set the stage for a humancentered future of work, and we can't wait to see that future unfold."
Ringmaster Technologies’ pharmacy consulting platform presented by its wholly owned subsidiary, “Ringmaster Rx”, is a huge win for Brokers, TPAs, and PBMs (pharmacy benefits managers). Its cloudbased data warehouse integrated with a RFP workflow process gives clients the ability to:
• Solicit, Compare and Award PBM Contracts and Programs
• Perform contract reconciliations & audits on contract performance
• Deliver sophisticated analytics and generate value added reports
• Customize their own panel of preferred PBM’s
• Efficiently manage cost for their employer groups
About Built In
Built In is creating the largest platform for technology professionals globally. Monthly, millions of the industry's most in-demand professionals visit the site from across the world. They rely on our platform to stay ahead of tech trends and news, learn skills to accelerate their careers and find opportunities at companies whose values they share. Built In also serves 2,000 customers, innovative companies ranging from startups to those in the Fortune 500. By putting their stories in front of our uniquely engaged audience, we help them hire otherwise hard-to-reach tech professionals. Visit www.builtin.com
HMA is Proving What's Possible in Healthcare®. Our team of caring experts design and deliver high-quality, innovative, and affordable health plans for self-funded employers. We are the service-oriented partner employers trust to protect two of their most important assets, their people and their
Customer Service, Cost Controls, Quality Performance
We deliver value other TPAs can’t match. Our three-year medical trend is beating the industry at 2.6%, our claims reviews are finding an extra 15% in savings before network discounts, and our Excellent NPS Score tells us we’re keeping our clients very happy. Our people deliver incredible value for our customers. They can do it for you too.
health plan dollars. With over 30 years of industry experience and a team of proactive, highly skilled professionals, we help employers improve their bottom-line. We call this "Winning Together" because we're on the same side and share the same goals – healthier outcomes for members at the best possible value. Visit www.accesshma.com
6 DEGREES HEALTH WELCOMES COLIN JEX AS VICE PRESIDENT OF BUSINESS DEVELOPMENT
6 Degrees Health is pleased to announce that Colin Jex has joined the company as VP of Business Development.
We want to welcome Colin Jex to the 6 Degrees Health family. Colin is a 30-year veteran of the Group Benefits industry. His career began as a group benefits broker in the Detroit, Michigan, market.
In 2002, he was appointed Vice President of Sales for a Michiganbased TPA offering FSA, Cobra, HRA, and Consolidated Billing service solutions for UBA partner firms.
After that, he worked as a Senior Sales Executive for Henry Ford Health System and Rogers Benefit Group. As Regional Sales Director for Cofinity and First Health Networks, he established regional and national TPA relationships. He continued to expand his TPA experience with self-funded business sales prior to joining 6 Degrees as VP of Business Development focused on TPA markets.
“We are very pleased to have Colin Jex as a member of our team,” said Heath Potter, Chief Growth Officer, “His depth of knowledge and relationships will be very valuable to our channel partners and their clients.”
Colin can be reached at email@example.com and 248.207.0434.
About 6 Degrees Health
Ensure Fairness and Transparency in Healthcare. We set healthcare free from the constraints of traditional models and out-of-date billing practices. With our clinical expertise, industry experience, and proprietary evidencebased technology, we help solve some of the most complex issues in healthcare. Visit www.6degreeshealth.com
UME NAMES JEFF DIEKEMA AS NEW CHIEF REVENUE OFFICER
Philadelphia, PA – Underwriting Management Experts, one of the largest privately held MGUs, has named Jeff Diekema as new Chief Revenue Officer.
UME is pleased to continue a pattern of growth with the addition of industry-veteran Jeff Diekema to the executive team. As Chief Revenue Officer, Jeff will be responsible for the overall business development of UME. He will focus on diversifying revenue streams and leading the sales team to bolster growth, while creating a strategic sales plan for the future.
Adding experience and depth to the management team, Jeff will maintain UME’s position as an industry leader and grow existing relationships with partners.
Jack McCarthy, President of UME, said, “We are extremely excited to add Jeff to our team. He brings a wealth of knowledge to the table and will be a huge asset to the growth of UME.”
Jeff has been in the benefits industry for over 30 years, in roles ranging from sales and sales/marketing management to TPA operations, underwriting and sales support, and product development.
Prior to his role at Underwriting Management Experts, Jeff held vice president positions at cost containment companies and national Third-Party Administrators. He has extensive senior management experience with several health plans, an MGU, TPAs, and consulting firms.
Jeff’s experience is in self-funded risk management and alternative funding arrangements with an emphasis on transparency and innovative payment and savings initiatives. He has utilized current technology to maximize the cost impact of well-designed and
integrated plan designs. Jeff has stated, “I am thrilled to be a part of UME family and look forward to using my skills and experience to help expand the products and services offered here.”
