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April 2017

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STATE OF

EMERGENCY How to assess the cost, quality and value of hospital services

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April

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC) Postmaster: Send address changes to The Self-Insurer P.O. Box 1237 Simpsonville, SC 29681

Editorial Staff PUBLISHING DIRECTOR Erica Massey SENIOR EDITOR Gretchen Grote CONTRIBUTING EDITOR Mike Ferguson

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EMERGENCY

DIRECTOR OF OPERATIONS Justin Miller DIRECTOR OF ADVERTISING Shane Byars

By Bruce Shutan

EDITORIAL ADVISORS Bruce Shutan Karrie Hyatt

2017

Volume 102

16 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 22

Opioid Epidemic, Substance Use, Predatory Treatment Facilities, & Complex Case Management Considerations

A Year Later . . . Montanile Remembered, Lessons Learned

Editorial and Advertising Office P.O. 1237, Simpsonville, SC 29681 (888) 394-5688

2016 Self-Insurers’ Publishing Corp. Officers

James A. Kinder, CEO/Chairman Erica M. Massey, President Lynne Bolduc, Esq. Secretary

Life Insurance Captive Reinsurers Are

Alternative Places of Service: An Era of Rapid Growth

Stepping Out of the Shadow

SIIA Endeavors

News from SIIA Members

By Karrie Hyatt

April 2017 | The Self-Insurer

STATE OF

EMERGENCY By Bruce Shutan

How to assess the cost, quality and value of hospital services

hile more self-insured employers are using reference-based pricing to settle or even prevent balancebilling disputes involving a range of hospital services, thereâ&#x20AC;&#x2122;s a much larger challenge afoot. The fact is that many payers struggle to objectively assess the cost, quality and value of these potentially sky-high bills in the first place in the absence of enough credible information. All hospitals and providers negotiate different prices on various services with multiple insurance carriers after in-network discounts apply. Industry observers argue that the resulting cost patchwork isnâ&#x20AC;&#x2122;t only arbitrary, confusing and unfair to payers, but perverse and even absurd.

STATE OF EMERGENCY | FEATURE

They also note that published evidence suggests higher cost does not necessarily equate to higher quality, which is the operative word. “There is not an abundance of ubiquitous quality measures on the outpatient side, although I do think the industry is improving,” observes Bill Kampine, an economist by training and SVP of analytics for Healthcare Bluebook.

weighted average calculation designed to steer their health plan members to safer hospitals by virtue of a lower co-payment, reduce infection rates and avoid more costly care. She hopes data will be available by summer to assess how the effort is working.

So what can the self-insured community do to avoid a string of seemingly endless uphill battles when it comes to assessing hospital care in a meaningful way?

Doran is heartened by Medicare’s collection of overall hospital ratings that allow for more meaningful facility comparisons. He says the challenge for self-funded health plans and TPAs is to incorporate price, quality and outcomes into their recommendations given the dearth of information about those latter categories in most networks.

The only way to make rational decisions is if payers and their partners are armed with useful information, resources or tools, according to Tom Doran, president of Medical Risk Managers. In keeping with that spirit, the objective is to let transparency and evidence-based guidelines drive the process over, say, word-of-mouth recommendations from friends or family.

Making data comparisons The federal government certainly recognizes the difficulty associated with credibly assessing hospitals. Mary Barton, VP for performance measurement with the National Committee for Quality (NCQA), notes that the Centers for Medicare and Medicaid made a substantial investment in Hospital Compare. CMS describes the effort as “a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients.” It’s a potential treasure trove of information that can help payers avoid having slogging through hospital record rooms to obtain helpful data. NCQA decided to use the information to help employers create a

With the health care system so prone to human error, starting with an assessment of mistakes can easily jumpstart a process of elimination en route to choosing the right facility. Consider the results of a Leapfrog Group analysis of Medicare data, which found that hospital errors drive up the cost of care about $8,000 on average per admission. The additional amount tied to surgical-site infections alone varied widely in a study published in 2013 by the Journal of the American Medical Association. For example, while Medicaid and Medicare paid an extra $900 and $3,000, respectively, commercially insured payers shelled out an eye-popping $57,000 per case. Leah Binder, president and CEO of the Leapfrog Group, thinks self-insured employers would benefit greatly by helping employees pick safer hospitals to eliminate preventable errors, as well as save money

Leah Binder and lives. Her group’s hospital focus is on the quality and safety of inpatient care, as well as how their efficiency can apply to the bottom line. Preparations also are being made to rate the exploding volume of outpatient and ambulatory surgical services.

“We don’t look at pricing per se, though we strongly support price transparency,” Binder reports. “It is remarkable how much is wasted in health care because of poor quality.” Her list is long and includes inappropriate or overused care, as well as rampant safety problems tied to hospital-acquired infections, errors, accidents and misdiagnoses. Landing the best surgeon in the world is meaningless if a patient ends up with an infection that is debilitating for months or results in death, she adds.

April 2017 | The Self-Insurer

STATE OF EMERGENCY | FEATURE

From a population point of view, Barton believes in the importance of “excellent infection control” so that patients who need, say, a hip replacement, knee arthroscopy or bladder operation aren’t “at risk for some misadventure by virtue of going into the hospital.” At the consumer level, Doran believes increasing adoption of high deductible health plans (HDHPs), along with online comparison-shopping tools, will force positive changes. To wit: employees will be more vigilant when seeking hospital services and the marketplace will need to meet the mounting demand for more transparent information about price and quality. But providers also have a critical role to play in shaping a more reasonable marketplace. Despite all the talk about value-based contracting in Medicare and on the pharmacy side, Doran doesn’t see much movement with regard to rewarding physicians who improve health outcomes. He recalls a riveting conference presentation by Marty Makary, M.D., a Johns Hopkins surgeon and professor of public health, tying outcomes data to practice patterns for a group of surgeons. Makary is the author of “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare.” The provider community at large needs a nudge to embrace this approach on a mass scale, Doran suggests. Another potential improvement would be if all were willing to at least pool their aggregate data to help determine the best possible outcomes across a number of hospital procedures, he adds. Binder is bullish on transparency and the free flow of data in ways that’s relevant to decisionmaking are critically important to assessing hospital cost, quality and value. “If I’m a clinician, and now I get a feedback on all of my patients who went to a different hospital, maybe the health plan could send me a summary of what happened,” she poses.

Her point is that attaching quality indicators to the discharge summary could result in better recommendations that are based on a hospital’s track record. Providing automatic feedback on every hospitalization to primary care clinicians would help break down silos that have been built up over time. “As a result,” she explains, “now we’ve got to tunnel a bit to get the free flow of information.”

Metrics and algorithms Mindful that payers cannot manage what they cannot measure, the need for helpful information will continue to guide hospital assessments. Doran cites the importance of several key metrics that always help steer patients to the best facilities. They include mortality and morbidity rates, overnight stays and fee averages, as well as how many operations are performed each year to treat the most costly or serious conditions (the idea being that practice makes perfect). “It gets granular pretty quickly,” he says, “and I think that’s powerful because if you’re going in for a normal service like an MRI or a colonoscopy, where you’re not really expecting anything dramatic, why should you pay three times the average?” This is particularly significant considering the era of HDHPs with coinsurance and co-pays that can quickly drain household finances and cause personal bankruptcy filings. Healthcare Bluebook uses an algorithm to help large self-insured employers identify fair market prices for various hospital services for millions of covered lives in every state and major metropolitan area. Jeff Rice, M.D., co-founded the company in 2007 with Kampine following a startling realization

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involving his then 12-year-old son, whose foot surgery cost ranged wildly from $1,500 to more than $15,000. Together, they’re on a mission to significantly improve the state of health care transparency – working with TPAs and also powering some regional health plans. Transparent pricing, of course, is critically important to HDHP enrollees who need to shop carefully for health care services in the face of rising out-of-pocket costs. Other industry players with similar online platforms or cost-transparency tools include health insurance carriers and technology companies such as UnitedHealthcare, Castlight Health and a Cambia Health subsidiary called HealthSparq. There’s also Leapfrog, which helps employers and other purchasers improve health care quality and safety. The nonprofit reports data on more than 1,800 hospitals and boasts regional partnerships in 38 states. Kampine points to significant and fairly common price differences ranging anywhere from 200% to 1,000% “virtually everywhere

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in the United States for every service that employers pay for and that patients consume.” For example, a hand X-ray that runs $27 in Nashville’s Blue Cross network might be as high as $427 at a hospital or hospital-owned outpatient imaging center. One of the bigger trends afoot is local provider organizations encouraging employers to embrace a narrow network, according to Kampine.

Bill Kampine

“There’s a huge difference in price between independent facilities and hospital-based services,” he explains, noting the need for “an unimaginably large discount” on the latter’s brain MRI to compete with an imaging center price. Similarly, there’s understandable concern that in making a tradeoff to narrow the network, payers may inadvertently exclude some high-performing hospitals.

STATE OF EMERGENCY | FEATURE

The key to success is matching each procedure to the best quality scores. “A hospital may perform brilliantly in terms of heart surgery, but may be an unbelievably poor performer in joint replacement,” Kampine cautions. Healthcare Bluebook uses Medicare claims to objectively evaluate hospitals and avoids self-reported or survey data. Key metrics include risk-adjusted mortality, complications and safety events, as well as best practices or compliance with care standards. Evaluations are then made across 36 clinical categories that can be applied to hundreds of unique procedures and adjusted for volume. Kampine urges self-funded employers to provide easy-to-use, practical transparency tools to their health plan members, who should be rewarded for making good choices when shopping for quality services.

health plan for state employees and their families as an encouraging signal. This proactive approach stands in stark contrast to often hostile stances taken in reaction to often huge balance-billing collections, including legal threats. “They must have been so frustrated with the networks and information that the carriers were providing to do something like that,” he opines. “That is not just evolution; that’s revolution, and I think it starts with determining how much you’re paying, but outcomes are critical as well.”

