Self Insurer SEPT 2020

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A S I P C P U B L I C AT I O N

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Restoring Resilience

in the Age of COVID-19

EAPS, VIRTUAL VISITS, DIGITAL APPS AND FLEXIBLE HOURS TAKE ON GREATER IMPORTANCE AS EMPLOYEE ANXIETY MOUNTS

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TABLE OF CONTENTS

SEPTEMBER 2020 VOL 143

W W W. S I P C O N L I N E . N E T

FEATURES 4

RESTORING RESILIENCE IN THE AGE OF COVID-19

EAPS, VIRTUAL VISITS, DIGITAL APPS AND FLEXIBLE HOURS TAKE ON GREATER IMPORTANCE AS EMPLOYEE

ANXIETY MOUNTS

By Bruce Shutan

10

BUOYANT BAYOU LOUISIANA WOOD-PRODUCTS MANUFACTURER OVERCOMES REGIONAL HEALTH PROBLEMS WITH COMPREHENSIVE SUITE OF ONSITE AND NEAR-SITE CLINICS AND PHARMACY

By Bruce Shutan

ARTICLES 18

INSIDE THE BELTWAY

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OUTSIDE THE BELTWAY

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RISE AND SHINE EMPLOYMENT-BASED HEALTH BENEFITS IN A POST-COVID FUTURE

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COMMON MISTAKES PROSPECTIVE CAPTIVE OWNERS MAKE

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HOW TO DECREASE YOUR HEALTH PLAN COSTS

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SIIA ENDEAVORS

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NEWS FROM SIIA MEMBERS

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC).

Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688

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PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF OPERATIONS Justin Miller, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISORS Bruce Shutan and Karrie Hyatt, 2018 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary

SEPTEMBER 2020 3

FEATURE

Restoring Resilience

in the Age of COVID-19

C

EAPS, VIRTUAL VISITS, DIGITAL APPS AND FLEXIBLE HOURS TAKE ON GREATER IMPORTANCE AS EMPLOYEE ANXIETY MOUNTS

C

OVID-19’s brutal path of death and destruction extends beyond the physical realm. Behavioral health is also in the pandemic’s crosshairs, but organizations are mobilizing resources to address this crisis and restore resilience across their workplaces.

“There’s a very palpable concern that people might not just be able to absorb all the levels of change in the economy, lifestyle, how work is done and interactions,” notes Paula Allen,

SVP of research, analytics and innovation for LifeWorks.

Behavioral health experts say COVID-19’s impact on the U.S. economy has created high anxiety among employees who’ve been furloughed or laid off and facing financial peril, as well as those juggling dependent care responsibilities while working at home. As such, the need for both physical and financial wellness programs may be at an all-time high.

Written By Bruce Shutan

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THE SELF-INSURER

Restoring Resilience The novel coronavirus has caused a ripple effect beyond severe economic damage as confinement from sheltering-in-place orders has taken a heavy toll. For example, the National Domestic Violence Hotline expects an unprecedented number of survivors of such crimes to report abuse and seek support in the coming months.

Minorities also have expressed safety concerns in the wake of massive and steady protests nationwide over George Floyd’s death in police custody in Minneapolis, Minn.

The latter has triggered a significant increase in requests for training around racial sensitivity, reports Bob Mines, Ph.D., chairman and chief psychology officer of MINES and Associates.

About half of all the behavioral health cases he has seen are related to COVID anxiety, a phenomenon detailed in the “The Psychology of Pandemics” by Steven Taylor, a recently published book that has shown significantly increased anxiety levels.

Mines also has noted an increase in substance use disorder diagnoses as well as suicides.

“We’ve had employers who’ve asked us to do trainings on leadership and the psychology of pandemics for their executive and managerial supervisor groups to help them recognize the symptoms in their own employees,” he reports.

Requests also were made regarding suicide training for leadership.

CRISIS PROPORTIONS Darcy Gruttadaro

The number of people experiencing both anxiety and depression has tripled during the past year, hitting African-Americans and Asians hardest, according to Darcy Gruttadaro, director of the Center for Workplace Mental Health under the auspices of the American Psychiatric Association Foundation.

She says computer modeling is anticipating a surge in these conditions, along with substance use, relapses and suicide.

“People are feeling very anxious at all levels of organization, so we know they recognize the need to take action,” Gruttadaro says, noting an uptick in medical claims. “What we’re seeing is employers partnering with their TPAs, health plans and EAPs, asking what innovative approaches they have to address concerns around people getting help if they need it.”

Some employees are afraid to go return to work, worried about exposing themselves or frail family members to COVID-19, Mines explains, while employers are wondering how to manage a post-pandemic workplace.

Chief among their concerns are compliance with the Americans With Disabilities Act, Family and Medical Leave Act and Occupational Safety and Health Administration requirements to ensure the health and safety of workers.

He says these issues are top of mind in overburdened and highly stressed first-responder communities where lives are on the line and municipalities dealing with blue-flu protests in the face of growing hostility over police brutality.

Employers are paying closer attention to promoting employee assistance programs (EAPs) much more than before, training managers to understand the signs that an employee isn’t doing quite right and referring them to company resources, Allen says.

A recent poll of LifeWorks clients showed that mental health issues were a top concern in terms of any lasting impact the pandemic may have on the workplace. In fact, the company has seen a massive decline in mental health across all major indicators since the start of COVID-19, including increased levels of anxiety, depressive symptoms and a sense of isolation. Optimism and productivity also have been on the wane.

Many organizations are adding questions to engagement surveys to gauge whether any individuals or groups are having a more difficult time than others in these uncertain times, according to

SEPTEMBER 2020

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Restoring Resilience Allen. She says smart leaders also are ensuring that employees stay connected with their teams through more frequent touchpoints and social time, even if it’s only videoconferencing, so that there’s still a sense of belonging.

“More employers could take that as a call to action and follow the path of the leaders,” Allen suggests, noting the growing importance of resilience as a desired outcome.

Bob Mines

COVID-19 has been a double-edged sword for behavioral health service providers. For example, MINES and Associates has seen clients cut headcounts amid sharp revenue decreases. “We’ve actually had more businesses go out of business this time than we did in 2009, so those are all off the books completely,” Mines reports.

At the same time, clinical demand to service clients through an EAP or managed care product has swelled. Dani Kimlinger, the firm’s CEO, installed a call center software system so that the firm’s associates could work remote within a week of pandemic shutdowns.

