F EB R UA RY 2 0 2 0
A S I P C P U B L I C AT I O N
Hospital Dominance: A Growing Problem? TWO HIGH-PROFILE SETTLEMENTS INVOLVING HUGE HOSPITAL SYSTEMS RAISE CONCERN ABOUT EFFORTS TO CURTAIL ANTICOMPETITIVE PRACTICES, SPOTLIGHT NEED FOR BETTER DUE DILIGENCE
AN INTEGRATED APPROACH TO SELF-INSURED SOLUTIONS
balance Experts in coverage solutions for single entities, groups and public entities, our integrated approach gives self-insureds greater stability and control over their self-funded plan. Unparalleled underwriting expertise, innovative risk management and in-house claims management, work in sync and in perfect balance for best possible outcomes.
A Safety National® Company
800.800.4007 midlandsmgt.com email@example.com
WORKERS’ COMPENSATION | PUBLIC ENTITY | CATASTROPHIC CLAIMS MANAGEMENT | THIRD PARTY ADMINISTRATION | EXCESS WORKERS’ COMPENSATION | AUDITS | COMMUTATION | UTILIZATION & REVIEW
TABLE OF CONTENTS
FEBRUARY 2020 VOL 136
W W W. S I P C O N L I N E . N E T
HOSPITAL DOMINANCE: A GROWING PROBLEM?
TWO HIGH-PROFILE SETTLEMENTS INVOLVING HUGE HOSPITAL SYSTEMS RAISE CONCERN ABOUT EFFORTS TO CURTAIL ANTICOMPETITIVE PRACTICES, SPOTLIGHT NEED FOR BETTER DUE DILIGENCE By Bruce Shutan
A CASE STUDY IN SAVINGS: HOW THE PHIA GROUP IS OFFERING EMPLOYEES FREE HEALTHCARE
By Philip Qualo, J.D.
THE HIGH COST OF INSURANCE AGENCIES NOT FACING THEIR FEARS
37 SIIA ENDEAVORS
THE NEW MATH FOR POPULATION HEALTH MANAGEMENT UTILIZING A CAPTIVE
TECHNOLOGY, TRUCKING LIABILITY, AND CAPTIVES
NEWS FROM SIIA MEMBERS
The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688
Self-Insurer’s Publishing Corp.
PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF OPERATIONS Justin Miller, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISORS Bruce Shutan and Karrie Hyatt, 2018 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary
Hospital Dominance: A Growing Problem? TWO HIGH-PROFILE SETTLEMENTS INVOLVING HUGE HOSPITAL SYSTEMS RAISE CONCERN ABOUT EFFORTS TO CURTAIL
Written By Bruce Shutan
ANTICOMPETITIVE PRACTICES, SPOTLIGHT NEED FOR BETTER DUE DILIGENCE
rom President Trump and foot soldiers in his administration to at least two state attorneys general, government officials have tried to rein in dominant hospital systems whose business practices raise antitrust concerns. A related worry is balance billing, aka “surprise” bills, which have drawn ire in countless conversations from kitchen tables to boardrooms across the nation.
While two high-profile court cases at the state level have put behemoths on notice from coast to coast within the past two years, critics warn that multimillion-dollar settlements have done nothing to move the needle on these systemic issues. Industry leaders, meanwhile, implore the self-insured community to pursue any number of increasingly popular strategies to avoid price gouging, improve health outcomes and ultimately lower costs.
Hospital Dominance HIGH CONCENTRATION OF PROVIDERS More than half of the nation’s major metropolitan areas are highly concentrated in terms of providers, reports Suzanne Delbanco, Ph.D., executive director of Catalyst for Payment Reform. There’s also a lot of consolidation among third-party administrators (TPAs), which she says means “there’s only so many choices.”
A growing body of evidence suggests that hospital industry consolidation “almost always leads to higher prices and very rarely improves quality, and may in fact lead to worse quality, which impacts the total cost of care,” she observes.
Atrium Health, North Carolina’s largest healthcare system with more than 40 hospitals in the Carolinas, was sued for restricting access to information on the cost and quality of alternative health benefit plans that would help health care consumers seek better value. The hospital system reported $11.1 billion net operating revenue in 2018, which included joint venture and affiliated enterprises.
The number of primary care physicians and specialists acquired by hospitals in the U.S. nearly doubled between 2010 and 2018 to where nearly half of all physician practices are now owned by a hospital. So said Richard Scheffler, a health economics and public policy professor at the University of California, Berkeley’s graduate school, during a lively panel discussion on health care market concentration at SIIA’s 2019 national conference in San Francisco.
FROM ATRIUM TO SUTTER Sutter Health, Northern California’s largest hospital chain, was poised for a court trial expected to last three months that would have been the latest litmus test for highlevel antitrust scrutiny of health care market concentration at the state level. While the nonprofit giant reached a tentative settlement to avoid damages of up to $2.7 billion, details of which were still being worked out as this issue went to press, it faces a separate federal antitrust lawsuit tentatively slated for the spring. The hospital system, which reported $13 billion in operating revenue in 2018, has 24 hospitals, 34 surgery centers, 5,500 physicians and 12,000 affiliated doctors across Northern California. A 2014 civil suit initially filed on behalf of a health plan run by the United Food and Commercial Workers International Union & Employers Benefit Trust was later certified as a class action representing roughly 1,500 employer-funded health plans across California. The state’s attorney general joined the lawsuit two years later. A civil antitrust case involving another dominant industry player accused of anticompetitive practices was settled in 2018. One of the nation’s largest nonprofit healthcare systems was prohibited from using so-called steering restrictions in contracts between commercial health insurers and its providers.
Jaime King, J.D., Ph.D., associate dean and professor of law at the UC Hastings College of the Law, describes the Sutter Health lawsuit as “a landmark case that could have brought to light a lot of the issues surrounding massive health systems in states and the strategies they use to increase prices.” Once settlement details are announced, she predicts they will “end up being very important for setting the tone for other states and AGs about what kind of practices will be allowed in those contracts going forward.” Sutter Health has a reputation for highly aggressive pricing strategies – a practice that King believes other health systems watched and then mirrored. The chain also was one of the first players
Claims Processing, Simplified.
See for yourself.
Hospital Dominance of its kind to aggressively acquire other entities to increase its market power. Scheffler alluded to a recent study by the Nicholas C. Petris Center at the University of California-Berkeley about the impact of Sutter Health on health care prices in California. What the stateled court case suggests for self-insured employers is the importance of reviewing hospital pricing practices, Elizabeth Mitchell, CEO of the Pacific Business Group on Health, suggested in reaction to the high-profile court settlement. Her region pays 50% more on average for health care than in the Los Angeles metropolitan area. Knowledgeable observers agree that going to trial could have been a public relations nightmare for Sutter Health and that airing details in a courtroom is
almost always a slippery slope for all hospital operators. “There is story after story about hospitals bringing their prices down in the face of public shaming, or coming back to the table after walking way to negotiate for a better deal,” King noted during SIIA’s 2019 national conference. Delbanco assumes all parties to the suit, including California Attorney General Xavier Becerra, received the remedies they were looking for. Although most of the Atrium settlement terms are under seal, King says what’s known is that anticompetitive contract terms were not enforced and some amount of money was paid to North Carolina.
NO-FAULT SETTLEMENTS But will these antitrust settlements actually change long-standing practices that have been the bane of existence for employers and the public at large? “There’s no reason to think these practices won’t continue,” laments former SIIA Chairman Adam Russo, Esq., CEO of the Phia Group, LLC. Adam Russo
Data Integration • Real Time • Automated • Accurate
Hospital Dominance He says the deals represent an ominous sign and will continue to hurt the self-insured industry, including employers, employees and their dependents, because they don’t determine any liability. Russo even referenced a Sutter Health statement that explained its settlement was not an admission of wrongdoing. Indeed, he says these actions are merely a slap on the wrist and that they won’t produce any meaningful change in how nearly every major hospital system across the U.S. negotiates prices with self-funded employers, insurance companies and networks. When large facilities continue to gobble up smaller hospitals, specialty practices and physician groups, Russo says it tightens the screws on self-insured employers who are beholden to overpriced network contracts. Recalling a 2009 whistleblower case involving a close friend, Russo notes how then-California Insurance Commissioner Dave Jones lauded a $46 million settlement as a historic change in how facilities bill for anesthesia charges. But he says not much has changed since that deal, which was made to settle allegations that claims were triple billed. He describes most network contracts as not only anticompetitive, but also antidemocratic and anti-American.
DIRECTING CONTRACTING AND POOLED PURCHASING POWER There are several steps employers and other purchasers of health care can take to combat anticompetitive practices. “The most immediate is to connect plan
members with providers who deliver the highest value,” Delbanco says. Others include steering members into narrow or tiered networks, centers-of-excellence programs, reference-based pricing “or even just basic transparency around healthcare provider prices and quality,” she adds. However, these strategies aren’t possible if a TPA has contractual agreements with hospitals that prevent employer clients from tiering or steering health plan members, or pursuing transparent practices that would be considered detrimental to the dominant, powerful health system, Delbanco cautions. She says they also would be undermined if high-priced health systems are allowed into a top-tier or narrow network where they don’t belong. Her organization provides employers with a model health plan with request-forinformation and contractual language. “We think being thoughtful about the sourcing and contracting process is really critical,” she observes. As a result of hospital consolidation, Delbanco expects more direct contracting and carving out specific services and procedures with the help of third-party vendors, as well as engagement with alternative TPAs that use more precision in building provider networks. She also sees a rise in retail clinics and urgent care facilities, as well as onsite or near-site clinics that employers share, or even telehealth and more careful referrals to control utilization of overpriced services. Reputation is also a factor in determining a hospital’s market share or domination. Delbanco notes that this phenomenon is often seen with academic medical centers whose impressive reputation gives them clout.
Hospital Dominance The biggest lesson or takeaway of these high-profile antitrust cases is that “the more employers can band together, the stronger and better they will be in negotiating and getting their point across,” according to King, referencing smaller and midsize companies. Examples include joining a local business group on health or coalition or captive insurance group. She says other winning strategies include setting referencebased prices, bundling services with crystal-clear pricing strategies and establishing onsite or near-site health clinics. In the face of continued marketplace dominance, Russo says self-insured employers still have several options. They include direct contracting with the help of a TPA, joining a large network, regional narrow network or using no network at all. The trouble with large networks, he explains, is that it’s nearly impossible to avoid facilities owned by dominant chains that come with a much higher price point and lack transparency.