Looking ahead What the future holds for assessing hospital care is anyone’s guess, but there are some encouraging signs. For example, Binder has noticed that “hospitals are willing to give out that data because they want to be responsive to purchasers.”

Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefits industry for nearly 30 years.

Doran is sanguine about the prospects for a more transparent marketplace. He describes Montana’s embrace of reference-based pricing for hospital contracts in the self-insured

April 2017 | The Self-Insurer

Life Insurance Captive Reinsurers Are

Stepping Out of the Shadow

ince 2012, life insurance captive reinsurance companies, also known as special purpose reinsurance vehicles (SPRVs), have faced scrutiny from both the public and private sectors. 2016 saw several reports released about the sector and a lawsuit challenging the opacity of SPRVs. Critics are calling for transparency, similar to what is required of traditional insurers. The NAIC and domicile regulators are working to create more transparency, while still allowing SPRVs to function as alternative risk transfer vehicles.

Written by: Karrie Hyatt

The controversy surrounding SPRVs began with their rapid growth from 2002 onwards. In the early 2000s, the NAIC adopted Regulation XXX and Regulation AXXX requiring substantially higher reserves for companies writing premium term life insurance policies and some universal life policies with secondary guarantees. While these rules helped to stem strategies being used by some insurers

OUT OF THE SHADOW | FEATURE

to reduce statutory reserves, it created a discrepancy between product pricing and product reserves with some life insurance products requiring a statutory reserve many times higher than the reserves most actuaries would find necessary. Due to this discrepancy, life insurance companies began looking for alternate ways of securing additional capital. Using special purpose financial vehicles was a financially sensible route for commercial insurers to take. Between 2002 and 2014, the niche sector grew from $11 billion to approximately $213 billion (some reports put it at closer to $350 billion).

Recent Developments The NAIC began looking into SPRVs in 2012, when the association formed a subgroup to look into their activities. This was followed in 2013 when New York Department of Financial Services (NYDFS) issued a report calling them “shadow insurers.” The NYDFS was the first to label SPRVs as a “shadow” financial company—a term used to describe a financial intermediary that is not subject to regulatory oversight. That term has become an epithet for SPRVs used by critics of the structure.

subject to the NAIC’s accreditation standards since they operate only in their domicile state. However, SPRVs sometimes will operate in states other than just their domicile. The (F) Committee’s intention to include SPRVs in the accreditation standards is to make their transactions and regulation more transparent. Also in 2014, the Federal Reserve Bank of Minneapolis released a report titled “Shadow Insurance” by Ralph S.J. Koijen and Motohiro Yogo. This report was highly critical of SPRVs indicating that left unchecked captive reinsurers could cause another financial collapse, similar to that in 2008. Although, the report did recognize that SPRVs allowed life insurance companies to grow where otherwise they would be hindered by capital requirements. In 2016, the authors of the report released a revised edition. While still critical of SPRVs, the report was not so inflammatory as the previous version. The data the authors used for the updated report indicates that the sector may not be unstable, but that data used only accounts for a small portion of all active SPRVs. The report calls for more transparency in SPRV transactions in both the U.S. and globally. Last year saw the release of a report by U.S. Office of Financial Research titled “Mind the Gaps: What Do New Disclosures Tell Us About Life Insurers’ Use of Off-Balance-Sheet Captives?” which analyzed NAIC data on SPRVs for the 2014 filing year. About 55% of SPRVs were required to report that year due to exemptions in the reporting requirements.

Even more attention was called to SPRVs in 2014 and 2015 when the NAIC’s Financial Regulation Standards and Accreditation (F) Committee, in the process of revising the Part A: Laws and Regulations Accreditation Preamble sought to include SPRVs of life insurance products. After several revisions and dozens of comments from interested parties, the (F) Committee adopted the revised Part A, which includes these types of reinsurance captives. Captives are not usually April 2017 | The Self-Insurer

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OUT OF THE SHADOW | FEATURE

“Mind the Gaps” made the same endorsements as the “Shadow Insurance” report—SPRVs must be subject to more transparency through financial reporting. In addition to increased reporting requirements already requested by the NAIC in the last three years, “Helpful additional steps would be more disclosure and the adoption of asset quality requirements for captive use for other higher risk product lines, such as long-term care.” The report concluded that “Captives can be an integral part of a life insurer’s operations. They can also cloud regulatory reporting of an insurer’s financial position and create ‘blind spots’ in the monitoring of threats to financial stability.”

The Lawsuit More controversy along the same lines is brewing for SPRVS. Last summer, a lawsuit was filed in Iowa regarding “Shadow Insurers.” In the suit, Joseph M. Belth vs. Iowa Insurance Division and Nick Gerhart, Commissioner, the Plaintiff accuses Iowa Insurance Division of deliberately withholding public information and seeks to have that information made available. The information sought are transactions and financial data from large SPRVs operating in Iowa, such as Transamerica Life Insurance Company. Joseph M. Belth, Ph.D. is professor emeritus of insurance at Indiana University and is an author (Life Insurance: A Consumer’s Handbook) and blogger. After being denied access to his request for public information, Belth called on Commissioner Nick Gerhart to release the information in accordance with an Iowa law that grants the Commissioner discretion to release such data.

The lawsuit states that Belth “Have access to information and documents related to certain kinds of now-secret financial instruments used in the life insurance industry that have the consequence of hiding critical information from policyholders, shareholders, and the public, of the life insurance companies’ potential risks and also lowering the amount of capital that state regulators require life insurance companies to maintain.” According to Belth, as stated in the court documents, Iowa Code § 508.33A: Limited Purpose Subsidiary Life Insurance Companies allows life insurance companies to participate in risky practices such as transferring “substantial life insurance policy liabilities” to their captive reinsurance subsidiaries and then masking “liability exposure” with various types of letters of credit. On the books, this appears to show “excess capital” which in turn allows the life insurer to use “liquid assets away from the capital that is legally required.” While the Iowa Insurance Division monitors such activities, Belth claims that in a “darkened regulatory environment” regulators aren’t looking out for the interests of the public, policyholder, or taxpayer. While the lawsuit is in Iowa and refers to Iowa laws, the case could have a much larger impact. Depending on how the suit is decided, it could become case law for either side of the issue. In many respects, the lawsuit is seeking the same thing that all critics of SPRVs are seeking—more transparency in SPRV transactions and financial disclosures.

April 2017 | The Self-Insurer

OUT OF THE SHADOW | FEATURE

Transparency Captives are not subject to the same financial disclosures as traditional insurers and reinsurers. Therein lies the bulk of the problem. Critics of SPRVs believe them to be “shady” since their financial dealings are not generally released to the public. This leaves regulators reacting to satisfy critics’ need for transparency and the ability for life insurers to make best use of SPRVs.

asset information. Another method that is being implemented is to test an insurers financial standing without including any Letters of credit that are on the books for the SPRV. As state insurance regulators adopt these practices and more SRPVs are subject to increased financial disclosures, critics call for transparency will hopefully be met. However, treating SPRVs more like traditional insurers may have a detrimental effect and decrease their usefulness.

Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.karriehyatt.com.

The NAIC’s Financial Condition (E) Committee Reinsurance Task Force has made strides to improve the reporting of life insurance captive reinsurers, by requiring additional disclosures regarding

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ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:

Practical

Q& A T

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 Womenâ&#x20AC;&#x2122;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, and Dan Taylor 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 and Washington, D.C. law firm. Ashley Gillihan, Carolyn Smith and Dan Taylor are 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 questionerâ&#x20AC;&#x2122;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 john.hickman@alston.com. 16

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Repeal and Replace: What’s In Store for Employer Plan Sponsors: After much anticipation, a “leaked” draft of the House health care reform reconciliation bill became public in mid-February. In less than a week, the final proposal was released and it has now been passed out of the House Ways and Means and Energy and Commerce Committees. Some provisions changed significantly from the leaked draft, including dropping a proposed cap on the IRC 106 employee exclusion for employer provided health and providing income limits on eligibility for the new health coverage tax credits that replace the ACA premium subsidies. This bill, the American Health Care Act (or AHCA), is the first concrete step in the legislative process to fulfill Republican campaign promises to repeal and replace the ACA. While the commitment to repeal and replace remains firm, as we are writing this some details of the legislation have raised concerns among both conservative and moderate Republicans, although the reasons for the concern vary. Debate was fueled by the recently released official cost estimate from the Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT). The CBO/JCT analysis shows budget savings of $337 billion over 10 years but also estimates that 24 million Americans would lose coverage over the same period. Some conservative Republicans argue that the budget savings are not enough, while some more moderate Republicans are concerned about the extent of estimated loss of coverage. These issues are currently being debated and it is possible that there may be some changes as the AHCA moves through the House floor and on to the Senate. Nonetheless, employer plan sponsors will need to know what is in the AHCA in order to evaluate its potential impact if it becomes law (whether significantly revised or not). This article provides a quick recap of the issues of most importance to employer sponsors of health benefit plans and how they are addressed in the current version of the AHCA.