Apart from a continuation of telehealth in video and telephonic forms, Mines would like to see self-insured employers consider adding to that mix text-based counseling for reimbursement. There’s a high consumer satisfaction with this service, which he says many EAPs are already providing because texting has become so popular.

LifeWorks began a transformation of the traditional EAP model well before COVID-19 hit in acknowledgment that workforces are becoming more

“What we didn’t want to do is to stay in the box of just addressing 5% to 10% of the population,” Allen dispersed.

explains.

‘ZOOM FATIGUE’ With virtual visits replacing in-person behavioral health sessions for the first few months of state lockdowns, the public has cottoned to this model. Once they had a taste of telehealth, many MINES and Associates clients rhetorically quipped: “You mean I don’t have to drive for an hour or two hours to see my therapist each way in heavy traffic? I can just have a phone session or a videoconference?”

Mines predicts more creativity and flexibility in delivery systems between all the virtual modalities from clinical, consulting and meeting points of

We’re also dealing with Zoom Paula Allen fatigue on the part of our clients, and stay-at-home problems involving certain employees who are not going to be able to send their kids back to daycare and maybe not to school,” he says.

view. “

Her company offers a mobile app that provides ongoing support to help employees find relevant articles, podcasts, online self-directed cognitive behavioral health programs and habitchanging tools. It has been paired with a total wellbeing assessment that recommends specific resources and provides employers with confidential insight on an aggregate basis into how their employees are faring to help make strategic intervention decisions.

Indeed, more employers are offering free digital apps that provide navigation services for mental health care, medication and mindfulness to help their employees and families feel calmer, Gruttadaro notes. “There’s a high interest in things like building resiliency and stress management to help people understand how to really engage in selfcare,” she says.

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Restoring Resilience Many people who are still gainfully employed aren’t taking vacations, which Gruttadaro says means that employers need to be modeling good behavior around work-life balance and working reasonable hours. She notes that some employers are offering a shortened workday on Fridays in summer closing and closing down offices to force proverbial recharging of batteries.

In an effort to rebuild morale, the Center for Workplace Mental Health has created a framework for organizations called LEAD, which stands for leadership, effective communication, adapt to change and doubling down on access to care.

The objective is to share resources that help managers spot warning signs for common conditions like depression, anxiety, substance use and trauma. Gruttadaro says early intervention leads to the best results. It’s also a matter of reminding new hires about the EAP when they’re onboarded and telling employees who to contact when they’re feeling down, lonely or isolated.

One issue that needs to be addressed moving forward is payment parity for mental health professionals who aren’t paid the same as primary care providers to provide nearly identical care.

“Tele-psychiatry and telebehavioral health have not always been reimbursed at the same level as office visits, which is of course quite problematic for people who live in very underserved areas,” Gruttadaro explains.

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.

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Bouyant Bayou

FEATURE

Buoyant Bayou

LOUISIANA WOOD-PRODUCTS MANUFACTURER OVERCOMES REGIONAL HEALTH PROBLEMS WITH COMPREHENSIVE SUITE OF ONSITE AND NEARSITE CLINICS AND PHARMACY

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Written By Bruce Shutan

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he use of onsite or near-site medical clinics have helped transform both primary care and occupational health services for self-insured group medical and workers’ compensation plans. A wood-products manufacturer based in Alexandria, La., has done just that and is even sharing these facilities with other employers.

But RoyOMartin has taken other bold steps to broaden and improve the delivery of care. For starters, it offers its employees and their dependents access to a company owned and operated pharmacy, which is also open to the public and has seen an increase in its retail sales. Another layer of protection involves the use of a fiduciary pharmacy benefit manger (PBM).

Behavioral health is also offered, while physical therapy is being considered as a future service that would prove particularly beneficial to a blue-collar workforce with musculoskeletal challenges. All of the manufacturer’s 1,200 full-time employees in four locations are eligible for employer-provided health benefits.

What makes this comprehensive strategy so critically important is a constant uphill climb in the face of regional social ills. Diane Davidson, the company’s director of employee benefits, describes the area in and around corporate headquarters as “the sickest district in the sickest state.” Louisiana is home to some of the nation’s highest prevalence of obesity, diabetes and cardiovascular deaths, as well as rates of children in poverty and low infant birth weight, according to a 2020 report by the United Health Foundation.

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THE SELF-INSURER

Bouyant Bayou ROAD TO RECOVERY Nearly a decade ago, RoyOMartin took concrete action to rein in group health and workers’ comp costs. Manufacturing facilities in Oakdale, La., Chopin, La. and Corrigan, Texas have an onsite occupational health nurse.

A near-site primary care clinic branded Legacy to honor the Martin family’s nearly 100-year ownership is 30 minutes away from Diane Davidson both Louisiana plants. Employees and their dependents pay just $12 per visit. The Texas location has contracted with the owner of three clinics who charges $15 per visit with a nurse practitioner who’s onsite once a week. Legacy also does pre-employment screenings and post-hire evaluations for employees before they’re even eligible for health insurance.

RoyOMartin is self-insured for both group health and workers’ comp with Blue Cross of South Carolina serving as the third-party administrator on the group health side, while it is self-administered on the work comp side. One unintended, albeit positive, consequence of offering comprehensive services to employees is that it has united the occ and non-occ areas, and produced better results.

“When we started the clinic, we never even figured in occupational health as part of the return on investment because we can’t tell them to go to that doctor,” she explains, noting that Louisiana is an employee-choice state for choosing physicians to treat work comp cases. “One of the main advantages of having the clinic now is occupational health.”

Occupational health nurses perform basic triage on employees who are injured on the job, which may include anything from removing a splinter and flushing out an irritated eye to first-aid measures. They’re also the ones who determine whether additional care is needed at a Legacy clinic, which can stich up wounds and offer similar support, or the emergency room where a deeper level of care is required.

The arrangement has worked so well that 90% of covered lives use the onsite or near-site facilities. The cost of primary care visits flattened over the past three years to a point where there has been only a $1 change in the per-employee-per-year price tag. The company also went for a long while without ever hitting its stop loss before the streak ended with a high-cost patient being treated for cancer at MD Anderson.

On the work comp side, costs plummeted to plummeted to .13% of payroll from 1.49% of payroll since 2011. Davidson credits a safety culture and philosophy that has not only improved over the years, but also been elevated to a core value.

