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Talent War WITH A REINVESTMENT OF HEALTH CARE SAVINGS, CL ASSIC AUTO GROUP IS POISED FOR A COMPETITIVE LEG UP DURING AN AIR-TIGHT L ABOR MARKET
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TABLE OF CONTENTS
JANUARY 2022 VOL 159
W W W. S I P C O N L I N E . N E T
JUMP-STARTING THE TALENT WAR
WITH A REINVESTMENT OF HEALTH CARE SAVINGS, CLASSIC AUTO GROUP IS POISED FOR A COMPETITIVE LEG UP DURING AN AIR-TIGHT LABOR MARKET
By Bruce Shutan
CYBER RISK MANAGEMENT AND CYBER LIABILITY INSURANCE GO HAND-IN-HAND By Karrie Hyatt
ARTICLES 20 MITIGATING THE IMPACT OF LIVER DISEASE FOR HEALTH PLAN MEMBERS — IMPROVE OVERALL HEALTH AND PRODUCTIVITY, REDUCE PRESCRIPTION COSTS
SAVING MONEY ON WORKERS’ COMPENSATION: EVALUATION FROM THE TOP DOWN OR THE BOTTOM UP?
NEWS FROM SIIA MEMBERS
RISING COSTS AND FREQUENCY OF ORGAN AND TISSUE TRANSPLANTS
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 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
JANUARY 2022 3
F E AT U R E
Talent War WITH A REINVESTMENT OF HEALTH CARE SAVINGS, CL ASSIC AUTO GROUP IS POISED FOR A COMPETITIVE LEG UP DURING AN AIR-TIGHT L ABOR MARKET
or nearly a decade, Classic Auto Group’s employee health care benefits weren’t firing on all cylinders. The group of 19 mostly independent automobile dealerships in Texas, Oklahoma and Florida struggled to offer high-quality care that also was affordable.
Written By Bruce Shutan
Affordable is the operative word, especially for lower-paid employees who often will ration or skip care, altogether. When the Affordable Care Act passed 10 years ago, Bently Durant was optimistic that there would be a larger and more diverse pool of Americans with health insurance coverage that would benefit his family run business. “But then we saw the prices on health care services starting to skyrocket,” says the chief operating officer and general counsel who also handles HR and employee benefit duties for the network of dealerships his father started. “By 2015, with 15% and 30% premium increases every year, we were getting very concerned that we wouldn’t be able to afford health insurance, and we’d have to dump all of our employees onto the exchanges as the only affordable means to get health insurance.” It turns out that 2018 was one of those critical years. “We try to make more money and increase salaries every year, but the car business was declining,” he recalls,
noting the need to offer larger discounts on products and services to attract customers. “That’s when we started researching [more meaningful solutions].”
SHALLOW POCKETS One big mistake that many employers frustrated by rising health care costs make is passing along annual increases to their employees, explains Steve Kelly, CEO of ELAP Services. It’s being exacerbated by a pandemic Steve Kelly that has triggered what one leading academic described midway through 2021 as the Great Resignation. Between unusually high quit rates and about 11 million recent U.S. job openings, employers are struggling to retain top talent and grow their businesses.
“Health insurance is a form of compensation, so when the costs come out of the employee’s pocket instead of the employer, it’s really a cut in pay,” he says. “So we ask employers to look at this as a quality-of-life issue. By taking a firmer stance on payment to become a little bit more proactive, they can actually do a lot of good for the workforce. They take some of the savings realized from reference-based pricing [RBP] and reduce deductibles, copays and premium contributions.” As part of that strategy, employers may declare a premium “holiday” wherein employee contributions are not deducted from their paycheck for several pay periods. But that’s just a baseline. In some instances, Kelly sees employers providing ridesharing services to help their employees. “If you’re working in Chicago, for example, you may be allowed three Uber rides a month to work on the coldest day,” he says. Other gestures may include handing out daycare bonuses to recognize employees for a job well done and show they’re valued. “When you’re in a competitive market for labor, these kinds of things really resonate with the workforce, and people feel good about that,” Kelly says. “We’ve seen some employers get very creative with these kinds of approaches in terms of providing perks and benefits from the savings of a reference-based pricing plan that they then
pass on to the workforce.” Classic Auto Group has taken the lead when it comes to mining health plan savings and reinvesting dollars back into the workforce. Durant says the first step to controlling health care costs was turning employees into more health-conscious consumers. It began with health savings accounts that the company matched dollar for dollar. This way, employees didn’t have to rely on their health insurance to pay for everything. But the change didn’t come without pain points. Premiums totaled $12 million in 2018 as a group, with a $3 million increase proposed at renewal time. “That’s a lot, even for a large group of people like us,” he says. A year later, employees didn’t understand how to purchase services without a brand-name network, though they were unencumbered by any health plan restrictions. Providers also know what to make of it. That made the first year rather rocky. “To some extent, we’re still trying to figure that out because our current benefit package has several networks for different items,” Durant reports, referencing drugs, doctors, hospitals, labs and imaging as part of a single network under the Imagine Health brand.
SWITCHING GEARS WITH RBP Switching to RBP allowed Classic Auto Group to keep premiums flat since that first year, while co-pays also have remained unchanged. Members ended
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Talent War up being much happier because of fewer balance-bill issues, plus deductibles were cut in half at a time when the cost of insurance was increasing for most Americans.
“My premium plan had a $2,000 deductible, and if you were using your Imagine Health services instead, going in network it was Bently Durant a $1,000 deductible,” Durant says. “I think it was 2004 the last time I had a plan with a $1,000 deductible.” RBP offers self-insured employers a much better look into what they are actually paying a medical provider for rendered services, according to Kelly, whose firm specializes in this area. “We’re always struck by the fact that employers are good at containing costs in every area of their enterprise, except for health care,” he notes, blaming the PPO model for failing to contain costs or improve quality. But there’s no cookie-cutter way to crafting
One of the things that I’ve learned is that not all reference-based pricing companies are created equal,”
such a program. “
observes Rick Stephens of Higginbotham, the Rick Stephens largest independent brokerage in Texas, who has handled the Classic Auto Group account for about eight years. Among the distinguishing characteristics that he suggests to have in place: a single entry point and simplified instructions for health plan members, as well as plan designs that steer toward desire utilization and outcomes. Beyond offering patient advocacy that involves a nurse navigator or concierge, he suggests also having to have a streamlined, automatic legal support component. For many years the knock on RBP was it created friction among health plan members who realistically cannot be expected to shop wisely for their health care coverage when they need hand-holding, much less understand their benefits. But Kelly says that point is overstated.
“I’m certainly not denying that balance bills occur,” he says. “But balance bills occur under any benefit model.” It’s a problem that most employers very easily can manage if proper advocacy and support are in place. When balance bills do occur, Kelly says there are several courses of action to pursue. They include defending and supporting the plan member with patient advocates who are not only trained to be empathetic, but also can reach out to medical providers and settle a bill. “Behind all of that, if necessary, we have to be able to provide legal support,” he adds. RBP’s impact is particularly dramatic in certain parts of the country such as Indiana because the managed care climate isn’t good for the employer community and providers routinely charge higher multiples of Medicare, Kelly explains. That means Indiana might save as much as 35% vs. a traditional PPO model, whereas other states might save in the 10% to 15% range. “We consistently see an average of 20% to 25% savings across the country in the first year from reference-based pricing,” he reports.
CARVING OUT RX When Classic Auto Group’s peremployee-per-year (PEPY) cost was $7,693 in 2018 and its renewal was climbing to $9,686, Stephens knew that his client had to do something differently. Those efforts included an RBP solution with ELAP Services and drug carveout, paving the way for more robust benefits for roughly 1,800 employees made possible by reinvested dollars.