• Delay (but not repeal) of the so-called Cadillac Tax. The IRC 4980I tax on high cost health coverage (the “Cadillac Tax”) is retained in lieu of the leaked version’s proposed employee exclusion cap. However, the Cadillac Tax is further delayed until 2025. The Cadillac tax remains as originally in effect. Thus, unlike the leaked bill, which included a carve-out for HSA contributions for the exclusion cap, the AHCA would continue to include HSA contributions from employers (including pre-tax salary reduction contributions from employees). This issue is likely not over, however, as we are hearing that the employee exclusion cap will likely be part of the tax reform discussion later this year..

• Elimination of so-called “pay or play” taxes under IRC 4980H. The employer shared responsibility taxes are eliminated as they are reduced to zero effective 1/1/16. This would allow employers to revise eligibility language to pre-2015 terms (if desired) – with the only limitations being those that arise under 105(h) for self-funded coverage or insurance contract minimum participation rules.

• ACA premium tax subsidies remain through 2019. The existing premium tax subsidies, with some modifications, would remain in place through 2019. The modifications include allowing the credit for catastrophic plans and certain qualified health plans purchases off Exchanges. Starting in 2020, a new health coverage tax credit would replace the ACA premiums tax subsidies (see below).

• No elimination of ACA Reporting (at least not right away). Unfortunately, applicable large employers (ALEs) will be required to continue reporting offers of coverage during the year to 4980H full-time employees as required by IRC 6056 (Part II of the 1095-C) through the 2019 calendar year (the last forms will be furnished/filed in 2020). The 6056 reporting is relevant not only to the employer shared responsibility taxes but also the ACA premium tax subsidies, which continue through 2019.

• Elimination of individual mandate; the penalty for failure of an individual to have coverage is reduced to zero effective 1/1/16. Thus, the so-called “individual mandate” would cease back to 2016.

April 2017 | The Self-Insurer

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This reporting may be simplified, however, as employers would likely be able to merely look back at the end of the year and identify those who had months with 130 or more hours of service. The complicated “look back measurement” approach is likely no longer required. Since the individual mandate taxes are reduced to zero effective 1/1/16 the reporting required by IRC 6055, which is used to enforce the mandate, should no longer be required. Although the repeal of the mandate dates back to 2016, the ACHA likely will not be adopted before you complete the 6055 reporting (Part III of the 1095-C or Form 1095-B for non-ALEs) for 2016. Starting in 2020, there will be streamlined reporting on Form W-2 relating to the new health coverage tax credit (see below).

• Additional changes of interest beginning in 2018:

o ACA taxes OTHER than the Cadillac Tax would be repealed (including

the sector tax on health insurance premiums, the additional .9% Medicare tax, etc)

o Medicare Part D (prescription drug) expenses would again be deductible AND eligible for the RDS subsidy.

• Provisions to curtail adverse selection. Beginning with special enrollments in

o The Health FSA salary

the 2018 year or annual enrollment for the 2019 plan year in the individual/small group market, if an individual went 63 days or more in the last 12 months without minimum essential coverage, they must pay a 30% surcharge on the premium to the carrier.

o The prescription

The surcharge applies to all late entrants (regardless of health status) and is for a 12 month period.. The bill relies on the existing HIPAA certificate of creditable coverage reporting from plans to identify the duration of coverage. Some changes to the details of the reporting may be appropriate to reflect the specifics of the AHCA.

reduction limit (now at $2600 for 2017) is repealed;

requirement for OTC drugs is eliminated;

o Several significant HSA

improvements go into effect – including an increased contribution limit and a retroactive effective date for eligible expenses (up to 60 days after the HSA is established).

• New refundable tax credit in lieu of premium tax subsidy. Beginning in 2020, the current premium tax credit/subsidy will be replaced with a refundable tax credit that increases with age and is phased out based on income. It can be used to purchase coverage in the individual market (not just the Exchange) or pay for unsubsidized COBRA coverage. It is not available to anyone who is eligible for a group health plan other than COBRA or excepted benefits coverage. This affects employers in several ways:

April 2017 | The Self-Insurer

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o When an employee applies for an advance subsidy to pay for coverage, the application must include a written statement

from the employer that the employee is or is not eligible for coverage. Employers are required to provide this statement upon the request of the employee. The details relating to providing the statement are left to the IRS to determine.

o Employers will have to report offers of group health plan coverage to ALL employees on Form W-2 starting in 2020. It is

not clear whether a reporting requirement will apply with respect to retirees for whom a W-2 is not otherwise required. This new reporting requirement is intended to replace the current offer of coverage reporting under 6056. Note the W-2 reporting applies regardless of employer size. (The current requirement that employers report the cost of coverage on Forms W-2 is not changed by the bill.)

o Employers who provide unsubsidized COBRA coverage (as well as insurers that provide coverage eligible for the new

credit) will have a new reporting requirement with respect to such coverage, including information such as the names of the individuals covered, the amount of the premium and the amount of any advance credit paid. Information on payment of advance credits is required monthly.

o A mechanism for paying any advance credits to employers for unsubsidized COBRA continuation coverage is to be

developed by the IRS. What employers will need to do to receive advance credits will not be clear under the mechanism is developed.

As we go to press, the AHCA is still being debated. All eyes should be on Congress for the next several weeks.

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Opioid Epidemic, Substance Use, Predatory Treatment Facilities, & Complex Case Management Considerations Written by: Richard T. Lindsey, Ph.D., COO & Psychologist, Robert A. Mines, Ph.D., Chairman & Psychologist & Dani Kimlinger, Ph.D, SPHR, SHRM-SCP. CEO

tatement of Problem

There are a number of changes in the USA that are contributing to a serious healthcare problem1. One notable example, is an increase in prescription drug abuse, particularly opioid abuse. As a response states are cracking down on medical prescribers. This has made it difficult for prescription opioid drug abusers to get opiates legally. Rather, they turn to street heroin to get access to cheaper and easier to obtain drugs. These changes have contributed to a rise in the incidence levels of heroin abuse/addiction are rising. Heroin use more than doubled among young adults ages 18-25 in the last decade and increased among genders, most age groups, and all income levels2. The evident result to the healthcare system is an increased demand for services at all levels. Since the Mental Health Parity and Addiction Equity Act virtually eliminated outpatient case management and oversight for both mental health and substance use disorders, the ability of health plans to clinically and appropriately manage their patient populations has been compromised. 22

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The Patient Protection and Affordable Care Act required that dependents up to age 26, married or single could stay on their parent’s insurance plan even if they have coverage through another employer adding additional costs to benefit plans, especially since the types of expenditure caps of the past are no longer tenable under parity. These factors have led to an increase in outpatient costs as providers have reverted to a conservative treatment approach of “more sessions rather than less.” This is equally true at inpatient and residential levels of care and have contributed to an environment where “predatory substance use treatment facilities” have been touting 60-90 inpatient stays despite the fact that evidenced based treatment research has shown that the only difference in outcome between inpatient substance use treatment and intensive outpatient substance use

treatment is a significant cost difference, no sobriety differences. Furthermore, self-insured entities, whether it’s Self-Insured Employers, Captives, Taft-Hartley Trusts, or MEWA Trusts have out of network benefits that pay typically 60% of the cost of out of network care. The predatory facilities are advertising on the internet, paying the cost of airfare for the patient to go out of state (usually to Florida or California), and then charging astronomical fees for care. For example, $4,000.00 a day for inpatient (usual and customary changes are closer to $800.00 - $1,200.00 per day), plus $600.00 to $4,000.00 or more per drug/ alcohol test per day (usual and customary should be $15.00-30.00 per test). Partial hospitalization programs are added to extend care at $2,000.00 instead of $300.00-600.00 per day. There are many treatment add-ons that are billed separately. These facilities purposely limit information to the case management and utilization review teams. The patient is then left with significant healthcare costs after the self-insured entity has paid outrageous fees already. Medical bankruptcy is already one of the most frequent types of bankruptcy. The average employee cannot afford these cost overruns, which they sign paperwork agreeing to pay, upon admission. This is under the duress of seeking treatment and not signing would result in being turned away for treatment at the very time they need care.

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Recommendations

Current Reality

Many self-insured client organizations are facing a crossroads related to their benefits structure. The current models that virtually all of these organizations have are no longer tenable in the current market place due to the exploitation by some, if not most, predatory programs.

As a result of the current policy changes in the field and aggressive online marketing tactics by predatory facilities, case management teams frequently learn of admissions after the fact, and may not hear until a patient has already been inpatient for a number of days. This is most troublesome when we learn that a patient has been admitted to an out-of-state, out-of-network, and extremely overpriced facility.

As a result, we are recommending immediate changes to most of the Summary Plan Designs (SPD). Furthermore, enhanced utilization review criteria are available to implement the next generation of complex case management and further refine the definition of maximal medical improvement.

Case Management When it comes to treatment, we have been guided by a number of core principles that are recommended for application in all care situations. These principles are enumerated below:

1. The best care occurs in the least restrictive environment necessary. 2. The best care occurs in the community in which the patient lives. 3. The best care occurs when the patient and their family system are actively engaged and thoroughly informed about all aspects of their care, including the financial implications, and are as involved as possible in their treatment.

4. The best care occurs when the treatment team actively partners with Case Management teams in all aspects and levels of care that are anticipated, already in progress, or when challenges in treatment occur. These core principles are most critical when patients are admitted, or are being considered for admission, to more restrictive levels of care (inpatient, residential, partial hospitalization, and/or intensive outpatient programs).