“Workers’ comp used to be a line-item discussion in all of our leadership meetings

because it was in the millions that we were spending, and this was before we hired our first occupational health nurse,” she reports. “It’s gone down ever since then.”

Wood-products manufacturing has more than its share of serious physical risk and danger. There have been several severe injuries at RoyOMartin – all of which have served as a wakeup call for developing a safety culture. “Prevention is what we preach and harp on for personal health and workers’ comp,” Davidson says.

TAKING OWNERSHIP Legacy started in 2011 as Central Louisiana Family Health & Wellness Center when it was run by First Onsite, a division of HCA. At that time, it made sense to have a company with medical expertise manage the operations.

Following the departure of a beloved physician’s assistant with a stellar bedside manner, RoyOMartin decided to take over the clinic.

Brian Elkins, M.D., who was a professor at Louisiana State University, was hired in December of 2014. Now Legacy’s medical director, he oversees nurses and medical programs as well as occupational health services.

Throughout this transition, RoyOMartin blazed a path to innovation by opening its Louisiana Legacy clinic to other employers in the region, starting with a construction company that builds roads and overpasses. Under that company’s fully insured arrangement through a local Blues plan, employees used their Health

SEPTEMBER 2020

11

Bouyant Bayou Spending Account to pay for visits to the clinic.

When Elkins took over, a $20 co-pay was instated for employees of the construction company and extended a year later to their dependents. Davidson says the change significantly improved buy-in and utilization. Two other selfinsured employers also send their employees and dependents to the clinics through an administrative-services-only contract with the same local Blues plan.

Monthly fees are charged per employee.

While the Legacy clinic isn’t exactly a profit center for RoyOMartin, Davidson notes that the intention has always been to improve the environment for employers in central Louisiana where recruiting and retaining talent is a

challenge. “It’s not a big city with a huge nightlife,” she says.

RX FOR RISING DRUG COSTS Rx spending is an area that Davidson, who’s on Louisiana’s state pharmacy advisory board committee, recognizes as critical for self-insured employers to manage.

Although RoyOMartin considered opening its own pharmacy in 2011 to rein in a rising pharmacy spend in the mid-20% range, the idea was deemed too costly. Some medical expenses were going to the pharmacy side because so many scripts were being written amid an endless shell game of spread vs. pass-through pricing with promises of rebates that did nothing to actually bend the Rx cost curve.

Over time, the company switched from one of the nation’s leading pharmacy benefit managers to Scriptcare, LLC, part of a small but growing cadre of fiduciary PBMs that are deeply committed to transparency. In lieu of complicated PBM pricing built on formulary rebates, Scriptcare only adjudicates claims and receives a modest admin fee per prescription.

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Bouyant Bayou

Another noteworthy development was a synergy that arose when the company found the perfect Rx consultant at the same time an ideal candidate for pharmacist was looking for a change in employment. When those two trusted sources converged, the vision of a company pharmacy finally took shape two years ago.

Legacy Pharmacy purchases drugs directly from wholesalers. If RoyOMartin is able to raise its volume, then it would be able to get rebates from the wholesaler. Aware of this steep hurdle, her hope for the future is to forget rebates and simply negotiate the lowest price.

Since the pharmacy opened, there has been a 10% overall decrease in pharmacy costs and Rx increases are in the 6% to 10% range. There also has been a much higher adherence rate for patients whose prescription is ready as soon as they leave the doctor’s office and walk down the hall to the pharmacy.

Elkins and the clinic’s pharmacist are easily able to have prudent discussions about finding the most efficacious, low-cost formulary drugs to treat patients.

Legacy Pharmacy lowered its coinsurance and co-pays as incentives for patients to use the facility and stay the course on their treatment regimen. The pharmacist is also licensed in Texas, which means employees in the Lone Star State can receive their medications through Legacy Pharmacy through the mail.

Given the high number of diabetics who are covered under

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THE SELF-INSURER

RoyOMartin’s health plan, the Legacy clinic has looked closely at population heath and used analytics to manage those risks. A health coach also becomes involved in helping intervene before employees or their dependents move into a high-risk category. “That’s made a tremendous difference in the fact that they’re identifying and targeting them,” according to Davidson, adding that message campaigns are tailored to rising-risk patients.

POST-PANDEMIC VISION Legacy also contracts with a clinical psychologist whom the company pays directly.

Davidson says she works miracles in just three or four sessions. One problem, however, is that with an 80% male workforce in a blue-collar setting, utilization is on the low side. This became clear during the pandemic when the nation became mired in a mental health crisis marked by isolation from stay-at-home orders, as well as furloughs and layoffs on a massive level.

It’s worth noting that when Covid-19 hit hard, the Legacy clinic never closed, nor were services ever reduced. In-person visits adhered to social distancing, patients were seen one at a time and testing for coronavirus antibodies was done in the parking lot. The same could be said about RoyOMartin’s pharmacy, which offered curbside pickups and started mailing almost every prescription. Virtual visits also became much more efficient.

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Bouyant Bayou

In time, Legacy hopes to add physical therapy given the prevalence of musculoskeletal disorders in a heavy manufacturing environment. Since the company began a direct-contracting arrangement with physical therapists, musculoskeletal diagnoses as a category plummeted to No. 9 or 10 from the No. 3 spot. It also would like to add dental and vision services to the clinic, though there’s no room currently to accommodate them.

Whatever the future holds, it has become increasingly clear over time that RoyOMartin has transformed its slice of an ailing bayou country into a rare outpost of holistic wellbeing. “We have all four wheels moving in the same direction: the health plan, doctor, pharmacist and patient,” Davidson exclaims. “I feel as though we are making health care work in this messed up health care world.”

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.

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Inside the Beltway

INSIDE

THE BELTWAY

CONGRESS ADJOURNS FOR AUGUST WITHOUT A COVID STIMULUS DEAL: SELF-INSURED HEALTH CARE POLICY IMPACTS

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ecently Congress decided to halt negotiations on a fourth round of economic stimulus legislation and head home for the August recess. While the House is slated to reconvene in the coming days to consider funding and policy related to the U.S. Postal Service, and the Senate set to consider a “skinny� stimulus plan, broader bicameral negotiations remain on hold.

According to recent SIIA conversations with Senate staff, any actions surrounding another round of stimulus will likely not be taken up until September, if at all. In addition, it is important to note that government funding runs out on September 30th, raising the specter of a government shutdown, and another tough political and policy fight on the near-term horizon.

