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A S I P C P U B L I C AT I O N
What Employers Really Want HEALTH CARE PURCHASER
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CONSTRUCTIVE PARTNERSHIPS TO IMPROVE OUTCOMES, CUT COSTS
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TABLE OF CONTENTS
MAY 2021 VOL 151
W W W. S I P C O N L I N E . N E T
WHAT EMPLOYERS REALLY WANT HEALTH CARE PURCHASER AND PROVIDER GROUPS LAY GROUNDWORK FOR MORE CONSTRUCTIVE PARTNERSHIPS TO IMPROVE OUTCOMES, CUT COSTS
By Bruce Shutan
LIVER HEALTH MATTERS TO SELF-INSURED EMPLOYERS: NONINVASIVE TESTS COST-EFFECTIVELY IDENTIFY INDIVIDUALS AT RISK FOR LIVER DISEASE, HALT DISEASE PROGRESSION, REDUCE COSTS By Jon Gingrich, CEO, Echosens North America
ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES THE AFFORDABLE CARE ACT (ACA), THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) AND OTHER FEDERAL HEALTH BENEFIT MANDATES
SPOTLIGHT INTERVIEW: RAJESH RAO, CEO, INDUSHEALTH; DAVID MAIR, SVP, HOSPITAL CIMA; AND BRAD COOK, PRESIDENT, MEDICAL TOURS COSTA RICA
SIIA’S CAPTIVE ADVOCACY TEAM IS GETTING THE WORK DONE
THE PANDEMIC MAY BE ON THE BACK NINE; BUT WHAT ABOUT ITS IMPACT?!!
NEWS FROM SIIA MEMBERS
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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
MAY 2021 3
F E AT U R E
What Employers Really Want
HEALTH CARE PURCHASER AND PROVIDER GROUPS LAY GROUNDWORK FOR MORE CONSTRUCTIVE PARTNERSHIPS TO IMPROVE OUTCOMES, CUT COSTS
ritics of the nation’s health care system often lament that key stakeholders are disconnected from one another and decisions are made in silos. But members of two such groups, health care purchasers and physicians, have engaged in strategic discussions over the past year or so to change the narrative. Their considerable influence and insight offer self-insured employers a path to better collaboration on improving care delivery, clinical outcomes and value.
Written By Bruce Shutan
It’s all part of a joint effort by the National Alliance of Healthcare Purchaser Coalitions, a nonprofit representing more than 45 million Americans whose members spend $300 billion a year on health care, and Council of Accountable Physician Practices (CAPP), which represents leading medical groups and health systems that include more than 80,000 physicians. Leaders of these organizations were featured at SIIA’s national virtual conference last fall.
What Employeers Really Want The most recent of two reports rooted in that outreach offer employers several recommendations. Takeaways include the need to develop integrated behavioral health models; work directly with provider groups to ease delivery of care; require an action plan to weed out waste, fraud and abuse; adopt alternative payment models that hold provider groups more accountable for cost and quality; and determine how telehealth can be scaled with alternative payment models for behavioral health, primary care consultations with specialists, partnerships with safety-net providers, and care for patients living beyond in-network service areas.
A FULLER UNDERSTANDING AND APPRECIATION Employers that talk directly with medical providers can collaborate and better understand each other’s perspectives in a way that’s not possible when they’re at the behest of
“Providers often don’t have a full appreciation of what employers are really looking for,”
notes National Alliance President and CEO Michael Thompson.
He says they may perceive that the aim is just about saving money but overlook their desire to improve the care and wellbeing of employees for which a stronger partnership is being sought. The trouble is that it’s inherently difficult for many employers to be highly vested in direct relationships when oftentimes their employees are spread across the country, according to Thompson. That’s why he says the need for aggregation and collaboration across employers or within markets is so important. “We’re finally getting some communication between the customer that’s paying for all this care and the provider,” reports CAPP Vice-Chairman Norman Chenven, M.D., who’s also founding CEO of Austin Regional Clinic and president and CEO of Covenant Management Systems. By talking directly to employers, he says providers gain a much better understanding of their pain points and can resolve problems more effectively. But the desire for these conversations depends on who’s having them. For example, he says a highend specialty group may not be as eager as, say, an orthopedic group with a surgery center that wants to talk about a center of excellence and bundled payment. One of the National Alliance’s most high-profile members, the Midwest Business Group on Health (MBGH) conducted some of its own focus groups with employers, providers and physician groups. The MBGH conducted some of its own focus groups with employers, providers and physician groups.
Notable findings were that value-based and enhanced care, as well as access to quality data on hospital and physician practices, are top of mind. However, there are serious obstacles that must be overcome. Most MBGH members, about 40% of which have 1,000 to 10,000 employees, don’t have direct provider contracts, and therefore, lack any influence over designing networks and alternative payment models. “Self-insured employers want to have a say-so, and they are often left out. Yet, they’re the real payers of health care,” explains MBGH President and CEO Cheryl Larson. “They are the ones that are paying the bills, and the PBMs [pharmacy benefit managers], health plans and others are intermediaries.” Third parties worry that sharing information with their employer customers will disclose proprietary provider discounts, which she says is why the data is kept under wraps. But this prevailing attitude flies in the face of growing calls for complete transparency.
PAIN POINTS AND OPPORTUNITIES
Thompson cites three pain points and opportunities for self-insured employers. One is that cost-sharing strategies over the past two decades have eroded the affordability of primary care for many employee populations. As such, there’s a need to deliver better value that supports the health and wellbeing of employees while also reducing costs. A more strategic investment in this area, which he calls “advanced primary care,” involves patient-centered medical
What Employeers Really Want homes and direct primary care, both of which add high value to purchasers and patients alike. The idea is that by spending more on primary care there will be a more meaningful downstream impact on health outcomes and cost. “We really want to work with providers that understand what purchasers need and that are committed to that higher performing level of primary care,” Thompson explains. Another major concern is that as health care systems consolidate, the issue of opaque hospital pricing has gone largely unchecked with significant variations from one market to the next. RAND’s margin and overhead analyses of hospitals provides substantial insight that can be used to move the needle on pricing transparency and fairness, according to Thompson. Moreover, he says the employer community will need to be active on the policy front to help prevent more hospitals and health systems from becoming a monopoly or oligopoly.
He believes regional centers of excellence have more of an impact than facilities with a national focus in terms of performance, price and consumer experience. An important consideration along the road to reference-based pricing is that “sometimes unit costs can miss the boat if you don’t consider the full course of care and outcomes of that care,” Thompson observes. His organization has leaned toward “more episodic bundles as the way to shift pricing to being more of a market-based approach that is more inclusive and really doesn’t reward health systems to make it up on volume with unnecessary care,” he adds. “The days of thinking buying discounts delivers high value are over. What delivers value is engagement at a level of transparency and accountability, and realignment of incentives that move plans to eliminate waste and manage to the specifications of the people paying the bills.” A third major issue is high-cost claims whose frequency and severity have become more untenable for health care purchasers over the past decade. Much of it involves the specialty drug area where $1 million to $2 million-plus treatments for a single individual have a catastrophic effect. “Those are not bills that are sustainable for most employers,” he says, noting how PBM pricing amounts to a shell game that preserves significant Rx margins. A key initiative at the National Alliance involves redesigning the market to better manage these claimants.
“We don’t see a strong correlation between the hospitals that are charging the most versus those who are performing the best and achieving better outcomes,” he reports. “Employers increasingly will need to be more value-oriented in how they are contracting, even for procedural type care.” MAY 2021
What Employeers Really Want
While predicting federal efforts to enhance health care benefits while making them more affordable and accountable to payers, Larson points to a “desperate need for change on the pharmacy benefits side.” Unregulated PBMs and other intermediaries typically add 10% to 40% to the already high cost of drugs, she says, hoping for a legislative solution to stem the high cost of drug utilization fees, rebates and clawbacks agreements. “We’ve got members of ours that are using a model that Caterpillar has offered for years, which is optimizing their PBM contracts to get rid of clauses that only serve the PBM,” she says. “And they’re doing direct contracting with retail pharmacies, formulary management and other things that take the misaligned incentives from PBMs out of the equation, which is what can creep up your cost.”
NEED FOR TRUST AND TRANSPARENCY
Larson sees the need for her members to develop partnerships with physician groups, noting that MBGH has made overtures to some state-based provider groups about ways to collaborate. She also touts the group’s ongoing association with the nonprofit Catalyst for Payment Reform and believes pandemic challenges will help right some of the wrongs
in fee-for-service medicine. There are several objectives that come into play in addressing what employers really want. One, for example, is for large national companies with multiple worksites to embrace models that may work in one region, but are not present in others. Another is to ensure that behavioral health is integrated into medical benefits largely through telehealth, which became the primary conduit because of Covid-19 restrictions. Employers would like to see the application of this model continue post-pandemic because they recognize that many employees prefer a more confidential environment in which they feel safer.
“I actually think it would be the opposite,” he observes. “When the emergency declaration allowed for telemedicine be paid at the same level as an in-person visit, we were up to 70% of our visits from 3% to 5%.” visits.
Any meaningful collaboration between self-insured employers and the provider community to move the needle on cost and clinical outcomes must be built on trust. “When we talk about employer pain points, waste is a big issue, so making sure the provider network is appropriate and the vendor solutions that they’re offering are being accountable,” Larson reports. There’s also the issue of inconsistency in the system, she says, noting the need to hold providers accountable for their outcomes. A RAND study for MBGH’s sister coalition, Employers’ Forum of Indiana, showed the commercial insurance market paid hospitals 250% to 350% or more on average than Medicare reimbursement rates, suggesting wasteful spending.
It’s also important that payment parity is in place to protect providers, who Larson says may earn higher fees from in-person visits. While many providers quickly adapted to virtual care, she notes that those who didn’t suffered, which means it’s critical to build a model wherein they’re “reimbursed appropriately.” A big lesson from the pandemic is that telemedicine works when done properly, according to Chenven. He attributes the huge pre-Covid-19 resistance to employers and insurers fearing that physicians would convert typical nurse triage calls into a visit and the cost of care would rise if they paid comparable levels for telemedicine Norman Chenven
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What Employeers Really Want
Larson believes these findings, along with antitrust lawsuits over egregious billing practices such as the one against Sutter Health in Northern California, will help pry open the door for greater price transparency. They also could spark more evidenced-based agreements, she adds. Chenven is heartened that employers are starting to recognize the importance of primary care and tethering it to behavioral health. “I just don’t think employers had understood the inherent value there,” he says. “And, frankly, the insurance companies should have been pushing this years ago.” Their chief concerns center around the need for trust and transparency with frustration mounting over the
dramatic cost variation of procedures. He notes that the cost to the patient for an appendectomy, for example, could range from $500 to $5,000 from one hospital to the next with varying levels deductibles, copay and coinsurance across dozens of different insurance contracts.