Talent Wars A COMPETITIVE EDGE Meanwhile, Classic Auto Group has reinvested its health care savings into telemedicine, which it made free during the pandemic for full-time, part-time, covered and non-covered employees because it was so critically important. More private medicine options also have been added in the form of medical tourism, stem cells transplantation and other areas to help patients with life-changing injuries that require surgery. “Our first investment was to reduce the out-of-pockets, and some point, completely eliminating them,” he explains, noting that there hasn’t been a premium increase since 2018. Under Classic Auto Group’s RBP initiative, surgeries and imaging are available at no charge to plan members so long as they’re scheduled at standalone service facilities. In terms of the Rx area, a thoughtful strategy was built around the “fiduciary” or “transparent” pharmacy benefit manager model, which allowed the company to retain 100% of drug rebates. It also featured a coupon program that saved about 25% on specialty drugs and overlay program with international pricing that are about 50% less than U.S. price tags. After three years with RxBenefits, the company switched to CVS for additional savings that are projected at anywhere from $268,000 to $578,000, depending on the programs it decides to implement. Stephens says the move reflects a more aggressive stance toward trying to control the prescription drug spend. Other significant results include a first-year PEPY of $6,236. “That’s an immature year, so we knew it was going to go up,” Stephens reports, noting that it hit $7,131 in 2020. However, the PEPY was still more than $540 cheaper than it was on a previous UnitedHealthcare plan. What’s more, his client is dealing with a medical trend that’s tied to Medicare, whose increases are in the 3% or 4% range vs. traditional insurance, which can fluctuate anywhere from 7% to 12%. One possible next step is a medical stop-loss captive, which Stephens describes as logical given that the current approach is just three years old.
While not a recruitment tool per se for marginally paid employees, Durant believes the beefed up health care coverage will help with retention, which
“I don’t have to recruit as hard because I’m not losing people,” he explains, “and my retention has been very high, despite this very tight labor market.” will lower turnover.
Other areas of improvement to help attract or retain talent include a higher minimum wage, doubled vacation pay for salespeople, increased holiday pay, a lowered tenure requirement for higher pay levels and signing bonuses. “We’re certainly looking at the 401(k) and ways to improve that and encourage participation,” he adds.
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Talent Wars Kelly can’t help but think about Warren Buffett’s famous quote on how “medical costs are the tapeworm of American economic competitiveness,” lamenting how it’s holding
“So, if we can drop a million dollars to the bottom line of a school district, that could be additional educational programs,” he says. “If we can drop a half million dollars to a machine shop, that makes them more competitive versus other markets.” back business growth.
Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.
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EXECUTIVE FORUM ‘22
F E AT U R E
Cyber Risk Management and Cyber Liability Insurance
Go Hand-In-Hand Written By Karrie Hyatt
ast November, internet domain host, GoDaddy, was the victim of a cyberattack which exposed 1.2 million WordPress customers’ information. While the domain host was able to contain the attack quickly, the exposure of customer information will have a ripple effect as the cybercriminals can now use the information to infiltrate WordPress customer accounts.
Cyberattacks such as this one can have a huge impact on a company’s bottom line and reputation, as well as affecting their customers and third-party service providers. While it’s important to be insured for cyber liability, it is just as important to have a fully implemented cyber security plan. Especially, as the insurance market for cyber liability tightens, exclusions become more prevalent, and premiums continue to skyrocket.
Cyber - Hand in Hand
Kirsten Bay, cofounder and CEO of Cysurance,
“In the beginning, companies really relied heavily on insurance versus security controls to manage the cyber risk. I think the most significant gap is that we didn't put enough effort into security. Now, we are proving that with basic controls in place, which are constantly monitored, we can drive down insurance losses and business impact.” said,
Insurance companies are tightening their belts where cyber liability is concerned. AIG announce plans in late 2021 to constrict the terms of cyber insurance policies in an effort to reign in premium increases after they rose nearly 40% globally. According to a Reuter’s report, Lloyd’s of London has discouraged its syndicate members from taking on new cyber business in 2022.
In the third quarter 2021 Commercial Property/Casualty Market Report, released by the Council of Insurance Agents & Brokers, cyber liability premiums increased by 27.6% over the previous quarter. This quarter-over-quarter increase has been observed over the last two years. The report attributed the continued rise of premiums in the cyber sector to the increase in cyberattacks, as well as market adjustments as underwriters become more knowledgeable about cybercrime events.
Since the rise and increase of cybercrimes over the last two decades, insurance policies have often been the default mechanism for coping with a cyberattack. Insurance coverage was effective for early one-off Trojan viruses and phishing scams. However, with the advent of more sophisticated attacks, such as Ransomware infiltration events, cyber liability insurance cannot be a one stop solution.
While cyber insurance premiums rise and coverage decreases, insurers are also beginning to require proof of cyber risk management before issuing policies.
JANUARY 2022 13
Cyber - Hand in Hand
Ken A. Crerar, president and CEO of the Council of Insurance Agents & Brokers, said in a statement, “Brokers and clients that take proactive action on cybersecurity risk by implementing stricter loss controls, such as requiring multi-factor identification for access to company systems and employee training, will be at a distinct advantage when it comes to finding robust, affordable cyber coverage.”
For Bay, “The term uninsurable risk is becoming such an interesting category in cyber insurance because we’re seeing so many companies who are just not being renewed. They’re homeless, they’ve got no place to go.”
“Our company does cyber risk management and cyber assessment for mid-market companies because today people don’t want to write checks or make investments unless there is a sound foundation dealing with cyber security,” said Steven T. Francesco, chairman, CEO, and president of Cohere Cyber Secure, a company providing cyber security services to the financial sector.
“We believe that soon all firms are going to have to prove their cyber security to deal with their insurance carriers.” In the 2021 Annual Cybersecurity Behaviors and Attitudes Report published by the National Cybersecurity Alliance, 59% of participants found that online security was easy, while 30% felt that information about online security was confusing. A large percentage (43%) of participants felt that online security protection was too expensive.
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People are talking about Medical Stop Loss Group Captive solutions from Berkley Accident and Health. Our innovative EmCap® program can help employers with self-funded employee health plans to enjoy greater transparency, control, and stability. Let’s discuss how we can help your clients reach their goals. This example is illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.
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Cyber - Hand in Hand
In the face of devastating financial and reputational losses, so many companies still are not stepping up their cyber security even as they are becoming more vulnerable. For big companies, such as GoDaddy, a cyberattack can have a huge impact their market value, but for a medium or small company, a hit to their business could put them in a situation where they have to shut down for a period of time, or even permanently.
According to a report titled Ransomware: The True Cost to Business, a global study on Ransomware business impact released by cyber security company Cybereason, 31% of businesses in the U.S. that experienced a Ransomware event were forced to close their business for some period of time after infiltration. That vulnerability can be devastating for businesses.
“I think companies that don’t have the ability or the capability to have a strong security posture just feel there is just nothing they can do about cyber security,” said Bay. “What we’re really trying to do is to help people see that security is very manageable, but you have to be proactive.” “I call it our cyber seatbelt. Back in the days when seatbelts were first instituted, they had a mass impact on reducing fatalities and injuries in car accidents. It was just that one simple thing. That’s what we need in cybersecurity, that one thing or element or host of them that can reduce cyber exposure. That’s what we’re really trying to help people get across in this conversation.” She continued,
Francesco finds that “a lot of folks don’t know how to manage cyber security, as well as the cost of it. Our company deals with people who have real concerns about business exposure and understand their credibility could be at risk if they get infiltrated.”
Captives, with their focus on risk management, can be a useful tool in meeting the challenge of cyber risk both before and after an incident. Insuring cyber risk is important, but without mitigating that risk through security management, businesses are leaving themselves to the mercy of cybercriminals.
“I think companies need to understand the risk versus the reward,” said Francesco. “If they run the firm sloppily and think that an insurance policy is going to save them, they’re fooling themselves. They really need to evaluate their business and then go to the insurance carriers to show all the work they have done. Then ask what kind of policy they can write with all the work done inside of the infrastructure to button it up.”
“For me, it’s really about reduction impact. We know that zero isn’t possible with anything. What we’re really trying to help the market see is that we can either mitigate the risk or reduce impact financially to get the loss ratios back to an alignment that is acceptable to everybody,” said Bay. “Really, what we do is portfolio analysis. We’re building a platform around this so that we have a continuous underwriting model to help correlate security controls to insurability.”
Bay’s company, Cysurance, works both sides of the problem, providing cyber security as well as captive insurance policies for their clients, who are the customers of managed service providers
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Cyber - Hand in Hand
and security product providers. Bay has found that when talking to potential customers that lack of knowledge about captive
“The biggest pushback I get is a fundamental disbelief that it’s possible. They ask, ‘who is your backer, how are you solvent?’ For us, we buy layer upon layer of reinsurance from name brand reinsurers to give our clients comfort, but captive insurance still feels very opaque to a lot of people.” insurance can make it a hard sell.
Bay continued, “I hope we can make people feel more comfortable with captive insurance because it’s the future of risk management. I think this is one of the best ways to soften the market.”
Cyber risk management and solid cyber liability insurance are a two-pronged approach to keep businesses both safe and solvent in the event of a cybercrime.
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.