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These statements are illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.

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Inside the Beltway CONGRESSIONAL STALEMATE It is no secret that negotiations between House and Senate leadership surrounding a new round of stimulus have gained little traction. Negotiations have thus far been an exercise between White House Chief of Staff Mark Meadows, U.S. Treasury Secretary Mnuchin, Speaker Pelosi and Senate Minority Leader Schumer. Senate Majority Leader McConnell, while keeping apprised of negotiations, has not been physically in the room.

While Sec. Mnuchin and Speaker Pelosi have made a number of past deals, the addition of former Congressman Meadows to the table, who does not have a friendly history with Speaker Pelosi as a leader of the House Freedom Caucus, gives a new and tougher dimension to the current discussions. As one leadership staffer recently told SIIA, the negotiating environment in the room has been one of the ‘most toxic’ they have ever seen.

IMPACT ON SELF-INSURED HEALTH PLANS

What do these stalled negotiations mean to the self-insurance industry? On one hand, key priorities like surprise billing and price transparency are not likely to make it into legislation in the short-term.

On the other hand, concerning policy proposals, such as additional coverage mandates and risk corridor payments now appear unlikely as congressional negotiators focus on other priorities.

A particular policy priority that seems to have been put on ice is Federal subsidies for COBRA coverage. Self-insurance industry stakeholders continue to wrestle

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with issues relating to the recent extension of various HIPAA and COBRA deadlines, with particular concern over the COBRA deadline extensions and the impact these extensions could have on the administration of self-insured plans.

Surprise billing is one issue that has ebbed and flowed throughout the legislative year, with interest groups, including hospitals and private equity firms, spending tens of millions of dollars to kill a bipartisan, bicameral compromise that called for a private sector in-network benchmark rate and an arbitration process as way to solve the surprise billing problem.

Speaker Pelosi has indicated that she will not move on surprise billing language until there is an agreement among the Chairs of the House Energy & Commerce, House Ways & Means, and House Education & Labor Committees.

While Energy & Commerce and Education & Labor have engaged in productive discussions over the past few weeks, Ways and Means has largely been absent from recent talks, preferring a pure arbitration and rulemaking approach favored by provider groups.

In addition, Majority Leader McConnell, while open to a solution, is not willing to include surprise billing in the next stimulus package according to recent SIIA conversations. Like many complicated health care policy issues, the debate over surprise billing is likely to be tabled, perhaps until 2021 and beyond. SIIA has – and will – continue to be heavily involved in this debate.

Another hot topic that will not likely see inclusion in upcoming legislation is the Trump Administration’s regulations to increase the transparency of medical prices. However, with a District Court recently upholding the Department of Health & Human Services (‘HHS’) hospital transparency regulations, the Department continues to move forward on implementing the rule, despite a forthcoming appeal of the ruling by the hospital industry.

SIIA is also waiting for HHS’s proposed transparency in coverage regulations for “group health plans” to be finalized. At this point, the best guess is that a final regulation may be issued as early as end of September and as late as mid- to lateOctober.

SIIA’S ONGOING ADVOCACY EFFORTS While Congress may have adjourned for August without enacting any new health care policy, SIIA’s Government Relations Team continues to talk to congressional offices, educating them about the self-insurance industry and SIIA’s policy priorities.

We also continue to work with federal agency officials on issues relating to transparency and COBRA coverage, suggesting ways to improve and streamline these administrative requirements. Lastly, SIIA is proactively engaging with congressional offices on issues related to the use of Flexible Savings Accounts, and

Inside the Beltway

other means, by which employers can continue to provide cost-effective and efficient health care coverage for employees and their families.

SIIA is closely tracking the upcoming political conventions and the November election, and is already underway in developing strategic plans for 2021 and beyond.

We look forward to member engagement as we enter 2021, and a new political and policy landscape.

Speaking of the election, you will not want to miss the keynote presentation included as part of SIIA’s Virtual National Conference & Expo, scheduled for October 12-15.

One of the country’s top political pollsters, Kristin Soltis Anderson, will provide a live “Election Day Preview” presentation and take questions from the audience. Event details can be accessed at www.siiaconferences.org Should you have questions regarding this update or would like additional information, please contact Ryan Work (rwork@siia.org) or Chris Condeluci (ccondeluci@siia.org).

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Outside the Beltway

OUTSIDE THE BELTWAY

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his is an update of state legislative and regulatory developments affecting companies involved in the self-insurance/captive insurance marketplace. Should you have any questions regarding the information provided in these reports, or would like to alert SIIA of new state legislative and regulatory activity (health care, workers’ compensation and/or captive insurance matters), please contact Adam Brackemyre, Vice President of State Government Relations directly at 202/5950641, or via e-mail at abrackemyre@siia.org.

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Outside the Beltway STATE LAWS, BULLETINS, EXECUTIVE ORDERS AND GUIDANCE RE-

3. There was a positive COVID test

LATING TO COVID EXPOSURE AND WORKERS COMPENSATION

and;

4. The test results were provided to an insurer.

SIIA has compiled a chart for you to reference as COVID-related treatment have been billed to TPAs and, potentially, to stop-loss carriers for reimbursement. The chart can be accessed here.

CONNECTICUT On July 24th, Governor Ned Lamont issued Executive Order (EO) 7JJJ, creating a rebuttable presumption of work comp eligibility for “essential” Connecticut employees who meet specific conditions:

1. The work occurred outside of the home; 2. The employee was essential (per EO 7H) and the injury occurred more than 14 days after March 23rd;

The presumption shall only be effective for COVID cases contracted between March 10th and May 20th.

NEW JERSEY The New Jersey legislature has advanced S2380 to Governor Phil Murphy’s desk. The legislation, which as of the date of this email has not been signed into law, would

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Outside the Beltway establish a rebuttal presumption of work comp eligibility for “health care workers,” “public safety workers” and “essential employees” all of whom are defined in the legislation.

The legislation contains a provision that if an “essential” employee was offered the ability to work from home, but chose not to, he/she shall forfeits the work comp presumption.

VERMONT Governor Phil Scott signed S.342 into law on July 13, 2020, creating a COVID work comp presumption for several classes of employers including first responders, health care workers and long-term facility employees.