“I don’t think that the health care system is going to change unless employers understand what’s going on and exert pressure on the brokers and health plans to help organize them,” Chenven believes. “That’s what they’re being paid to do, and in my opinion, it’s not working out very well.”
Holding service providers more accountable may be the key to fighting inertia.
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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F E AT U R E
LIVER HEALTH MATTERS
TO SELF-INSURED EMPLOYERS: NONINVASIVE
TESTS COST-EFFECTIVELY IDENTIFY INDIVIDUALS AT RISK FOR LIVER DISEASE, HALT DISEASE PROGRESSION, REDUCE COSTS
Written By Jon Gingrich, CEO, Echosens North America
ven prior to the COVID-19 pandemic, costs associated with providing healthcare in the U.S. were escalating, with premiums for employers on the rise. Rather than seeking immediate, short-term solutions, such as raising deductibles, decision makers are turning to sustainable solutions designed to create a more resilient U.S. health care system, improve care quality and lower costs. The first step is to address one of the most pervasive significant health issues, such as the silent epidemic of liver disease. Nearly one-third of Americans have asymptomatic liver disease, most commonly fatty liver disease (FLD), while the CDC estimates that only 1.8% are diagnosed. Part of the challenge is that many employers do not see the prevalence of FLD in their workforce by simply examining their claims or biometric screening data. These reports often mask or do not accurately represent the incidence of diabetes or obesity – the conditions which lead to onset of FLD, including non-alcoholic fatty liver disease (NAFLD).
Liver Health Matters Furthermore, there is not yet an approved pharmacological treatment for this disease, making it more critical to detect, prevent, halt and monitor every worker, particularly those at risk. The opportunity to turn the tide on this health crisis and curb associated costs is within reach, and employers are starting to take action.
In an anecdotal survey sponsored recently by Echosens to elicit employer understanding of the prevalence of FLD in the workforce, decision-makers reported: “Not aware where this ranks in our population.” “Not a good understanding.” “Not well understood.” “Very limited unless we are paying for a transplant.” “Moderate” “Liver disease has not surfaced as a primary issue within our population, at this time.” “Unknown at this time. However, after having read up on the subject, it sounds like it's the next upcoming healthcare crisis given nearly 75% of the population is expected to have this disease and don't know it.” But the statistics are alarming: approximately 85 million Americans have NAFLD, and 20% have the more problematic non-alcoholic steatohepatitis (NASH). Ten-year market projections for the direct costs of FLD are estimated to reach more than $1 trillion, and the disease often leads to developing other issues such as advanced fibrosis, increased risk of cardiovascular events and -- at the extreme -- liver cancer, liver transplantation and death.
HIGH COST OF LIVER EPIDEMIC Not simply a result of alcohol consumption, NAFLD is the most common type of liver disease in the Western world. Today, NAFLD is an asymptomatic disease affecting 1 in 3 American adults and costs the health care system over $100 billion. Between 5% and 12% of people with NASH will progress to cirrhosis.
One study determined that the mean total annual per patient cost of NASH was $3,306, $5,883, and $6,592 for direct medical, direct non-medical and indirect costs, respectively. Costs increased with fibrosis and decompensation, driven by hospitalization and comorbidities, while indirect costs were driven by work loss. Because NAFLD and NASH are so tightly intertwined with obesity, diabetes and lifestyle, a “whole person” 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.
UNDERSTANDING LIVER DISEASE
NAFLD is a spectrum of diseases, ranging from elevated liver fat to cirrhosis, and not all patients progress to more severe forms: about 25% of people with elevated liver fat progress to fibrotic-NASH and of those 25% progress to cirrhosis. This asymptomatic condition is characterized by elevated levels of fat in the liver and is the most common type of liver disease in the Western world. 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. NAFLD without advanced fibrosis has a 1.1% five-year mortality rate and advanced fibrosis has an 18% mortality
MAY 2021 13
Liver Health Matters rate. NAFLD alone costs on average $19,000 per year, while cirrhosis ranges from $26,000 to $66,000 per year depending on degree of damage.
amount of free fatty acids circulating in the blood and inside the liver cells. As employers struggle to find the most optimal way to manage population health, chronic care disease management (CCDM) promises to be the most effective approach for treating patients with liver disease and comorbidities, such as obesity and Type 2 diabetes.
Source: Than, New & Newsome, Philip. (2016). Fatty liver disease: a condition caused by modern day lifestyle.
NASH is a potentially progressive liver disease that can lead to cirrhosis, hepatocellular carcinoma (HCC) or liver cancer. Estimates show that 357 million people will have NASH globally by 2030. What’s more, NASH has created a global treatment market projected to reach $21.5 billion by 2025, and is on track to becoming the leading cause of liver transplantation in the United States. Liver disease rates have risen along with obesity rates in the United States. In 2000, 30.5% of American adults had obesity, meaning they had a body mass index of 30 or higher. That rate increased through 2015-2016, helping to fuel related health issues like diabetes, cardiovascular disease and some cancers. Recent data from the CDC that the obesity rate reached 42.4% in 2017- 2018 – surpassing 40% for the first time.
ROLE OF OBESITY Obesity is not simply a matter of over-eating, but rather a complex disease that involves an excessive amount of body fat. To overcome the stigma of obesity, it’s important to view this disease as a complex medical issue that increases the risk of heart disease, diabetes, high blood pressure and certain cancers. Given its overwhelming prevalence–obesity is now recognized as a chronic disease by several organizations, including the American Medical Association. The Centers for Disease Control and Prevention (CDC) defines chronic disease as conditions that last one year or more and require ongoing medical attention or limit activities of daily living, or both. Of the $3.3 trillion spent annually on medical care for chronic conditions, obesity alone is associated with $1.4 trillion. The impact of obesity on vital organs can be devastating, especially on the liver, causing insulin resistance that leads to buildup of blood sugar and increases the
Implementing a CCDM program that targets liver health can address the broader needs of individuals and prevents them from developing NASH. In fact, this is essential given the costs and complications associated with NASH--a challenging, high-volume and chronic condition that lacks a standardized care delivery model. Diet and exercise interventions have been shown to be 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. In recent years, the fibrosis stage of liver disease has been identified as the most important predictor of liver outcomes. For this reason, identifying patients with NAFLD and NASH with more advanced stages of fibrosis is critical for management.
Liver Health Matters A follow-up visit ensures that the patient is following the weight loss program, consulting with a dietician or nutritionist and adhering to the program. It’s also useful to share the patient’s liver exam score with them to illustrate the change in liver fat and the need for adjusting their treatment. This is where noninvasive tests play a key role.
Moreover, the researchers identified combinations of direct biomarkers with circulating blood biomarkers, such as the FAST™ Score as cost-effective options to identify the probability of active fibrotic NASH among people suspected of having NAFLD. A CCDM program can leverage a noninvasive tool, like FibroScan, to quickly provide 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.
Source: Effect of Weight Loss, Diet, Exercise, and Bariatric Surgery on Nonalcoholic Fatty Liver Disease - Clinics in Liver Disease (theclinics.com)
COST-EFFECTIVE, NONINVASIVE LIVER EXAMS Fortunately, employers can turn to the medical community for diagnostic and treatment assistance. Increasingly, primary care physicians and specialists understand the growing need for cost-effective ways to detect and monitor liver disease. Current approaches for identifying fibrotic NASH, however, are complicated, expensive and potentially wasteful. A recent expert review conducted through the Chronic Liver Disease Foundation suggests a streamlined approach that is costeffective. This approach begins with a practical decision tree/algorithm to risk stratify NAFLD/ NASH in clinical practice. These algorithms use serum biomarkers, which offer the strongest evidence for identifying fibrosis in NAFLD. In addition, clinicians can risk stratify patients with NAFLD using noninvasive tests (NITs), such as NAFLD Fibrosis Score (NFS), Fibrosis-4 Index (FIB-4) or liver stiffness measured by elastography. Researchers identified Vibration Controlled Transient Elastography (VCTE) as a useful direct biomarker of liver stiffness and fat in point of care. Other direct biomarkers include magnetic resonance elastography (MRE) and ultrasound-based 2D shear wave elastography (2D-SWE), often available in specialist or radiology departments. Dr. Binoy
With the introduction of new treatment options, a targeted CCDM program can integrate non-invasive, point of care liver examinations to leverage the launch of these drugs in a way that improves outcomes and lowers costs for employers. FibroScan in point of care, for example, provides a simple, validated and reliable exam that creates savings to benefit payers in two ways: 1) early identification of patients with fatty liver disease to allow for proactive intervention and behavior change to slow disease progression; and for those identified with liver fibrosis, 2) reduce the aggregate volume of some current diagnosis methods, such as liver biopsy. Researchers who conducted scenario testing demonstrated positive net savings within two years across most scenarios and regions. They concluded that broad deployment of VCTE devices is a financially advantageous solution to address the fatty liver disease epidemic.
Liver Health Matters VALUE OF INNOVATIVE TECHNOLOGY
The first drug, Ocaliva is expected to launch in late 2021 with a potential price tag of $15,000-20,000 per year, followed The most effective non-invasive liver exam tools are highly mobile, can be operated by later entrants with likely pricing by a medical assistant and interpreted by the healthcare professional. They produce ranging from $10,000-15,000 annually. numeric measurements—not images—for simplified interpretation and consistency Given these extraordinary, projected of measurement. This enables clinicians to monitor changes in liver tissue over time. Experts anticipate that such rapid tools that provide consistent liver measurements will expenses, it will prove to be more costeffective for employers to address liver be performed as a routine part of patient management. disease with diet and lifestyle interventions.
FDA-cleared point-of-care device to aid diagnosing and monitoring adult patients with liver disease, as part of an overall liver assessment.