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MITIGATING THE IMPACT OF LIVER DISEASE FOR HEALTH PLAN MEMBERS — IMPROVE OVERALL HEALTH AND PRODUCTIVITY, REDUCE PRESCRIPTION COSTS
he liver is the primary organ responsible for multiple functions in the body, including filtering and neutralizing toxins in the blood, eliminating waste, breaking down fats in the small intestine, producing proteins for blood plasma and regulating blood clotting. Given its important functions, maintaining a healthy liver can have a significant impact on overall health and wellbeing. For self-insured employers and plan sponsors, the benefits of preventing and managing chronic liver disease can improve member health—creating a more productive workforce—and reduce medical costs.
Written By Jon Gingrich, CEO, Echosens North America
As companies strive to optimize the health management of their members, a growing number have come to recognize that chronic care disease management (CCDM) programs that integrate non-invasive tests (NITs) in the diagnosis and ongoing management of plan members with chronic liver disease can play a significant role in effectively halting disease progression.
Being overweight or obese is responsible for about 85% of fatty liver disease (FLD). Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are the leading causes of liver disease. Over 30% of the U.S. population has some degree of NAFLD, which is linked to diabetes, obesity, insulin resistance and other metabolic risk factors.
Of the $3.3 trillion spent annually on medical care for chronic conditions, obesity alone is associated with $1.4 trillion. For employers, CCDM represents the most effective approach
This disease costs the health care system over $100 billion. Between 5% and 12% of people with NASH will progress to cirrhosis.
for treating patients with liver disease and comorbidities, such as obesity and Type 2 diabetes.
UNDERSTANDING LIVER DISEASE TRENDS HIGH COST OF HEPATITIS C A number of diseases and conditions can affect the liver, including excessive amounts of acetaminophen, statins, alcohol abuse, hepatitis A, B, C, D, and E, infectious mononucleosis and iron overload, known as hemochromatosis.
A recent U.S. population-based study focusing on cirrhosis-related mortality observed that increasing cirrhosis death rates driven by alcoholic cirrhosis, with the greatest increases seen among young adults aged 25 to 34 years. The challenge is that FLD in the workforce cannot be determined by examining claims or biometric screening data, which often fail to accurately represent the incidence of diabetes or obesity – two conditions that lead to the onset of FLD. Currently, no approved pharmacological treatment exists for this disease, making it more important than ever to detect, prevent, halt and monitor every employee who may be at risk.
Because NAFLD and NASH are so tightly intertwined with obesity, diabetes and lifestyle, a holistic approach to patient engagement can help support behavioral changes that will lead to better outcomes across the co-morbid conditions affecting the individual patient. What’s more, recent studies show that noninvasive exams at the point of care can cost-effectively identify individuals at risk for liver disease.
Up to 70% of patients with chronic hepatitis C have fatty liver. While antiviral drugs for hepatitis C virus (HCV) are very effective, they come at a steep cost. In fact, one Sovaldi pill costs $1,000 and a full 12-week course of treatment costs $84,000.
The price of other HCV drugs include:
Harvoni costs $94,500 for a 12- week treatment
Mavyret costs $39,600 for a 12- week treatment
Zepatier costs $54,600 for a 12- week treatment
Technivie costs $76,653 for a 12-week treatment
IMPACT OF OBESITY
Obesity is not simply a matter of over-eating, but rather a complex disease that involves an excessive amount of body fat. It’s important to think of this disease as a complex medical issue that increases the risk of heart disease, diabetes, high blood pressure and certain cancers.
Another factor adding to the high cost is the lack of competition from other drug companies. As a result, hepatitis C drug manufacturers can essentially charge whatever they want.
Obesity can be devastating on vital organs, especially on the liver, causing insulin resistance that leads to buildup of blood sugar and increases the amount of free fatty acids circulating in the blood and inside the liver cells.
TARGETING LIVER HEALTH Diet and exercise are effective at reversing steatosis and modification of cardiometabolic risk factors. For many patients, a 3% reduction in body weight has been associated with reversal of steatosis and a reduction of greater than 7% may resolve NASH in many patients.
A CCDM program should be designed to target liver health to not only address the broader needs of individuals, but also prevent NASH—a challenging, high-volume and chronic condition that lacks a standardized approach to care.
In recent years, the fibrosis stage of liver disease has been identified as the most important predictor of liver outcomes, making it critical to identify patients with NAFLD and NASH.
A follow-up visit ensures that the patient is following the weight loss program, consulting with a dietician or nutritionist and adhering to the CCDM program. It’s also helpful to share the patient’s liver exam score with them to illustrate the change in liver fat and potential need for adjusting treatment. This is where noninvasive tests play a key role.
THE VALUE OF NONINVASIVE LIVER EXAMS
Employers should look for primary care physicians and specialists who understand the growing need for costeffective ways to detect and monitor liver disease, being mindful that current approaches for identifying fibrotic NASH tend to be complicated, expensive and potentially wasteful. A recent expert review conducted through the Chronic Liver Disease Foundation suggests a streamlined approach that is costeffective.
Researchers identified vibration controlled transient elastography (VCTE) as a helpful direct biomarker of liver stiffness and fat in point of care. A CCDM program helps educate plan members about maintaining liver health, mitigates the high costs of prescriptions and aids preventive measures.
What’s more, a VCTE tool creates even greater value by quickly providing a quantitative assessment of liver stiffness and liver fat at the point of care to make the detection of liver disease and long-term care for individuals with NAFLD and NASH more effective.
At the point of care, FibroScan, for example, provides a simple, validated and reliable exam that creates savings to benefit payers. It does this by early identification of patients with FLD for proactive intervention and behavior change to slow disease progression. For those identified with liver fibrosis, this exam can also reduce the aggregate volume of some current diagnosis methods, such as liver biopsy.
The most effective non-invasive liver exam tools are highly mobile, can be operated by a medical assistant and interpreted by the healthcare professional. They produce numeric measurements, rather than images, for simplified interpretation and consistency of measurement. This enables clinicians to monitor changes in liver tissue over time. In fact, experts anticipate that such rapid tools that provide consistent liver measurements will be performed as a routine part of patient management.
The good news is that self-insured employers and plan sponsors can take proactive steps and gain the advantages of helping plan members prevent and manage chronic liver disease, and improve health and productivity among plan member while reducing medical and prescription costs.
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RISING COSTS AND FREQUENCY OF ORGAN AND TISSUE TRANSPLANTS Written By John Richert, RN BSN MSM, Vice President, Lead Underwriter, QBE
ost trends in organ and tissue transplants point to increasing costs and frequency that will challenge the stability of employer-funded healthcare plans, as claims for a single transplant often exceed $1 million.
While traditional medical stop loss insurance has helped employers manage the risk, many insurers have become more vigilant of the potential for covered individuals to require a transplant in the next year. An approach known as “lasering” singles out such potential cases for higher deductibles compared to the general covered population.
Lasering can significantly affect healthcare plan budgeting, as it accounts for the potential risk. It is critical for employers with self-funded healthcare plans to be aware of potential financing solutions, such as first-dollar organ transplant coverage, as
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well as organ transplant trends. Many factors impact transplantation including regulatory, technological advances, health insurance and the availability of donor organs. The following are some of the more-recent developments around transplantation.
SOLID ORGAN TRANSPLANTS
Costs continue to increase for solid organ transplants year-over-year. Examples from Milliman’s 2020 triennial report includes double lung transplants at $1.3 million and heart transplants at more than $1.6 million in average billed charges, respectively.
The U.S. is on pace to top 40,000 transplants in a single year for the first time according to the United Network for Organ Sharing (UNOS), the engine that powers the national donation and transplant system. Organ transplants from deceased donors are also up by 11% for a total of 17,821 deceased donor transplants performed in the U.S. for the first half of 2021 compared to 15,933 in the first six months of 2020.
Despite a dip in transplants early in 2020, the year marked the tenth consecutive record-breaking year for organ donation from deceased donors and the eighth in a row for deceased donor transplants. While 2021 deceased donor transplants still lag slightly compared to 2019’s pre-COVID frequency, they have exceeded 2020’s frequency. The return to expected transplant frequency and trend to pre-COVID-19 levels seems to indicate the success of providing these lifesaving procedures.
COVID-19 VIRUS AND LUNG TRANSPLANTS
COVID-19 has now infected nearly 33 million people in the U.S. with reports that up to 80%, including many who were asymptomatic may suffer lung injury. The residual effects of the “honeycombing” or fibrosing of lung tissue could significantly increase the need for lung transplantation due to COVID-19. Since the first U.S. lung transplant, due to COVID-19, performed at Chicago’s Northwestern Memorial Hospital in June 2020, 134 lung transplants have been reported with COVID-19 through May 2021.