The law gives the Commissioner of Labor the ability to add other employees to the presumption list if, in his judgement, they face an elevated COVID exposure risk.

STATE STOP-LOSS LAWS AND REGULATIONS

SIIA has complied a chart of state stoploss laws, regulations and bulletins. The chart does not include any “desk drawer” rules that have no statutory or regulatory basis. The chart can be accessed here.

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RISE AND SHINE

EMPLOYMENT-BASED HEALTH BENEFITS IN A POST-COVID FUTURE Written by Ron E. Peck, Executive Vice President and General Counsel The Phia Group, LLC

I I

t is a summer day in August. The year is 2020. I dropped my son off at daycare this morning. I feel guilt, fear and anxiety over having done so. That is not how I felt upon doing so in August of 2019. What has changed? We are busy enduring COVID-19; a pandemic the likes of which the United States has not seen in one hundred years.

COVID-19 has caused a ripple effect, felt by almost every facet of our modern society.

From retail and food services, to ride sharing and travel. Tourism, education, and of course – health care.

One would reasonably assume that, when discussing a pandemic and health care, the natural direction in which we would head next would be a discussion regarding the health impact – present and future – of COVID-19. The treatment options, the cost of said treatment, as well as short-term and long-term impact of the disease on patients.

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Yet, here I will not attempt to dissect the clinical issues presented by coronavirus, and the immediate, direct impact it will have on our health benefit plans, and self-funded plan sponsors. Instead, I will be discussing a threat to our industry not called COVID-19, but rather, a growing sociopolitical threat that has emerged in response to a larger economic victim of the virus.

As retail and restaurants have closed shop – for many, permanently; as businesses have had to suddenly adjust to a “work-from-home” environment – for many, without success; as an economy that was thriving has suddenly been thrust into a recession – so suddenly you would be forgiven for thinking you have whiplash … Employers, and thus employees, have been victims of a pandemic economy.

People have been furloughed or laid off in record numbers. Visit any nation, anywhere on the planet, and involuntarily losing one’s job is never deemed by the ex-employee to be a happy, welcome circumstance.

Universally, we work to provide for ourselves a sense of purpose, make a positive impact, and enjoy an income.

Thus, regardless of where you live, losing your job is usually not a cause for celebration. In the United States,

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however, another reason for which people seek employment is to receive benefits.

Amongst those highly desired benefits, and perhaps primary amongst them, are health benefits. Whether an employer pays premium to a carrier in exchange for traditional, “fully-funded” insurance… or… the employer sets aside contributions from itself and its employees, to “self-fund” its health plan… employees appreciate health benefits.

So much so, it only makes sense that employers realized they could craft, manage, and fund attractive health benefit plans, using them as an incentive – luring in job seekers and keeping existing employees. Indeed, in a capitalistic economy like ours, employers are always hunting for the most effective ways to attract and keep the best talent. In an economy that is functioning well, it only makes sense to allow employers to do so.

What about an economy that is not functioning well? If and when employers are not using health benefits to attract the best talent, because they cannot afford to pay for health benefits – let alone hire said talent in the first place… naturally, those people who were banking on employment as a source for benefits; people who only a few months prior were singing employment based benefits’ praises… will now question the wisdom of such an arrangement. One study1 suggests that more than five million Americans have lost their health benefits due to being laid off, as a result of COVID-19.

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Add this to a society that – at least in part – is already contemplating a “Medicarefor-All” option, and we have a perfect storm.

“Corporate America fights single payer universal health care afraid to lose power over workers.

Insurance companies fight single-payer universal health care because they make money not providing health care.

If small business didn’t have to pay for medical, they could raise wages, modernize, expand their businesses and grow our economy. Workers could leave toxic and unsafe working environments or raise their voices when feeling abused without fear of losing their benefits2” and they aren’t alone. There One person wrote,

exists a perception that employment-based health plans offer no benefit whatsoever over Medicare, and that – therefore – there is no reason to maintain it.

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Whenever we, as human beings, make a decision – we perform a cost/benefit analysis. When I wake up in the morning, and decide to brush my teeth, I perform a cost/benefit analysis. I weigh the time it takes to brush against the bad breath and tooth decay I’ll suffer if I fail to brush. If and when we have an interest in another’s cost/benefit analysis, it behooves us to explain to them the benefits and costs involved in that decision. Consider the following example…

When my previous automobile hit 100,000 miles, I began contemplating my next automotive purchase. I am constantly being exposed to manufacturer’s marketing – lauding their cars’ qualities.

Thus, when I was shopping around, I was more than armed with the costs and benefits of each option.

Consider the average American voter. Can you confidently say they are aware of the benefits of employment-based health plans? I doubt it! Can you confidently say they are aware of the costs of an alternative? I doubt it!

The bottom line is this – most people believe that providers of health care services charge one amount to all payers.

They believe that different health care providers in the same area charge about the same amount for the same services.

They believe that health insurance – whether it is fully-insured, self-funded, Medicare, or Medicaid – pays the bill in full, and if there is a discount, those savings are for the benefit of the payer, not the patient.

They believe there is no difference between a private plan and Medicare, aside from the means by which they pay for coverage – premiums or taxes.

Rather than continuously allow our industry to be bashed by the media, to be misunderstood by the public, and thus fall short when forced to endure a cost/benefit analysis against Medicare-for-All … all with a backdrop of a pandemic economy … it behooves us to educate the public regarding the benefits of employment based health plans.

Looking at my own employer, and our self-funded health plan; if Medicare-for-All or some other public option were made available at a lower cost to me than my current plan, I would not make the switch. Why?

The answer, simply put, is that I understand the benefits of our plan. I recognize that it is customized to match the needs of a population most like me in needs and wants. I recognize that the costs I pay up front are used to enhance benefits I may need later. I recognize that individuals who passionately care about my wellbeing are monitoring my plan and ONLY my plan, to ensure it functions well.

COVID-19 and the unemployment it has triggered armed our adversaries with ammunition. They point at the state of things and argue that health benefits are a human right – and as such – they cannot be tied to something as fickle as employment.

Yet, they fail to address that, whether through premiums or taxes, someone needs to pay for health care. Should we all be covered by Medicare, those unemployed individuals will be called

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upon to pay their share, via taxes, using funds they don’t have. As such, passing the buck is not a solution either. The burden is on us to offer a better solution, and to suggest policies meant to contain the cost of the care itself.