Past Reality Due to the parameters of the parity law, all case management and utilization review organizations have lost their authority to manage the full continuum of behavioral health care for patients (assumes the medical care is also not managed on the full continuum), and as a result, have not been afforded the opportunity to intervene as early in problem sequences as has been done historically. In the past, case management teams could craft a clinical intervention treatment plan that minimized hospitalizations and emergency room visits, especially among the most troubled patients, through their ability to coordinate all levels of care and insure an active communication and cooperative pattern between all providers. The end result was a highly treatment-effective, cost-saving system of care.

This compromises our ability to case manage these patients because the teams are arriving late to the scene. They spend significant time and resources catching up, filling in the back story, and attempting to secure Letters of Agreement to help manage the financial impact on the patient. Letters of Agreement from out-of-network providers have become increasingly difficult to secure, exposing the patients and the benefit plans to a level of financial risk that they may not be able to afford or sustain. This de facto decrease in our level of involvement has led to an increase in overall admissions and regrettably to an increase in recidivism as discharge plans are often poorly outlined and inadequately executed. Admissions to predatory treatment facilities represent the most egregious outgrowth because, under the rubric of treating a patient, they are compromising that patient and their familyâ&#x20AC;&#x2122;s future by creating a debt the patient may not be able to financially manage. These predatory facilities are often aggressive in their marketing efforts and ultimately take advantage of patients who are, by circumstance, more vulnerable to manipulation due to their compromised mental health and/or substance use problems. These are the very practices, as history has shown, that were the key factors that initiated the managed mental health care era of the 1980s. April 2017 | The Self-Insurer

Future Reality Most unfortunate are what we see as poorer outcomes, increased levels of recidivism and increased cost to the payor and the individual. As these patterns have become clear, a number of protocol modifications have been identified that can help patients and their benefit plans while remaining soundly within the parameters of the current parity laws. These interventions would include:

1. Have benefit plans review their level of reimbursement to outof-network and out-of-state programs to some percentage (%) of â&#x20AC;&#x153;usual and customaryâ&#x20AC;? charges of in-network fees or to Medicare reimbursement standards.

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2. Ideally, case management would have the authority to deny care outright for treatment at these facilities. However, most current plan designs do not allow that. Case management teams can withhold an authorization for services until they are able to speak directly with the patient (unless medically compromised such that they are unable to do so) to insure that they have been thoroughly informed of all aspects of their care, including the actual cost(s) that they will bear for their stay. In addition, under current in network provider contracts, case management teams may have the authority to deny authorization to facilities for not precertifying care when they are in-network and the facility per those contracts the provider cannot pass through costs onto the patient or family that were incurred without approval. In the out-of-network examples, the patient signs a contract that they will pay the costs regardless of insurance reimbursement or authorization.

3. As a strategy to manage the continuum of care for those going inpatient for either mental health or substance use disorders, we recommend that the case management protocol be expanded to include aftercare follow up which includes required discharge/aftercare treatment plan meetings with a case manager and the facility. This extension is based on the clinical assumption that follow-up aftercare is part of the same episode of care continuum and not a discrete next outpatient episode of care.

This would be similar to viewing after surgery care as part of the surgery continuum of care on the medical side. Authorization for inpatient care can be contingent upon compliance with this and receipt by the case management team of the discharge materials. The case management team will follow the patient and family for their outpatient treatment. The case management team will consult with the outpatient team and family on treatment issues and relapse prevention. It is our opinion that this does not interfere with the intent of the Mental Health Parity Act that medical and mental health benefits be treated the same as far as utilization review and authorization. Please have your attorneys review this and sign off on it.

Complex Case Management Complex Case Management is the next level of care and intervention for those with chronic conditions or who have reached maximum medical/psychological improvement. Engagement of the patient in a “Complex Case Management” protocol occurs when there is evidence of previous treatment failures or repeated relapses with multiple stays. This would involve determining a patient has reached “maximum medical improvement”, due to multiple repeated treatment failures (two or more) at the highest levels of care (e.g., inpatient or residential substance abuse treatment), wherein only detoxification and outpatient (OP) treatment could be authorized thereafter. When there is no clinical evidence that a level of treatment is effective, it is not clinically or fiscally prudent to keep repeating the intervention. For example, liver transplants are not done for those with alcohol dependence unless they have demonstrated a significant period of sobriety as it would be a waste of resources to transplant a healthy liver when the odds were high that this liver would also be compromised by the patient’s alcohol consumption. There is no indication that substance use disorders get better as a function of level of care when the patient is not motivated to change or has not demonstrated behaviorally that they can change as well.

April 2017 | The Self-Insurer

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Other Benefit Considerations 1. Consider excluding coverage for all out-of-state facilities when there are comparable in-state, in-network options available. Emergent care is excepted if episode occurs when patient is out-of-state.

2. Move mental health and alcohol/substance abuse services under a Disease Management Model where the entire continuum of care can be case managed. Engaging in a Disease Management Model of case management is being granted, by the Self-Insured Organization, the authority to review and manage “all levels” of care for the patient, out-patient as well as inpatient, especially if the patient is not following through with treatment recommendations. If disease management models are already in place on the medical side for illnesses such as diabetes, chronic obstructive pulmonary disease (COPD) or others, it is not inconceivable for disease management programs to be put in place for depression or substance use disorders.

When an employee returns to work, engage in the interactive process with the employee determine if there are reasonable accommodation needs. Some accommodations may include time off for treatment or modified work schedules. Time off may fall under FMLA as the time off for treatment not for use of the substance is also protected by the Department of Labor. These areas of law are mentioned as the employees covered under these benefits may need additional case management consideration and coordination with human resources and absence management personnel.

3. Human Resources considerations related to ADA and FMLA. ADA: From a human resources point of view, early intervention and access is important for returning workers to work with full productivity. There may be necessary accommodations and return to work specifications which need to be complied with. Employers have a duty legally to reasonably accommodate known mental or emotional impairments of the applicant or employee unless it imposes an undue hardship on the employer.

When it comes to reducing healthcare costs and plan management, you may need some help. Is what you are doing effective? What are you doing that’s different? Are your employees engaged and willing to help? Are your employees “educated consumers?” Are your employees and management satisfied? The thinking that got us to this point is not the thinking that will lead us out.

Providing access to cost effective provider networks

April 2017 | The Self-Insurer

Our Complex Case Management (CCM) protocol is engaged under the following conditions:

Summary There are three key strategies to consider:

1. Benefit plan design modifications to limit financial exploitation by out of

1. A patient has been re-

network facilities.

admitted to the same level of care for the same or similar diagnosis within a six (6) month period of time.

2. Enhanced case management protocols to effectively intervene at the patient and family level to increase the likelihood of adherence and follow through with complex and/or chronic conditions.

2. Evidence over a number of

3. Utilize a Disease Management Model that is Mental Health Parity

years of repeated admissions to the highest levels of care for the same clinical concern.

compliant to manage the entire continuum of care which was highly clinically effective as well as fiscally successful.

Richard T. Lindsey, Ph.D. is the COO and Clinical Director at MINES and Associates. Robert A. Mines, Ph.D. is the Chairman at MINES and Associates. Dani Kimlinger, Ph.D., SPHR, SHRM SCP is the CEO at MINES and Associates. Information about MINES and Associates health psychology and managed behavioral healthcare services can be found at www.minesandassociates.com

References 1 Johnson, A. & Vincent, L. k. (2015) Mental Health Management â&#x20AC;&#x201C;Substance Abuse Treatment: What your Fund Needs to Know, International Foundation of Employee Benefits Plan Annual Conference, Honolulu, HI. 2 CDC report, Todayâ&#x20AC;&#x2122;s Heroin Epidemic, (July 2015) http://www.cdc.gov/vitalsigns/heroin/

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A Year Later . . . Montanile Remembered, Lessons Learned By: Christopher M. Aguiar, Esq.

hings were going so well. In the game of subrogation cases being heard by the Supreme Court of the United States, self-funded benefit plans under the purview of ERISA were on a roll. First, it was Sereboff v. Mid Atlantic Medical Services, Inc., 547 U.S. 356 (2006), then U.S. Airways v. McCutchen, 133 S. Ct. 1537 (2013). Some even considered Great West Life & Annuity Ins. Co. v. Knudson, 534 U.S. 204 (2002) to have been unfairly viewed as a loss for the subrogation industry because despite a decision against Great West Life, it provided the blue print followed by Mid Atlantic Medical Services, Inc. to elicit the favorable decision that led to the recovery in Sereboff. As is the case in most games, momentum can be lost in the blink an eye.

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Often times, when the momentum is heavily in one’s favor, the successors eventually let their guard down. Enter Montanile v. Board of Trustees of Nat. Elevator Industry Health Benefit Plan, 136 S. Ct. 651 (2016). Montanile was the victim of an accident with a third party who was driving under the influence of alcohol. Montanile’s benefit plan paid approximately $120,000 in medical claims arising from the accident. Following the accident, he sued the driver of the vehicle and obtained a settlement in the amount of $500,000. Settlement negotiations between Montanile and the Plan broke down and his attorney warned the Plan that he intended to disburse the funds to Montanile. The Plan did not respond until almost seven months later when it filed a lawsuit in which the Plan argued that even though Mr. Montanile had spent some or all of the settlement funds, the Plan still had a right to the funds. The Supreme Court disagreed, stating that the Plan would have had an equitable right if it had “immediately sued to enforce the lien against the settlement fund then in Montanile’s possession” and that suing Montanile to attempt to attach his general assets was a legal remedy not available to the Plan under ERISA 502(a)(3). Id. at 658.