Among them, 82 patients have developed Acute Respiratory Distress Syndrome (ARDS), 48 developed pulmonary fibrosis, and four had unspecified lung failure.
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Moreover, one heart-lung transplant was performed for COVID-19-related pulmonary fibrosis and heart failure.
antiviral medications, hepatitis-C is more manageable in the recipient.
Based on the residual damage to lungs in people that have been infected with COVID-19, it would seem this could be a chronic disease that could impact lung transplant frequency for possibly years to come.
BONE MARROW/STEM CELL
DONOR HEARTS OF ILLICIT DRUG USERS
Recent findings could support increased availability of donor hearts through greater acceptance of organs from deceased illicit drug users. According to studies published by the American Heart Association, survival rates of heart transplant recipients from donors who had died due to a drug overdose or who used illicit drugs had no effect on recipients.
In one study covering January 2007 to 2017 and 23,000 adult heart recipients, researchers identified the donors had used opioids, cocaine, methamphetamine, alcohol, marijuana, barbiturates, amphetamines, phencyclidine, and others.
The study found comparable survival outcomes between recipients of illicit drug donor hearts versus non-illicit drug use donor hearts. The second study was focused on hepatitis-c donor hearts with similar results. With the advent of new, direct-acting
Milliman’s 2020 triennial report shows allogeneic bone marrow transplants with an average estimated billed charge of over $1 million and autologous bone marrow transplants at nearly $500,000 per procedure.
The number of bone marrow and stem cell transplants continues to increase in the 4% range annually, according to the Center for International Blood & Marrow Transplant Research (CIBMTR), which tracks transplants performed worldwide and in the U.S. Persistence Market Research reported in 2019 that the global bone marrow transplant market is expected to exceed $12 billion by the end of 2028.
The growth is expected to be at a CAGR (Compound Annual Growth Rate) of 5.45% for the forecast between 2018 and 2026. North America will continue to lead the growth, followed by Europe. Together, the two will account for over 80% of global demand. The projection reflects the rising frequency of using bone marrow transplants to treat certain cancers. Between 2016 and 2020 (estimated), the combined number of autologous and allogeneic transplants performed in the U.S. increased 11%.
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The proliferation of lasers for organ transplants has increased the relevance of fully insured group organ and tissue transplant policies for self-funded health plans. These policies give self-funded health plans the ability to carve out transplant risk in response to lasers through a predictable per employee per month (PEPM) premium. This budget stabilization approach to funding transplant risk, coupled with the fact that most stop loss carriers discount premium when an organ transplant policy exists, makes this approach to managing transplant risk a valuable tool for self-funded health plans.
– first dollar or deductible per transplant claimant
– claims payment direct to providers or reimbursement to policyholder for paid claims
This illustration below demonstrates the potential financial benefit of carving out transplant risk.
Without organ transplant insurance
– lifetime maximums, travel/ lodging/meals reimbursement, covered transplant services
With organ transplant insurance •
An employer of 209 people has stop loss coverage with a $100,000 deductible plus a potential liver transplant lasered at $800,000. The employer pays $439,000 in premium, and the plan’s internal budget for the laser is $318.00 PEPM premium.
If the same employer adds organ transplant coverage with no deductible, they pay $33,000 in premium, but also earn a 4.5% discount on the stop loss premium ($19,755). This means the net extra cost of the organ transplant coverage is only $13,245, or the equivalent of $5.28 PEPM premium.
Does the policy include transplant medical management services?
– Medical Director/ Reviewer, Case Management and Utilization Review Nurses registered or licensed in states where required
– Organizational URAC When comparing group transplant insurance policies, the plan sponsor should consider the following in their purchasing decision:
accreditation and/ or registered as a UR Agent in states where required
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Will the transplant carrier cover transplant claims when pre-authorization or prenotification did not occur, including transplantation when notified after the fact?
Price is a considerable factor in the purchasing decision. However, reviewing these considerations prior to purchase will help ensure the plan sponsor receives the best value from their organ transplant policy and that members have a supportive customer service experience in the event they need the benefit. Plan sponsors should also be confident that the carrier has the expert knowledge of the latest developments in organ transplants.
Human organ and tissue transplantation will continue to evolve. While new therapies such as CAR T cell, immune and genetic therapies may eventually replace or augment bone marrow transplant as the treatment of choice, certain diseases may continue to be best treated with bone marrow transplants.
John Richert, RN BSN MSM, Vice President, Lead Underwriter, QBE, has 30 years of experience in developing and managing organ transplant insurance, including medical management, network development, claims and underwriting. John can be contacted for more information about QBE’s solution for Organ Transplantation. This article is for general informational purposes only and should not be construed as legal, commercial or other professional advice. QBE makes no warranty, representation, or guarantee regarding the information herein or the suitability of this information for any particular purpose. Any case studies herein are only hypothetical. Actual coverage is subject to the language of the policies as issued.
Solid organ transplantation will continue to evolve with continued research, the use of rehabilitated marginal donor solid organs, development in xenotransplant, mechanical and hybrid devices. In these cases, transplantation will continue into the foreseeable future increasing in cost and frequency.
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
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Medical Stop Loss from Berkshire Hathaway Specialty Insurance comes with a professional claims team committed to doing the right thing for our customers – and doing it fast. Our customers know they will be reimbursed rapidly and accurately – with the certainty you would expect from our formidable balance sheet and trusted brand. That’s a policy you can rely on.
Reimbursement done right. www.bhspecialty.com/msl The information contained herein is for general informational purposes only and does not constitute an offer to sell or a solicitation of an offer to buy any product or service. Any description set forth herein does not include all policy terms, conditions and exclusions. Please refer to the actual policy for complete details of coverage and exclusions.
SAVING MONEY ON WORKERS’ COMPENSATION: EVALUATION FROM THE TOP DOWN OR THE BOTTOM UP? Written By: Nelson Hendler, MD, MS, former assistant professor of neurosurgery, Johns Hopkins University School of Medicine, past president -American Academy of Pain Management, Dennis Picha, Chief Executive Officer, Veritycare Management, Jackie Vergne, MBA, PhD, CPCU, CIC, AU, API, former vice-president of Chubb Insurance and Fireman’s Fund Insurance
raditional methods of cost savings in workers compensation cases rely on outsourced vendors to deal with claimants on a case-by- case basis, while executives examined the more global concepts, such as pricing and accident prevention. Fraud evaluation using traditional means were not cost effective. Record reviews were flawed since 40%-80% of claimants were misdiagnosed, compounded by the use of medical tests which had a 56% to 78% false negative rate and failed to detect treatable pathology. We describe methods of granular case by case evaluations, with documented cost savings ranging from 25% to 60%, which rely on identified “centers of excellence.” This technique was advocated by Walmart and other companies to produce cost savings and improved care of claimants. When the services are combined, it produces over-all cost savings of 40% or more compared to current methods of claims evaluation.
There have been some interesting advances in the approach to cost savings for occupational injuries in the past decade. Traditionally, companies relied on the outsourced reports of the treating physicians, third party administrators, and case managers to address the more granular issues of actual patient care, while corporate officials examined more global concepts leading to increased costs, such as fraud profiling to determine workers compensation fraud, national medical care offering a capitated health care plan, the use of Special Investigation Units (SIUs) to investigate fraud, cost savings based on pricing, early intervention programs, accident prevention programs, analysis of loss and medical expenses, using the ACG system from Johns Hopkins Hospital which examines every element of physicians’ medical records, including diagnoses and testing, to try to identify high cost diagnoses, and other broad conceptual approaches (https://www. hopkinsacg.org/).
technique of averaging results, which causes the loss of data, and leads to erroneous conclusions1. The next most obvious error is the use of medical records, which contain medical tests such as an CT, which has 56% to 76% false negative rates2, and medical claims based on the misdiagnosis rate of 40%-80%3,4,5,6. So the reviews of medical records and claims, no matter how elegant the mathematics, are gathering inaccurate information. These errors are a formula for a classic case of GIGO—garbage in resulting in garbage out. Emerick challenged the assumption that the treating physician was providing accurate information and good medical care7. While he was vice-president of employee benefits at Walmart, he resorted to the use of “Centers of Excellence” to control the expense of surgery for the Walmart employees8. He found that 25% of surgery suggested by community physicians was unnecessary, and the misdiagnosis rate approached 40%9. By referring employees to high quality medical centers around the United States Emerick was able to reduce the cost of surgeries by 30% or more10. Emerick and Hendler describe these techniques which embrace an individual case by case evaluation, which resulted in significant over-all cost reductions11. Bernacki, Chairman of the Division of Occupational and Environmental Medicine, at Johns Hopkins School of Medicine had even more dramatic results at Johns Hopkins Hospital, where, as part of a fully integrated program of early intervention, safety education and injury prevention, and patient advocacy, he was able to reduce workers' comp costs from $5,600,000 a year to $2,400,000 a year12.