Above all else, our job is to remind people of the benefits of private health plans – benefits that Medicare can’t match. We need to change the dialogue – shifting the focus away from unemployment as an excuse to abolish health plans, and instead shift the focus onto reducing the cost of care regardless of who is paying.

Ron E. Peck has been a member of The Phia Group’s team since 2006. As an ERISA attorney with The Phia Group, Ron has been an innovative force in the drafting of improved benefit plan provisions, handled complex subrogation and third party recovery disputes, healthcare direct contracting and spearheaded efforts to combat the steadily increasing costs of healthcare.

Considered to be not only one of the nation’s top ERISA lawyers, Attorney Peck is also viewed as one of the nation’s premier self-funded health plan consultants and health benefits attorney; lecturing at and participating in many industry gatherings including but not limited to The National Association of Subrogation Professionals (“NASP”) Litigation Skills Conference, Society of Professional Benefit Administrators (“SPBA”), the Health Care Administrator’s Association (“HCAA”), The Health Plan Alliance, and Self-Insurance Institute of America (“SIIA”). Ron is also frequently called upon to educate plan administrators and stop-loss carriers regarding changing laws and best practices. Ron’s theories regarding benefit plan administration and healthcare have been published in many industry periodicals, and have received much acclaim. Prior to joining The Phia Group, Ron was a member of a major pharmaceutical company’s in-house legal team, a general practitioner’s law office, and served as a judicial clerk. Ron is also currently of-counsel with The Law Offices of Russo & Minchoff.

Attorney Peck obtained his Juris Doctorate from Rutgers University School of Law and earned his Bachelor of Science degree in Policy Analysis and Management from Cornell University. Attorney Peck now serves as The Phia Group’s Executive Vice President and General Counsel, and is also a dedicated member of SIIA’s Government Relations Committee.

References 1 https://www.familiesusa.org/resources/the-covid-19-pandemic-and-resulting-economiccrash-have-caused-the-greatest-health-insurance-losses-in-american-history/ 2 https://www.concordmonitor.com/End-employer-based-health-care-35555925

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COMMON MISTAKES PROSPECTIVE CAPTIVE OWNERS MAKE

Written by Karrie Hyatt

A A

s there would be entering any new type of business, prospective captive owners have a lot to learn. Even with guidance from their service providers, new captive owners still take missteps. The most common mistakes they make are not understanding that a captive is an insurance company, that good governance takes work, that not every domicile is the same, and that a captive investment is for the long-term.

However, with instruction provided by experienced service providers, prospective captive owners can avoid the pitfalls these mistakes and misconceptions entail.

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CAPTIVES ARE INSURANCE COMPANIES

Many prospective owners begin the process of starting a captive with both misleading information and little knowledge about owning an insurance company. The most common mistakes that prospective owners make at the very first stage of starting a captive are that they are interested in forming a captive for the wrong reasons, they don’t understand that they will be owning an actual insurance company, and they aren’t knowledgeable about insurance business models, practices, and processes.

When a company comes to a captive manager to start a captive, Les Boughner, chairman of Business Insurance at Advantage Insurance Inc., finds that “[We provide] a very thorough education for all sizes of captives … and there is a steep learning curve in some cases.”

Managing expectations is a key issue when captive managers begin working with companies wishing to start a captive using the 831(b) tax designation. They come to the table with the idea that forming an ERC is going to save them money on taxes or other business dealings, but they don’t understand how or why.

“The majority of people forming [ERCs] have been given false expectations by people that promote them. It ranges from flagrant tax abuse to just ignorance.

It’s very easy to form a captive, the challenge is structuring it properly for tax purposes. [ERC] owners need to understand, it’s not just forming an insurance company, it’s owning an insurance company.”

According to Boughner,

He continued, “Whereas if you’re dealing with a traditional captive, generally they have been self-insured—particularly for workers’ compensation—and they now want to put an insurance wrapper around their reserves because it’s financially a lot more efficient to do it that way.”

For any start-up captive, there will be a lot to learn to understand the in-and-outs of managing an insurance company—regulatory requirements, risk management, coverage available for different types of risk, and other minutia that a consumer of traditional insurance doesn’t have to know.

This holds true particularly for Enterprise Risk Captive (ERC) start-ups whose owners may not have any experience with selfinsurance.

SEPTEMBER 2020

35

According to Stephanie J. Mapes, director with Paul Frank + Collins P.C., “From the legal perspective, our education role surrounds the formation and structure of the captive, including the tax position the captive may take, which differs of course depending on many factors, including whether or not the parent is a non-profit entity. Most of our captives have sorted this out before even hiring their local law firm. Others have not, and that can be a learning curve that requires some lead time.”

As ERCs are the fastest growing segment of the captive sector, captive managers and attorneys specializing in captives find they have to explain that owning a captive means owning an insurance company. Which means making risk financing decisions about funding, capital, risks, and allocation— things that many business owners are not familiar with.

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THE SELF-INSURER

“For some of our smaller and less experienced captives and cells, it can be difficult to get them to remember that their captive or cell belongs to them,” said Mapes. “The decisions they make about funding the captive are all about where their money resides. Either at ‘home’ where it can be readily deployed by the parent, or in the captive to fund for that rainy day.”

“We also educate on board governance, which often involves gentle reminders as to ‘which hat’ a board member is wearing at any particular time,” Mapes continued. “The parent/insured hat? Or their captive hat.”

DOMICILES ARE NOT ALL THE SAME

With so many captive domiciles to choose from, prospective captive owners can be overwhelmed with choices. It may seem to them that one domicile is the same as another, so they choose a domicile that is conveniently located or has the least expensive terms, but this leaves out many considerations that new captive owners should be looking into.

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“They have to understand that they are getting into something serious and that it’s a long-term commitment,” said Boughner. “I wouldn’t say they are not willing to invest for the long-term, I just think they don’t realize that they will be investing for the longterm.”

The benefits—other than saving money—are not always readily apparent to new captive owners.

“My best advice is to choose a well-established and well-respected domicile for your new captive,” said Mapes. “The folks in these domiciles, including Vermont of course, are the best.... They are experts in their field, accessible, and they know how to walk that fine line between being a good regulator and allowing the captive to serve the objectives and interests of the parent company.”