CAVEAT EMPTOR If details of Sutter Health’s settlement end up favoring employees and employers alike, then King believes it “will demonstrate to major health systems the power that these unified employer groups can have, and that might give them much more leverage in contracting.” But there also is an important caveat to consider. Since self-insured employers have long relied on third-party beneficiaries to negotiate in their best interest, she says these lawsuits demonstrate a need to pay closer attention to contractual details, hold those organizations more accountable for the services they provide and generally become more savvy health care purchasers. “A lot of the contract terms that have been agreed to pretty systematically over the years may not be in the best interests of employers and consumers,” King cautions. Many industry observers say it’s vital to carefully vet contracts with health care facilities because it makes good business sense and can produce better health outcomes, but there’s also another reason. Russo and others warn against a wave of litigation alleging a breach in fiduciary duties under ERISA if health plan assets are mismanaged, which mirrors a trend in the 401(k) arena. What needs to change is the mindset among many employers that believe they cannot fix the health care system and, therefore, accept rising premiums, copays, deductibles and coinsurance, Russo opines. “They don’t realize that they can empower the plan to actually lower costs,” he says. His own firm ended out-of-pocket costs for employees starting January 1, 2020, setting an example that employer clients may well follow. Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.
Reference Based Pricing is Changing. Are Your Stop Loss Partners Keeping Up? AccuRisk Solutions isn’t satisfied with following RBP trends— we’re out to lead the Stop Loss pack. Ready to set the pace together? Contact us today. firstname.lastname@example.org | accurisksolutions.com | (312) 857-9100
Written By Philip Qualo, J.D.
A Case Study in Savings: How The Phia Group Is Offering Employees Free Healthcare
he Founder and Chief Executive Officer (CEO) of The Phia Group, LLC, Adam V. Russo, Esq., made an announcement at our most recent Christmas party that caused a reaction that could be heard all throughout the New England region.
An overwhelming explosion of applauses, screams, and in some cases, tears and sobs, shook the entire venue as the CEO described a major milestone that made Phia history. What was this groundbreaking announcement? The Phia Group has joined the ranks of only a handful of employers in the United States that offers free healthcare… yes… FREE… healthcare coverage to their employees!
Despite astronomical increases in healthcare and prescription drug costs throughout the nation, and soaring insurance premiums, Phia now offers free healthcare coverage to all employees who have been enrolled in the group health plan for a period time. We did this without raising out-of-pocket costs or employee contributions!
Free Healthcare Six months before this announcement, when the CEO first considered offering free healthcare, I was tasked with identifying other employers that offer free healthcare, and more importantly, how they did it.
TO INSURE … OR SELF-INSURE?
Although identifying employers that offered some variation of free healthcare was an easy task, since there are approximately only ten or eleven employers currently doing this, what we could not find was information on how they did it.
The Phia Group started with a handful of employees twenty years ago, and now, we have several offices throughout the country. But when Phia was still a seedling, we knew that the key to our success hinged on not only attracting top talent to our workforce, but more importantly, retaining them.
Consistent with our stated mission to reduce the cost of healthcare through innovative technologies, legal expertise, and focused, flexible customer service, we have decided to break away with this tradition of mystery and intrigue and share with the world how we accomplished this milestone. This is how we did it…
Our journey started many years ago when we decided to self-insure our employersponsored group health plan. We realized early on that choosing the right type of health insurance would be an essential part of the growth and long-term success of our company.
As healthcare is one of the top factors that employees consider when they assess their employment satisfaction, we knew the key would be to offer a robust health plan that would appeal to a wide demographic of diverse individuals. With healthcare costs skyrocketing, however, we weren’t sure how to accomplish this without annihilating our budget.
Ultimately, we decided to take the risk and self-insure our group health plan. We realized that by self-insuring our own group health plan, we could avoid the offthe-shelf price tag sticker shock of a fully-insured plan, and have the flexibility to customize our benefits to meet the specific needs of our growing employee population.
TRUST BUT VERIFY There’s a good reason your Administrative Services Agreement allows you to audit your self-funded medical plans.
Serving Self-Funded Health Plans for 30 Years
LET THE EXPERTS HELP Medical
Free Healthcare Unlike traditional health insurance plans which require employers to pre-pay for potential claims through monthly premiums, self-insuring our health plan provided us with a wide range of saving opportunities as we were only required to pay claims as services were rendered.
By choosing a benchmark that met the needs of our workforce, we were able to cut out the wasteful benefits we do not need to keep our costs low. The savings allowed us to add more desirable benefits to our health plans that kept our employees not only healthy, but more importantly, happy. Healthy and happy employees are more likely to be more productive and stay with their employer even in the most competitive of job markets.
MAXIMIZE SAVINGS So we decided to self-insure â€Ś what next? Since our goal was to enhance our savings potential, with the hope of one-day passing along the savings to our workforce, our next step was to develop the most effective and clear plan language that would minimize our risk and liability while keeping our expenditures low. We wanted to accomplish this, however, without stripping our plan of the benefits are employees have grown to enjoy.
To meet this goal, we developed our own plan design and incorporated the most innovative cost-containment techniques, working within the boundaries of our network agreement, and integrated them into our group health plan in easy to understand language aimed at educating our participants to ensure they utilize the high quality lower cost healthcare options.
For example, our plan rewards employees for making cost-effective decisions by waiving co-pays when utilizing the reasonably priced yet effective facilities, generic prescription drugs and other low-cost alternatives. Finally, to avoid the financial pitfalls of excess or erroneous payments, we created and adopted some of the strongest subrogation plan language in the country that further empowered our plan to identify more claim recovery opportunities as well as maximize those recoveries.
EMPOWER THE PLAN â€Ś EMPOWER THE EMPLOYEES Another benefit of self-insuring that played a role in our ability keep our costs low was access to our claims data. In the fully-insured world, carriers traditionally raise rates annually with little to no explanation.
Since carriers are not required to provide employers with claims data, fully-insured employers are basically left powerless to develop strategies to keeping their premiums low. Information is power. Because we self-insure, we enjoy
• Consulting • Case Management • Big and Small Data Analysis & Predictive Modeling • Claims Audits • Risk Management
Call Us Toll Free: (888) 448-2470
Aratai International provides services to build and develop cost-effective and high quality healthcare strategies. We invest time in understanding your business goals, and we develop programs to help you reach them. We are committed to developing strong business relationships by exceeding your expectations. MEDICAL LEGAL
C O N S U LT I N G
D A T A A N A LY S I S
Free Healthcare complete access to our claims data and rely on this vital information to identify wastes, high expenditures, and develop innovative and unique ways to save costs on an annual basis. However, we were still not satisfied.
For example, by simply consulting with our Human Resources department before selecting a provider for certain procedures, a participant is eligible to receive a percentage of the savings that may result from the consultation. We also created a plan option with a Direct Primary Care (DPC) feature that is paid for company and completely free to our employees – no copays and no out-of-pocket when utilizing our DPC – ever!
As an industry expert in the self-insured arena, we knew there was more we could do as a plan sponsor to maximize our savings even more, but we knew we could not do this alone. We realized that without the support of our employees, our efforts to enhance our group health plan savings could only go so far.
As an employer invested in our workforce, we always strived to keep our employee contributions low. However, by incentivizing employees to make cost-effective decisions about their healthcare needs and keeping their contributions low, employees not only became interested in keeping our health plan costs low … they became obsessed! In their mind, they were in it for the incentives – extra cash for picking the best care at the lowest cost? Why not?
PASSING IT ON Without employees, a group health plan is nothing but a Plan Document/ Summary Plan Description. So how do we get employees interested in, and more importantly, excited about keeping plan expenses low by opting for high quality low cost options? We wanted to be able to maximize options for our employees without dictating their healthcare needs or placing restrictions on our health plan.
The lightbulb went on – rather than dictate or limit healthcare options – we decided to incentivize our employees towards high quality low cost care options. We developed a broad range of employer costcontainment incentives aimed at educating our employees about their healthcare options with an irresistible incentive – a percentage of the savings!
What our employees did not realize until our most recent Christmas party, however, is that by utilizing our cost-containment incentives we covertly evolved into a work culture with a shared commitment – keeping our health plan costs low.
peace of mind
Weâ€™ve got your back. Four words that you want to hear when seeking to self-fund employee medical benefits, particularly when facing the potential costs and risks associated with a self-funded benefit plan. At Swiss Re Corporate Solutions, our integrative National Employer Captive program brings our brokers, payers and their clients extra peace of mind through protection against catastrophic claims. Designed for groups with 50-400 enrolled employees, this captive program allows a small or medium size employer to participate as a member of a risk bearing entity with like-minded employers, providing both peer support and long-term financial stability. Most importantly, captive members get to jointly control their own risk and spend only the money they use. Weâ€™re smarter together. corporatesolutions.swissre.com/eslcaptives Insurance products underwritten by Westport Insurance Corporations and North American Specialty Insurance Company. ÂŠ Swiss Re 2019. All rights reserved.
Free Healthcare To our employees, our incentives were just opportunities to get some extra funds or save some money while still accessing the best healthcare. With a strong group health plan, and plan participant’s eager to reap the rewards of our cost-containment incentives, our dream became a reality. Our group health plan savings had maximized to a point that we are now able to offer our employees a benefit that few companies provide … free healthcare coverage.
Philip Qualo, J.D., joined the The Phia Group, LLC in June 2018. In his current role as a Compliance and Regulatory Affairs Consultant, Philip provides consulting services to employers, third-party administrators, brokers, and vendors on an array of topics focused on Human Resource and group health benefit plan compliance. He earned his J.D. from Villanova University School of Law and his B.A. in both Philosophy and English from Loyola University Maryland. Philip’s professional experience has ranged from practicing employment law, specializing in disability litigation, to managing federal grants.
We watch the trends.
We share our knowledge.
There’s no simple way to overcome the rising claims trend in today’s market. But we know that incorporating smart practices into our business model is helping us to gain more control of the situation. We’re making informed decisions based on data analytics and industry knowledge; using the insight of in-house experts to create thoughtful solutions; and choosing our cost containment partners wisely as we work to protect our clients’ financial well-being. Learn more about our efforts to help manage the unpredictable at hmig.com.
We deliver solutions you can trust.
MANAGED CARE REINSURANCE
Products are underwritten by HM Life Insurance Company, Pittsburgh, PA, HM Life Insurance Company of New York, New York, NY, or Highmark Casualty Insurance Company, Pittsburgh, PA.
Delaware Advantage • Delaware takes captive insurance company licensing to a new level that Speeds to Market the licensing process. • Delaware is the first in the nation to electronically offer a conditional certificate of authority as part of the general application. • Delaware’s conditional certificate of authority means receiving a license to conduct insurance business the same day of submitting the application to do business.