For employers and employees alike, it is critical to recognize liver disease, such as NAFLD and NASH, so that early intervention can be implemented. Lifestyle modifications and strict control of metabolic risk factors are the most effective treatment. The benefits of managing chronic disease are to not only improve health and reduce medical costs, but also to create a more productive and healthier workforce. Now more than ever, it is a strategic imperative for self-insured employers to address the serious health and cost challenges associated with liver disease. The opportunity to embrace and leverage new technology and work with physicians and specialists who are keeping pace with this silent epidemic must become a top priority. As the pharmaceutical industry begins to introduce Rx treatments with associated high costs of specialty drugs, employers will face extraordinary expenses. Major pharmaceutical companies are now targeting fatty liver and developing new chronic therapies that should be on the market in the next year or two.
Q A Q & A &
ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:
he Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Women’s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other federal benefit mandates. Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, Ken Johnson, Amy Heppner, and Earl Porter provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley, Carolyn, Ken and Amy are senior members of the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at firstname.lastname@example.org.
GROUP HEALTH PLAN PROVISIONS OF THE CONSOLIDATED APPROPRIATIONS ACT: A DEEPER DIVE On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA) was signed into law. In addition to funding the government and further COVID-19 relief, the CAA included significant provisions impacting health benefit coverage. Over the next several articles we will discuss four of the provisions relevant for group health plans: (1) expanded relief for health and dependent care flexible spending arrangements; (2) new expanded compliance requirements under the Mental Health Parity and Addiction Equity Act (MHPAEA); (3) new reporting requirements for commission and similar compensation; and (4) new requirements to limit surprise billing.
BROKER AND CONSULTANT DISCLOSURES FOR HEALTH CARE SERVICES
The CAA contains new service provider disclosure requirements for “brokerage services” and “consulting” services and requires group health plan fiduciaries to take action if they do not receive those disclosures. The effective date of this provision is December 27, 2021 (one year from the date of enactment). We expect future guidance from the DOL to fill in some of the gaps and ambiguities in the statutory provisions.
a prohibited transaction (with certain exceptions when the plan fiduciary takes action for the service provider’s failure to disclose). Finding that there were significant differences between service provider arrangements with welfare plans and with retirement plans, the DOL did not issue guidance for welfare plans at that time. The CAA now institutes disclosure requirements for certain service providers to “group health plans” by amending Section 408(b)(2) of ERISA. These statutory requirements, in many ways, mirror the regulatory requirements applicable to retirement plans and are modeled on the regulatory provisions. Some of what is below, therefore, may be familiar for plan fiduciaries and plan sponsors who are acquainted with the required retirement plan disclosures. The CAA’s rules will likely be new for many group health plan brokers and consultants, and planning should begin immediately on how these disclosures will be implemented.
Covered plans and covered service providers Background ERISA Section 406 provides that furnishing services between a plan and a “party in interest” is a prohibited transaction. A party in interest includes any person providing services to a plan. Looking at ERISA Section 406 alone, this would make almost all arrangements between plans and plan service providers prohibited transactions. There is an exception, however, in ERISA Section 408(b)(2) for contracts or arrangements for services with a party in interest if the arrangement is reasonable, the services provided are necessary for the establishment or operation of the plan, and no more than reasonable compensation is paid. Current DOL regulations require retirement plan service providers to disclose both the direct and indirect compensation they receive. The DOL reasoned that it is impossible for a “responsible fiduciary” to know whether compensation or an arrangement is reasonable unless that plan fiduciary knows what compensation the service provider receives for each service rendered. Therefore, under those regulations, an arrangement with a service provider where such disclosures are not made is not “reasonable” and could generally result in
The CAA’s amendment to ERISA Section 408(b)(2) covers “group health plans,” which are defined as employee welfare plans that provide “medical care.” Significantly, the CAA does not exempt what are known as “excepted benefits” from this definition of a group health plan. So the CAA sweeps in not only traditional fully insured and self-funded group medical plans but also dental and vision plans, health FSAs, on-site clinics (except those that are limited to only rendering first aid to employees during working hours), many employee assistance programs, and health reimbursement arrangements (HRAs).
Examples of plans that are not group health plans are group term life insurance, accidental death and dismemberment insurance, and longand short-term disability insurance. Also, while HSAs are generally not group health plans, the HDHP that accompanies an HSA is a group health plan. Disclosure is required only if the service provider receives $1,000 or more in certain types of compensation pursuant to the consulting or brokerage contract or arrangement. Compensation includes “direct compensation” from the covered plan itself or “indirect compensation,” which is compensation from any source other than the covered plan, the plan sponsor (often the employer), the service provider, or an affiliate of the service provider. In other words, if the only compensation that the service provider receives derives directly from the employer, then disclosure is not required. This could arise, for example, with a consulting agreement for a self-funded group health plan where the employer is responsible for all fees associated with the agreement, no fees are paid with plan assets, and the service provider does not receive compensation from any other source for the plan. Plan assets can take the form of amounts paid from a formal trust or amounts paid with any participant contributions. So to avoid reporting, care must be taken to ensure that the service provider is not paid with any participant contributions (and that it does not receive indirect compensation). It appears that disclosure will be required for an insured arrangement, where a portion of the premiums that generate the insurance commissions are paid by plan participants, because those
commissions will be deemed to be paid by the plan. Disclosure is required regardless of whether the services are performed, or the compensation is received, by the service provider, its affiliate, or its subcontractor. The CAA’s amendment to ERISA Section 408(b)(2) covers two types of services as “covered service providers”: brokerage services and consulting.
“selection of insurance products (including vision and dental), recordkeeping services, medical management vendor, benefits administration (including vision and dental), stop-loss insurance, pharmacy benefit management services, wellness services, transparency tools and vendors, group purchasing organization preferred vendor panels, disease management vendors and products, compliance services, employee assistance programs, or third party administration services.” The definition of brokerage services includes a
Consulting services are nearly identical but do not need to involve “brokerage” and include services “related to the development or implementation of plan design, insurance or insurance product selection (including vision and dental), recordkeeping, medical management, benefits administration selection (including vision and dental), stop-loss insurance, pharmacy benefit management services, wellness design and management services, transparency tools, group purchasing organization agreements and services, participation in and services from preferred vendor panels, disease management, compliance services, employee assistance programs, or third party administration services.” We must wait for further clarification of these definitions, but the consulting category appears especially broad. It is unclear whether consulting just includes advising on the selection of service providers such as TPAs or pharmacy benefit managers or whether it also applies to the service providers themselves when they “consult” (e.g., a TPA consults on plan design or a pharmacy benefit manager consults on a plan’s drug formulary). If it is the latter, then the disclosure requirement would potentially include not only insurance brokerage firms serving in a consulting capacity to self-funded plans but a host of other service providers, including:
· TPAs (both for self-funded group health plans and for health FSAs and HRAs).
· Stop-loss carriers, stop-loss panels, and stop-loss consortiums. · Pharmacy benefit managers.
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· Wellness vendors. · Disease management vendors including data analytics. · On-site clinic managers. · Any entity providing “compliance services” (including attorneys and actuaries).
· Employee assistance program vendors.
What must be disclosed The covered service provider must provide the following information (including the information of any affiliate or subcontractor):
· A description of the services provided. · If applicable, a statement on whether the covered service provider will serve as an ERISA fiduciary.
· A description of all direct compensation the covered service provider reasonably expects to receive in connection with the services. There are several different ways compensation can be expressed, including a monetary amount or a formula.
· A description of all indirect compensation that the covered service provider reasonably expects to receive. This includes “compensation from a vendor to a brokerage firm based on a structure of incentives not solely related to the contract with the covered plan.” We will need to wait for further guidance on what this would include, but it could relate to items such as a vendor providing brokers with gifts, trips, etc., for the amount of business they place with the vendor or even the vendor being a financial sponsor at a client-facing event held by the brokerage firm.
Delaware’s Captive Bureau is business at the next level
In Delaware, our captive regulators are dedicated exclusively to our captive insurance clients’ needs, and work under the direction of our Captive Bureau leadership, directed by Steve Kinion.
There are 34 people working on Delaware’s Captive team. Of this total 15 are financial analysts. Under Delaware’s regulatory organization, the financial analyst is the first-line regulator who communicates with the captive manager or owner. As a result, all inquiries, business plan changes, dividend requests, and other related matters are first addressed by the analyst. The experience level of these analysts is unmatched. STEVE KINION, DIRECTOR
Call us today to speak with a team member
Bureau of Captive & Financial Products Department of Insurance Steve.Kinion@delaware.gov
Our team has 15 analysts 12 hold the Associate in Captive Insurance (ACI) designation 12 hold the Accredited Financial Examiner (AFE) designation 9 hold the Certified Financial Examiner (CFE) designation 2 are Certified Public Accountants (CPA)
BUREAU OF CAPTIVE & FINANCIAL INSURANCE PRODUCTS 1007 Orange Street, Suite 1010 Wilmington, DE 19801 302-577-5280 captive.delaware.gov
· A description of the arrangement under which the indirect compensation is paid.
· Identification of the services for which an indirect compensation will be received.
· Identification of the payer of the indirect compensation. · A separate description of any compensation that is set on a transaction basis (such as commissions, finder’s fees, or other similar incentive compensation based on business placed or retained) that will be paid among the covered service provider, affiliate, or subcontractor.
· A description of any compensation that the covered service provider will receive upon termination of a contract or arrangement. Timing of disclosure Disclosures must be made to the responsible plan fiduciary “reasonably in advance” of the date of entering into, extending, or renewing any contract or arrangement.
Changes to the information disclosed must be provided as soon as practicable, but generally not later than 60 days from the date on which the covered service provider is informed of the change. If, however, a covered service provider acting in good faith and with reasonable diligence makes an error or omission with disclosure, the contract or arrangement may still be reasonable if the correct information is provided within 30 days after the error or omission is discovered. The effective date of this provision is December 27, 2021. Contracts entered into before this date are not subject to these requirements, but any renewal or extension of a contract after the effective date is covered.
What if the disclosure is not made? Upon discovery of a disclosure violation, a responsible fiduciary can avoid a prohibited transaction by taking the following actions. First, the responsible fiduciary should request, in writing, that the covered service provider make full disclosure. Second, if the covered service provider refuses to make full disclosure or does not respond within 90 days, then the DOL must be notified of the failure within 30 days following the earlier of the refusal to respond or the lapse of the 90-day period to respond. Section 408(b) (2) specifies the information that must be provided to the DOL. Finally, if the disclosure failure relates to past services, then the responsible fiduciary must make a determination on whether to retain the covered service provider based on ERISA’s fiduciary prudence standards. If the failure relates to future services, then the responsible
fiduciary must terminate the contract or arrangement as expeditiously as possible as consistent with those prudence standards.