For Boughner, as a captive manager, he urges new captive owners to look into three or four different domiciles. “We encourage them to actually visit with the regulators because then they get can get a feeling about how the regulator works and can be confident that that domicile can handle their business. I can tell you, even if a regulator says they understand the business, you will quickly get a sense that they are not comfortable with the business your bringing to them. If they are very comfortable with that business, you’ll see that through their enthusiasm.”

CAPTIVES ARE FOR THE LONG HAUL

Just as some prospective owners have trouble grasping that a captive is an insurance company, they also have trouble understanding that captives are not an investment that they can easily divest in a few years. Common mistakes that companies looking to form a captive is that they don’t understand that it’s a long-term investment, they don’t define multi-year objectives and goals, and they don’t see risk management as an on-going venture.

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This is why education plays such a large part of getting a captive up and running. “Once you’ve completed the education and the captive has been operating for a while, they become extremely engaged in it and they look forward to the annual meeting and look at it as a very positive experience. I would say that once new captive owners understand and are committed to getting the proper structure, they become enthusiastic supporters of the captive,” said Boughner.

Another question Boughner often gets in the initial stages of opening a captive is how will the owner be able to close the captive—indicating that they are not thinking of a captive as a longterm investment. Bougher said, “The thing that I find is that you routinely get the question of ‘how do I shut it down or when do I close it,’ but once they understand and begin to use it, they never shut it down unless they sell the business.”

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What it comes down to, according to Mapes, is that once “Insureds own their own risk, the incentives are clearly there to understand loss trends and loop these back to risk management and quality control.” Prospective captive owners may come to the table with little understanding of using captives as a risk financing mechanism and have a lot to learn. However, that’s where experienced service providers can help.

“Many [captive professionals], like me, have been in this industry for over 30 years,” said Mapes. “We don’t let that experience go to waste. We make sure all of our clients benefit from that and we often keep them from making mistakes.

In fact, that is part of our job. We lead and educate our captive owners, and if a new client comes along that is forming a captive for all of the wrong reasons, we let them know.”

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After many years working with captives, Boughner still enjoys working with new clients. “Captives are a fun business, once new captive owners understand what the captive is doing, they really enjoy getting involved.”

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

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ow is the time to innovate to decrease your health plan costs. Doing so is a two-step process; finding the best doctors and getting your people to them.

GOOD HEALTHCARE COSTS LESS

Healthcare is not a commodity. We all think that our doctor is the best‒or at least above average‒but we don’t live in Lake Wobegon where all the children are above average. Exactly half of all children are above average, and exactly half are below. It’s the same with doctors‒and the specialists and surgeons that they refer us to, and the hospitals that they put us in.

Although it seems counter-intuitive, going to a good doctor costs less overall than going to a bad one. 30% of healthcare costs are unnecessary, the result of poor or ineffective care and good doctors don’t incur those excess costs.

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THE SELF-INSURER

Delaware’s Captive Bureau is business at the next level

In Delaware, our captive regulators are dedicated exclusively to our captive insurance clients’ needs, and work under the direction of our Captive Bureau leadership, directed by Steve Kinion.

There are 34 people working on Delaware’s Captive team.

Of this total 15 are financial analysts. Under Delaware’s regulatory organization, the financial analyst is the first-line regulator who communicates with the captive manager or owner.

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Good doctors make fewer errors, perform fewer unnecessary procedures, experience fewer patient complications and get their patients better faster.

But how do you find the best doctors? The best doctors have the best outcomes.

MEASURING QUALITY IN HEALTHCARE

Many purport to measure healthcare quality and identify the best doctors, and every insurance company has a “narrow network” listing the best doctors in their network, but you have to ask what they’re measuring to do so?

What they’re measuring are proxies for a good outcome that they hope will predict one, such as:

•

Whether the doctor complies with a checklist of recommended processes and procedures?

•

Whether patients “like” the doctor?

•

Whether the doctor went to a prestigious medical school?

•

And thrown into this mix is what the doctor charges for an office visit or procedure?

To find the doctors that achieve the best outcomes, you have to measure the outcomes.

QUANTIFYING OUTCOMES

There are two ways to quantify healthcare outcomes. Which one you use depends on who you are and what data you have.

Occupational Outcomes If you’re an employer that self-insures your health plan you own your claims data; and you can combine those claims with your human resource (HR) and absence data.

Begin by defining a “good outcome” as an ill or injured employee being at work.

You then measure all the costs to get the employee back to work and/or keep them there over the entire continuum of care. For serious illnesses and injuries, those costs are not only the claims paid to the doctors and hospitals, but the absence costs while the employee was out, which can be even more.

You can then rank each provider by root diagnosis, from the best with the lowest average riskadjusted cost (claims + absence costs) when treating employees with that condition, to the worst with the highest‒and you can use those employee-derived rankings to move everyone to better care.

The charts below compare two knee surgeons against each other and the average for the group of knee surgeons in a provider network. The chart on the top left in green compares

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THE SELF-INSURER

the average risk-adjusted claims costs. Surgeon A is above the group average, while Surgeon B is below. Stopping here‒and everyone else does‒Surgeon B is the best choice.

Now moving to the right, we see their absence costs in orange‒the average risk-adjusted amounts that the employer paid to each surgeon’s patients while they were out sick. These are not only real costs to the employer, but double as an indication of the effectiveness of the care. The quicker the surgeon got the employee better and back to work, the more effective the surgeon was.

Here Surgeon A is much better than average, while Surgeon B is worse.

The bottom chart combines the two. Both Surgeon A and Surgeon B are better than average, but Surgeon A is the best.

Something you would never have seen by just looking at the claims.

Clinical Efficiency If you’re a health insurance company or just don’t have HR data to match against the claims, including an employer quantifying the outcomes for the spouses and dependents in its plan, you can measure the outcomes using just the claims. Instead of asking how much it cost and how long it took to get and/or keep an employee at work, now ask how much it cost in claims to keep a person well?

SEPTEMBER 2020

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Define being well in terms of healthy days, which you can see in the claims. Healthy days are days that the person does not spend in the healthcare system (e.g. hospital stays, doctor’s visits, etc.) or at home in a non-functional state (e.g. recuperating or otherwise unable to carry out their normal activities). You can then rank each doctor by root diagnosis, from the best with the lowest average risk-adjusted claims per healthy day, to the worst with the highest.

On the other hand, if a person has headaches it doubles to over $20 per day, and if they have a drug or alcohol problem it doubles again to over $40.