STEVE KINION, DIRECTOR Bureau of Captive & Financial Products Department of Insurance
BUREAU OF CAPTIVE & FINANCIAL INSURANCE PRODUCTS Delaware Department of Insurance 1007 Orange Street, Suite 1010 Wilmington, DE 19801 302-577-5280 | captive.delaware.gov Trinidad Navarro, Insurance Commissioner
Written By Kevin Trokey
THE HIGH COST OF INSURANCE AGENCIES NOT FACING THEIR FEARS
don't have to tell you; it's scary times in our industry. We talk to agency owners every day who are afraid. There are many insurance agency fears, but the most frightening thing for most is the concern over their ability to grow their agency predictably in the future. While the current changes and disruption the industry is experiencing has caused the fear to reach a fevered pitch, the circumstances driving that fear are nothing new. Until now, the fears have been ignored. You may have heard us say before, "The financial reward for mediocrity in our industry has been way too high." It's this historic financial reward that has allowed agencies to survive, even thrive, despite irrational reactions (or avoidance) to their core fears. Unfortunately for many, with bonuses/commissions being slashed, they are being forced to face those fears. They have to respond in, what is for many, very challenging ways. The cost of not addressing their insurance agency fears in a healthier manner will be the ultimate price of maybe going out of business. Be honest, do you experience any of these fears? If so, how are you responding?
PROSPECTING FEAR We see agencies that are so afraid to pick up the phone that they pay outside firms to do their prospecting. This might be fine if it was done effectively, but that is rarely the case. The high cost of this fear – Empty pipelines and inadequate growth rates. Overcome the fear – Prospecting is the scariest and most difficult part of a scary and difficult job. However, producers are paid exceptionally well to do that scary and difficult job and must be held accountable for performing. And, if you're not going to hold them accountable and choose to outsource the prospecting for them, then adjust their compensation accordingly. But don't even consider this unless you take the time to create clearly defined processes and messaging to ensure the effectiveness of the lead generation firm.
REFERRAL FEAR Not only do we see agencies afraid to call strangers, we see agencies afraid to call their clients for referrals. It's not that they don't know the value of referrals, but they are either uncomfortable asking or not prepared to do it successfully. Agencies so clearly see the value of referrals that many pay others (e.g., benefits agencies with P&C agencies) to bring them the referrals they are afraid to ask for themselves. The high cost of this fear – The high cost here is two-fold. The first is an opportunity cost when agencies won't ask their own best clients. They lose the opportunity to put high-quality leads in the pipeline, and they lose the opportunity to enhance an already strong relationship (people do like helping other people.) The second is a real cost. A one-time referral fee would be fine, but we often see agencies paying new and renewal commissions to the referral source indefinitely; we've seen the split as high as 50%! Overcome the fear – It is human nature that we want to help people who have helped us. Your best clients are more than willing to help you if you make it easy
for them. Do a little research to identify other businesses they know to whom you would like an introduction and ask. If you will ask them for referrals and make it easy by already having the list of whom you want them to call, you WILL get referrals. With a full pipeline, you won't have to worry about paying someone else to generate referrals for you.
RETENTION FEAR This one may be the most mind-boggling to me of all. We have seen agencies who are so afraid of being able to retain an account in the absence of the producer that they continue to pay commission to the producers even after the producer leaves. The high cost of this fear – What was probably a marginally profitable account, to begin with, becomes even less profitable. Overcome the fear – Make sure that every client has a relationship with the agency rather than with the producer. This fear doesn't merely manifest itself when producers leave. Because of this fear, agencies allow producers to remain OVERLY involved in the servicing of the account. This, in turn, takes them out of new production activities and leads to a self-fulfilling prophecy of depending on the producer.
PRODUCER FEAR We see agencies that are actually afraid of their producers; or at least that's how it appears. Why else would they not establish meaningful production goals, make the producers accountable for hitting those goals, and get rid of those producers who are unable or unwilling to do the job they were hired to do? Why would they not tie their compensation to the new business results they hire them to produce rather than rewarding them
for sitting on a book of business? The high cost of this fear – When agency owners don't hold producers as accountable to their job (ALWAYS producing new business) as they do others on the team, the cost is devastating. The agency has no predictable growth, there is a loss of team confidence, the agency's reputation suffers, and profit margins disappear (the cost to service continues to go up even if revenue isn't growing). Overcome the fear – Reward the behaviors that drive the results you need. For a producer, this means paying them generously for new business (even more than what the industry typically pays), reasonably for renewal business (way less than what the industry usually pays), and over-the-top for over-the-top levels of new production. In the end, this is a model that is WAY more rewarding for your top producers.
FEAR OF DELIVERING RESULTS We see agencies that are so afraid of their ability to deliver results that instead of charging clients for new services/ resources, they continue to pile on new services "for free." If the agency knew they could use that new service/ resource to bring more value to their clients, they wouldn't be afraid of asking to be paid more for doing so. The high cost of this fear – Obviously, giving stuff away for fee results in a reduced profit margin. However, worse than that is the opportunity cost of not strengthening the relationship by bringing, through effective solution implementation, increasingly more value and results to the relationship. Your clients will find improved outcomes somewhere; if it isn't with you, it will be with your competition. Overcome the fear – Every new solution/ resource addresses a specific need.
1. Start by clearly identifying what that need looks like when it is present in the business of a prospect or client.
2. Establish the questions you will ask to help the prospect/client see that they are struggling as a result of that need.
3. Establish a plan of implementation for your new solution/resource to ensure the need is addressed successfully, and improved results are delivered.
WE GET THE FEARS I get how genuinely terrifying these fears are; I understand how difficult it is to bring this kind of change to your agency. But you have no choice. If you don't face the fears, if you don't bring the change, you are on a dead-end path. Change is beyond difficult, and we typically don't change until our current reality becomes scarier and more complicated than the change itself. If you haven't been honest with yourself yet, I will tell you that you have likely reached that tipping point. If you are ready to face your fears and bring healthy change to your agency, but are unsure how to get started, let us know; that’s what we do. Kevin Trokey is the Founding Partner of Q4intelligence, a marketing and sales enablement firm committed to the preservation and transformation of the independent agency system. He writes prolifically regarding the many challenges being faced by today’s agencies, providing guidance to overcome those challenges. He is a frequent industry speaker and was recognized by the National Association of Health Underwriters as their speaker of the year in 2016.
Protecting plans and patients across the U.S
On average, KF
KF has generated a
KF has handled
savings of 98.5% off
claims in all 50 states
within 297 days of
disputed charges for
1111 Superior Avenue East Suite 2500 Cleveland, OH 44114
P 216-539-9370 www.aequumhealth.law
No Guarantee of Results – Outcomes depend upon many factors and no attorney can guarantee a particular outcome or similar positive result in any particular case.
Smarter, better, faster healthcare
Discover a smarter way to manage risks and lower your medical costs Now you can intervene from the earliest
care management, claims management and
point possible in the claims process to
assurance services for a more effective way
maximize healthcare cost savings and
to analyze cost and quality data. For the
quality of care. Vālenz™ delivers the only
insight you need to control your health plan
single source, end-to-end analytics platform
spend and outcomes, call us today:
that brings together provider networks,
(866) 762-4455 ext. 377
23048 N 15th Ave., Phoenix, AZ 85027 • (866) 762-4455 ext. 377 • valenzhealth.com Proud to be a Diamond Member
THE NEW MATH FOR POPULATION HEALTH MANAGEMENT UTILIZING A CAPTIVE Written By Mark Troutman and Chris Payne
PHM = (C + R) (S)Â˛ Population health management solution = (captive + reinsurance) x (support services for captive risk assumption and population health management).
BACKGROUND Captives are increasingly being utilized by health plans assuming population health risk and by groups of employers collectively self-funding their employee benefits programs for a common purpose. Employers and health plans face exposure to financial loss due to unforeseen events. Most mitigate this volatility risk with the purchase of insurance or reinsurance. The purchaser trades the certainty of a small known cost (the premium) for the promise that the insurance or reinsurance company will pay for any contingent uncertain losses. The removal of annual and lifetime limits on claim payments has resulted in greater exposure to catastrophic risk for self-funded employers and health plans with commercial Medicare and Medicaid risk. The increased frequency of catastrophic claims exacerbates this risk exposure.
YOUR BEST PARTNER LEADS THE WAY
For more than 35 years, self-funded employers have trusted Sun Life to deliver ﬂexible stop-loss solutions and seamless claim reimbursement. And now, with our new Clinical 360 program, our clinical experts will review your claims data to identify cost savings and care optimization. With high-cost medical and pharmacy claims growing every year, you need your best partner with you every step of the way. Ask your Sun Life Stop-Loss specialist about our latest innovations.
DENTAL / VISION
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. © 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503k SLPC 29427 02/19 (exp. 02/21)
With many health systems and Accountable Care Organizations (ACOs) forming or acquiring their own health plans, assuming more risk from payers via ACO contracts, and even directly contracting with employers in a narrow network strategy population health management and protection from catastrophic medical claims becomes imperative. If a health plan or hospital has an affiliated captive insurance company, it has an effective risk management tool at hand. Although an existing health plan captive may have been formed to accept medical malpractice or professional liability or other property and casualty coverages, it may have excess capital or access to capital that would allow it to assume additional types of risk. The captive insurance company may be well-suited to accommodate various levels of medical excess, provider excess, and/or employer stop loss risk.
KEY DRIVERS OF THE INCREASED USE OF HEALTH CAPTIVES WITH REINSURANCE The following industry trends have contributed to an increase in health captives with appropriate reinsurance1:
• A growing number of healthcare entrants (e.g. providers, property and casualty insurance carriers, and venture capital investors).
• An abundance of low-cost capital has made reinsurance a cost-effective option for capital planning and management and catastrophic risk protection.
• New health programs requiring protection in early years (e.g. Next Generation ACOs) and unlimited maximum risk.
• A desire to draft custom insurance policy or reinsurance treaty terms and conditions.
• A desire to better understand fundamental risks and exposures and to access strategic partners to help manage risk.
• A desire for analytics to provide customers with insights and confidence to vary reinsurance buying patterns to mitigate and diversify risk.