Summary and action items The clear intent of the CAA was to mirror the disclosure requirements of retirement service plan providers. Plan sponsors and fiduciaries may be familiar with this process from their experience with their retirement plans, but work still needs to be done. Actions for plans sponsors and fiduciaries include:
· Identify any person or entity that consults in any way with a group health plan and all brokers for any group health plan and determine if they are a covered service provider.
· Determine whether any covered service provider receives any direct compensation from any group health plan and the amount of that compensation.
· If known, determine whether the covered service provider receives any indirect compensation and the amount of that compensation.
· Prepare, once effective, to make a demand to any service provider that has not provided adequate disclosure.
· Establish and document that a responsible fiduciary actually reviews the disclosures and determines that the compensation arrangement for consulting or brokerage services is reasonable. Group health plan brokers and consultants have a much heavier burden. They will need to analyze all instances when they receive either direct compensation or indirect compensation. The identification of any indirect compensation is especially crucial because the reason for this provision was a belief that group health plan brokers and consultants are receiving forms of “hidden” compensation. Also remember that these disclosures apply to all group health plans regardless of size as long as the compensation threshold is met. Finally, the disclosures must be designed and formatted to include all required information. This may require new software or revisions to existing software to automate these extensive disclosure requirements.
SIIA’S CAPTIVE ADVOCACY TEAM IS GETTING THE WORK DONE
Written By Karrie Hyatt
IIA has long been supportive of captives in the self-insurance sector. The organization’s Captive Committee has been at the forefront of addressing issues that affect captives industry-wide. A more recently formed sister task force, the Captive Advocacy Team, is focusing on critical and real-time regulatory and legislative issues that affect captives, particularly enterprise risk captives (ERCs).
The Captive Advocacy Team was formed in 2014 to counteract the negative reputation that the IRS is still trying to attach to ERCs. According to Jeffrey K. Simpson, partner with Womble Bond Dickinson (US) LLP, “The reason we formed the task force was to change public discourse regarding ERCs for the positive. All that has been getting into the media and the trade press is the IRS’s negative view. We want to be a voice from the industry talking on behalf of the industry to try and have a positive impact.”
Education is the key, Team members say. The focal point of advocating for captives is to educate regulators, legislatures, owners, and interested parties in the real benefits provided by ERCs. “We look to educate the detractors and the uninitiated. Captive insurance is not some hocus pocus, sleightof-hand thing. It’s a real insurance product and provides real benefits to its owners and insureds,” said Alan Fine, Partnerin-Charge of Insurance Advisory Services with Brown Smith Wallace LLP and a member of the Team.
For Joanne Shaver, senior vice president of The Intuitive Companies, the Captive Advocacy Team’s main purpose, “Is to educate members of congress about the importance of captives to small and medium sized business owners. My goal in working with the task force is to do my part as an industry stakeholder to help SIIA spread the word both in my local community and in Washington, D.C.
“Captive insurance companies are an integral part of risk management for nearly every large Fortune 1000 company,” said Josh Miller, CEO, The KeyState Companies and task force
member. “Our goal is to show how mid-size businesses utilize and benefit from captives.” LAST YEAR’S SUCCESSES
Despite being hindered by the pandemic shutdown, the Captive Advocacy Team was able to do important work.
On December 1st, the U.S. Supreme Court heard oral arguments in CIC Services v. IRS. This was the first time a captive-related court case has been argued before the Supreme Court. The case asks if the IRS’s Notice 2016-66 was legal as pertains to the Administrative Procedures Act and the Anti-Injunction Act. In support of CIC Services, a broad coalition of industry organizations came together to submit an amicus brief. SIIA’s Captive Advocacy Team was integral in coordinating the brief.
For Simpson, the amicus brief was the most important work that the task force did in 2020. “The reason is not so much in the substance of the brief, but in the broad support for it—the way we were able to coordinate not only with SIIA members but other industry associations and organizations towards working together on this common goal. As an industry, we never really have done something like this before. I think that is a good sign that our industry is getting organized. Let’s see what we can do together as a collective.”
A decision from the Supreme Court is expected to be handed down in June or July.
Another thing the Advocacy Team did last year, to forward the goal of education, was to put captive business owners in direct contact with their elected representatives.
local business owners … to tell their captive story in a small, intimate setting,” said Shaver.
SIIA scheduled and held over 60 virtual congressional meetings. According to Fine,
“I think one of the things we did that we were very proud of is that we were able to set up a number of meetings between captive owners and their representative and/or senators in Congress. The purpose of these was educating our legislators about the importance of captive insurance.”
For Miller, connecting business owners with their elected officials was the most critical aspect of the Team’s work. “The business owner can outline the tangible benefits the captive has for their business, employees, and customers. These real-world examples are the only way that elected officials will understand the impact their support of captives has on their constituents and their local economy.”
“The congressional town hall events that SIIA held last year were a great way to get the task force’s message out to members of Congress. This format worked well for the
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For Shaver, “I believe the IRS feels, wrongly so, that most captives taking the 831(b) exemption are doing so merely for the tax deduction that the insured receives and subsequent exemption of the underwriting profits on the insurer side. Those of us serving on the Advocacy Team all know this is not the case, but it’s difficult to convince the IRS of this.”
The Captive Advocacy Team had scheduled an in-person event at the end of March 2020 in Washington, D.C. for owners to meet with their representatives on Capitol Hill. That meeting was, of course, cancelled.
The event was replaced by town hall webinars which Simpson believes could be a more effective way of bringing captive insurance concerns to Congress. “When we go to D.C. and we visit congressional offices, we don’t usually get the senator or representative themselves, just their top staff. In going to these meetings, we really want the congressperson themselves and through these webinars we got to do that. The extraordinary part for me was that Representative Lisa Blunt-Rochester [DE] was on our webinar and we had her direct attention. You might argue that we did better this way than we did in person.”
THE IRS AND CAPTIVE DETRACTORS
The IRS doubled down on its pursuit of ERCs, or what they call microcaptives, in 2020. On October 1, the Service issued Letter IR-2020-226 which indicates that it will be even more aggressive towards microcaptives using the IRC 831(b) option. This statement came at a time when captives were both showing their worth and expanding in the wake of the pandemic.
“As the audit and enforcement teams focus their efforts going after abusive captives,” said Miller, “I’m worried that they have tunnel vision and do not take the time to consider and evaluate captives are operating correctly. This is really the main issue. The industry and the IRS have a completely different view on the how many captives are operating abusively. The IRS believes it is a very high percentage, and based on my industry experience, it’s actually the opposite.”
The IRS can’t seem to see that captive insurance has been beneficial for their owners. According to Fine, “The captive insurance industry has done a lot of good things for business owners by being able to provide insurance where other insurance was simply not available. For example, if you think about the events of the past 12 months, most commercial policies specifically exclude anything emanating from something like a virus, like the pandemic. Yet, I have a number of clients who were able to continue business because they were able to submit claims to their captive insurance company and that allowed them to weather the storm.”
While the Captive Advocacy Team would like for the IRS to change its stance on captive insurance, the Service has made it clear that they have no intention of changing their focus. Instead, the task force would like to work with them to create guidance. For Simpson, “I don’t think we’re ever changing the attitude of the IRS, but we would like to get them to agree on some substantive things that can help distinguish good operations from bad.”
“I’d like to see the captive industry and the IRS agree upon some clear, objective criteria that demonstrates that a captive insurance company is operating reasonably and should not be subject to additional scrutiny or reporting requirements. Captives that meet the criteria wouldn’t be presumed to be abusive, which is how it currently seems the IRS views 831(b) captives.” According to Miller,
THE FUTURE OF ADVOCACY
Education will continue to be the main focus of the Captive Advocacy Team. Educating both detractors and those new to captive insurance will take several approaches, including more congressional meetings and educational webinars. The Team is looking to partner with a think tank or academia to produce studies on the benefits of captives written by experts not directly involved in the industry.
On the top of the list for task force members is sponsoring more meetings between captive stakeholders and their congressional representatives. “Ryan Work, who leads captive advocacy activities on behalf of SIIA, always stresses the importance of captive owner engagement,” said Shaver. “I think this is going to be key in 2021, especially given everything that our captive owners faced last year. My understanding is that the task force is planning to hold more congressional town hall events this year. I am hopeful that the Team members will reach out to their clients to ask more captive owners to tell their stories during these town hall events.”
According to Miller, “I think the task force needs to redouble our efforts to keep captive owners engaged with members of Congress and other elected officials. It’s critical that members of Congress understand how these businesses utilize captives.”
“The pandemic has provided concrete examples of risks that people believed would never ever happen. Things that weren’t even considered a real risk. Yet here we are with captives paying claims on those risks,” said Simpson. “We need to get word out about those positive examples of captives providing real benefits.”
“As an industry stakeholder and captive manager, I believe the best thing we can do is to work with captive owners and their advisors to ensure that captives are being formed for the right reasons. In today’s hard insurance market and given the business interruption losses that most of our clients faced during the pandemic, there has never been a better time to own a captive. I believe we should take advantage of this situation and ask our captive owners to tell the story of how their captive helped them create leverage with the insurance carriers and/or helped them offset the business losses they faced during the government shutdowns in 2020.” Shaver said,
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THE PANDEMIC MAY BE ON THE BACK NINE; BUT WHAT ABOUT ITS IMPACT?!! Written By Christopher M. Aguiar, Esq. – The Phia Group, LLC VP, Legal & Stop Loss Recovery Services
hat a year; 2020 was one for the history books - the year almost everything changed (except aggressive, polarizing, political rhetoric)! Presidential Administrations changed as we witnessed an historic election, the results of which were not determined for over a week and disputed for several more. Live shows became live streams and drive ins. Movie theatres turned into ghost towns. Remote working became the norm. City dwellers fled in droves in search of more space and cheaper housing costs. Iconic/historic hotspots became relics of the past. Supply in the housing market, nationally, reached never-before seen lows while the future of the commercial real estate market spiraled into question. Parents doubled as financial providers and teachers. Finally, and perhaps most upsetting of all, remote learning became a norm that virtually all school systems were forced to learn to implement, cementing that future generations of children may never again experience the magic of a snow day! As vaccinations ramp and millions of Americans march towards “herd immunity”, many are starting to feel that we are reaching the home stretch. What exactly, though, does life after COVID, the so-called “new norm”, look like?