The Johns Hopkins ACG system models and predicts an individual’s health over time, using existing data from medical claims, electronic medical records, and demographics like age and gender. They claim to gain insights needed to evaluate and compensate providers, stratify risk, and identify patients who would benefit from care management. Attendant to these broad approaches were certain assumptions, which bear reexamination. Chief among these faulty assumptions is the mathematical
He accomplished this by diverting injured hospital workers to a select group of doctors, rather than community doctors, who were misdiagnosing employees 40%80% of the time, as reported by physicians at Johns Hopkins Hospital13. Directing employee care to high quality physicians resulted in an overall savings of 54% on workers’ compensation costs12, 13. These articles fully support the cost savings associated with using a small, select physician network. There are several other variables which influence workers comp costs. The first is the structure of the workers' comp system on getting an injured workers back to work. Talo, winner of the prestigious Volvo Award from the journal Spine, and Hendler reported a 3 times higher return to work rate in auto accident patients versus workers' comp. The only difference was the type of litigation14. The second issue is the presumed fraud, which influenced how insurance adjusters handle their cases, i.e. fraud investigation15. Techniques, such as Independent Medical Evaluations, Functional Capacity Evaluation, the use of the Minnesota Multi-phasic Personality Inventory (MMPI) , and surveillance have been reported by Elaine Howle, the auditor for the State of California, as not cost-effective, i.e. the return to companies is less than the money spent16. The impact of the inability to detect inaccurate diagnosis is further amplified in the example from Laidlaw, a 90,000 employee school bus leasing company and owner of Greyhound, as reported in an earlier issue of The Self Insurer13.
At the request of Laidlaw, Hendler and Goff, former president of the Self Insurance Institute of America, evaluated workers' comp cases13. Of the 90,000 workers, there were 260 workers compensation cases which were 6 months old or older. Of these 260 cases older than 6 months, 126 (48%) were "diagnosed" with lumbar strain. By medical definition, 100% of all of these cases were misdiagnosed, since a sprain or strain cannot last 6 months. The medical literature reports that sprains and strains are self-limited disorders, which average no more than 7.5 days of disability3,6,11. So (a) these claimants were misdiagnosed, and (b) the correct diagnosis was overlooked. Of these 126 ultra-long term workers' compensation cases, the cost to Laidlaw was $12,365,366 with an average cost of $98,137. With proper diagnosis, these 126 cases could have been accurately diagnosed as facet syndrome, or internal disc disruption, and treated for $15,000 to $45,000 a case, a savings of at least $43,000 a case or more for an overall cost savings of at least $43,000 X 126 or $5,418,000 or at least 44% cost savings compared to current case management techniques.13 Using the example above, the reserves on these cases could have been reduced from $98,137 to at least $43,000, and comparable reductions in reserves could be realized for other commonly misdiagnosed disorders. (See appendix A- the attached list of bad diagnoses versus correct diagnoses.)
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Finally, there is the reduced workplace performance, where the employee doesn't file any legal claim, but has a high rate of absenteeism and reduced work-place performance.
This software gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors23. This
This results in an estimated $61,000,000,000 a year loss to businesses. The largest source of this poor performance… headaches and back pain17.
granular approach to evaluating an injured workers saved between $20,000 to $175,000 for long term expensive cases.
The use of the bottom-up granular approach provides the skill sets often missing in a typical top-down evaluation. The bottom-up approach addresses multiple elements which contribute to the overall cost of a workers’ compensation case, by using highly specialized focus in each component part. Fraud evaluation can be done using an Internet based Software as a Service (SaaS) Pain Validity Test, developed by a team of physicians from Johns Hopkins Hospital, which has always been admitted as evidence in 9 states, unlike other fraud evaluation methods which are often disallowed, or discounted18, 19, 20, 21. The cost of this evaluation is a fraction of the cost of a typical fraud evaluation, with reported savings of $1,654 per case22. Another Internet-based SaaS test is the Pain Diagnostic Test, also developed by a team of physicians from Johns Hopkins Hospital, which addresses the 40%-80% of injured workers who are misdiagnosed.
With the new year comes new opportunities for growth, success, and education. I want to thank the members of the SIIA community for their relationships and partnerships over the years. As President and CEO of HPI, I am committed to delivering on the promise that HPI established over 40 years ago: creating innovative solutions that put employers in control. I hope 2022 brings new collaboration and transformation to all of us in the self-insured industry. – Deborah Hodges
As an example, the MRI is poor test to evaluate damaged discs. It has a false positive rate of 28%-34%, and a false negative rate of 77%-79% compared to a provocative discogram24, 25, yet most physicians do not use provocative discograms.
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Medical testing is based on the accurate diagnosis provided by the Pain Diagnostic Test. The recommended tests are the ones with the highest degree of accuracy, with the lowest false negative and false positive rate.
References: 1) Hendler,N, CHAPTER 3 -Statistics and Evidence Based Medicine, in Why 40%-80% of Chronic Pain Patients Are Misdiagnosed and How to Correct That, Nova Medical Publishing, New York, 2018. 2) Zinreich SJ1, Long DM, Davis R, Quinn CB, McAfee PC, Wang H, Threedimensional CT imaging in postsurgical "failed back" syndrome. J Comput Assist Tomogr. 1990 Jul-Aug;14(4):574-80. 3) Hendler N, Bergson C, Morrison C. Overlooked physical diagnoses in chronic pain patients in litigation, Part 2 Psychosomatics. 1996 Nov-Dec 37 (6):509-517. 4) Hendler N. Differential diagnosis of complex regional pain syndrome. Pan Arab
By evaluating an injured worker as soon as the injury occurs, this “early intervention” diagnosis steers the treating physician on the correct path, and reduces inaccurate diagnoses, and the use of the inappropriate medical testing. The use of the “Centers of Excellence” approach identifies the patients who have been recommended for unnecessary surgery and reduces surgery by 25%. If surgery is indicated, the injured workers is referred to one of the identified “Centers of Excellence” where any surgery is performed at a discounted rate by top surgeons in the country, with overall cost savings on surgery of 15%-20%.11 Medical management of complex medical care cases, directed by experienced nursing staff using the “best practices” methodology has documented cost savings of 45%. The nurses select medical care from centers which has documented outcome studies, and eliminate unnecessary care and overtreatment, which are leading causes of inflated medical expenses. Finally, a negotiated benefits package saves hundreds of dollars per injured worker on discounted medicine and durable medical goods. Taken in the aggregate, each component of medical care of an injured worker, when optimized by highly specialized expert evaluations and care, produce a documented overall cost savings of 40%-50% from current levels of costs. This is the great advantage of a bottom-up, fully integrated granular approach to workers’ compensation cost containment.
Journal of Neurosurgery. 2002 Oct6(2):1-9. 5) Dellon AL, Andronian E, Rosson GD. CRPS of the upper or lower extremity: surgical treatment outcomes. J. Brachial Plex Peripher Nerve Inj. 2009, Feb;4(1):1-7. 6) Long D, Davis R, Speed W, Hendler N. Fusion for occult post- traumatic cervical facet injury. Neurosurg. Q. 2006 Sep16(3):129- 134. 7) Emerick. T and Lewis, A., Cracking Health Costs p. ix, Wiley, Hoboken, NJ, 2013 8) Emerick. T and Lewis, A., Cracking Health Costs, p. 11, Wiley, Hoboken, NJ, 2013 9) Emerick. T and Lewis, A., Cracking Health Costs pp 104-107, Wiley, Hoboken,
NJ, 2013 10) Emerick. T and Lewis, A., Cracking Health Costs p 103, Wiley, Hoboken, NJ, 2013
11) Emerick, T and Hendler, N, How Surgery Saves Money: A Paradox Explained. International Journal of Pain Research and Treatment, 2020, 3:17. 12) Bernacki EJ, Tsai SP.Ten years' experience using an integrated workers' compensation management system to control workers' compensation costs. J Occup Environ Med. 2003 May;45(5):50816.