ADVANTAGES OF A CAPTIVE There are many advantages of placing employee benefits and other risks in captives. These focus on cost and control issues, as follows:
a. Coverage availability and flexibility – captives can provide coverage when commercial insurance markets do not provide the desired insurance benefits or charge unreasonably high premiums. The captive has more flexibility in the types of coverages it provides.
b. Control of essential services – the captive owners retain control of underwriting, pricing, investments and claim management. Loss
control services and risk management can be focused on the unique needs of the parent organization and incorporate specific experience into the rating.
c. Information – comprehensive data provides a firm basis for loss projections and can help with establishing appropriate insurance or reinsurance coverage for a captive. A captive owner is not subject to the limitations of the information management provided by the insurer or reinsurer.
d. Stability of insurance cost – the captive allows an organization to realize insurance or reinsurance costs that are more closely related to its own loss experience and minimize fluctuations from year to year.
e. Appropriate reinsurance – a captive can provide centralized procurement after determining what coverage to provide and what levels of risk are retained and where to seek quota share or excess-of-loss reinsurance for the more volatile portions of the program. This allows it to match its
insurance or reinsurance coverage to meet its own specific needs. It also creates a consolidated repository of retained risk that may allow more risk to be held by the client and allows allocation of unique retentions by various lines of business.
f. Tax efficiency – an insurance company typically receives a tax deduction for loss reserves. This permits an insurance company to more closely match the timing of its revenues and expenses and allows for partial deferral of income taxes. A captive may allow a captive participant to receive these same benefits.
b. Capitalization – a captive requires capitalization as a riskbearing entity (possibly at reduced equity levels). In addition, other forms of security besides cash may be acceptable, such as a letter of credit or parental guarantee.
A captive is neither a panacea nor a placebo. A captive insurance company may have some additional potential disadvantages or issues to be addressed by the organization wishing to participate in a captive. These can include:
a. Resources – captives need dedicated internal resources, such as underwriting, claim management and loss control. Internal resources and management still need to understand the risk they have assumed and manage it. Captives may need to employ captive management companies and other services such as auditors, accountants and actuarial firms, to comply with financial and licensing requirements.
so there’s nothing stopping you in yours
MANAGE THE CARE AND MANAGE THE RISK A population health management (PHM) model is customized for given populations based on the nature of the contract, the interventions needed to drive contract performance and the current state of the physician practice operations. It is further personalized for patients based on their disease states, utilization patterns, risk and socioeconomic factors and family situation. An effective PHM model gives providers strong incentives to address gaps in care and to utilize quality metrics when doing so.
to supplement and complement the PHM in the following areas: These represent three (3) types of services:
1. Services to help manage certain types of claims (e.g. cancer, neonatal, transplant).
2. Services designed to review the cost-effectiveness of care (e.g. bill review or national preferred provider “wrap” network).
3. Other value-added services related to medical management program protocols and training needs (e.g. operations evaluations or benchmarks).
Any health plan assuming population health risk or any employer self-funding its employee benefits may look to partners or vendors for a wide variety of managed care programs and services desired to mitigate claim severity and frequency while providing high-quality, cost-effective healthcare to the designated population of insured members. They can access an array of managed care programs and services
The goal of each service is to provide appropriate treatment paid at a fair price for services rendered. This includes positive identification of all potential high dollar catastrophic cases, verification of diagnosis, treatment plan validation and cost comparisons.
RISK IS UBIQUITOUS A captive can also subcontract for various risk management services. Unbundled risk management services for captives include the following:
• Providing fronting services that allow a risk-bearing entity to cede risk to the captive via insurance policy or reinsurance treaty
• Appropriately pricing and underwriting stop loss coverage on medical risks placed into the captive
• Evaluating the actuarial adequacy of pricing of stop
loss coverage provided through ACO contracts
• Providing medical case management support for excess medical risk on large claims inside or that leak outside a health plan’s contracted provider network
• Calculating premiums and executing billing function for various employers and/or lines of business
• Adjudicating claims • Obtaining quotes here and/or excess of loss reinsurance for non-retained risk.
AN APPLE A DAY… The following is an example of a captive arrangement employing population health management techniques for employer stop loss risks ceded to the captive. The Pioneer ARU captive is a multi-employer captive open to brokers & agents nationwide that reinsures stop loss coverage for commercial employers self-funding their employee benefits plans. The committee governance structure is accepted prior to acceptance into the captive. (See Exhibit A.)
It allows all employers to share a common vision, mission and goals for their employee benefits programs. Several options are provided to each employer:
Utilization metrics are provided to each group for their own experience compared to national benchmarks. This allows each employer and the captive in total to target the most needed population health management programs for each employee and their dependents. It also provides each employer the information it may need to consider customized plan design changes to its ERISA plan. Such utilization metrics allow the group to see their “spend” in various diagnostic categories relative to a national benchmark. (See Exhibit B.) Wellness assessments and health hazard appraisals are required to participate in the Pioneer captive. The employers joining the captive share a strong desire to control healthcare costs while promoting wellness and consumer involvement. Disease management programs are focused in the areas where the population has the most potential for health improvement. (See Exhibit C.) Many of the captive members have selected a Medicare referenced-based pricing product as their employee benefits option. Referenced-based pricing programs require carefully coordinated communication and decision support tools for members shopping for healthcare. This includes both identifying lower cost providers and dealing with any balance billing issues with the higher cost providers. Potential claim dollars avoided by lifestyle and health improvements are provided to each employer group. (See Exhibit D.)
1. Managed care network 2. Third party administrator 3. Specific deductible
At AmWINS Group Benefits our team of specialists wakes up every morning committed to bringing your team innovative solutions to the opportunities and challenges you and your self-funded clients face. Thatâ€™s the competitive advantage you get with AmWINS Group Benefits.
CONCLUSION Captive solutions can play an important role in successfully managing risks assumed by health plan providers as risk contractors and employers. A successful managed care plan should position itself to increase market share and drive volume to its affiliated provider organizations, while maintaining its financial viability through enterprise risk management and reinsurance. Health plans which include PHM for managed care risk within a captive vehicle have a winning formula for success. References: 1) [Rob Fast, Willis Towers Watson, presentation on healthcare captives, Managed Care Organization (MCO) conference, Chicago, September 2017. Used with permission.]
MARK TROUTMAN is president of Summit Reinsurance Services, Inc. He can be reached at email@example.com. Located in Fort Wayne, Indiana, Summit Reinsurance Services, Inc. underwrites and administers medical stop loss insurance and reinsurance on behalf of Zurich American Insurance Company, Companion Life Insurance Company, and numerous health plans. CHRIS PAYNE is president of Alternative Risk Underwriting, LLC (ARU). He can be reached at firstname.lastname@example.org.Â Located in Schaumburg, Illinois, ARU manages captive programs in the healthcare (e.g. Pioneer), construction, manufacturing, distribution, service and retail, transportation and agriculture industries.Â
TECHNOLOGY, TRUCKING LIABILITY, AND CAPTIVES Written By Karrie Hyatt
ew technology for the trucking sector poised to make a sea change in how fleets operate and how their insurance is priced. While the commercial auto liability (CAL) sector has been languishing in the traditional marketplace, new technology is still years away from making a difference in that insurance segment. But for captives, they are flexible enough to incorporate the cost-saving technology for trucking fleets into their underwriting processes more quickly.
In a report on CAL, released by Fitch last August, the ratings company reported that direct written premiums were up by 13%. This segment of insurance market has been rising for the better part of a decade. While carriers have increased their rates, it has not been enough to cover their losses. According to Fitch, between 2009 and 2018, the average paid loss per closed claim increased 47%. An increase in the severity of claimsâ€”with average paid losses going from $9,200 in 2009 to $13,500 in 2018â€”has suppressed any gains from the increased premiums. The report indicated that positive changes in this segment were not likely to be seen before 2021, if that early.
According to Todd Reiser, vice president of the transportation practice at Lockton, the reason CAL has been underperforming for so long is due to a combination of factors. “[There has been] too much insurance capacity in the marketplace that was underpriced; medical cost inflation and higher vehicle replacement/repair costs; underwriters that were too slow to react to increase in claim costs and verdicts; an increase in distracted driving; a tort system out of control and a seed change in the social justice perspective.”
For trucking companies, premium rate increases have ranged from single digits to double digits or more. While the insurance market has been underperforming, the trucking industry itself is facing mounting problems. From deteriorating infrastructure and more vehicles on the road than ever before to rising medical costs to high driver turnover and distracted driving, these factors are also contributing to the dramatic rise in insurance costs.
For captives operating in the trucking sector, their pricing has not been affected by the volatility of the open market, but their fleets are still subject to problems facing any trucking company. The captive sector has provided capacity to the CAL market and has shown that it is a worthwhile alternative to the traditional insurance market. Especially when adopting new technologies.
NEW TECHNOLOGIES INCREASING SAFETY AND REDUCING CLAIMS
As claims become more costly to insurers in the trucking industry, technology is playing a role reducing incidents that result in claims. Technology that has become available over the last few years helps drivers avoid some of the biggest issues that plague the industry—overwork, collisions, and inexperience.
In 2017, the Department of Transportation mandated that all commercial trucking vehicles be equipped electronic logging devices (ELD), with full implementation due at the end of last year. These telemetric data devices track driver hours of service and prevent violations of legal working hours and the illegal revising of driver’s logs. The devices also help a driver more efficiently communicate with the home office as part of their regular duty and in the event of an incident. For drivers, ELDs have been shown to reduce paperwork, automate workflow, and help to facilitate inspections. An ELD will alert drivers to time-sensitive events such as breaks or driving limits and helps to build a driver's safety record. The devices also operate as a “black box” in the event of an incident capturing both driver and vehicle behavior for easier postincident reconstruction. ELDs are also being used by insurers to help underwriters make actuarial determinations.
REFERENCE-BASED PRICING D O N E R IGHT N
o two groups are exactly alike and no one Reference Based Pricing program design is right for them all. That’s why HHC Group starts by learning each group’s objectives and constraints. Then we help design and implement the right Reference Based Pricing program for them. Some want pre-cert and concierge services. Others want just claims repricing or repricing, provider appeal support and patient advocacy. Some want customized models and some provider contracting. We have the experience and expertise to help the group design and deliver the RBP program that’s just right for you.
163 CONTACT US 301.963.0762 sales@HHCGroup.com EXT.
www.HHCGroup.com Claims Negotiation & Repricing | Claims Editing | Medical Bill Review (Audit) | Reference-Based Pricing
| DRG Validation | Utilization Reviews and Independent Reviews | Independent Medical Examinations
Still in testing phase is the side-view cameras that could replace side-view mirrors. This is a technology that has been deployed in non-commercial vehicles in Europe and Japan but has only recently begun being considered by the U.S. Federal Transit Agency (FTA). For commercial vehicles, the FTA has approved testing for the MirrorEye camera system by Stoneridge Inc. Cameras provide better optics in inclement weather and in the dark, allowing the driver to see down the sides of the vehicle unimpeded. They also can move with the truck, so that the driver never has a blind spot while operating the vehicle.
The telemetrics gathered by the devices over the course of a year for a trucking company provides valuable data for insurers. While ELD devices are important in the event of collisions, they can also provide information about unsafe driving and critical events that don’t result in an incident. The devices can measure speed, hard braking, lane departures, and other factors that can help trucking companies and insurers see what’s going on. For trucking companies, this allows them to take action, such as further driver training, before an incident can occur. For insurers, it helps them to identify at-risk behaviors.