Even after the pandemic is behind us, we will be experiencing its effects, and perhaps some newly established behaviors, well into the future. Whether it be an increase in virtual meetings and remote work, a change in the way we greet each other upon meeting, an increase in mask usage during peak viral seasons, or as society deals with some of the financial consequences of a year of lock downs and fear, people and organizations will need to find ways to address some of the financial concerns that came with this pandemic. Benefit plans, for example, may need to find new innovative ways to cut costs as they deal with what some are projecting to be a greater than normal increase in medical spend. Some projections, like those made by the American Institute of Certified Public Accountants, indicate that national health spending projections are showing a per year increase over the next decade at 450% of the inflation rate seen between 2014 – 2018 (from 1.2% to 5.4%). This COVID surcharge is no doubt intended to make up some of the losses suffered by hospitals who, according to healthaffairs.org, saw a 35.8% decrease in hospital spending in March and April of 2020 alone – thanks in large part to a decrease in non-critical services, those among the most profitable delivered by hospitals. Luckily, regulators across the country are seeking ways to make cost containment for benefit plans a bit more possible. A perfect example of this is with potential
changes in worker’s compensation coverage – an area of insurance traditionally heavily regulated by state government. Why are changes necessary in the worker’s compensation arena? Proving someone contracted the virus at work can be very difficult, even in situations where the person has a high-risk job. For example, a nurse assigned to a COVID unit is much more likely to contract the virus than, say, a grocery store cashier. Yet, both may be considered essential employees and, by the very nature of their employment, contract the virus while working. Both could also easily contract the virus at the grocery store on the way home from their shift while running errands after work. How, then, do you prove causation - the most important element of an injury claim? Causation is the element that ultimately establishes an employee contracted the virus while dealing with an infected person rather than getting too close during a walk and breathing in that person’s droplets. Every state treats the key legal concept differently, that of ‘Presumptive Illness’. This presumption, often used for firefighters who contract certain diseases such as lung disease or cancer that were likely caused by their time on the job, requires the insurance company to presume causation while allowing them to prove otherwise. So, the nurse assigned to a COVID unit would be presumed to have contracted the virus there; the insurance carrier then has the burden to prove otherwise. Causation, then, becomes a significantly lesser barrier to benefits.
As of March 22, 2021 - 16 states have some type of presumption that would cover COVID-19 already on the books; the remaining 34, however, do not. 20 of those states either have no activity considering a change to their presumptive illness practices as it relates to worker’s compensations benefits, or bills have been introduced but not passed. All entities providing or administering health benefit plans in America should be evaluating all their cost containment options in a post COVID world and preparing for what could be a significant increase of medical bills both, directly and indirectly related to this pandemic. The potential cost to health benefit plans as a result of this virus will no doubt be significant. We have all heard the stories, COVID treatment itself is very expensive; the other charges, however, are also likely primed to see increases as hospitals review their charge masters and attempt to remedy a black hole of non-emergent care caused by lock downs and folks unwilling to trek to the hospital. After months of record losses, it is only natural that they will find ways to recoup them. If benefit plans, too, are going to stem the tide, they must seek options to account, budget, and wherever possible, mitigate this surge of inevitable costs.
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SPOTLIGHT INTERVIEW: RAJESH RAO, CEO, INDUSHEALTH; DAVID MAIR, SVP, HOSPITAL CIMA; AND BRAD COOK, PRESIDENT, MEDICAL TOURS COSTA RICA This interview was conducted by SIIA’s partner in the Connect from Anywhere (CFA) live Medical Travel seminars and was originally released as a special issue of their digital newsletter, prior to the Costa Rica live seminar. A recording of the seminar is available to SIIA members at www.siiacanoe.org. Medical Travel & Digital Health News (MTDHN): Give the readers an overview of why Costa Rica is a popular medical destination.
Rajesh Rao (RR): Since IndusHealth began offering medical travel programs to selfinsured employers in 2005, we have worked with a variety of top-notch providers in destinations around the globe in the pursuit of providing viable solutions to members of employer-sponsored programs who consider traveling for medical treatment.
Costa Rica provides an ideal combination of affordable healthcare and being relatively easy to travel to. It helps that they have a nice tropical climate yearround and that Costa Ricans have a very hospitable and welcoming culture that makes visitors feel well cared for, and patients even more so.
Costa Rica also provides the right combination of top-notch providers and multi-specialty hospitals with costs that generate sizable savings when applied in service of company-sponsored medical benefits. We require all hospitals in our network to be JCI-accredited so even though we secure lower costs, there is no compromise to the quality of care that our patients receive.
Brad Cook (BC): I've been working with hospitals in a variety of ways with international insurance billing, so I knew Costa Rica could offer a high-quality level of medical care from really great doctors. When I would travel to the U.S., I kept hearing people talk about, "Oh, I've been to Costa Rica. I want to go to Costa Rica or my cousin went to Costa Rica with a buddy on a trip." I started thinking there is a lot more we could do here because Costa Rica has emphasized their health system as a priority. They abolished their army in 1948 and have been investing those funds in education and healthcare for many years. We began to put things together and created a concierge type of service assisting and being an interface between the hospital and the doctors in Costa Rica and people interested in visiting for medical care. People just feel very, very comfortable in Costa Rica. Like Rajesh said, it's nearby and easy to get to. Costa Ricans have a special way about them that makes people feel welcome and safe, and that is why it is such a popular destination.
David Mair (DM): At its foundation, destination medical care, as I call it, is built on four basic principles for both employer groups and individuals: access, affordability, quality of care, and medical outcomes. Costa Rica and Hospital CIMA, in particular, deliver on those principles.
Although several providers claim to provide medical travel solutions, many are geared to cater to the self-pay market with markedly different needs and expectations. Only few providers can make it work for employer-sponsored programs in which participants consistently receive superlative care compared to what they have access to locally. The better the care and recovery experience, the more it gets talked about in a manner that makes it a highly desirable option in the member communities we serve.
Doctors and nurses are well-trained and highly skilled on par with their North American counterparts, medical technology is sourced from the same companies used by hospitals in the U.S. (some of it is even manufactured in Costa Rica before being exported elsewhere), and medications come from the same pharmacy companies. For international patients, it’s fast and easy to access care; in fact, we often hear about how much faster it is than at home for people. Costs are transparent and affordable as compared to the U.S. Hospital CIMA, which celebrates its 21st anniversary this month, has long been highly regarded for its focus on delivering exceptional quality medical care. The latest affirmation of that success is that we earned the JCI’s Gold Seal of Approval ® under the Seventh Edition of the JCI standards. It is the newest standard that's been released. We have been consistently accredited now through five consecutive review cycles. Many of Hospital CIMA’s physicians have trained internationally. They're multilingual, which creates a terrific environment for patients who are willing to look at care outside of their own communities, caring and take time with each patient. You surround that with a destination where people are caring and thoughtful, and you end up with a phenomenal combination of services, people and technology that really lends itself to exceptional medical care.
What’s worth noting here is that we make destination medical care decisions all the time. We just don’t call them that. When we select a doctor, dentist, hospital, etc. that is not the closest one to us, we’ve made a destination medical care decision. We are willing to travel to other cities or states, like travel to MD Anderson for cancer care as one example. The difference here is travel to a high-quality medical center crosses an international border in order to gain financial, access and outcome advantages. For more than 10 years, I’ve been working with self-funded health insurance on plan designs that integrate destination medical care into the plans. When it’s done properly, and there are few people who know how to truly integrate the benefits into a plan design that hits the
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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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right targets, we are able to integrate financial incentives, reduce overall costs, and take advantage of tax deductibility, in some instances.
One of the concerns we had early on was how well our typical patients unfamiliar with foreign travel would adjust to being in a country where English is not the primary language. We found that all it takes is for the professionals we work with to be able to converse well in English when working with patients.
It is those plan designs that lend themselves to insurance coverage so that employers can look at a place like Costa Rica and this team and find accessible, affordable high quality of care in a single package.
BC: Yes, Costa Rica has a large number of expatriates from the U.S., so the hospitals and the healthcare providers are very comfortable assisting English-speaking patients and Americans in particular.
The team that you're interviewing here has really focused on doing medical travel for corporations, for business health plans in ways that others have really not contemplated or delivered well.
MTDHN: What would you consider your centers of excellence as far as service lines and are there service lines there that are new or unusual that you can't get elsewhere?
DM: Hospital CIMA offers more than 60 medical specialties and subspecialties. We have centers of excellence in cardiovascular care, maternity care, orthopedics, oncology endocrinology and neurosurgery, among many others. RR: Besides the availability of excellent medical care, another important factor is personal safety.
We also include an International Pharmacy Program for our clients to address the high cost of pharmaceuticals in the U.S. and later this year we’ll be adding new arrangements that help monitor patients’ needs from the comfort of their homes.
Costa Rica has a low crime rate and extremely friendly people. Not only do you get served really well, but you feel really safe there when you're walking around.
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MTDHN: Can you talk about affordability? How are costs bundled? Are costs inclusive and are they comparable to bundles that are now being offered in the United States?
MTDHN: How do you measure outcomes?
DM: A starting point for us as a key measure of the patient experience is Hospital CIMA's Net Promoter Score. Net Promoter Score is essentially the number of people who tell you that they would recommend the hospital to friends and family minus those who would not. Hospital CIMA’s Net Promoter Score is currently 94. The average for the American healthcare industry is in the 50’s. It is something that we're proud of, because it speaks directly to multiple aspects of the overall patient experience, including the quality of their medical care, the physicians and nurses, the staff who support them, and their medical outcomes. One isn’t a Promoter in the NPS system if the quality of their care and outcomes aren’t excellent. We had one patient who was so pleased with his medical experience that he flew his therapist to Dallas to continue his care. That continued for several years. I'm sure that Rajesh and Brad can tell you from their experience, it only takes about three people from a company to turn into a regular flow of people coming because they hear about the high-quality care, compassionate care and affordability for both the individual and the employer.