Pain. Journal of Occupational Medicine 30(2): 98-102. 19) Hendler N, Cashen A. Hendler S, Brigham C, Osborne P, et a!. (2005) A Multi-Center Study for Validating The Complaint of Chronic Back, Neck and Limb Pain Using "The Mensana Clinic Pain Validity Test". Forensic Examiner 14(2): 41-49. 20).Hendler N, Baker A (2008) An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients. Pan Arab Journal of Neurosurgery 12(1]: 15-24. 21) Hendler, N, An Internet based Questionnaire to Identify Drug Seeking Behavior in a Patient in the ED and Office, Journal of Anesthesia & Critical Care, Volume 8 Issue 3 –
13) Hendler, N, and Goff, D, Innovations Include Pain Validity Testing: Self-Insured Johns Hopkins Hospital Cuts Workers Comp Costs by Half The Self-Insurer, July 2013 pp 28-30 14) Talo, S, Hendler, N, and Brodie, J Effects of Active and Completed
2017, pp. 1-3. 22) Hendler N. Assessing pain: real and imagined, National Council on Compensation Insurance Carriers, 11/29/99 –on the website. 23) Hendler, N., Berzoksky, C. and Davis, R.J. Comparison of Clinical Diagnoses Versus Computerized Evaluation for Pain in the Neck, Back and Limbs. Pan Arab Journal of Neurosurgery, October:8-17, 2007.
Litigation on Treatment Results: Workers'
24) Jensen, MC, Brant-Zawadzki, MN,Obuchowski, N, Modic, MT,Malkasian,D, Ross, JS,
Compensation Patients Compared with
Magnetic resonance imaging of the lumbar spine in people without back pain, N England J
Other Litigation Patients, Journal of
Med 1994 Jul 14;331(2):69-73.
Occupational Medicine, Vol. 31, #3, March 1989 pp. 265-269 15) Hendler, N, An internet based expert
25) Sandhu HS1, Sanchez-Caso LP, Parvataneni HK, Cammisa FP Jr, Girardi FP, Ghelman B, Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI, J Spinal Disord. 2000 Oct;13(5):438-43.
system to control workers compensation costs documented by outcome studies, Anaesthesia, Pain & Intensive Care, Vol. 17, No. 2, pp 166-170, May- August 2013. 16) Howle, E, Workers’ Compensation Fraud, Detection and Prevention Efforts Are Poorly Planned and Lack Accountability, Publication 2002-018 April 2004, as reported in Workers’ Compensation Report. 15(11): p 206, May 17, 2004. 17) Stewart, W, Ricci, J, Chee, E, Morganstein, D, Lipton, R, Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce, JAMA. 2003;290(18):2443-2454. 18) Hendler N, Mollett A, Talo S, Levin S (1988) A Comparison Between the Minnesota Multiphasic Personality Inventory and the 'Mensana Clinic Back Pain Test' for Validating the Complaint of Chronic Back
Biographical sketches of authors: Nelson Hendler, MD, MS former assistant professor of neurosurgery, Johns Hopkins University School of Medicine, past president American Academy of Pain Management. Author of 4 medical text-books, 33 medical textbook chapters and 71 articles. He has served on the board of directors of two multi-billion dollar public companies, Columbia Bank, and Lifeco, which owned a life insurance company and a broker-dealer. Address reprints request to DocNelse@aol.com Dennis Picha- President and CEO Veritycare Management, a medical risk management company. Prior to this position, he was Vice President Mergers and Acquisitions at Accelerated Health Systems Jackie Vergne, MBA, PhD, CPCU, CIC, has served as vice-president of The Franklin Mutual Insurance Company, Chubb Insurance Company, Selective Insurance Company, and Parkway Insurance Company (formerly Fireman’s Fund Insurance)
Appendix A List of incorrect diagnoses and their reserves compared to reserves of the correct diagnosis
he Self-Insurance Institute of America, Inc. (SIIA) has announced its preliminary in-person event calendar for 2022. The schedule is provided below. Additional events may be added and announced later.
This calendar of in-person events will be supplemented by monthly live webinars covering timely educational topics. Please watch for separate webinar announcements on a regular basis.
We look forward to your involvement in the new year!
ENDEAVORS SIIA 2022 IN-PERSON EVENT
SIIA Price Transparency Forum Sheraton Dallas Hotel, Dallas, TX February 28-March 1, 2022 The association’s inaugural Price Transparency Forum will feature leading participants in price transparency efforts, from federal agency regulators to selfinsured industry professionals, to talk about the opportunities, challenges, and needs in the space. From the Transparency in Coverage Rule to the No Surprises Act, this Forum will provide an interactive opportunity to learn what these new rules and regulations mean for your business and clients, from strategy to implementation.
SIIA Spring Forum JW Marriott Grande Lakes, Orlando, FL March 30-April 1, 2022 The SIIA Spring Forum is expected to be the largest gathering of senior-level self-insurance industry professionals for the first half of 2022. Industry expertise and perspectives will be shared through targeted educational sessions, group discussions, and a unique “focus group” participation opportunity. This will be combined with multiple networking functions along with a table-top exhibitor program to help you make important connections. New for this year, we have incorporated “business hours” into the program to make it convenient for attendees to schedule/participate in important meetings.
SIIA Future Leaders Forum The Westin Indianapolis, Indianapolis, IN April 11-12, 2022 If you are a younger (under 40) selfinsurance/captive insurance industry professional, this is a must-attend for you. Developed by the SIIA Future Leaders Committee, this forum will feature educational content targeted for younger professionals with multiple networking opportunities to help you make important connections with those in your age group.
SIIA Corporate Growth Forum May 2022 Specific Date and Location to be Announced Soon This new SIIA event has been designed to help SIIA members better understand growth strategies made possible by corporate financial transactions (mergers, acquisitions, capitalizations, etc.). In addition to targeted educational content, attendees will have the opportunity to connect with representatives of private equity firms and related advisors and network with owners/senior executives of other SIIA member companies.
SIIA National Conference & Expo JW Marriott Desert Ridge Resort & Spa, Phoenix, AZ October 11-13, 2022
Do you aspire to be a published author? We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world. The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984. Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ sipconline.net The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ sipconline.net for advertising information.
The world’s largest self-insurance/ captive insurance industry event will be back with its traditional, fully in-person format.
NEWS FROM SIIA MEMBERS 2022 JANUARY 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. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at firstname.lastname@example.org.
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NEWS DIAMOND MEMBERS ALLEGIANCE'S RON DEWSNUP TO RETIRE, STEPHEN TAHTA
NAMED AS NEXT PRESIDENT & GENERAL MANAGER
Missoula, MT — Allegiance Benefit Plan Management, Inc., announced that Stephen Tahta, MD, will succeed Ron Dewsnup as president and general manager of the company. The transition is effective January 7, 2022. Dr. Tahta joined Allegiance in 2018 as the company’s chief medical officer. He previously worked private practice as a cardiothoracic surgeon and has several years of experience in administrative leadership at provider organizations. Dr. Tahta holds an Executive Masters of Business Administration degree from the Wharton School of the University of Pennsylvania.
“I look forward to working with Dr. Tahta in his new role and continuing to expand Allegiance and serve our clients and their employees around the nation,” said Dirk Visser, chairman and CEO of Allegiance. Dewsnup joined Allegiance in 2005. During his tenure, the company grew from serving 70,000 customers in Montana and adjoining states to 500,000 customers across the country.
“Ron has been instrumental in Allegiance’s growth and direction over the years,” said Visser. “His influence has made an indelible impact on all of the Allegiance team members and our clients. I want to thank Ron for all he has done for the development, growth and progress of Allegiance.” About Allegiance Originally founded in 1981 as a full service TPA in Montana, Allegiance has grown to serve customers in all 50 states. In 2008, Allegiance became a wholly-owned subsidiary of Connecticut General Life Insurance Company (CGLIC), a subsidiary of Cigna Corporation, when CGLIC purchased Allegiance’s holding company Benefit Management Corp. Allegiance Benefit Plan Management, Allegiance Care Management, Allegiance Life & Health Insurance Company and Allegiance COBRA Services are all subsidiaries of Benefit Management Corp. Allegiance works with Cigna, independent consultants and advisors to serve Employers and Health Plans who require customized TPA services capable of enabling client specific plan design and select integrated product services of their choice. Allegiance has seen significant growth across the nation as a result of our highly customizable suite of services and our affiliation with Cigna. Since its earliest days, Allegiance has been a leader in providing TPA services for health and flexible benefit plans to employer groups and their plan participants. Allegiance is known for customized TPA services flexibility and outstanding customer service. That commitment continues today as strong as ever. Visit askallegiance.com.