Jeff received his bachelor’s and master’s degrees from Central Michigan University with degrees in psychology, physical education, and sport psychology. He also holds the Certified Employee Benefits Specialist (CEBS) designation for the International Foundation of Employee Benefit Plans (IFEBP) and the Wharton School at the University of Pennsylvania.
We look forward to the new momentum that Jeff will provide as UME continues to develop innovative and flexible solutions to meet the needs of our partners.
As a full-service Managing General Underwriter (MGU), UME offers underwriting, policy binding, contract issuance, premium collection, and claims payment. UME provides excellent customer service by focusing on responsiveness and flexibility to meet the needs of our partners. Contact Robert Glorioso, Chief Operating Officer, at rglorioso@ umexperts.com and visit www.umexperts.com
BLACKWELL CAPTIVE SOLUTIONS WELCOMES NEW NATIONAL VICE PRESIDENT, SALES
CHICAGO -- Blackwell Captive Solutions, an innovative medical stop loss captive domiciled in South Carolina and sponsored by Carrick Capital Partners, announces Tina Willenborg as a new National Vice President, Sales.
"Our team brings unrivaled knowledge to the growing and complex stop loss market. Tina is a purposeful leader who complements our culture and brings a deep understanding of medical stop loss captives,” said Kari L. Niblack, President of Blackwell Captive Solutions. “She will play a lead role in driving our growth strategy and is a terrific addition to the Blackwell team."
Willenborg comes to Blackwell Captive Solutions with more than 26 years of industry and medical stop loss experience. She has been a leader in her past roles, serving as Assistant Vice President Stop Loss at Xchange Benefits, LLC, Assistant Vice President at Employer Benefit Underwriters, Inc., and Assistant Vice President, Business Development at Arch Insurance Group.
"Employer medical stop loss is a financial risk product at its core. Thus, funding medical stop loss risk through a captive enables companies to offset future costs and reinvest the returns to enhance benefits,” said Willenborg. “
Why not recognize and deploy surplus more efficiently with Blackwell?"
Headquartered in Chicago, Blackwell Captive Solutions is a medical stop loss captive that differentiates by delivering essential stability with desired flexibility via access to cutting-edge health and well-being solutions for our clients. We’ve proven that combining employers’ buying power with tailoring freedom maximizes the impact of self-insurance and reduces market volatility associated with the ultimate cost of healthcare benefit delivery to employees. Contact Kari L. Niblack, JD, SPHR, at KariN@BlackwellCaptive.com and visit www.blackwellcaptive.com
At Blackwell Captive Solutions, we take great pride in helping clients make informed benefit decisions.
SELF INSURANCE INSTITUTE OF AMERICA, INC. 2023
BOARD OF DIRECTORS
CHAIRWOMAN OF THE BOARD*
Vice President, Emerging Markets
AmeriHealth Administrators, Inc.
CHAIRMAN ELECT & TREASURER AND CORPORATE SECRETARY *
President & CEO
Captive Planning Associates, LLC
Founder/Chief Medical Officer
Advanced Medical Strategies
Matt Kirk President
The Benecon Group
Shaun L. Peterson
VP, Stop Loss
Chief Operating Officer
Adam Russo CEO
The Phia Group, LLC
Canton, MA DIRECTOR
Deborah Hodges President & CEO Health Plans, Inc.
Captive Insurance Committee
Innovative Captive Strategies
Future Leaders Committee
Director of Business Development
Price Transparency Committee
Christine Cooper CEO aequum, LLC
Captive Insurance Advocacy Task Force
Jeffrey K. Simpson
Womble Bond Dickinson (US) LLP
Workers’ Compensation Committee
Regional Underwriter, Group Self Insurance
Midwest Employers Casualty
SIEF BOARD OF DIRECTORS
Daniél C. Kimlinger, Ph.D.
MINES and Associates
AL Self-Insured Workers' Comp Fund
Advantage Insurance Management (USA) LLC
Chief Executive Officer
Hudson Atlantic Benefits
Strategic Account Director
Verisk/ISO Claims Partners
* Also serves as Director
SIIA NEW MEMBERS
REGULAR CORPORATE MEMBERS
Beit Nekofa, Israel
Matthiesen, Wickert & Lehrer, S.C.
SVP Employer Engagement
Chief Executive Officer
Quality Care Partners
Director of Business Development
Rocky Mountain Review
San Francisco, CA
Zach Nye General Counsel
Blackhawk Claims Services
SVP of Sales
Head of Partnerships
New York, NY
Marketing Director PayMedix
Rejuvenate Kidney Transplant Solutions
Director of Strategic Growth Initiatives
Security Health Administrative Services
Equity Risk Management, Inc
Las Vegas, NV
TIB Risk Management, Inc.
Las Vegas, NV
Catastrophic claims can arise unexpectedly. If the plan has the right Stop Loss protection in place, focus can remain on achieving business goals and welcoming Leo back when it’s time. When you work with the experts at HM Insurance Group, you can have confidence that the claims will be paid. Find more on hmig.com