Two other technologies, that have been popular in non-commercial vehicles, are poised to make a huge difference in trucking fleets—collision mitigation, or active braking systems, and lane departure warning systems. Active braking systems use sensors placed around the vehicle to monitor other vehicles close by with the ability to detect an impending collision and to automatically apply the brakes. Lane departure warning systems don’t automatically stop a driver from drifting out of the lane, but the system does sound and alarm to let the driver know.
Video cameras are also being deployed to help driver safety. Forward facing cameras, or dash cams, have been widely deployed and help companies to determine the circumstances in rear-end collisions. Coming online with more frequency are inside facing cameras that monitor driver behavior. This type of video is used primarily for training purposes but can help defend a driver’s actions in the event of an incident.
With all this new technology becoming available that can help increase driver safety and reduce claims, why aren’t more fleets becoming early adopters?
Some of the new technologies may not work for every company. For example, one trucking company, who works their fleet with tandem drivers, found the land departure warning systems would wake the driver not on duty, interrupting their much-needed rest.
Many drivers don’t approve of the use of the inside facing camera that monitors their behavior. While the resulting video is important for training purposes, drivers feel like their personal space is being invaded. With driver turnover being so high and experienced drivers in constant demand, some trucking companies will not use inside facing cameras in order to keep their drivers happy.
However, the primary reason that the sector isn’t quickly adopting new tech is that it’s expensive to introduce new tech into trucking fleets. New technology is expensive and when you need to deploy it among 50 to 100 to 1,000 vehicles or more, it adds up. Then there are additional costs for driver training and maintenance. With this sector of the market having so many issues, insurers aren’t in a place that they can offer discounts for adoption of the eventually money-saving technology. With skyrocketing premiums and the burdensome cost of the technology, most trucking companies don’t have the capacity to introduce new technology to their fleets and many are being forced out of business.
While premiums for captives in the trucking sector hasn’t had the volatility of the traditional market, technology is still an expensive component of operations. However, captive insurance companies in this sector have the ability to respond much more quickly when new technology is introduced as opposed to the traditional market which responds more slowly to major changes in the marketplace.
TRUCKING CAPTIVES ADOPTING NEW TECH
This exciting new technology comes with a hefty price tag, especially since much of it has been introduced in only the last few years. There are very few vendors for each of these technologies, so the pricing hasn’t been brought down through competition. The new technology is not affecting insurance premiums for trucking companies in any positive way. Because the tech is new, it can even increase premiums as there is not enough actuarial data that can be used for underwriting yet.
From operating rooms to board rooms,
According to Reiser, “Single-Parent and Group Captive insurance options are really risk financing mechanisms that allow for increased flexibility as to how risk is managed or financed. A company who is comfortable in taking on risk through a captive will likely be more comfortable making investments in new technologies.”
QBE is there.
No matter where you do business, you can trust QBE to deliver flexible solutions for self-funded and alternative risk structures. As an integrated specialist insurer, QBE applies deep technical expertise to deliver future-ready products, customized underwriting solutions and superior service — all backed by a strong balance sheet and well-diversified portfolio. Turn to QBE for the certainty you need to manage your business across the globe and discover what’s possible, wherever you are.
Learn more about QBE at qbe.com/us
NEW YORK • LONDON • SYDNEY • HONG KONG
QBE and the links logo are registered service marks of QBE Insurance Group Limited. © 2019 QBE Holdings, Inc. 182724 (7-19)
Unlike the commercial market, currently captives have more capacity for CAL and often have the ability to offer discounts to their owner/members when they onboard new technology. Captives may also be able to help their members invest in new technology through profit-sharing or year-end dividends.
Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.karriehyatt.com.
Group captives are made up of companies with similar business models and similar risk. Captives often require their members to follow explicit policies and to use specific technologies. Group captives are known for their propensity for sharing best practices and risk management systems among their members. “One of the advantages of group captives is that you are able to share information among the group, share best practices,” said Reiser. “A group member that’s having great success with a certain type of technology will want to share that with other members, underwriters, and captive managers.”
Trucking captives, in addition to keep the costs of CAL down for their members, are poised to be at the forefront of making use of new technology that will improve safety, reduce claims, and defend drivers after an incident for the trucking industry.
INNOVATIVE STOP LOSS AND ANCILLARY SOLUTIONS At BenefitMall, we know that employer groups benefit most from treating their health plan as an investment rather than an expense. Our team of self funded consultants can help you succeed by offering: • Reporting, Compliance Services and Plan Document Review • Billing and Premium Collection • Ancillary Products and Services
• Unbiased Expertise and Review • Initial Placement, Implementation and Renewal of Coverage • Claims Audit, Submission, Tracking, and Resolution Services
©2019 BenefitMall. All rights reserved.
IIA will hold a Future Leaders Mentor Connection Forum April 6-7th at the The Notary Hotel, Autograph Collection, in Philadelphia, PA.
This interactive event has been designed to connect younger SIIA members (under age 40) with several of the most successful senior self-insurance/captive insurance industry executives in a “speed-mentoring” format. Attendees will have unique access to those who can provide practical career advancement advice, including tips on how they can be more valuable to their employers.
The format will also encourage interaction among attendees, which is important in helping them develop the professional networks necessary for them to be successful in the self-insurance/captive insurance industry – networks the mentors have spent years developing for themselves.
ENDEAVORS Groups of three to five attendees will meet with designated mentors for 30-minute discussion sessions and then rotate to visit with other mentors for successive 30-minute sessions.
Due to logistical restrictions of the format, attendance will be limited to 100, so please register early if you would like to attend.
SIIA intends for this to be a “safe” environment with regard to employment solicitations. In this regard, we ask that attendees refrain from approaching any of mentors regarding employment opportunities with their companies and that mentors likewise not engage in employment discussions with any attendees.
The following list of mentors have confirmed their participation. As you will see, they represent all segments of the self-insurance marketplace (group health, captives & workers’ compensation) and each of them have been very successful in their respective careers as well as being highly involved with SIIA in various capacities. Additional mentors may be announced closer to the date, so please check www.siia. org periodically to see the latest line-up.
Les Boughner Chairman Advantage Insurance Management (USA) LLC Les entered the insurance business in 1977. He held senior positions with FM Global, AIG, CNA, Zurich and Willis prior to joining Advantage Insurance Management (USA) LLC. He holds a Bachelor of Mechanical Engineering (with Distinction) from Carleton University, Ottawa, Canada, and an MBA from York University, Toronto, Canada.
As Chairman of Advantage Insurance Management (USA) LLC, Les is responsible for developing Advantage’s captive insurance and related businesses globally, including its direct underwriting activity at Lloyd’s reinsured by Advantage Property & Casualty Company SPC. In his role as Managing Director of Willis Global Captive Practice, Les was responsible for the profit and growth of “The Americas” Practice with offices in Barbados, Vermont, Cayman, Bermuda and Hawaii. He is Past Chairman of the Captive Insurance Companies Association (CICA), is on the Program Committee of the World Captive Forum and Chairman of the Self Insurance Information Association (SIIA).
Charles C. Caldwell CEO Midlands Management Corporation Mr. Caldwell has over fifty years of experience in the insurance industry, the majority of which have been in management positions of managing general agencies. Mr. Caldwell founded
ENDEAVORS Midlands Management Corporation in 1990 and currently serves as its CEO and President. He was responsible for planning and developing Midlands from the startup phase and continues to be the driving force in the development of new programs and in the tremendous growth Midlands has experienced.
Mr. Caldwell is active in the management of a large book of primary and excess workers’ compensation business and is experienced in captive formation and reinsurance negotiation. He is recognized as an authority in self-insured workers’ compensation and insurance pools, has participated as a speaker in numerous insurance seminars, and currently serves on SIIA’s Workers’ Compensation Committee.
He has received various insurance industry awards in recognition of his efforts on behalf of the property and casualty insurance industry by his involvement in trade associations, professional societies and the promotion of education-al and civic duties. Mr. Caldwell is a longstanding Coverholder at Lloyd’s of London and former member of Lloyd’s.
Pat Campola Director, Business Development Windsor Strategy Partners, Inc. Pat Campola is a Principal at Windsor Strategy Partners, Inc. as well as President of Campola Consulting and Intermediary Services. Pat has 30 years of senior management experience in the insurance industry. He is Past President of several organizations that include Alden Risk Management Services, a John Alden Insurance Co. subsidiary, Lincoln Re. Risk Management Services, a Lincoln National Insurance Co subsidiary, and John Alden International.
One in eight employees will have difficulties starting a family. ARC’s Customized and Cost Effective Fertility Benefits help employees reach their family building goals.
Learn about ARC’s Employer Program email@example.com or (888) 878-0025 www.arcfertility.com/employers
ENDEAVORS Jerry Castelloe Principal Castelloe Partners
Richard J. Fleder President and CEO ELMC Risk Solutions, LLC
Jerry Castelloe founded Castelloe Partners, LLC in January 2015. As a foundation for his consulting practice, Jerry has used his expertise, relationships and experiences in the self-funding industry to assist clients with a variety of strategic endeavors. He has assisted a variety of clients, including employers, high performance networks, cost management specialists and claims administrators with strategic planning management, product development, talent identification, mergers and acquisitions, and ACA compliance.
Which he co-founded in 2013. ELMC is the latest venture in a series of successful insurance related entities he has created including Comprehensive Benefits (CBSC), in 1978, and Thesco Benefits, LLC, in 1995. Since 2013 Richard has built ELMC through the acquisition of best-in-class MGUs with funding partnership from the international investment firm J.C. Flowers & Co. Richard is a graduate of Franklin & Marshall College.
Jerry gained valuable experience in all aspects of healthcare and self-funding during 31 years of leadership at CoreSource, Inc., a large national Third Party Administrator. During his tenure at CoreSource, Jerry provided leadership to all functional and geographical areas. Most recently, as Regional President, he led the SouthEast region and was responsible for business development, client management and administration for the clients in the region. In addition, Jerry provided strategic consulting advice to several of CoreSourceâ€™s major national clients, including the establishment and relationship management of CoreSourceâ€™s State High Risk Pool strategy.
He is a member of the Board of Directors of Unimerica Insurance Company of New York (Executive Committee member). Richard is a past member of the HMO Board of Directors of Oxford Health Plans and the National Advisory Councils of Aetna, CIGNA, HealthNet, and UnitedHealthcare. He is a former member of the Legislative Council of NAHU and the founder of the Empire State Healthcare Coalition.
ENDEAVORS Liz Mariner-Ford Senior Vice President, National Health Care Practice Risk Strategies Company
Deborah Hodges President and CEO Health Plans, Inc.