Vālenz ® Solutions Suite
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Validation, Integrity & Accuracy
Care Management Clinical Review Member Concierge Navigation
Reimbursement Reliance Payment Assurance Claim Transparency
Start your year right. Partner with Vālenz®. Simplify the complex issues of health insurance with Valenz. Through our data-rich Valenz ecosystem, we provide unrivaled transparency and solutions that improve cost, quality and outcomes for you and your members. By bringing together clinical care management, member advocacy and navigation with our commitment to assuring the validity, integrity and accuracy of claims, Valenz simplifies the complexities of self-insurance. That’s how we engage early and often for smarter, better, faster healthcare. To see how you can achieve significant savings and make your business strong, vigorous and healthy this year, visit valenzhealth.com or call (866) 762-4455.
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NEWS With a focus on quality and cost metrics, their mission is to make benefits more affordable and accessible. Under Scott’s leadership, The Phia Group’s Provider Relations team will continue to support plans and partners that utilize or manage innovative pricing methodologies, while also providing Phia Group based solutions such as Claim Negotiation and Signoff, Phia Unwrapped, and Balance Bill Support.
About Cigna Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Cigna delivers choice, predictability, affordability and access to quality care through integrated capabilities and connected, personalized solutions that advance whole person health. All products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth companies or their affiliates, and Express Scripts companies or their affiliates. Such products and services include an integrated suite of health services, such as medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Cigna maintains sales capability in over 30 countries and jurisdictions, and has over 190 million customer relationships throughout the world. To learn more about Cigna®, including links to follow us on Facebook or Twitter, visit www.cigna.com.
THE PHIA GROUP ADDS SCOTT BENNETT TO THE TEAM Canton, MA – The Phia Group announced that Scott Bennett has joined their already robust team of health benefit professionals, as its Vice President of Provider Relations. Scott will strengthen The Phia Group’s efforts to empower plans by leading a team that enhances the overall provider experience.
As new laws and regulations impact how health benefit plans process and pay medical claims, Scott and his team will develop new approaches to the future of claims processing, while continuing to provide ancillary support to other programs as well. Relevant to this mission, Scott boasts an impressive background as an attorney, data analyst, and a certified professional coder. Scott's past experience includes: Vice President at a national third party administrator, a Director of dispute resolution, and the designated company witness for six years at a nationwide medical bill review company focused on commercial reimbursement and workers’ compensation fee schedules and disputes. In addition to designing and defending cost containment programs, Scott has successfully litigated and participated in trials, depositions, negotiations, and mediations concerning medical billing disputes among providers, patients and payors involving reference-based pricing, workers compensation, ERISA, antitrust law, and personal injury damages.
WE ARE HERE FOR YOU Now, more than ever, it is important to do business with partners you can depend on. For more than 35 years, self-funded employers have trusted Sun Life to deliver flexible stop-loss options and seamless claim reimbursement. Helping you make the best decisions for your business is our business. Our team of dedicated experts is ready to support you with innovative solutions, tools, and resources to help you manage your self-funded plan every step of the way. Ask your Sun Life Stop-Loss Specialist about what is new at Sun Life or click here to learn more!
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. © 2021 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503-n
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NEWS “Adding Scott to the team solidifies The Phia Group as a leader in the industry. It means we can continue to develop and offer solutions and services that empower plans,” remarked The Phia Group’s CEO, Adam Russo. “We have always been proud of our ability to stay ahead of regulatory hurdles; the hurdles are getting bigger, but adding Scott ensures we can conquer whatever comes next.” Regarding his new role at The Phia Group, Scott Bennett remarked, “I am thrilled to be part of such a respected company, and look forward to working with this expert team to further develop their already extensive products and services, especially at a time where increased data transparency and new regulations will challenge the industry to innovate.”
containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Visit www. PhiaGroup.com.
To learn more about The Phia Group, what it is doing to empower plans, and to learn more about its Provider Relations solutions, please contact Garrick Hunt by email at firstname.lastname@example.org or by phone at 781-535-5644. About The Phia Group The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost
Specializing in serving the risk management needs of over 2,300 clients. GPW offers a unique combination of captive and reinsurance management, accounting, tax compliance, and actuarial services all under one roof, providing clients with efficient and comprehensive service. GPW’s team of experts includes credentialed Actuaries, Certified Public Accountants, and Associates of Captive Insurance. GPW and Associates, Inc. 3101 North Central Ave., Suite 400 Phoenix, Arizona 85012 Ph 602.200.6900 Fx 602.200.6901
NEWS VĀLENZ® PROMOTES NATHAN NELSON TO CHIEF REVENUE
VĀLENZ® RENEWS TRIPLE URAC
PHOENIX, AZ — Vālenz®, the innovators behind the industry’s most transparent, data-driven ecosystem for self-funded employers and their health plan partners, announced Nathan Nelson, MBA, has been promoted to Chief Revenue Officer.
PHOENIX, AZ — Vālenz® is proud to announce the renewal of its three URAC accreditations in Health Utilization Management, Case Management and Disease Management. URAC is the independent leader in promoting healthcare quality through leadership, accreditation, measurement and innovation. By achieving this status, Valenz has demonstrated a comprehensive commitment to quality care, improved processes and better patient outcomes.
Nelson, who joined the firm as Vice President of Business Development in April 2019, was promoted to the executive team when he was appointed Senior Vice President of Growth earlier this year. “Nathan’s rapid rise within our organization speaks volumes about the ways he embraces a client-centric focus in everything we do, from clinical and member advocacy to assuring the validity, integrity and accuracy of claims,” said Rob Gelb, Chief Executive Officer. “His commitment to the character, culture and vision that drive Valenz is laser-focused on keeping the client at the center of all decisions and propelling forward the power of the ecosystem for smarter, better, faster healthcare.” Nelson brings 20+ years’ experience driving strong business growth across all areas of revenue – with proven success in sales and account management for the healthcare industry, primarily in the managed care segment. Prior to joining Valenz, he held sales and leadership positions in claim management, workers’ compensation, underwriting and account management. “I am excited to lead our sales and client relationships forward,” Nelson said. “The opportunities for our clients are as limitless and groundbreaking as the Valenz vision. I look forward to expanding our clients’ success – and our own – in this new role.”
“Because it underscores our staunch commitment to meeting rigorous standards in quality and accountability for clinical care management, we are very proud to renew our URAC accreditation,” said Janet Koch, RN, BSN, CCM, Vice President of Care Management at Valenz. Rob Gelb, Chief Executive Officer, explains how clinical quality is integral to optimization within the entire claim-cost continuum – and pinpointing quality-first, cost-saving solutions for self-funded health plans requires the ability to see all intricacies and connections between clinical care and reimbursement.
“Valenz is unique in the way we combine clinical care management, advocacy and navigation for every member with assurance in the validity, integrity and accuracy of every claim,” said 52
NEWS Gelb. “Within the Valenz ecosystem, these two functions are inextricably linked – and fueled by data to ensure all claims are valid and true for accurate payments.” That innovative and proprietary approach is foundational to the true value of the Valenz ecosystem and its ability to deliver the desired returns for Valenz clients. “Ensuring we consistently meet the high standards required for URAC accreditation is just one of many ways we keep our promise to engage early and often for smarter, better, faster healthcare,” said Gelb. About Valenz Valenz enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz offers transparency through data to pinpoint members at highest risk, address gaps in network designs, ensure appropriate and accurate charges, and expertly navigate employees to optimal care solutions for substantial cost savings and improved health outcomes. Visit valenzhealth.com. Valenz is backed by Great Point Partners. About URAC
Founded in 1990, URAC is the independent leader in promoting healthcare quality through leadership, accreditation, measurement and innovation. URAC is a nonprofit organization using evidence-based measures and developing standards through inclusive engagement with a range of stakeholders committed to improving the quality of healthcare. Our portfolio of accreditation and certification programs span the healthcare industry, addressing healthcare management, healthcare operations, health plans, pharmacies, telehealth providers, physician practices, and more. URAC accreditation is a symbol of excellence
We are Advocates for Healthier Living As Advocates for Healthier Living, we’re improving clinical outcomes while reducing the Total Cost of Care. It’s the foundation of the service we provide our clients, members and business partners. We Change Lives. We create positive change in every interaction we have. By listening and understanding our clients’ needs, we offer flexible, cost-effective and easy-to-use health care solutions. We are dedicated to providing compassionate support and guidance to help our members be active participants in their health care.
For more information, visit www.meritain.com.
JANUARY 2022 53
NEWS for organizations to showcase their validated commitment to quality and accountability. Visit www.URAC.org.