RR: We have arrangements where we get bundled prices for all medical services associated with each patient encounter. We then add the cost of travel, meals, accommodations and other qualified travel expenses such as passports. The health plan receives a single allinclusive bill. We make sure that all these costs are in compliance with ERISA and insurance billing standards. We also take care of everything, so the patient doesn't have to pay anything out of pocket. Although certain domestic providers are starting to offer competitive bundled rates, there are certain differences in the way their packages are structured. One of the key differences is the length of recuperative stay and professional care during that period. In our model, it’s essentially another tier of choice available to patients.
MTDHN: What is the comparison of cost to the United States? What does it cost?
RR: Depending on the type of surgery and the pricing obtained provided to an employer, net cost-savings typically varies between 25 to 50%. For example, Joint Replacements typically generate savings in excess of $25,000, and
certain Lumbar and Cervical Spine Repair procedures can save well over $50,000, in some cases to the tune of $100,000. Bariatric Surgeries yield around $15,000 in savings, whereas various types of Joint Repair, Hernia Repair and Hysterectomies can deliver between $10,000 to $15,000. If you just look at the medical component, it's probably a smaller fraction but by the time you add on the other overhead costs with travel, you'd actually save about half across the board. I should note it varies from one market to another as there's a wide variation across the U.S.
MTDHN: Are there any opportunities for a guarantee or warranty, if there is a less than optimal outcome? What happens if something goes wrong? RR: Medical care invariably presents scenarios where things don’t go exactly as planned. When there are incremental costs, additional charges tend to be a fraction of corresponding costs in the U.S., resulting in further cost savings. Managing such eventualities and accommodating changes to plans is an integral part of our service offering. If something goes wrong, we work closely with patients and providers to ensure that the patient is equipped to pursue an appropriate resolution.
DM: I've heard hospitals around the world who claim to offer a services warranty before, but I’ve seen very few stand behind it in meaningful ways. In part that’s because the issues that arise are often ones of compliance or patient activity after surgery. There’s also the problem of patient’s who have returned home. If the experience doesn’t go well, they are rarely inclined to go back for a second effort. At Hospital CIMA, our focus for the patients we serve is getting the procedure done properly the first time, and our record shows we succeed in hitting that target. That said, there are times when something happens during a surgery that requires additional attention or surgical time. Minor cost variations can result, and we disclose that potential to patients ahead of time.
MTDHN: Can you address employers interested in introducing this benefit? Do you suggest they do it during the signup season? Can they do it any time of the year? How do they carve in or carve out payers? Do you have any advice for that?
RR: It depends on the employer. We find that some employers are geared to be able to offer it outside of open enrollment and begin the process anytime, others are not. Larger employers tend to align it with their plan year and announce it during open enrollment, whereas smaller employers are better equipped to communicate interim plan changes within their smaller. We are able to support them either way.
DM: In the employer groups that we serve directly and others with whom we speak, the fact that medical travel is available as an add-on option or a fully integrated benefit, allows them to look at what they have in their existing plan and add medical travel benefits at any time. They may not at mid-year have the full robust nature of what they will have later but they're certainly able to add that and begin achieving a cost savings for both patients and the corporation.
RR: Some choose to start with a particular specialty that they perceive as more urgent for their needs, for example, orthopedics before expanding to other specialties.
MTDHN: Can you tell the readers about the kinds of companies that you're currently working with?
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RR: We have served HSM Solutions, for the past 15 years, as well as companies like Ashley Furniture and CommScope. We encounter a variety of needs and perspectives in the self-insured market depending on the size of the employer, and whether they are public or private companies. We typically work with their benefits consultants to support with claims analysis, plan design, communications and implementation of our medical travel option to their members.
DM: We have direct contracts with employers, and we work with third-party administrators, care navigators, and others. For the most part, the employer groups are self-funded, because they realize the direct savings from these initiatives, but there are situations in which an insured company or individual reach out to us as well. We’ve had some preliminary discussions with stop-loss insurers about integrating services for their clients.
MTDHN: Do you see any opportunity to work with a Medicare Advantage Plan for the United States?
RR: We have talked about it to a couple of players that have tried to implement solutions in that arena, but it has not gone beyond theoretical because they have found some hard limitations when they try to structure it.
They do find there are some issues they run into when they begin to propose this where some of them are more political in nature. I think it will happen eventually and there will be plans that begin to offer these.
DM: Medicare Advantage is a very interesting question because it's a public program administered through a private insurer. One of the challenges is getting the insurers to appreciate the fact that something with a Medicare label doesn't have to stop at the border as traditional Medicare does. Because Medicare Advantage insurers are also private health insurers, they tend to utilize their existing medical networks. That’s a challenge on both sides of the medical travel equation. I’ve spoken with some who understand the advantages but have a hard time determining how to integrate medical travel without disrupting relationships in their existing provider networks. I’m encouraged that some are willing to talk about it.I share Rajesh's feeling that it's going to expand in terms of opportunity, but it may happen slowly.
BC: About 10 to 12 years ago, there were two different Medicare Advantage Plans that came to Costa Rica and had us do a lot of work going through different things to see if it was feasible. At one point it looked like they were going to do something but neither one of them actually panned out. But it has been something that has been on the radar.
RR: I think that there are some intrinsic challenges there, anything that has the big insurers kind of diverting traffic is going to create issues for them.
MTDHN: Can you explain the COVID-19 situation in Costa Rica? What are the policies for U.S. citizens traveling? Do
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they need vaccination proof? Do they need to have testing?
We're averaging less than about 200 cases per day. Numbers are lowering as vaccines roll out. It'll take a while to get the whole country but every week more and more populations are being vaccinated.
BC: Costa Rica is doing quite well. The borders were closed from about March to October. There were a few states open in a few countries, but everything opened as of November.
DM: Costa Rica now requires for entry that visitors purchase an insurance policy that covers medical care for COVID-19 as well as accommodations should they need to be quarantined. I think this is a really positive move by the government to make sure that everyone is well protected and the people are able to isolate effectively.
There was a previous requirement for a COVID-19 test, but they do not require it anymore because of the robust protocols in place for tourists.
The government seems to have done a very good job of managing social distancing and other kinds of protective measures. They have been very successful to the point that the country was able to fully open its air borders, as Brad said, in early November to international travelers.
U.S. citizens will however have to get a test before returning home as per the U.S. protocol. For medical travelers, before they go to a hospital for surgery, they do have to have a COVID-19 test and must test negative before they can have surgery.
MTDHN: What happens if a traveler tests positive before returning to the United States? Do they quarantine in Costa Rica for two weeks?
DM: Yes. Airline passengers traveling into the United States are required to have a negative COVID-19 test, either PCR or antigen, within three days of their flight back.
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Other nations have similar requirements. In the unlikely event someone tests positive, they are required to comply with the Costa Rican quarantine requirement. At the hospital, we've been able to continue to serve patients who are in the country from around the world. Unlike what U.S. hospitals experienced during the pandemic, at Hospital CIMA, we were able to continue to provide our full range of medical services without interruption. As Brad mentioned, any surgical candidate will receive a COVID-19 test as part of the treatment package. If someone tests positive for Covid, there is a required quarantine, and then and then we can do the procedure at the end of that period. For emergencies, we instituted a set of COVID-19 related protocols so that our staff knows they're working with a patient who's tested positive and are taking additional safety measures to protect both the patient, doctors and nurses in operating room and others in the hospital. Outside the operating room, we have had a dedicated unit for COVID-19 patients both in the medical-surgical rooms in the hospital as well as our ICU in order to care for them and minimize the spread of the disease.
MTDHN: Do you think there is going to be an upsurge in the medical travel industry, not only to Costa Rica but around the world?
RR: Absolutely. We have witnessed a pent-up demand due to the reduction of international travel during the first several months of the pandemic. Several patients waited patiently for the borders to open. It created a good test case for us to see how well the carefully established COVID-19 safety protocols were working. Thankfully, we haven’t had a single of a medical traveler being quarantined or testing positive. Medical costs are likely to continue to rise disproportionately in the U.S. as compared to the rest of the world. Trends suggest that medical travel will continue to grow as a desirable solution especially for those who cannot obtain affordable, high quality care in their local markets.
DM: There is clearly a pent-up demand for medical care in the U.S. that is not yet fully relieved. Many people were not able to receive surgeries they planned for due to U.S. hospitals having to suspend certain kinds of medical procedures in 2020. Most of those medical needs didn't go away; the patients just had to wait. I do think, though, that it may rebound slowly as people become comfortable with international travel again. We are, however, seeing the early stages of that. From a self-funded employer plan perspective, what you would have perhaps seen as savings on the surgical care side were unfortunately replaced by COVID-19 care expenses. Those two things continue into 2021 and are going to create an additional financial push for self-funded employers. Destination-based care especially coordinated the way IndusHealth, Medical Tours and CIMA put it together, gives employers an immediate opportunity to relieve that demand and get relief from the increased costs they may face, the impacts on stop loss insurance and other things, in ways that are meaningful without having to sacrifice quality of care. That in many ways is the real story of the benefit of medical travel to through this team.
RR: Basically, medical travel is an experience driven business in the sense that if patients and plan sponsors don't have a good experience, there's no business to be had. Patients returning home and talking about their experience is the key to generating interest in their communities and amongst their coworkers. Costa Rica has certainly done a great job of creating an environment where people will talk about it a lot. When people first hear about Costa Rica, most don't know where exactly it is but once they experience the program, they all want to go there, because they get such good care.
BC: Our jobs are to make sure that the whole process of traveling to Costa Rica for care is seamless. We take care of every detail for the patients. We assist them through the whole process of getting to the hospital and coordinating with doctors.
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If you picture yourself as a patient in the U.S., generally after surgery, a day or two later, you're back home. You're dealing with your spouse, the kids, who's going to feed the dog and what you are going to eat. Basically, that's why the experience is so different here, in this beautiful country. You are recovering, being visited by a nurse every day, doctors review your progress daily and you have physical therapy. There's a lot of things that go beyond what you would normally expect that really surprise the patients. We get patients that have come back after a surgery if they need something else done because they recognize how different this process is here.
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MAY CONNECT FROM ANYWHERE (CFA) EVENTS Medical Travel Seminar - May 5 Featuring Colombia, a World-class Medical Destination ProColombia is the entity in charge of promoting international tourism, foreign direct investment, non-traditional exports and the Country Brand of Colombia. It is committed with the promotion of Colombia as a medical destination.