In the almost fourteen months since Montanile, there has not been much movement. The case has been cited in several briefs and other cases, but there is nothing of a significant nature to report. That said, in the interest of keeping the issue fresh in everyone’s mind and not allowing the importance of a benefit plan’s third party recovery rights take a back seat, let us take the opportunity to recall the keys to a successful recovery program and some best practices – many of which have received favorable treatment in the few cases that have addressed the problem created by Montanile.

Immediately following the period when the Court announced that it would be granting certiorari and hearing arguments in Montanile, subrogation experts rationalized what they had hoped would be the outcome; mainly, that the highest court in the land would not put forth a decision that effectively allowed plan participants to take the money and run – but we all knew better, and the Court affirmed our fears; that the Plan’s equitable remedy may be extinguished when funds are disbursed.

… The Board protests that tracking and participating in legal proceedings is hard and costly, and that settlements are often shrouded in secrecy. The facts of this case undercut that argument. The Board had sufficient notice of Montanile’s settlement to have taken various steps to preserve those funds. Most notably, when negotiations broke down and Montanile’s lawyer expressed his intent to disburse the remaining settlement funds …unless the Plan objected …. The Board could have – but did not - object. Moreover, the Board could have filed suit immediately, rather than waiting half a year. Montanile at 662.

Plan Language Perhaps the most important thing to remember is that Montanile did not actually change the law. Plan language continues to be the most important consideration in determining whether a plan has a right to 100% reimbursement. Regardless of whether the funds have been disbursed to the participant and/or whether they have been spent on non-traceable assets, if a plan’s language is inadequate, the plan will not be able to enforce its right to a full reimbursement. Montanile did not change the decision in McCutchen, which clearly stated, “In a §502(a)(3) action based on an equitable lien by agreement—like this one—the ERISA plan’s terms govern. Neither general un-just enrichment principles nor specific doctrines reflecting those principles—such as the double-recovery or common-fund rules invoked by McCutchen—can override the applicable contract.” 133 S. Ct. at 1540. Ensuring your plan’s language is as strong as possible remains imperative to maximizing recoveries.

Investigation is the Key The Supreme Court in Montanile disagreed with the Plan’s assertion that its equitable remedy should be enforceable regardless of the whereabouts of the settlement fund and did not appear to have any pity for the burden on the Plan to protect its right. The Court stated:

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The Court’s statements here seem to indicate a pretty clear burden on plans to engage in their own investigations and take any and all steps necessary to protect their interests though it does seem to leave the door open for some flexibility in its decision in a situation where perhaps the facts are different. For example, would the Court have ruled differently if the Plan did not “have sufficient notice” of Montanile’s settlement? This appears to have been the case in AirTran Airways, Inc. v. Elem, 767 F. 3d 1192 (2014). In Elem, the attorney ultimately obtained a settlement of over $500,000 against the responsible driver but told Air Tran that the settlement had been for the insurance policy limit of $25,000. He then inadvertently sent a copy of the $475,000 check of which he had neglected to advise Air Tran. In this case, there appears to have been overt acts to deceive the Plan with regard to the settlement. Would the Court have ruled the same way if faced with these facts? Regardless, to avoid situations like this, the Plan MUST HAVE an effective investigation unit. All too often investigations are halted based on an insufficient self-report. Everyone can agree that a participant that falls down the stairs at home does not present a recovery opportunity; but what if that person’s “home” is a rental apartment and the “fall down the stairs” resulted from a broken stair and faulty railing in the main hallway? If the investigation unit is ill-equipped to ask the right questions or identify when someone is masterfully crafting answers to avoid the question without lying, a plan will miss recovery opportunities.

BULLDOG TENACITY. GREYHOUND SPEED.

And the Key to Investigation is Data A high quality investigation unit is a pivotal part of any recovery process, but access to a plan’s data is where it all begins. The Court’s decision in Montanile effectively put a ticking clock on a plan’s recovery rights. The earlier a plan is involved, the better chance it will have to be aware of potential recovery opportunities and on top of the availability and whereabouts of the potential recovery funds. The most effective way to do that is to both be able to access claims data and also be able to expertly analyze and identify opportunities in the data. When paired with the most cutting edge technology and resources, data can be utilized to find out about recovery opportunities quickly and put a plan in the best position to succeed.

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Funds Disbursed? … All May Not Be Lost … Certainly, Montanile threw subrogation professionals a bit of a curveball, but most of us knew this curveball was in the arsenal. Ensuring that you can trace the funds is always the best option; but since Montanile, some courts have reminded us that even if the funds are disbursed, a plan may still have some options. First, the Supreme Court in Montanile held that a plaintiff can “enforce an equitable lien only against specifically identified funds that remain in the defendant’s possession or against traceable items that the defendant purchased with the funds.... A defendant’s expenditure of the entire identifiable fund on non-traceable items ... destroys an equitable lien.” Montanile, at 658. For the Plan to lose its right of recovery, the participant must spend the money on items that cannot be traced. So, if the participant purchases a car, property, or asset of some sort, the plan may still be able to enforce its right. Further, even if the funds are disbursed, the Plan may have a claim for accounting or disgorgement of profits. In Homampour v. Blue Shield of California Life and Health Insurance Company, the Northern District of California stated the following:

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Montanile does not entirely foreclose plaintiffs’ claim. Plaintiffs have not alleged how or from what funds plaintiffs seek to recover disgorgement of profits. It is possible that plaintiffs will present evidence demonstrating that the profits they seek to disgorge are specifically identifiable and within defendants’ possession. Slip Copy, 2016 WL 4539480 at 8

Finally, even in a circumstance where a plan’s equitable remedy is completely lost, the plan may still have a legal remedy under a breach of contract theory. In Unitedhealth Grp. Inc. v. MacElree Harvey, Ltd.., the U.S. District Court for the Eastern District of Pennsylvania noted that “assuming Ms. Neff had at that point already dissipated the settlement recoveries, then, pursuant to Montanile, the Plan could seek legal redress against Ms. Neff for breach of contract.” Slip Copy, 2016 WL 4440358 at 7,

Conclusion Subrogation, like many cost containment options, is complicated. Understanding the legal framework, the differences between the remedies that may be available, the advantages and drawbacks to the different options and utilization of different remedies, and having all the resources to recover effectively can be incredibly burdensome. It requires experience, technical aptitude with data, and access to legal resources necessary to protect the plan’s rights. Montanile served as a painful reminder, but all is not lost. A plan can take steps to protect itself, maximize its recovery dollars, and ensure compliance with its fiduciary duty to enforce the terms of the plan and ensure its viability.

Christopher Aguiar is an attorney with The Phia Group, LLC. Since 2005 he has managed thousands of subrogation and third party recovery cases nationwide and spearheaded negotiations between plan participants, plaintiffs’ counsel, and plan administrators on matters of State and Federal Law as well as ERISA Preemption, recovering millions of dollars on behalf of benefit plans. Since receiving his license to practice law in the State of Massachusetts in 2014, Chris has also handled plan drafting and plan consulting matters ranging from plan language analysis, claims appeal assistance, balance billing defense, prepayment claim negotiations, overpayment recovery, stop loss, PPO, and administrative service agreements.

April 2017 | The Self-Insurer

Alternative Places of Service: An Era of Rapid Growth Written by: Robin Gelburd

here once consumers would have gone to a doctorâ&#x20AC;&#x2122;s office or hospital, they are increasingly seeking healthcare from alternative places of service. They may visit a retail clinic, an urgent care center or an ambulatory surgery center (ASC), or they may receive care at home or via telehealth. Understanding the growth in consumer choices in settings for care and the trends in costs associated with them can inform nearly every aspect of the design of health coverage, including the structure of benefits plans, formation and selection of networks and the use of communications to drive member behavior. As organizations that carry the risks of their membersâ&#x20AC;&#x2122; healthcare, self-insurers may want to explore how these alternative places of service can keep costs down while ensuring that members get the care they need.

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Robust, reliable data from an independent source is key to understanding the significant changes in utilization of alternative care settings, and the implications of those changes. Data from our database of over 22 billion privately billed medical and dental claims reveal important information about trends in alternative places of service.

Urgent Care Centers Urgent care centers have been growing nationally as a less costly alternative to hospital emergency rooms (ERs) and a more convenient alternative to doctorâ&#x20AC;&#x2122;s offices. They typically offer care after regular business hours and on weekends, and do not require an appointment. Usually equipped with their own labs and X-ray machines, they can treat such acute conditions as infections, sprains, broken bones and cuts that require stitches. There are nearly 7,100 urgent care centers in the United States,1 and the urgent care market is expected to grow six percent annually through 2018.2 According to our data, claim lines associated with urgent care centers increased 638 percent from 2007 to 2014, a much greater rise than claim lines for ERs, which increased 173 percent. As shown in the chart below, average charges are much lower for urgent care centers than for ERs. From 2007 to 2015, the average urgent care encounter was less than half the cost of an ER encounter. (Of course, ERs must treat some conditions that are costlier than those that an urgent care center would treat.)

Robin Gelburd

The top five diagnoses associated with urgent care centers in the period 20072015 were, in order from more to less common, acute respiratory infections, general symptoms, urinary tract infections, ear infections and sprains and strains.