Liz brings to Risk Strategies over 25+ years of insurance and reinsurance experience. She is skilled in health, life, disability, the worksite market and a wide range of accident products, on both a group and individual basis. Well known for her talent in advising and collaborating with clients on growth strategies, product diversification and risk management techniques, Liz is equally recognized for her strong relationships within global reinsurance markets.
As President, Deb leads the company's diversification growth strategy and represents the organization to parent company, Harvard Pilgrim Health Care (HPHC). Deb works with the board of directors and senior management of both companies to develop longrange goals, strategies, plans, and organizational policies.
Liz started her career in 1982 at General Reassurance, the former life division of General Re, as an Account Manager in the Financial Reinsurance Unit and last held the position of Vice President of Treaty Operations for all individual and group life, accident and health lines of business for its successor company, Life Reassurance Corporation of America, subsequently acquired by Swiss Re.
In 1992, Liz joined Towers Perrin, where she became a Principal and held the position of Vice President responsible for business development in the Risk & Financial Services’ Life, Accident and Health Reinsurance Practice.
Liz is currently the Chair of the SIIA International Committee and a former Director of SIIA, holds an MBA from the University of Connecticut, a Bachelor of Science Degree in Pre-Med from Boston College, and professional designations as a Chartered Financial Consultant (ChFC), a Chartered Life Underwriter (CLU), a Health Insurance Associate of America (HIA), a Certified Employee Benefit Specialist (CEBS), and a Fellow of the Life Management Institute (FLMI).
Laura Hirsch Cofounder & co-CEO Aither Health Laura Hirsch is a visionary and innovative senior executive who has more than 30 years of experience in self-funding business strategy, private labeled business process outsourcing (BPO) services, mergers & acquisitions, operational excellence and business development.
Deb has held a number of senior executive positions over the past two decades and was a key participant during our acquisition by HPHC in 2005. Her experience and skills have directly impacted product marketing, business development, sales revenues and strategic planning, and the company’s recent risk management growth endeavors.
Deb joined Health Plans in 1993 to build our self-funded sales team as regional sales executive, serving as development architect as Health Plans transitioned operations to primarily administer self-funded health plans. Deb has since served numerous roles in the sales area including Vice President of Sales and Marketing. As Senior Vice President, Deb’s other responsibilities included Care Management and Health strategies, Reporting and Analytics, and Operations.
ENDEAVORS Earlier in her career, Deb served as an Underwriting Manager for R.E. Moulton, Director of Marketing at Mt. Vernon Associates, and was a member of the sales team at Blue Cross/Blue Shield Massachusetts.
priority on our ability to demonstrate and carry out the Renalogic mission and vision.
Lisa Moody President and Chief Executive Officer Renalogic
She has been instrumental in leading the development of core values that reflect our commitment to our clients and to the industry. Lisa consistently works to create a diverse and satisfying work experience for our growing employee base. A second generational familyowned company, Lisa has been with Renalogic since its inception in 2002. She encourages and leads the disruptive entrepreneurial spirit for positive change that continues to drive the evolution of Renalogic today.
Since 2008, Lisa has been President and CEO for Renalogic. Lisa is responsible for overseeing and directing all strategic initiatives as they relate to People, Process and Product, while ensuring the strength of our organizational health. Lisa places a high
Lisa has been a longstanding member of SIIA (Self-Insurance Institute of America,
She works closely on HPHCâ€™s self-insured line of business strategy, serves on the Executive Leadership Committee for HPHC and is a Government Relations Committee Member for the Self Insurance Institute of America, Inc. (SIIA).
Deb holds a Bachelor of Science degree in Health Care Administration.
I Learn more at TrustmarkHB.com Trustmark is the brand name used to refer to certain subsidiaries and operating divisions of Trustmark Mutual Holding Company that provide insurance and other products and services. For a complete list of these subsidiaries and operating divisions, please visit our website at trustmarkbenefits.com. All products may not be available in all states. ÂŠ2020 Trustmark
ENDEAVORS Inc.) and was instrumental in promoting Renalogic, as she was one of the first cost containment consultants for SIIA Diamond members. She is also a long standing member of HCAA (Health Care Administrators Association) and an active advocate and supporter within the self-insured community to help promote industry initiatives. Lisa graduated from the University of Massachusetts Dartmouth and is a highly respected leader for change management in the health care industry.
Mark Schmidt Head of TPA & Payer Solutions and Workers’ Compensation Prodigy Health Group Mark Schmidt is the head of TPA & Payer Solutions, which includes Meritain Health, American Health Holding, First Health and Aetna Signature Administrators specialty businesses, and Workers’ Compensation.
Mark joined Aetna in 2007 to lead the insurer’s Strategic Resource Company (SRC), which provides limited health and related employee benefits to part-time and hourly contract workers. In 2009, he joined the Local Employers and Customers segment where he served as a local market head with oversight and responsibility for the Arkansas, North Carolina, South Carolina and Tennessee markets.
Prior to Aetna, Mark spent 13 years with CoreSource, the last 10 years as president. While serving as president at CoreSource, he also held the role of
executive vice president for Trustmark, the parent company of CoreSource, leading both its operations and large group medical business. Additionally, Mark served two terms on the Board of Private HealthCare Systems (PHCS) including one term as chairman. Prior to his time at CoreSource, he spent 12 years in various financial roles with multiple insurance companies.
Harry Tipper, III Chief Operating Officer – Insurance CaptiveOne Advisors LLC Harry Tipper, III currently is the Chief Insurance Operating Officer for CaptiveOne Advisors LLC (a financial services firm focused on and with the expertise required to assess, develop, and manage captive insurance and reinsurance companies successfully).
Harry previously was a founder of and former President and Chief Executive Officer of Lyon’s Gate Reinsurance Company, Ltd. (“Lyon’s Gate Re”) a Class III, Bermuda reinsurance company licensed under the Act and the Segregated Accounts Act to offer reinsurance and segregated account (or rent-a-captive) cells and served on the Board of Directors of Su Vino Holdings, Inc. (an insurance and reinsurance consulting firm affiliated with ISG Group, Ltd.).
In order to keep registration cost low for our younger attendees, we invite SIIA member companies to consider becoming an event sponsor. This a perfect involvement opportunity who don’t typically sponsor/exhibit/advertise through SIIA but want to support a great cause and want to be recognized for it. Contact Justin Miller at firstname.lastname@example.org for details.
NEWS FROM SIIA MEMBERS
2020 FEBRUARY MEMBER NEWS SIIA Diamond, Gold & Silver 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. For immediate assistance, please contact Jennifer Ivy at firstname.lastname@example.org. If you would like to learn more about the benefits of SIIAâ€™s premium memberships, please contact Jennifer Ivy at email@example.com. 46
NEWS DIAMOND MEMBERS
VALENZ EXPANDS LEADERSHIP STRENGTH IN CLIENT SERVICES WITH TOM COX AND GREG
BERKLEY ACCIDENT AND HEALTH ANNOUNCES RETIREMENT OF CHRISTOPHER BROWN Berkley Accident and Health, a Berkley Company, announced that chairman Christopher Brown will retire at the end of 2019. Brown joined Berkley Accident and Health in 2009 as president and transitioned to chairman in December 2018. Under his leadership, Berkley Accident and Health grew from its early stage of operations into a national accident and health leader. “I want to express my deep appreciation for the strong foundation Chris established at Berkley Accident and Health,” said Brad Nieland, president of Berkley Accident and Health. “His vision and integrity, combined with his commitment to serving the best long-term interests of the company and our clients, have been key factors to our company’s success.” Chris Brown has had a long and distinguished career in group insurance, particularly the self-funding business. Before joining Berkley Accident and Health, Chris Brown was vice president of Stop Loss at an international life/health insurance company for nine years. He also previously worked at a U.S. insurance group for 22 years. Starting his insurance career in the 1970s, Chris held various leadership roles in that company’s group segment, which included life, medical, dental, disability, and workers’ comp. For the past year, Chris Brown has served as chairman, supporting the transition of incoming president Brad Nieland. During Chris’ tenure at Berkley Accident and Health, the company grew to be a market leader in employee benefit group captives, as well as the fastest growing top 25 stop loss carrier, according to NAIC data. Berkley Accident and Health is grateful for the legacy that Chris Brown leaves behind. About Berkley Accident and Health Berkley Accident and Health is a member company of W. R. Berkley Corporation, a Fortune 500® company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captives, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident. The company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. Visit BerkleyAH.com.
SHELLEY PHOENIX, AZ -- To support continuous expansion of the Valenz™ ecosystem and deliver solutions that meet the ever-evolving needs of clients and partners, leaders at Valenz announced the appointment of two new customer service experts at the helm of its Client Services team. Tom Cox, MBA, is the firm’s new Vice President of Client Services, and Greg Shelley is Senior Client Services Executive. Cox officially joins Valenz in midJanuary to lead the client services and business development support teams. With a career in customer relationship management that spans nearly two decades – most recently at Philadelphia Insurance Companies and Aqua America – Cox is known for bringing creative but data-driven approaches to service delivery. As Vice President of Client Services, he also plays a key role in providing support for Valenz’s business development team.
“Tom is a versatile leader with a deep conviction for service excellence and creating value for clients, partners and shareholders,” said Rob Gelb, Chief Revenue Officer. “His leadership experience and ability to leverage data for client solutions have positioned him well to head up our client services team.” Cox says this is an incredibly exciting time to join Valenz because the firm is making great strides in harnessing the power of data to deliver solutions for smarter, better, faster healthcare. “With
NEWS healthcare as complex as it is today, I am really excited about the depth of Valenz analytics,” he explained. “We have a great line of sight into client trends and needs, allowing us to pinpoint opportunities to truly bend the cost curve in healthcare.” Shelley joined Valenz in December 2019. As Senior Client Services Executive, he says he’s highly inspired by the firm’s innovative approach to data science and looks forward to finding new ways to foster ongoing growth. “Greg brings a unique mix of strengths to this role, including his skills in relationshipbuilding, client service, strategic execution and data analysis,” said Gelb. “Those attributes, combined with his consultative spirit and passion for helping clients solve challenges, make him a perfect fit for our team.” Shelley’s previous work experience includes a variety of management and leadership roles, most recently at One Call, a provider of healthcare solutions for the workers' compensation industry. “It’s an honor to join Valenz because this team truly understands how to reduce the total cost of care,” he said. “Valenz is making the smart, strategic moves necessary to bring results-driven solutions to our clients,” Cox and Shelley join a wave of new additions at Valenz as the company continues to build on the strength of its complete health administrative ecosystem, which it officially unveiled in 2019. Other new leadership appointments in recent weeks
include Larry Eisel as Chief Financial Officer; Kevin Gorham as Vice President of Human Resources; Colin Glen as Vice President of Product; and Ben Inabinet as Senior Sales Executive. More information about these and other new developments is available at valenzhealth. com/news.