ENDEAVORS Colombia has been placed as
· 1st country in Latin America · 10th place worldwide in the ranking of the medical tourism
· 2nd Place worldwide with lower costs associated with medical tourism
24 Colombian clinics and hospitals are included among the 58th best in Latin America
· 22nd best health system in the world according to the World Health Organization (WHO). Last year Colombia marked 16 years of uninterrupted work in the development of Colombia's unique health accreditation system that the Colombian Institute of Technical Standards (Icontec) has been responsible for implementing in the country's Health Care System. In its continuous search for excellence, the Joint Commission International has already recognized five Colombian institutions for their maximum quality in the services provided. Colombian medical institutions have also obtained other international accreditations like CARF - Commission on Accreditation for Rehabilitation Facilities, New Palex, Temos International, PlaneTree, among others. The 5 clinics accredited by the (JCI), recognized for their top quality services in medical specialties such as oncology, cardiology, fertility, bariatric surgery, ophthalmic surgeries, and comprehensive medical examinations are committed to working with international insurance companies assuring high quality
standards, technology and infrastructure, knowledge, warm services and innovation, thus giving patients a well-rounded option to treat different types of procedures and obtain satisfactory results. Centro Médico Imbanaco, located in Cali; Fundación Cardioinfantil, in Bogotá; Hospital Pablo Tobón Uribe, in Medellin; Hospital Universitario Fundación Santa Fé de Bogotá; and FCV institutions-Hospital International de Colombia and Instituto Cardiovascular, are committed to providing the best care to international patients. Colombia today is the perfect and emerging medical destination that offers integral care for many of the complex medical procedures supported by service quality, stateof-the-art technology, flight connectivity and competitive prices. With a population close to 50 million people, Colombia has a well-developed health care system with experienced professionals capable of performing highly complex medical procedures, with an exceptional care for every patient focusing on the quality of life. Current times have called for major adjustments, thus making sure we make all effort to best handle the pandemic with the use of technologies at the point-of-care, creating a mobile app (CoronApp) that uses artificial intelligence to actively search for contacts with positive cases, early detection in affected areas and providing alerts about nearby people with a positive diagnosis for COVID-19. With this and many other initiatives, Colombia has managed to be the first country in the world to adopt the Tourist Biosafety Seal, Certified Check-in, created by the Ministry of Trade, Industry, and Tourism and endorsed by the World Tourism Organization, which makes Colombia a medical destination ready to receive visitors following strict safety measures. Cost: Free to both SIIA members and non-members
Advocacy in Action - May 11, 2021 With a new Administration and new Congress in Washington, DC, 2021 promises to be a very active year with regard to legislative/regulatory developments affecting the companies involved in the self-insurance/captive insurance marketplace. To keep members informed about what they need to know, SIIA’s government relations team will be holding a monthly webinar series from January through June.
Direct Contracting Forum - May 18-20, 2021 There has been increasing attention in recent years about emerging opportunities for self-insured health plans (payers) and medical centers (providers) to work together in the form of provider direct contracting arrangements.
MAY 2021 55
ENDEAVORS To help encourage the growth of this market segment, SIIA is pleased to offer this unique educational event that has been designed to provide both payers and providers with practical guidance on how to navigate each stage in the “life cycle” of direct provider contracting arrangements. Each of the component educational sessions will incorporate both payer/employer and provider perspectives along with real world case study examples. The live format will also encourage audience interaction. For those organizations interested in entering this market segment, as well those already in it that want to “up their games,” this is simply a must attend event.
Networking Happy Hour - May 27 The casual “happy hour” format will start with an interactive trivia contest and then will prompt participants to rotate among small group video chat rooms to maximize connection opportunities. Following the conclusion of each event, an attendee list with complete contact information will be provided to all participants to facilitate easy follow-ups for anyone you connect with live.
Date: Thursday, May 27, 2021 Time: 5:00 p.m. to 6:30 p.m. EDT Cost: This is a free event for SIIA members only. For more information including webinar details and registration on all CFA events please visit www.siia.org.
NEWS FROM SIIA MEMBERS
2021 MAY 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 firstname.lastname@example.org. 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 and email@example.com. 58
NEWS DIAMOND MEMBERS RENALOGIC NAMED 2021 GALLUP EXCEPTIONAL
WORKPLACE AWARD WINNER Phoenix, AZ — Renalogic, a leader in dialysis cost containment and risk management, has received the 2021 Gallup Exceptional Workplace Award (GEWA). This award recognizes the most engaged workplace cultures in the world. In a year filled with unprecedented challenges ranging from the COVID-19 pandemic and civil unrest to political polarization, Gallup found that Renalogic has shown exceptional resilience and support for their employee base. “In 2020, organizational cultures saw historic threats. It took an exceptional amount of resilience for organizations, and their employees, to make it through,” said Jim Harter, Gallup’s chief scientist of workplace management and wellbeing. “The abundance of well-managed and highly inspired teams inside Gallup Exceptional Workplace Award-winning organizations puts them in a particularly strong position to adapt quickly to meet the needs of their customers.”
“As we all know, the last year has been a challenging one. Our growing team has relied on Gallup’s Strengths-Finder, the Q12, and our strong commitment to organizational health to keep us focused on what matters; our mission, our clients, and our members.” been instrumental in shaping our culture." Lisa Moody, Renalogic CEO said.
About Renalogic, Inc Renalogic has been the industry leader in dialysis cost containment for nearly 20 years and continues to innovate through the impact of the Kidney Dialysis Avoidance Program. We continue to revolutionize the industry by delivering predictive analytics to identify the progression of the disease, simplifying the costs and clinical complexities of chronic kidney disease to make a positive impact and reduce the dialysis incidence rate in every population we touch. Every chronic condition leading to End Stage Renal Disease is manageable and even preventable when identified early. Contact Carrie Tedore, Senior Director of Marketing, at firstname.lastname@example.org and visit renalogic.com.
The GEWA winners’ ratio of engaged employees to actively disengaged employees is 14 times higher than the international average. Worldwide, only 22% of employees are engaged — that is, committed to their work and connected to their workplace — and just 39% of employees in the U.S. workforce are engaged. Seventy-three percent of employees at winning GEWA organizations are engaged. “We are elated to be recognized by a company whose tools and approach have
MAY 2021 59
NEWS VĀLENZ® ANNOUNCES ACQUISITION OF KOZANI HEALTH
About Gallup Gallup delivers analytics and advice to help leaders and organizations solve their most pressing problems. Combining more than 80 years of experience with its global reach, Gallup knows more about the attitudes and behaviors of employees, customers, students and citizens than any other organization in the world. Gallup delivers the art and science of what’s humanly possible to help leaders and organizations achieve breakthroughs in customer and employee engagement, organizational culture and identity, leadership development, talent-based assessments, entrepreneurship, and wellbeing. Visit gallup.com.
Kozani Health integrates as ValenzProteKHtTM for complete and comprehensive bill review solution PHOENIX, Ariz. —Vālenz® announced it has acquired Kozani Health, integrating a new and innovative means for self-funded employers and the self-insured community to control costs across the life of a claim. Kozani Health, which provides customized solutions to meet the challenges of paying medical claims appropriately, joins the ever-expanding Valenz ecosystem of data and solutions as Valenz ProteKHtTM. The new solution offers detailed line-by-line bill reviews performed by nurses, certified coders and practicing specialists to uncover inappropriate billing and care provided. With success rates averaging 70 percent, Valenz ProteKHt is the industry’s recognized comprehensive and complete bill review solution. Valenz ProteKHt offers clear, defensible, transparent and plan-specific reviews that deliver savings of 10-30 percent above the PPO allowable with a signed contract, agreed upon and authorized by the provider.
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“We are excited to welcome Kozani Health as part of our data-driven Valenz ecosystem,” said Rob Gelb, Chief Executive Officer. “By bringing our teams together, we are providing selffunded employers and the self-insured community improved cost savings at each step in the life cycle of a claim, strengthening their ability to realize every opportunity to balance cost, quality and utilization under the Claim Cost ArcSM. Our solutions aside, which clearly align value for all, our cultures and the commitment to customer service and ‘customer love’ will be a continuing defining characteristic of our now, collective success.”
Valenz is focused on changing the trajectory of healthcare expenses, creating new opportunities for selfinsured employers to control costs while empowering members to lead strong, vigorous and healthy lives. Valenz delivers a 20-40 percent improvement in savings from traditional health plan approaches by bridging the divide between robust analytics, care management, high-value provider networks, payment integrity and claim management. “We are energized to begin our company’s next chapter as Valenz ProteKHt,” said Michael Scott, Chief Executive Officer and Co-Founder of Kozani Health. “Integrating our claim management solutions into the Valenz ecosystem will accelerate the growth and evolution of our services and bring value to our customers.” “With this integration, we assure clients they will experience the same close partnership and personal attention as they have with Kozani Health,” said Heather Wilson, Chief Operating Officer and Co-Founder
“Now, we can also offer the benefit of being part of the Valenz ecosystem. Together, we are committed to nurturing the same ‘customer love’ that has made Kozani Health a symbol of success in the market.” of Kozani Health.
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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 connects cost and quality data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim), complete bill review (Valenz ProteKHt), and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) for smarter, better, faster healthcare. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
Great Point Partners, founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm with approximately $1.3 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, which has $307 million of committed capital. Great Point manages capital in private (GPP I, $156 million and GPP II, $215 million of committed capital, and GPP III) and public equity funds. Great Point Partners has provided growth equity, growth recapitalization, and management buyout financing to more than 200 growing healthcare companies. The private equity funds
About Kozani Health Kozani Health, headquartered in Mesa, Ariz., provides customized bill review sign-off and bill audit solutions to analyze pricing, coding and care provided to ensure appropriate payment. Since its inception in 2015, Kozani Health has forged long-term customer relationships and continuously improved solutions to solve customer challenges.
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Learn more about our expedited onboarding model at trustmarkbenefits.com/SIIA Self-funded plans are administered by Trustmark Health Benefits, Inc.. ©2021 Trustmark Health Benefits® R45021-02
Comprehensive and complete bill review solutions Kozani Health has joined the Vālenz® ecosystem of data-driven solutions as Vālenz ProteKHt™ to provide you with transparent cost savings at each step in the life cycle of a claim. With clear, defensible, transparent and plan-specific reviews, Vālenz ProteKHt™ ensures appropriate and accurate charges are accounted for on every line of every claim. Vālenz ProteKHt™ delivers savings of 10-30 percent above the PPO allowable with a signed contract, agreed upon and authorized by the provider. Our enhanced bill review solutions join the Vālenz ecosystem in strengthening your ability to realize every opportunity to balance cost, quality and utilization.