Retail Clinics

While less expensive than ERs, urgent care centers are usually somewhat more costly than physiciansâ&#x20AC;&#x2122; offices and retail clinics. The average charge nationally for a 15-minute office outpatient visit in the period 2007-2015, for example, was $122 for an urgent care center, compared to $108 for an office visit and $81 for a retail clinic, according to our data. In both urban and rural settings, urgent care center usage increased every year from 2007 to 2014. Through 2012, however, urgent care center usage was more common in urban than rural areas. That shifted in 2013, when rural utilization of urgent care centers surpassed urban utilization, as it also did in 2014.

Retail clinics can be found in pharmacies, supermarkets, malls and shopping centers. Like urgent care centers, they offer convenient hours and do not require an appointment. However, they treat a more limited range of conditions than urgent care centers: usually specific minor acute conditions with clear clinical guidelines, such as ear infections, allergies and sunburn, as well as preventive care, such as flu shots. Some retail clinics are expanding to provide management for chronic illness. They are more often staffed by nurse practitioners or physicianâ&#x20AC;&#x2122;s assistants than doctors, and their cost of care is about a third of traditional outpatient settings.3

April 2017 | The Self-Insurer

With more than 1,800 locations nationally at present, retail clinics are projected to grow annually at 25 to 30 percent.4 According to our data, claim lines associated with retail clinics increased 438 percent from 2007 to 2014. As shown in the chart below, in the period 2007-2015 they were especially popular with female patients. Although boys and girls from age 0 to 4 received care at retail clinics at roughly equal ratesâ&#x20AC;&#x201D;49.75 percent for boys, 50.25 percent for girlsâ&#x20AC;&#x201D;thereafter the gender gap widened. In the age group 21 and older, women represented 60 percent or more of retail clinic patients.

Retail clinic utilization varies from state to state. Our data show that in the period 2007-2015, Minnesota was the state with the highest utilization overall, and Delaware the lowest. Minnesotaâ&#x20AC;&#x2122;s high utilization rate is not surprising. The first retail clinic opened there in 2001,5 and, in 2008, Blue Cross and Blue Shield of Minnesota began offering a benefit option that eliminated copays for members who used retail clinics, as an incentive for members to save on healthcare costs.6 The top five diagnoses associated with retail clinics in the period 2007-2015 were, in order from more to less common, persons with potential health hazards related to communicable diseases (a category that includes standard childhood shots and other vaccines), acute respiratory infections, arthropathies (such as arthritis), spine and back pain and ear infections.

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This isn’t our first

rodeo

WE’VE DONE THIS BEFORE.

Being in the medical self-insurance stop loss

market isn’t new to Houston International Insurance Group (HIIG). The experts and seasoned employees that founded the Company have decades of experience in this industry. In fact, HIIG was built using strategy, sound judgment, and business savvy from some of the same leaders who made this industry great from the very beginning. Don’t get thrown for a loss. Make HIIG Accident & Health your partner in stop loss.

Learn more at hiigah.com or call us at 800.796.9165.

ASCs

Home

ASCs specialize in same-day surgical care, including diagnostic and preventive procedures. They offer a less costly and more convenient alternative to hospital-based outpatient facilities. As of 2015, there were 5,400 ASCs in the United States.7 Annual growth has slowed from a brisk pace early in the century to an average of 2.6 percent from 2006 to 2013.8 According to our data, claim lines associated with ASCs increased 50 percent from 2007 to 2014. In that same period, ASCs had very similar utilization in rural and urban settings.

Increasingly, equipment, devices, diagnostics, therapy and other services are being provided in patientsâ&#x20AC;&#x2122; homes. As of 2014, there were 12,400 home health agencies9 nationally, with employment in home healthcare services expected to grow at a compound annual rate of 4.8 percent from 2014 to 2024.10 The home healthcare category can include both services provided in the home by outside care agencies and patient self-administered services using medical devices and equipment covered by health insurance.

As the chart below indicates, most patients using ASCs are 46 years and older: 72 percent of claim lines associated with ASCs in the period 2007-2015 were for patients in that age group. The average charge, however, did not vary greatly by age, increasing from a low of $1,138.96 for patients aged 0 to 4 to a high of $1,745.07 for patients over 65. That suggests that similar procedures are being offered across most age groups, with the major difference being that older people are more likely to require them.

As a percent of total data volume in our repository from 2007 to 2015, claim lines associated with home healthcare increased 63 percent. The chart below shows the top procedures billed in the home from 2007 to 2014, indicated by their HCPCS codes, according to our data. They are associated with devices and supplies for continuous positive airway pressure (CPAP)â&#x20AC;&#x201D;a common obstructive sleep apnea treatmentâ&#x20AC;&#x201D;as well as for diabetes, asthma and chronic obstructive pulmonary disease (COPD). Utilization of each procedure increased sharply during this period.

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The procedures billed in the home that increased at the fastest rate year over year during the period 2008-2014 included mental health services and services to young children with cognitive delays. Some advanced technologies, such as pneumatic appliances, also increased rapidly as they became adapted to home use. The increase in services that can be provided in the home potentially decreases the length of patientsâ&#x20AC;&#x2122; stays in medical facilities, saving money for payors, freeing facility space for other patients and allowing patients to recuperate at home.

HCPCS CODES E0601 Continuous Positive Airway Device

A7037 CPAP Tubing

E1390 Oxygen Concentrator

E0431 Portable Gaseous Oxygen

A7038 CPAP Disposable Filter

A7034 CPAP Nasal Application Device

A4253 Blood Glucose Test/Reagent Strips per 50 Strips

E0562 CPAP Heated Humidifier

A7035 CPAP Headgear

E0570 Nebulizer with Compressor

April 2017 | The Self-Insurer

Telehealth Telehealth or telemedicine, the exchange of medical information between patient and medical practitioner electronically from one site to another to improve a patient’s clinical condition, is growing dramatically as a convenient option for many consumers and a means of containing costs for employers and insurers. More than half of US hospitals today use some form of telehealth, and there are presently about 200 telehealth networks nationally.11 Nearly 70 percent of employers are expected to offer telehealth services as a covered benefit by 2017.12 According to our data, as shown in the chart below, telehealth use in the United States increased 88 percent from 2007 to 2015, rising from 8 percent of telehealth claim lines in that period to 15 percent.

relevance to its own employees, can help an organization make appropriate choices about plan design, network composition and member communications. Self-insurers also can make strategic use of alternative places of service to reduce costs while ensuring quality of care.

Robin Gelburd, JD, is the president of FAIR Health, a national, independent, nonprofit organization with the mission of bringing transparency to healthcare costs and health insurance information. Prior to being recruited as president of FAIR Health, Robin served for eight years as general counsel of a medical research foundation comprising approximately 30 premier academic medical centers, hospitals and research institutions in New York. References 1 http://www.ucaoa.org/?page=IndustryFAQs 2 https://www.staffcare.com/uploadedFiles/convenient-caregrowth-staffing-trends-urgent-care-retail-medicine.pdf 3 http://www.forbes.com/sites/brucejapsen/2015/04/23/retailclinics-hit-10-million-annual-visits-but-just-2-of-primary-caremarket/#74fa48a23891 4 https://www.staffcare.com/uploadedFiles/convenient-caregrowth-staffing-trends-urgent-care-retail-medicine.pdf 5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202999/

Telehealth has been playing a key role in rural areas, where a consumer might otherwise have to travel 30 minutes or longer to reach a medical facility. But, telehealth’s presence is growing in urban areas, as well. From 2007 to 2014, urban use of telehealth grew faster than rural use. While rural use remained greater than urban use, the gap between the two was smaller in 2014 (1 percentage point) than it was seven years earlier (3 percentage points). In the period 2007 to 2014, the two most common telehealth diagnoses were general symptoms followed by acute respiratory infections. The latter has been the fastest growing telehealth diagnosis, increasing 800 percent from 2007 (4 percent of claim lines) to 2015 (36 percent). But, many other diagnoses are frequently cited when telehealth services are billed, including sprains, fractures and mental disorders.

Conclusion Urgent care centers, retail clinics, ASCs, home healthcare and telehealth all exhibit a common pattern: increasing convenience for consumers while cutting costs compared to more traditional venues of care. All have been rising in utilization, and all are of increasing interest to payors, including self-insurers. Understanding the claims data regarding alternative places of service, particularly in an organization’s own geographic area and with demographic 44

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6 http://www.businesswire.com/news/home/20080729006230/ en/Blue-Cross-Blue-Shield-Minnesota-Offers-Co-Pay 7 http://www.ascassociation.org/advancingsurgicalcare/whatisanasc/historyofascs 8 http://www.beckershospitalreview.com/patient-flow/26-statistics-on-asc-growth.html 9 http://www.cdc.gov/nchs/fastats/home-health-care.htm 10 http://www.bls.gov/news.release/pdf/ecopro.pdf 11 http://www.americantelemed.org/about-telemedicine/ faqs#.V_LL_vkrJD12 https://www.foley.com/five-telemedicine-trends-transforming-health-care-in-2016/

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SIIA

Endeavors

SIIA has two events this May Join us May 3-4th at the Marriot Metro Center hotel in Washington, D.C. as we bring back the SIIA Legislative & Regulatory Conference. With a new Congress and White House Administration, this is certainly a very eventful time in our Nationâ&#x20AC;&#x2122;s Capital with new public policies expected to affect many industries and market segments. SIIAâ&#x20AC;&#x2122;s Legislative/Regulatory conference has been developed to help its members have a first-row seat to these developments by connecting them directly to the top policy-makers who have influence over the selfinsurance marketplace.