VALENZ ELEVATES HR FUNCTION WITH APPOINTMENT OF KEVIN GORHAM AS NEW VICE PRESIDENT PHOENIX, AZ -- As healthcare companies grow and evolve, so too does the need for enhanced talent acquisition, employee engagement, cultural cohesion and more. Those and other HR functions
MORE EFFICIENT, MORE COMPETITIVE, MORE CONTROL! Applications guaranteed to begin the New Year on the right track.
Join us on a Webinar to learn how Claros can help you succeed today!
REGISTER TODAY FOR A FREE WEBINAR | 609.275.6550 | HTTPS://CLAROSANALYTICS.COM/WEEKLY-WEBINARS/
NEWS are what Kevin Gorham, SPHR, SHRMSCP, plans to address strategically in his new role as Vice President of Human Resources at Valenz™. “As the nation’s first fully integrated health administrative ecosystem, Valenz is charting significant growth, underscoring the need to invest in our human resources infrastructure,” said Larry Eisel, Chief Financial Officer. “Because much of our growth will continue to come from leveraging the integration of new and existing companies and partners into one synergistic ecosystem, we knew Kevin’s previous successes with corporate integration, employee engagement and cultural alignment made him the ideal fit to lead our human resources department.” An award-winning human resources executive with 20 years’ experience leading organizations in such industries as healthcare, technology and financial services, Gorham describes his leadership style as a strategic business partnership model and says his guiding philosophy is “best people, best practices.” That approach has led to a career filled with corporate successes, from improving operations to achieving record-high employee engagement.
Gorham has both a master’s and bachelor’s degree in English from Eastern Illinois University, where he learned the art and science of effective communication. Later, while at Household International (now part of HSBC Corporation), he received the company’s Award for Excellence for his work in human resources and employee communications. In his HR leadership role at Avnet, he was one of three finalists for the President’s Award for his work in talent management. Gorham is a Senior Certified Professional in Human Resources and an active member of the Society for Human Resources Management. About Valenz Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Serving self-insured employers, third-party claim administrators, brokers and benefit consultants, trust and labor organizations, stop-loss carriers, integrated healthcare delivery networks, and health/dental plan payers, Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available online at valenzhealth.com. Valenz is backed by Great Point Partners. Call (866) 762.4455 and visit www.valenzhealth.com.
“For me, professional fulfillment comes from being part of a growing company, which brings many opportunities to evolve through innovative and forwardthinking practices,” explained Gorham. “I am honored to join the Valenz team and look forward to contributing to our ongoing success through excellence in human resources management and team support.”
NEWS About Great Point Partners Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading health care investment firm, currently with approximately $1.8 billion of equity capital currently under management and 28 professionals, investing in the United States, Canada, and Western Europe. GPP is currently making new private equity investments from GPP III. Great Point manages capital in private (GPP I, $156 million and GPP II, $215 million of committed capital, and GPP III which has $306 million in committed capital) and public (BioMedical Value Fund family, approximately $1.1 billion) equity funds. Great Point Partners has provided growth equity, growth recapitalization, and management buyout financing to more than 100 growing health care companies. The private equity funds invest across all sectors of the health care industry with particular emphasis on biopharmaceutical services and supplies, outsourcing and alternate site care, pharmaceutical infrastructure and information technology enabled businesses. The firm pursues a proactive and proprietary approach to sourcing investments and tuck-in acquisitions for its portfolio companies. Visit Great Point at www. gppfunds.com.
GOLD MEMBERS ECHO HEALTH ANNOUNCES TOM DEAN AS PRESIDENT Westlake, OH -- ECHO Health, Inc. is pleased to announce the appointment of Tom Dean as President, effective immediately. Tom will be responsible for all ECHO® operating units. He will report to Chairman and Chief Executive Officer, Bill Davis, who will continue in his roles. “Over the past three decades, Tom has built an impressive track record of strategic, operational and commercial accomplishments,” Bill Davis said. “He has proven to be a successful and trusted leader who brings a strong reputation for developing people and inspiring teams. Tom has a wealth of experience in leading financial services and healthcare IT organizations, including Advanced Financial Solutions, Critical Technologies, Revenue Management Solutions, and most recently, the payments business at Change Healthcare. He will be a valuable asset as we continue to accelerate growth at ECHO Health. Tom has the right blend of innovation and entrepreneurship, combined with a background of growing business in large organizations. These skills are critical for ECHO to continue our tradition as a leader in the healthcare financial services space.” For the past seven years, prior to joining ECHO Health, Tom was Senior Vice President and General Manager of the Payments business unit at Change Healthcare. Under Tom’s leadership, the Payments unit became one of the fastest growing businesses at Change Healthcare.
Prior to Change Healthcare, Tom was the founder and CEO of Revenue Management Solutions, a provider of payment and remittance services to some of the largest banks and healthcare delivery systems in the USA. This company is now part of the Thompson Street Capital Partners. Tom also helped Advanced Financial Solutions, an Oklahoma City based financial services company, grow its business from 30 employees and $5 million in revenue to over 300 employees and $100 million in revenue in seven years.
“ECHO’s Senior Management team unanimously agrees that Tom Dean’s leadership experience, strategic thinking and proven ability to deliver results make him the right person to help execute ECHO’s strategic priorities and drive sustainable growth,” Ryan Davis, ECHO’s Chief Operating Officer said. “Tom’s skills will complement Bill Davis’ abilities, making them a formidable team as they work to advance ECHO’s growth.”
About ECHO Health, Inc. ECHO Health, Inc. was founded in 1997 by William Davis, a payment visionary and pioneer with over 30 years’ industry experience. He developed a proprietary, patented payment system, and today ECHO offers revolutionary payment solutions for healthcare payers of all sizes. Payers, vendors, employers, providers and members benefit from the association with ECHO, realizing dramatic reductions in the costs of fulfillment and customer service.
C O M PA N I O N L I F E I N S U R A N C E C O M PA N Y
Get Into Gear With more than 47 years of experience and 18 consecutive years with an AM Best A+ rating, Companion Life has a proven track record of success. Our solid foundation can give you the agility you need to get to the front of the pack. STOP LOSS
We’ve forged strong partnerships because we listen to our
LIMITED BENEFIT HEALTH PLANS
customers. We can create tailored solutions that work for you.
SHORT TERM MEDICAL GROUP SUPPLEMENTAL EXPENSE MEDICARE SUPPLEMENT
Put Companion Life on your team. We’re here to help you cross the finish line.
LIFE DENTAL SHORT TERM DISABILITY LONG TERM DISABILITY VISION CRITICAL ILLNESS
Rated A+ by AM Best Company. Rating as of Dec. 10, 2019. For the latest rating, visit ambest.com
NEWS ECHO’s services comply with ERISA (Employee Retirement Income Security Act), HIPAA (Health Insurance Portability and Accountability Act), CORE (Committee on Operating Rules for Information Exchange), OFAC (Office of Foreign Assets Control), and Taft-Hartley regulations. Visit echohealthinc.com.
PARTNERS MANAGING GENERAL UNDERWRITERS INTRODUCES COST SAVING RX PLAN Phoenix, AZ -- Partners Managing General Underwriters (Partners), a full-service underwriting company specializing in excess stop loss re-insurance for self-funded health plans, is introducing its newly negotiated agreement with a top ten pharmacy benefit manager and specialty drug solution. Self-funded health plans are able to save as much as 30% on the cost of their prescription benefit plans through this agreement. As Mark Mertel, CEO of Partners, states, “At Partners, we continually strive to bring our producers value-add products and services that help lower their clients’ health plan costs. Today, I am proud to introduce the Partners Pharmacy Solution, another such value-add product, for the exclusive use of our producer partners. The Partners Pharmacy Solution will give our producer partners a real advantage in the marketplace with the significant savings they will be able to offer to their clients”. Mertel goes on to say, “In the last few months, we have begun producing cost saving estimates and are very pleased with the results we have seen thus far. In fact, there hasn’t been a plan that we were not able to project significant savings. Below are just three examples of the cost saving power of the Partners Pharmacy Solution: 525-employee life group $1,122,000 cost savings. 210-employee life group $470,000 cost savings. 2,280-employee life group $1,450,000 cost savings. How Partners Pharmacy Solution Can Achieve Such Significant Cost Savings When asked how the Partners Pharmacy Solution can achieve such significant cost savings, Mertel answers: “First, a little history. The Principals of Partners have deep experience in the PBM business, having built the 10th largest PBM in the country and selling it to Magellan Health. Using our industry knowledge and close relationships, we have negotiated extremely competitive pharmacy and specialty drug contracts.” The Partners Pharmacy Solution allows our clients to receive significant discounts and rebates that an average plan cannot typically negotiate on their own”. Mertel emphasizes that the Partners Pharmacy Solution is offered on a TOTAL PASS THROUGH basis. Plans receive 100% of the value of all discounts and rebates from
the Partners agreement with a national network of over 67,000 pharmacies! Lastly, Mertel points out: “Another advantage for producers is that they don’t need to be a PBM expert to take advantage of the Partners Pharmacy Solution. With the PBM expertise we have in house, along with the help of our partners, we are able to guide our producers through each step of converting their clients to the Partners Pharmacy Solution.” About Partners Managing General Underwriters Partners is a full service world class MGU that was started in 2016 and has grown to one of the largest independently owned MGUs in the country. Partners believes in a true Partnership approach to building its company and sharing its value with its producers with a focus on achieving the lowest possible health benefit costs for health plans. For more information about the Partners Pharmacy Solution, please contact Matt Ward, CSMO at firstname.lastname@example.org and visit www.partnersmgu.com.
SILVER MEMBERS H.H.C. GROUP ANNOUNCED THE RETIREMENT OF JEANNIE HURLEY H.H.C. Group announced the retirement of Jeannie Hurley, its Business Services Director, effective December 31, 2019. Jeanne has been responsible for overseeing the company’s for accounting, payroll, and benefits coordination and has been a member of the company’s senior management team since joining the company January 1, 2007.
NEWS “Following 13 years as Director of Business Services at H.H.C. Group, I am excited to start another chapter: retirement. H.H.C Group has offered me many opportunities and I am proud to have played a small part in the company’s success. I leave with mixed emotions: looking forward to starting my new endeavors and sad to leave behind the many colleagues and friends I have been fortunate to work with," says Hurley. “Jeanne has been a key contributor to H.H.C. Group’s success over the last thirteen years,” said Dr. Bruce Roffe’, H.H.C. Group’s President and CEO. “She has done a wonderful job of meeting the needs of our clients and the other members of the H.H.C. Group team. We wish her well.” About H.H.C. Group H.H.C. Group provides containment solutions for Insurers, Third Party Administrators, Self-Insured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA and Government Health Plans. H.H.C. Group utilizes a combination of highly skilled professionals and advanced information technology tools to consistently deliver targeted solutions, significant savings and exceptional client service. H.H.C. Group's services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing,
Medical Peer Reviews/Independent Reviews, Independent Medical Examinations (IME), and Pharmacy Consulting. H.H.C. Group is an URAC accredited Independent Review Organization for Internal and External Reviews. For additional information about H.H.C. Group and our services, visit www. hhcgroup.com or contact Bob Serber at email@example.com or 301-9630762 ext. 163.