Get started on the path to smarter, better, faster healthcare with Valenz ProteKHt™ today. Call 904-414-3213 or visit valenzproteKHt.com.
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NEWS invest across all sectors of the healthcare industry with a particular emphasis on biopharmaceutical services and supplies, pharmaceutical infrastructure, alternate site care, medical device and information technology enabled businesses. The firm pursues a proactive and proprietary approach to sourcing investments and tuck-in acquisitions for its portfolio companies. Reach Great Point at 203-971-3300 or www.gppfunds.com
· Focused Edition - This option also focuses on member and plan savings through RBP; however, the standard balance bill settlement is offset with pre-care steerage to friendly providers and AMPS America contracted providers to reduce member abrasion and pushback.
GOLD MEMBERS ADVANCED MEDICAL PRICING SOLUTIONS (AMPS) ANNOUNCES
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LAUNCH OF THREE NEW PRODUCT PACKAGES TO REDUCE HEALTHCARE SPEND
ATLANTA -- Advanced Medical Pricing Solutions (AMPS), a pioneer in healthcare cost containment, launched its innovative product solutions with three distinct offerings. The packages include the following:
· Core Edition - This solution focuses on member and plan savings through reference-based pricing (RBP).
Reimagine. Rediscover. Benefits
Looking for a transparent way of paying for medical care? Maybe now is the time to look at reference-based pricing. For more information, contact Mike Benson | Mike.Benson@umr.com 66
focuses on balancing member savings and member experience. The savings and reduction in provider pushback are through AMPS America contracts and care navigation services. Member abrasion is also reduced by the rapid response to balance bills where the AMPS provider relations team settles after the second balance bill.
NEWS Additionally, each package has optional add-on services, depending on client needs. These options can further reduce healthcare costs for both the employer and their employees. Drexi, an AMPS company, is one of those options. It is a non-traditional pharmacy solution that enables savings by transparent pricing and pass-thru on prescription medications. Additionally, stop loss coverage is offered that is competitively priced and specifically tailored to AMPS's RBP performance, experience and 15+ years of accumulated data. AMPS has a history of providing highly successful cost containment solutions to
the self-funded employer market and these new package bundles are part of AMPS's strategic vision to further reduce the impact of healthcare costs through a variety of products and services. These new product packages are much more than an RBP solution as they address most healthcare costs associated with self-funded employers, allowing for an effective long-term solution to healthcare spend. Not only does this include savings on medical and pharmacy, but also offers stop loss coverage options and other risk management solutions. This type of integration allows AMPS to drive savings on more than 90 percent of the benefit expense associated with a self-funded group, saving employers up to $4,000 per employee per year. "AMPS has always been focused on making healthcare dollars go further for our clients," said Kirk Fallbacher, AMPS president and CEO. "We are continuously exploring new opportunities for cost-effective solutions and enhanced member experiences. With AMPS's new spectrum of programs, it allows our clients to discover additional savings while, at the same time, promote high-quality patient care."
Health Benefits Consulting Suite ( Simulate expected plan changes
and calculate precise claim rates
( Identify a risk-appropriate self-
DELIVER MORE at Every
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( Calculate optimal budget rates
and model impact of forecasted enrollment Generate a refined, actuarially sound IBNR easily and quickly
Actuarial Advisor ( Build credible rates for groups of
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( Project first dollar, specific,
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Corporate Solutions You want unparalleled customer service. Employers need the right stop loss coverage. At Swiss Re Corporate Solutions, we deliver both. We combine cutting-edge risk knowledge with tech-driven solutions and a commitment to put our customers first. We make it easy to do business with us and relentlessly go above and beyond to make stop loss simpler, smarter, faster and better. We’re addressing industry inefficiencies and customer pain points, moving the industry forward – rethinking employer stop loss coverage with you in mind. corporatesolutions.swissre.com/esl
Employer Stop Loss: Limit Health Care Exposure. Advancing Self-funding Together.
Insurance products underwritten by Westport Insurance Corporations and North American Specialty Insurance Company. © Swiss Re 2020. All rights reserved.
As healthcare costs continue to rise with little to no transparency, AMPS's new product packages provide employers and their employees true cost savings through innovative approaches and tools that provide clarity into the process. About Advanced Medical Pricing Solutions (AMPS) Advanced Medical Pricing Solutions (AMPS) provides market-leading healthcare cost containment solutions serving self-funded employers, brokers, TPAs, and reinsurers. The 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 Kelly Neumeier, Director of Marketing, at kneumeier@ advancedpricing.com and visit www.amps.com.
SILVER MEMBERS 6 DEGREES HEALTH WELCOMES DOUG HANSON AS CHIEF OPERATING OFFICER
Hillsboro, OR- 6 Degrees Health is pleased to announce that Doug Hanson has joined the company as Chief Operating Officer. Doug is an operations veteran with over 20 years of leadership experience. He has built a career accelerating growth and driving operational efficiency across a variety of companies, including Amazon, Microsoft, Grubhub, and VividSeats. He brings extensive experience in sales, marketing, operations, and customer service. During his tenure, Doug was instrumental in getting the Amazon grocery business started and later launching Prime Now. He helped guide Grubhub through rapid growth, exceeding street expectations, and surpassing a billion dollars in revenue. At VividSeats, he built a world-class analytics department that unlocked revenue opportunities and improved profitability. Doug’s unwavering focus on the customer while using data to make decisions has been vital to his success. Doug can be reached at email@example.com. "Doug was a key addition to our team. His success in rapidly scaling businesses while remaining customer-obsessed made him a natural fit for 6 Degrees Health. We're excited about the work he's already started and look forward to this next chapter for 6 Degrees." -Scott Ray, Chief Executive Officer
About 6 Degrees Health 6 Degrees Health is built to bring equity and fairness back into the healthcare reimbursement equation. Industryleading MediVI technology supports our cost containment solutions with objective, transparent, and defensible data. 6 Degrees Health’s solutions include everything from provider market analyses, reasonable value claim reports, ad hoc claim negotiations, evergreening provider contracts, and referenced-based pricing. Our veteran cost containment team partners with health plans and their channel partners to deliver unparalleled cost containment results. Visit www.6degreeshealth.com.
SELF INSURANCE INSTITUTE OF AMERICA, INC. 2021 BOARD OF DIRECTORS
CHAIRMAN OF THE BOARD* Robert Tierney President StarLine Osterville, MA
Mike Ferguson SIIA Simpsonville, SC
DIRECTORS Thomas R. Belding President Professional Reinsurance Mktg. Svcs. Edmond, OK John Capasso President & CEO Captive Planning Associates, LLC Marlton, NJ
Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston Salem, NC
Laura Hirsch Co-CEO Aither Health Carrollton, TX
TREASURER AND CORPORATE SECRETARY*
Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN
Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA
Lisa Moody President & CEO Renalogic Phoenix, AZ Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN
*Also serves as Director
SIEF BOARD OF DIRECTORS Nigel Wallbank, SIEF Chairman
Directors Freda H. Bacon Les Boughner Alex Giordano Virginia Johnson Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP
SIIA NEW MEMBERS MAY 2021
REGULAR CORPORATE MEMBERS
Kyle Mrotek Actuary Actuarial Advantage, Inc. Sussex, WI
Sheila Davis Director, Business Development Beacon HCI Salem, VA
Todd Kuehl Vice President, Employer Sales Bright HealthCare Inc. Minneapolis, MN
Carol Bahl HR Manager Gravie, Inc. Minneapolis, MN
SILVER MEMBERS Doug Hetherington CEO/Founder Health 2 Business Boise, ID
Angela Phillips President Phillips Tube Group Middletown, OH
Brad Zappin Prizm Financial Company Cincinnati, OH
Anthony Barrett Vice President, Strategy Capital Rx New York, NY
Thomas Munninghoff Progressive Insurance Limited Covington, KY
Eric Pach President Envision Captive Consultants Phoenix, AZ
Matt Kunish Chief Business Development Officer RiverStone Manchester, NH
Robert Barker Scott National Assurance Company Covington, KY
Brigitte Dayton Berry Employer Relations Cancer Treatment Centers of America Goodyear, AZ
Josh Sweeney Treasurer Jake Sweeney Automotive Cincinnati, OH
Charlynn Harless President & CEO Legacy Enterprises Benefits Consulting, Inc. Stockton, CA
SIIA NEW MEMBERS MAY 2021
EMPLOYER CORPORATE MEMBERS
David Haeussler,Sr., DVM CEO Animal Care Centers of Cincinnati Lebanon, OH
Scott Flannery CFO Blue Grass Stockyards Lexington, KY
Kimberly Trapp President Bobcat Enterprises, Inc. Hamilton, OH
Matt Kramer Vice President - Finance & Accounting Brandicorp Bellevue, KY
Jason Manni CFO Cincinnati Commercial Contracting, LLC Cincinnati, OH
Scott Crader President Crader Distributing Company Marble Hill, MO
Dewayne Vaught CFO Kenwood Dealer Group Mason, OH
Dennis Kuna President DMK Industries, Inc. Middletown, OH
John Rhodenbaugh Manager Kutol Products Sharonville, OH
Bruce Medd Controller Fromm Family Foods Mequon, WI
Olu Oye President Maxmed Healthcare, Inc. San Antonio, TX
Rachel Rorie President GroundSystems Cincinnati, OH
E. Richard Newman Newman Tractor, LLC Verona, KY
Bob Rack Holland Roofing Florence, KY
Jason Langhammer COO Quality Gold, Inc. & Affiliates Fairfield, OH
Paul Cluxton General Manager Kelsey Chevrolet Greendale, IN
Michael Langhammer CFO Quality Gold, Inc. & Affiliates Fairfield, OH
SIIA NEW MEMBERS MAY 2021
EMPLOYER CORPORATE MEMBERS
Neil Hoynes Ripple Junction Design Company West Chester, OH
Jay McKim CFO Sovereign Healthcare Mission Viejo, CA
Carol Weinstein CFO TruStaff Management, Inc. Covington, KY
Scott Soutar CFO Valco Cincinnati, Inc. dba Valco Melton Cincinnati, OH
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.
IS 1 TRILLION
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 2021 Zelis. All rights reserved.
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)