The Self-Insurer | www.sipconline.net

The event will combine timely educational sessions with high profile speakers along with opportunities for attendees to meet directly with their elected representatives to advocate for self-insurance industry priorities. During SIIA’s “Walk on the Hill”, you will be able to obtain inside information, ask questions and advance SIIA’s legislative agenda. SIIA staff does all the work setting up your appointments with your representatives and will provide you with easy to relate talking-points on the issues that matter most to our industry. Please be sure to check the “Walk on Capitol Hill” box on your registration form to participate.

• Ask OSHA – The New Reporting Rule for 2017, with Billie A. Kizer, MPH, CSP, Compliance Officer, Southeast Division, Occupational Safety and Health Administration, US Department of Labor

• Panel Discussion on

For those interested in supporting the Self-Insurance Political Action Committee (SIPAC), please plan to attend a reception/dinner fund-raising event scheduled on the front side of the conference.

Advancements in Medical Management that Lead to Prompter Care and Improved Outcomes with Niel Simon, Senior VP of Strategic Partnerships and Managed Care, Gallagher Bassett Services Inc., Keith Lavin, Senior Director Sales & Marketing, Corporate Care, RWJ Barnabas Health, David Abbene, US Practice Leader and Managing Director, Marsh Risk Consulting

Then on May 16th-17th SIIA will hold its Annual Self-Insured Workers’ Compensation Executive Forum at The Omni Grove Park Inn, in Asheville, North Carolina. This event is the country’s premier association sponsored conference dedicated exclusively to self-insured Workers’ Compensation. In addition to a strong educational program focusing on such topics as excess insurance and risk management strategies, this event will offer tremendous networking opportunities that are specifically designed to help you strengthen your business relationships within the self-insured/alternative risk transfer industry. Educational session highlights include:

• Medicare Secondary Payer Under Trump, with Roy Franco, Chief Client Officer of Franco Signor, LLC

• Employsmart, with Megan Coville, MS, OTR/L, Risk Management Consultant, ONEGROUP and Chris Mason, Esq., Executive Vice President, ONEGROUP

• Why Current Medical Management Strategies are Failing…and What to Do About It, with Matt Condon, JD, Founder of Bardavon Health Innovations and Jeff Hathaway, DPT, Partner at Confluent Health

• Pharmacy Formulary: A Tale of Two States, with Chris Broadwater, House of Representatives of State of Louisiana and Matthew Zurek, Deputy Commissioner – DWC, Texas Department of Insurance

• Team Management of Complex Workers’ Compensation Claims, with Dr. Fernando Branco, Medical Director, Midwest Employers Casualty Company and Steven Moscowitz, MD, Senior Medical Director, Paradigm Outcomes

• Does Work Comp Need Federal oversight? with Charles R. Davoli, Past President, Attorney At Law, Workers’ Injury Law & Advocacy Group (WILG) and Wayne Goodwin, Former Commissioner of North Carolina Department of Insurance

•

Is Marijuana Medicinal? with Edward Moriarty, Jr., Senior Partner, Moriarty, Shay & Associates, P.C. and Mark Pew, Senior Vice President, PRIUM

For more information on the Legislative & Regulatory Conference or the Workers’ Compensation Executive Forum, including programs, sponsorship opportunities and registration, please visit www.siia.org.

• The Practical Use of Analytics in Underwriting and Claims, with Stu Thompson, CEO of The Builders Group and Mike Zucco, Director of Program Development, Alabama Self-Insured Workers’ Comp Fund

• Why Your Mobile Workforce is Driving Up Your Exposure with Kimble Coaker, CEO, AL Trucking Association Fund, Matt McDonough, Senior Risk Control Manager, Safety National and Stu Thompson, CEO, The Builders Group

April 2017 | The Self-Insurer

NEWS

from SIIA

Members

2017 APRIL MEMBER NEWS

SIIA Diamond, Gold & Silver Member News SIIA Diamond, Gold, and Silver member companies are leaders in the selfinsurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to Wrenne Bartlett at wbartlett@siia.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. For immediate assistance, please contact Jennifer Ivy at jivy@siia.org. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and jivy@siia.org.

Diamond Members The Phia Group Announces Strategic Alliance with Specialty Care Management The Phia Group, LLC, the premier source of health benefit plan consultative services, plan document drafting, subrogation and cost containment services, announced that it has formally developed a strategic alliance Specialty Care Management. Headquartered in Lahaska, PA, Specialty Care Management (“SCM”) is a premier source of innovative catastrophic claim cost containment services, with a cutting edge approach to dealing with the ever rising cost of renal disease and dialysis. This strategic alliance keeps SCM on the cutting edge; emphasizing the management of catastrophic claims with a special focus on dialysis care, and combating excessive treatment and billing presently associated with it. 48

The Self-Insurer | www.sipconline.net

“Our joint venture with The Phia Group allows SCM to expand and enhance the array of services we already provide with an eye toward developing unique programs to further cost containment,” explains Rick Garrison, CEO of SCM. “This alliance adds a new dimension to SCM’s business and gives us the opportunity to offer even more robust cost containment strategies.”

For more information about The Phia Group, please contact The Phia Group’s Sales Executive, Garrick Hunt, at 781-535-5644 or Info@PhiaGroup.com.

With The Phia Group, SCM will now offer a Renal Claims Defense program, eliminating exposure to legal risks associated with renal dialysis claim analysis, repricing, and cost containment. Both The Phia Group and SCM have proven records of innovation and performance, and are excited to bring forth new programs and strengthen existing ones. “The Phia Group is pleased to work with Specialty Care Management,” remarked Ron E. Peck, The Phia Group’s Senior Vice President and General Counsel, “because SCM appreciates the importance of powerful plan document language, and they understand the need to operate in accordance with those terms. They have worked with us to prepare a potent defense strategy - protecting both benefit plans and participants.” For more information about Specialty Care Management LLC, please contact Rick Garrison at 267-544-0365 or email at marketing@specialtycarecm.com.

SHOWER YOUR PLAN WITH SAVINGS Using Renalogic’s services can make the savings pour in. Renalogic improves the health and outcomes of Chronic Kidney Disease patients. We specialize in avoiding or drastically reducing dialysis costs.

Call (866) 265-1719 or visit www.renalogic.com April 2017 | The Self-Insurer

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STOP LOSS MTG-3045 (12/16)

MANAGED CARE REINSURANCE

Berkley Accident and Health Announces Reorganization and Promotions to Better Serve Self-Funded Market Berkley Accident and Health, a W. R. Berkley Company®, announced several organizational changes and promotions that will better align its Medical Stop Loss and Group Captive operations with external customer and market needs. Jim Hoitt, formerly Vice President of Sales, has been named Senior Vice President of the Captive segment. In his new role, Hoitt will lead the sales, underwriting, and account management efforts for the company’s rapidly growing Medical Stop Loss Group Captive solution. Reporting to him are Scott Byrne, Jeff Kandzer, and Shawn Lanter, who all have been promoted to Vice President of Business Development. Lee Davidson, formerly Senior Vice President of Product Management and Development, has been named Senior Vice President of the Stop Loss segment. In addition to his current duties, Lee will assume responsibility for sales, underwriting, and account management for Traditional Stop Loss distributed through regional producers.

Previously, the Stop Loss and Captive areas were organized functionally, with senior leadership spanning across different business segments.

“These changes align our internal operations with external markets, giving each business segment a clear line of sight directly to customers and their needs,”

Berkley Accident and Health is a member company of W. R. Berkley Corporation, a Fortune 500 company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captive, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident. The company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. For more information, please visit BerkleyAH.com or BenefitsCaptives.com.

There are no changes to Berkley’s Centralized Stop Loss segment, which distributes Stop Loss through arrangements with institutional producers.

About Berkley Accident and Health

said Christopher Brown, President and CEO of Berkley Accident and Health.

“It also positions us well for continued growth. Each business segment can now adapt to changing market needs with greater speed and flexibility,” explained Brown. April 2017 | The Self-Insurer

Access Your Healthcare Plan Data AT THE OFFICE OR ON THE GO Lucent Health continues to innovate compelling and proprietary technology solutions that enable Employers to have more visibility into their healthcare spend and to control it.

LucentHealth.com

Silver Members Strategic Risk Solutions Earns 97 Percent Satisfaction Rating Strategic Risk Solutions (SRS), a provider of captive management and consulting services, announced today the results of its annual customer survey. In 2016, 97 percent of customers responded that they were “highly satisfied” with SRS’s services. This builds off the company’s previously excellent ratings, raising them to a three-year high.

“Maintaining the trust and confidence of our clients by delivering high quality captive services is the essence of SRS,” said Brady Young, President of Strategic Risk Solutions. “SRS and the captive market generally were very active in 2016. To be able to improve our customer satisfaction ratings in that fast-paced environment is particularly pleasing,” he added. Key areas where the highest scores were attained include captive consulting, the quality, accuracy and timeliness of financial reporting and the overall responsiveness of staff. For copies of the survey results, please contact Andrew Berry at andrew.berry@strategicrisks. com or (781)672-3454.