GILSBAR ADDS PHARMACIST DR. DAVID DUPRE TO MEDICAL ADVISORY COMMITTEE COVINGTON, LA -- Millions of people depend on prescription drugs to stay healthy, but sometimes those necessary
Flexible health plan solutions for self-funded employers Save up to 30% Unrivaled Member Advocacy Customized Plan Design Learn more about the leader in reference-based pricing. firstname.lastname@example.org | elapservices.com
Medical stop loss insurance from Berkshire Hathaway Specialty Insurance comes with a most trusted name and the stability of an exceptionally strong balance sheet. Our executive team has 30 years of experience and a commitment to tailoring solutions and paying claims quickly. All of which is key to ensuring your programâ€™s success for years to come. With so many choices, you can make this one with certainty.
Atlanta | Boston | Chicago | Houston | Indianapolis | Irvine | Los Angeles New York | San Francisco | San Ramon | Seattle | Stevens Point | Adelaide Auckland | Brisbane | Cologne | Dubai | Dublin | Hong Kong Kuala Lumpur | London | Macau | Madrid | Melbourne | Munich Paris | Perth Singapore | Sydney | Toronto
NEWS drugs come with a high price tag. To help our clients manage the growing cost of prescription drugs, particularly specialty medications, Gilsbar has established an employment relationship with a pharmacist with more than 30 years of experience helping manage healthcare expenses. In his role, Dr. David Dupre will act as a professional resource and peer advisor for Gilsbar’s Medical Directors when they make determinations concerning the most appropriate course of treatment and prescriptions used. Gilsbar’s Nurse Case Managers will also use Dr. Dupre’s expertise when caring for patients who have been prescribed high-cost specialty drug treatments. Dr. Dupre also sits on Gilsbar’s Medical Advisory Committee, which meets to review cases and provide guidance to Gilsbar's Medical Directors and Population Health Management team members. “We are always looking for ways to improve the health of our clients and at the same time, lower costs. Dr. Dupre's extensive experience as a lead investigational pharmacist for new drug therapies in California and as a member of the University of California San Francisco’s Institutional Review Board brings an exceptional perspective to our clinical decision making and treatment plan review. The new challenge in the health care industry is the high costs of specialty drugs and gene therapy. Dr. Dupre will help us address this challenge.”, says Paul Johnson, Senior Director of Gilsbar’s Population Health Management.
Gilsbar continues to invest in the expansion of its personnel with specific skill sets that are needed now, more than ever. They are proud to continue providing solutions and support for businesses and associations looking for happier constituents and healthier bottom lines.
About Gilsbar, LLC Established in 1959, Gilsbar, LLC® is one of the largest privately-held insurance services organizations in the country. Recognized as a catalyst for creating healthy businesses, Gilsbar, LLC® offers self-funded and fully-insured benefit plan management services, along with Wellness, Advocacy, and overall Population Health Management. Gilsbar, LLC’s integrated delivery model improves the health and wellbeing of its members, resulting in significant health plan savings for its clients. Gilsbar, LLC® has been honored by Inc. magazine for its sustained growth, Modern Healthcare and Business Insurance magazines as a Best Place to Work, and WELCOA and the American Heart Association for its proven wellness methodology. Visit www.Gilsbar.com.
DEERWALK INTRODUCES REPORTING TO SIMPLIFY STOP LOSS ANALYSIS BOSTON -- Deerwalk, Inc., an innovative population health management, data management, and healthcare analytics software company is proud to introduce new stop loss reporting functionality. This new reporting provides a "one-stop shop" for stop loss reporting and is available with the latest release of Plan Analytics, Deerwalk’s interoperable healthcare reporting and analytics application. From within Plan Analytics, clients now have access to a data entry portal and two new reports, Specific Stop Loss (i.e., Individual Stop Loss) and Aggregate Stop Loss. The data entry portal allows users to enter a group's stop loss contract parameters to calculate specific or aggregate stop loss, including custom parameters such as lasered members, run-in and run-out provisions, and uncommon (i.e., non-January) contract renewal months. The reports generate an overall financial picture by combining the input contract parameters with medical/pharmacy claims and eligibility data. Reporting that integrates the actual paid claims experience and accounts for specific contract variables simplifies analysis, allowing for a comprehensive understanding of how a group is performing in relation to its stop loss policy.
NEWS Armed with this information, healthcare decision makers can more accurately assess exposure to fluctuating claims costs, easily track where a group is in terms of meeting its stop loss deductible and reimbursement levels, and plan accordingly for budgeting for contractual purposes. Deerwalk’s Vice President of Product Ed Hausman stated, “From our experience working with a client base that includes over 45 third party administrators, as well as brokers and stop loss entities, we were aware of the need for a better, centralized solution for stop loss reporting. We’ve solved for this by designing a tool that draws on our data expertise to deliver easy-to-use stop loss reporting that is specific to each group’s unique situation and can be easily run and distributed.” Not only does Deerwalk’s stop loss reporting provide a clearer, more detailed overall picture, but having all this data in one place eliminates the need to collect information from disparate sources (such as carriers, claims databases, and numerous reporting tools) that must then be compiled and reconciled with the stop loss contract. Deerwalk’s dynamic reporting replaces this manual work, essentially automating this time-consuming process by bringing together all of the critical pieces of information into one place to quickly generate a report that can be shared with stakeholders.
About Deerwalk, Inc. Deerwalk is an innovative population health management, data management, and healthcare analytics software company based in Lexington, Massachusetts. Founded in 2010, Deerwalk is privately held with over 300 employees worldwide, including a technology campus in Kathmandu, Nepal. We partner with industry leaders responsible for making decisions for the health of a population to optimize costs and improve the quality of care. Deerwalk offers a complete population health management suite built on a foundation of data integrity that delivers reliable data insights and actionable intelligence. Visit www.deerwalk.com.
To see a live demo of this new functionality, visit info.deerwalk.com/demorequest or reach out to Tim Huke, Chief Growth Officer at Deerwalk, at (949) 233-4908 or email@example.com.
Only WellRithms has the medical, legal, and data expertise to accurately review medical bills. Start saving REAL dollars and experience the WellRithms diierence today. Find out more at www.wellrithms.com
SIIA 2020 BOARD of directors & committee chair ROSTER
CHAIRMAN OF THE BOARD*
David Wilson President Windsor Strategy Partners, LLC Princeton, NJ
Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston-Salem
Jeffrey K. Simpson Attorney Womble Bond & Dickinson (US) LLP Wilmington, DE
CAPTIVE INSURANCE COMMITTEE John R. Capasso, CPA, CGMA, PFS President & CEO Captive Planning Associates, LLC Medford, NJ
Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA
Mike Ferguson SIIA Simpsonville, SC
Robert Tierney President StarLine East Falmouth, MA
TREASURER AND CORPORATE SECRETARY* Gerald Gates President Stop Loss Insurance Services AmWins Worcester, MA *Also serves as Director
SIEF BOARD OF DIRECTORS Nigel Wallbank Chairman Heidi Leenay President
Thomas Belding President Professional Reinsurance Marketing Services Edmond, OK Laura Hirsch Co-CEO Aither Health Carrollton, TX Lisa Moody President & CEO Renalogic Phoenix, AZ
GOVERNMENT RELATIONS COMMITTEE Steven B. Suter President & CEO Healthcare Management Admtrs., Inc. Bellevue, WA CHAIR, INTERNATIONAL COMMITTEE Liz D. Mariner Ford Senior Vice President Re-Solutions, a Risk Strategies Company Minneapolis, MN CHAIR, SIIA FUTURE LEADERS COMMITTEE Brady Bizarro Director, Healthcare Attorney The Phia Group, LLC CHAIR, TPA BEST PRACTICES TASK FORCE Jerry Castelloe Principal Castelloe Partners, LLC CHAIR, WORKERSâ€™ COMP COMMITTEE Shelly Brotzge Regional Underwriter, Group Self-Insurance Midwest Employers Casualty
Freda Bacon Director Les Boughner Director Alex Giordano Director
SIIA new members FEBRuary 2020 REGULAR CORPORATE MEMBERS
GOLD CORPORATE MEMBER Robert Munninghoff Business Development Director Valley National Admin. Services, LLC Covington, KY
Bryan Gross Associate Krieg DeVault Indianapolis, IN
Chip Burgett SVP Payer Partnerships Global 1 Carlsbad, CA
Alexis Scarpinato Marketing Leader Health Data & Management Solutions, Inc. (HDMS) Chicago, IL
Robert Basil CFO Self Pay Medical New York, NY
Principal & National Practice Leader Captive Consulting Ryan, LLC Scottsdale, AZ
EMPLOYER CORPORATE MEMBER Teresa Clarke-Myers Office Manager DeNovix Inc. Wilmington, DE
COMPLEX CLAIMS. FOCUSED RESULTS.
Point6 delivers Financial Savings, Risk Reduction, Growth, Innovation, Value and Efficiency to entities Managing Large Complex Medical claims and Stop Loss Insurance for employers.
IS 1 TRILLION DOLLARS
in healthcare waste & errors too much?
YES. At Zelis, we listen to what payers and providers want and bring technology, people, expertise, and entrepreneurial energy together to create smart solutions and a better way for the industry. Integrated solutions to price, pay, and explain healthcare on a claim by claim basis, all offered by one trusted company.
Maximized Claim Savings. Optimized Payments. Transparent Explanations. Contact Zelis today at 888.311.3505 or visit zelis.com to find out how our pre-payment solutions are helping control the rising cost of healthcare.
Better Service. Better Performance.
zelis.com Copyright 2019 Zelis. All rights reserved.
When a fever disrupts a daily routine or the results of a diagnostic test disrupt your everything, weâ€™re here to help. From episodic illnesses to the most complex and costly medical conditions, Teladoc Health is transforming how people access healthcare. In 2002, we set out to find a better way to connect doctors and patients. Today, Teladoc Health is the global virtual care leader, helping millions of people resolve their healthcare needs with confidence. With an award-winning user experience and scalable technology platform, Teladoc Health provides access to high-quality care for millions of people around the globe.
TeladocHealth.com | 1-844-798-3810 389048332 | 09032019
ÂŠ 2019 Teladoc Health, Inc. All rights reserved.