Migrating away from a manual process to a more automated approach
Access to more data and information for higher quality assistance
Rapid dispute resolution and confirmation
Prioritization of member security and privacy
GOLD MEMBERS AMPS INNOVATES MEMBER EXPERIENCE WITH NEW TRANSUNION HEALTHCARE PARTNERSHIP
ATLANTA – Advanced Medical Pricing Solutions (AMPS), a pioneer in healthcare cost containment, is pleased to announce it has partnered with TransUnion Healthcare (NYSE: TRU), a wholly owned subsidiary of TransUnion, that makes trust possible throughout the healthcare ecosystem by helping organizations improve health and financial outcomes. AMPS is the first cost containment company in the industry to align with TransUnion Healthcare to improve member experience. The new partnership enables AMPS to give members more convenience while reducing abrasion and friction. While it is rare for members to receive true credit impairments related to medical debt, as part of the new TransUnion partnership, AMPS can implement new processes to monitor, in real time, any negative credit reporting made by medical providers due to unfair, improper overcharges. AMPS’ partnership with TransUnion will allow AMPS to expedite the resolution process, and access consumer credit reports through a secure, controlled TransUnion portal, among other improved processes, including:
“AMPS and TransUnion Healthcare are aligned when it comes to providing transparency. We understand credit reports carry so much weight with plan members, and our consumer credit reporting standards reflect that. By using our secure portal, AMPS can create a more convenient, friendly experience for their members and better assist them with dispute resolutions,” said David Wojczynski, president of TransUnion Healthcare. “AMPS continues to stay on the cutting edge of cost containment as the only company in the industry to partner with a credit bureau. With these ongoing, significant investments in partnerships, services, and technology, we are giving our clients and their members more satisfaction and transparency around their healthcare spend,” said AMPS President and CEO, Kirk Fallbacher. “Our partnership with TransUnion Healthcare is proof that we fully support our clients’ growing and evolving needs, respecting their privacy, and acting in their best interests as healthcare consumers.”
About Advanced Medical Pricing Solutions (AMPS) Advanced Medical Pricing Solutions (AMPS) provides market leading healthcare cost containment solutions serving self-funded employers, brokers, TPAs, health systems, health plans, and reinsurers. AMPS mission is to help clients attain their goals of reducing medical and pharmacy costs while keeping members satisfied with quality healthcare benefits. AMPS leverages its 15+ years of experience and data in auditing and pricing medical claims to deliver "fair for all" pricing. AMPS offers detailed analytics and transparency to provide clients with insights based on plan performance. Contact Amanda Hertig at email@example.com and visit amps.com. About TransUnion (NYSE: TRU) TransUnion is a global information and insights company that makes trust possible in the modern economy. We do this by providing an actionable picture of each person so they can be reliably represented in the marketplace. As a result, businesses and consumers can transact with confidence and achieve great things. We call this Information for Good®.
informed decisions on payments and reimbursements, and assess financial and socioeconomic risk to ensure program success. TransUnion Healthcare partners with over 1,850 healthcare organizations and 570,000 physicians. Collectively, we help our clients realize more than $1.2 billion annually in revenue. A leading presence in more than 30 countries across five continents, TransUnion provides solutions that help create economic opportunity, great experiences and personal empowerment for hundreds of millions of people. Visit transunionhealthcare.com.
SILVER MEMBERS MARPAI EXPANDS MARKETING LEADERSHIP WITH CHRISTINA DIBONA AND MARCELLA WITHERS TO DRIVE MEMBER ENGAGEMENT AND BUSINESS GROWTH
NEW YORK -- Marpai, Inc., ("Marpai") (Nasdaq: MRAI), a deep learning technology company transforming third-party administration (TPA) in the healthcare self-funded market, announced two marketing director hires this month. Christina DiBona joins Marpai as Marketing Director Member and Client Engagement and Marcella Withers as Marketing Director Brokers, Employers, Partners. Christina DiBona leads marketing and communications that reach Marpai's members to drive health literacy and utilization of plan benefits and exclusive Marpai features.
TransUnion Healthcare, a wholly owned subsidiary of TransUnion, makes trust possible throughout the healthcare ecosystem by helping organizations improve health and financial outcomes. Our clients leverage comprehensive data, accurate insights and industry expertise to engage healthcare consumers with confidence, make
JANUARY 2022 55
Christina brings 20 years of marketing experience with 10 years of healthcare marketing, most recently with the Stamford Health System where she was recognized as a top hospital marketer in 2021 by DTC Perspectives. Christina also serves on the Board of Directors for NESHCo (New England Society Healthcare Communications). Marcella Withers leads business-tobusiness marketing focused on brokers, employers with self-funded health plans, and health partners. Her responsibilities include public relations, digital marketing, events and implementation of co-op marketing programs. Marcella, a seasoned brand and marketing strategist, brings over 16 years of experience working with multimillion dollar companies, most recently as Senior Director of Marketing and Communications at The Frye Company.
"As Marpai builds industry leadership by deploying deep learning to reduce healthcare costs and improve outcomes in new 56
ways, we've expanded our marketing team to more comprehensively drive change," said Edmundo Gonzalez, CEO of Marpai. "Christina and Marcella bring perspectives and skills that we need as a technology company to connect with the diverse groups involved in the healthcare experience." About Marpai, Inc. Marpai is a technology company providing an AI-powered alternative to traditional TPAs (third party administrators), serving self-funded health plans that account for over $1T in healthcare claims each year and cover 95 million Americans. Marpai uses advanced technologies, including deep learning models, to drive healthcare costs down and health outcomes up. Marpai's SMART system predicts health states to prevent and reduce costly events, elevates care quality, rigorously processes claims and empowers plan members to maintain proper care and live better. Marpai operates nationwide in serving 60+ self-funded employers and over 40,000 members and works with world-class brokers and provider networks including Aetna and Cigna. Visit marpaihealth.com.
SELF INSURANCE INSTITUTE OF AMERICA, INC. 2021 BOARD OF DIRECTORS
CHAIRWOMAN OF THE BOARD*
Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston Salem, NC
Laura Hirsch Co-CEO Aither Health Carrollton, TX
Deborah Hodges President & CEO Health Plans, Inc. Westborough, MA
Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN
TREASURER AND CORPORATE SECRETARY*
John Capasso President & CEO Captive Planning Associates, LLC Marlton, NJ
Lisa Moody Board of Directors Chair Renalogic Phoenix, AZ
SIEF BOARD OF DIRECTORS Nigel Wallbank SIEF Chairman Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP, SIEF President
DIRECTORS Freda H. Bacon Les Boughner Alex Giordano Virginia Johnson
Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN
Thomas R. Belding President Professional Reinsurance Mktg. Svcs. Edmond, OK Amy Gasbarro Chief Operating Officer Vālenz Phoenix, AZ
* Also serves as Director Please forward any changes to your contact information to Amy Troiano at firstname.lastname@example.org.
JANUARY 2022 57
SIIA NEW MEMBERS JANUARY 2022 REGULAR CORPORATE
Doug Cohen Senior Vice President A&G Healthcare Plano, TX
Emad Samad President Octaviant Financial, Inc. New Brunswick, NJ
Suzanne Hance VP Finance & Accounting Axiom Product Administration Inc. O'Fallon, MO
Adam Pegram Vice President Shore Capital Partners Chicago, IL
Romy Carlson VP of Partnerships b.well Connected Health Overland Park, KS
SILVER CORPORATE MEMBERS
Joseph Callahan Principal Cabot Risk Strategies Woburn, MA
Erik Hecht Health Outcome Liaison Director Grifols Raleigh, NC
Shawn Evans CEO DC Risk Solutions/Integrated Payor Solutions San Francisco, CA
Clair Canada Executive Vice President, Innovation REVELOHEALTH Frisco, TX
Stability for those balancing risk and reward.
Those who self-fund a health plan seek autonomy and control over their benefits program and costs. It can be rewarding, but it does come with risk. Stop Loss protection from HM Insurance Group works to mitigate that risk for self-funded employers should high-dollar claims arise – delivering steadiness to the performance and confidence in the outcome. Find more on hmig.com.
CONNECT WITH ONE OF OUR EXPERTS ON OUR INSURANCE AND REINSURANCE OPTIONS: Employer Stop Loss: Traditional Protection • Small Group Solutions • Coverage Over Reference Based Pricing Managed Care Reinsurance: Provider Excess Loss • Health Plan Reinsurance
In all states except New York, coverage may be underwritten by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA. In New York, coverage is underwritten by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. MTG-3355 (R3/21)