Polsinelli’s New York Office Adds Two Veteran Finance Lawyers Polsinelli, an Am Law 100 firm with offices in 20 cities across the U.S., announced today two highly-experienced finance attorneys joined its New York office. Barry Biggar and Stephen Rutenberg have joined the firm’s national Capital Markets and Commercial Lending group. The new additions are the latest in a significant growth period for the New York office as Polsinelli continues to add strong talent to its roster, most notably in real estate, financial services and intellectual property.

About Strategic Risk Solutions (SRS) SRS is a leading independent captive management firm with representation in all major onshore and offshore domiciles. It provides financial reporting, regulatory compliance and program management services to existing and prospective captive insurance companies. For more information, please contact Strategic Risk Solutions at (781)487-9800 or info@strategicrisks.com.

April 2017 | The Self-Insurer

Biggar joins Polsinelli from Pillsbury Winthrop. For more than 25 years he has represented financial institutions in complex structured debt and tax advantaged financings in both the U.S. domestic and cross-border markets, including extensive experience in the aviation, rail, maritime and manufacturing sectors, as well as nuclear fuel resources. Biggar has represented creditors in the United Air Lines and Northwest Airlines bankruptcy cases. He earned his Juris Doctor degree, cum laude, from Pace University School of Law, and his bachelor’s degree, cum laude, from Manhattan College. Biggar is included in Euromoney’s “Guide to the World’s Leading Aviation Lawyers” as one of the premier practitioners in North America.

“We are very lucky to have attracted Barry, a true dean of the equipment and aviation finance bar,” said Dan Flanigan, Chair of the firm’s Financial Services Department and Managing Partner of the New York office. Rutenberg joins the firm from Arnold & Porter Kaye Scholer, where he counseled hedge funds, private equity firms, and global financial institutions on legal issues relating to the purchase and sale of loans and securities, including those of distressed and bankrupt companies, and on cross-border bankruptcy claims trading-related matters. “Stephen has a significant and valuable specialty. He adds a whole new dimension to our par and distressed loan and claims trading and bankruptcy practices,” Flanigan

On Feb. 2, the UJA-Federation of New York, the world’s largest local philanthropy, honored Rutenberg with the James H. Fogelson Emerging Leadership Award at the Lawyers Division Annual Event, which brought together more than 600 influential members of New York’s legal community. Rutenberg received his Juris Doctor degree from the University of Pennsylvania Law School along with a certificate of Management and Policy from the Wharton School. He earned his bachelor’s degree from Brooklyn College. In addition to being admitted to the New York bar, Rutenberg is a solicitor in England and is listed as a Rising Star by IFLR1000.

said.

Self-funding options for small to mid-sized groups with GBS HealthyAdvantage.

The Time Has Come for Level-Funded Health Benefits

If you have fully-insured clients looking for an alternative, HealthyAdvantage is ideal for you. GBS HealthyAdvantage offers: • Lower Fixed Costs: Most businesses realize immediate monthly savings • Claims Fund: You own the claims fund and receive 100% of it back • A-Rated Stop-Loss Carriers • Wide variety of customized benefit designs including HSA, HRA & FSA plans • Claims reporting • Online quoting and underwriting platform • Level-funding and traditional Self-funded Benefit Plans—Available in most states

Visit the Healthy Advantage website at www.gbshealthcare.net to access our quoting tool and online underwriting platform, or call 800.638.6085 to speak with a sales representative.

The Self-Insurer | www.sipconline.net

Biggar and Rutenberg join the New York office amidst a noteworthy growth period, particularly in the Real Estate and Financial Services and Intellectual Property Departments. Recent additions to the Intellectual Property Department include cybersecurity lawyer Jarno Vanto and patent prosecution attorney Pete Thurlow. For more information, contact Carrie Trent at ctrent@polsinelli.com.

Gold Members Guardian Recognized as a 2017 Top 125 Training Organization by Training Magazine The Guardian Life Insurance Company of America (Guardian), one of the nation’s largest mutual life insurers and a leading provider of employee benefits, was recently recognized as one of Training magazine’s 2017 Top 125 Training Organizations. This recognition underscores Guardian’s focus on its customers and on building and maintaining a strong financial foundation to serve them. Executives in every business division are responsible for developing and training employees and financial professionals by sharing best practices across business lines to ensure these programs are consistent and are state-ofthe-art in the industry.

“As a mutual insurance company with a 150-year history of delivering results, Guardian’s top priority is serving our clients and policyholders, and that is reflected in everything we do. We are committed to training our professionals so they can exceed the expectations of our customers,” stated Kurt Shallow, Senior Vice President, Agency Distribution, Individual Markets. “We focus on creating a destination organization for those interested in a flexible career as a highly skilled professional. Having the right tools and resources in place helps us recruit and retain the right people.”

Do you aspire to be a published author? Do you have any stories or opinions on the self-insurance and alternati ve risk transfer industry that you would like to share with your peers? We would like to in vite you to share your insight and submit an article to The Self-Insurer ! distributed in a digital and print format to reach over 10,000 readers around the world. The Self-Insurer has been delivering information to the self-insurance /alternative risk transfer community since 1984 to self-funded employ ers, TPAs, MGUs, reinsurers, stoploss carriers, PBM s and other service providers.

Articles or guideline to Editor Gretchen Grote at ggrote@sipconline.net also has advertising opportunities available. Please contact Shane

Byars at sbyars@sipconline.net for advertising information.

April 2017 | The Self-Insurer

Now in its 17th year, the Training Top 125 is the only report that ranks companies unsurpassed in harnessing human capital. Training magazine’s Top 125 ranking is determined by assessing a range of qualitative and quantitative factors, including financial investment in employee development, the scope of development programs, and how closely such development efforts are linked to business goals and objectives. For more information about career opportunities at Guardian, visit www.guardianlife.com/financial-representative-careers.

About Guardian The Guardian Life Insurance Company of America® (Guardian) is one of the largest mutual life insurers with $7.3 billion in capital and $1.5 billion in operating income (before taxes and dividends to policyholders) in 2015. Founded in 1860, the company has paid dividends to policyholders every year since 1868. Its offerings range from life insurance, disability income insurance, annuities, and investments to dental and vision insurance and employee benefits. The company has approximately 8,000 employees and a network of over 2,750 financial representatives in 57 agencies nationwide. For more information about Guardian, please follow Guardian on Facebook, LinkedIn, Twitter and YouTube.

TPA SUMMIT 2017 July 17-19, 2017 The Hilton at the Ballpark St. Louis, MO

The Self-Insurer | www.sipconline.net

SIIA would like to Recognize our Leadership and Welcome New Members 2016 Board of Directors CHAIRMAN* Jay Ritchie Executive Vice President Tokio Marine HCC – Stop Loss Group Kennesaw, GA PRESIDENT/CEO Mike Ferguson SIIA, Simpsonville, SC TREASURER & CORPORATE SECRETARY* Duke Niedringhaus Senior Vice President, J.W. Terrill, Inc. Chesterfield, MO CHAIRMAN-ELECT* Robert A. Clemente CEO Specialty Care Management LLC Lahaska, PAKennesaw, GA

Directors Adam Russo Chief Executive Officer The Phia Group, LLC Braintree, MA Joseph Antonell CEO/Principal A&M International Health Plans Miami, FL Kevin Seelman Senior Vice President Lockton Dunning Benefit Company Dallas, TX Andrew Cavenagh President Pareto Captive Services, LLC Philadelphia, PA Mark L. Stadler CEO BridgeHealth Denver, CO

Mary Catherine Person President HealthSCOPE Benefits, Inc. Little Rock, AR David Wilson President Windsor Strategy Partners, LLC Princeton Junction, NJ

Committee Chairs CAPTIVE INSURANCE COMMITTEE Michael P. Madden Senior Vice President Artex Risk Solutions, Inc. San Francisco, CA

HEALTH CARE COMMITTEE Kari L. Niblack Executive Vice President of Client Engagement & Services Apex Benefits Indianapolis, IN INTERNATIONAL COMMITTEE Robert Repke President Global Medical Conexions, Inc. Novato, CA WORKERS’ COMP COMMITTEE Stu Thompson CEO The Builders Group Eagan, MN

GOVERNMENT RELATIONS COMMITTEE Lawrence Thompson Senior Vice President, Sales & Client Services POMCO Group Syracuse, NY

April 2017 | The Self-Insurer

SIIA New Members Regular Corporate Members Michael Feighan SVP - US Head of A&H Aspen Insurance New York, NY Nick Hentges CIC MBA President/Principal Captive Resources LLC Schaumburg, IL John Cattie Jr. Special Counsel MSP Compliance Cattie P.L.L.C. Charlotte, NC Timothy Hyde President ClaimDOC Stuart, FL

Joe DiBella Managing Director Benefits Practice Conner Strong & Buckelew Marlton, NJ James Piper VP & General Manager GemCare Wellness Hudson, OH Jose Rivero CEO HealthComp Fresno, CA Michael Colucci CEO Idilus Plan Management Services LLC Warrenville, IL

The Self-Insurer | www.sipconline.net

Greta Vaught President & CEO Midlands Choice Inc. Omaha, NE

Douglas MacGinnitie CEO River Oak Risk LLC Atlanta, GA

Laurent Laor CEO Viveka Health New York, NY

Employer Member

Paul Clark Chief Technology Officer WorldCare International Inc. Boston, MA

Silver Member James LeRoy Senior Vice President Meadowbrook Risk Solutions Bloomington, MN

Tara Conger VP Human Resources Palmer Johnson Power Systems Sun Prairie, WI Steven Chambers Director Human Resources Veterans of Foreign Wars of the United States Kansas City, MO

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