RISK SCORES The chart below illustrates this concept with behavioral health issues. If a person doesn’t have any behavioral health issue, it takes $10 per day to keep them healthy (i.e. almost everyone will have some claims and unhealthy days during a year).

You’ll notice that the above methods refer to “risk-adjusted” claims and absence costs. Risk scoring is critical when quantifying outcomes. If you ask any doctor why their costs are more than another doctor’s, they’ll always give the same answer. “Because my patients are sicker.” And sometimes they’re right.

Sicker patients cost more and take longer to get better. If you have two patients with the same back injury, one of them young and otherwise healthy,

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THE SELF-INSURER

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while the other older, overweight and diabetic, the older patient is going to cost more. So you need to adjust for comorbidities by assigning each patient a risk score. That way the provider rankings are based solely on the doctors’ performances, not the patients that they treated.

A good risk scoring system to use is CDPS (Chronic Illness and Disability Payment System). CDPS is an open source system designed by the University of California, San Diego and employed by many Medicaid programs around the country.

Accordingly, it is demographically appropriate for a working age population. In contrast, if you are working with a Medicare Advantage plan you might use the HCC risk scoring system (Hierarchical Condition Categories) used in Medicare.

The CDPS system looks at various demographic and clinical data, including age, gender, diagnoses, and the prescription drugs that a patient is taking, and assigns the patient a score: 1.00 being an individual of average health, below 1.00 healthier than normal (the lower the score, the healthier), and above 1.00 sicker (the higher the score, the sicker).

The chart below shows the relationship between an employee’s risk score and the number of days that they miss from work. As you would expect, the higher the risk score, the more time that they miss.

GETTING FOLKS TO THE BEST DOCTORS

Quantifying the outcomes and ranking your network’s doctors based on the outcomes that they achieve is only half of it. Now you have to get your folks to them. There are a number of ways to do so.

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Network Design The most obvious answer is to design your provider network to include the best doctors for each root diagnosis, or at least eliminate the worst. And it’s the worst doctors, who often see only a few of patients, that cost the most. You can think of this in terms of Malcolm Gladwell’s “10,000-hour rule,” his hypothesis that you must practice something for 10,000 hours to become an expert at it. If a doctor sees only a few back patients a year, that doctor probably won’t be very good at treating back patients.

The takeaway is that eliminating the worst doctors from a network, who may be seeing only a few patients anyway, can make a big difference!

If you’re a health insurance company, that’s your answer‒unless you’ve contracted with a health system that precludes you from excluding any of its doctors.

What if you’re a self-insured employer? You have a contract with an insurance company to provide you with a network of doctors and process your claims, i.e. a TPA‒ Third Party Administrator. Will the insurance company let you add and delete doctors from the network? The answer is almost always “No.” Next.

Stratify the Network If you can’t choose the network, stratify it. Decrease or eliminate co-pays and out-ofpocket costs when plan members go to the best doctors. Properly structured, you’ll save more in decreased claims and absence costs than you’ll lose by giving up those co-pays and deductibles.

If you have a HDHP (High Deductible Health Plan) coupled with HSAs (Health Savings Accounts) you can do essentially the same thing by contributing to the employees’ HSAs when they go to the best doctors. Be careful with those HDHPs, however.

Is shifting upfront costs to your employees causing them to defer care? When a problem arises, an employee will go to the doctor if they know that all they will pay is the co-pay. They might not go, however, if they’ll have to pay the entire doctor’s bill.

Make sure you’re not saving a little on the front end, only to pay a lot more later, when a problem that could have been remedied early festers into a much larger problem.

Do you aspire to be a published author?

We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world.

The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984.

Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ sipconline.net The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ sipconline.net for advertising information.

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Case Managers You have case managers who work with your high cost and chronically ill members. Give them a list of the best doctors for each diagnosis so that they can help those members get the best care. You can provide this list to the case managers interactively over an internet portal.

You can give the doctors in your network, and even your members themselves, similar portals to look up the best doctors. Primary Care Physicians (PCPs) often don’t know the best specialists and surgeons to whom to make referrals.

Now they can just look them up. And you can give your plan members a portal to look up the best doctors for what they need themselves. The problem will be getting them to use it.

Your plan’s members will only make up a fraction of any doctor’s overall patient load. Will the doctor change their routine for your members and stop to look up the best specialist or surgeon when referring them?

On the other hand, patient steering tools have a notoriously low participation rate.

Not without good reason, patients suspect that they’re being directed to the cheapest option. And if you have a sick child you don’t want cheap, you want the best. These analytics identify the best, but it takes some effort to educate the members so that they understand that.

Wellness Programs We’ve concentrated on quantifying the outcomes achieved by doctors, but these analytics can quantify the outcomes for other things too, like wellness programs.

Everyone knows that generic lifestyle wellness programs don’t work.

For every $1.00 spent on them, they save 50¢‒a negative return of 50%. On the other hand, targeted wellness programs do work, those specifically for patients with diabetes, hypertension, etc. For every $1.00 spent, they save an average of $3.80.

These analytics can identify which wellness programs are right for an employer’s population, and then quantify the outcomes those programs achieve and calculate the ROI.

WORKERS’ COMPENSATION

We’ve been focusing on health plans‒a word about workers’ compensation programs.

In most health plan settings, you can only encourage someone to go to the best doctor. They can go to whoever they want.

It’s Almost Renewal Season.

Do Your Partners Have You Covered?

AccuRisk Solutions has the people, the process, and the options you need to take care of your renewal.

Contact us today.

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Workers’ compensation is different. In many states, an employer can direct care and require an injured employee to go to the provider that the employer selects, the one that these analytics identify as the best doctor for that type of injury. Accordingly, although the numbers are smaller, an employer can capture a much larger percentage of the potential savings, while getting its injured employees better care.

A FINAL THOUGHT: THE TALE OF TWO SURGEONS

One of the more interesting insights involved one employer’s network of orthopedic surgeons, which included Surgeon A and Surgeon B. Both surgeons did neck surgeries and back surgeries. The chart on the next page compares their neck patients over four years. Surgeon A was very good at neck surgery, and Surgeon B was very bad.

The chart on the right compares their back patients over this same four years. Here it was reversed. Surgeon A was very bad at back surgery, while Surgeon B was very good.

The chart on the bottom shows that this employer could have saved $893,573 over these four years by flipping each surgeon’s patients to what that surgeon was good at‒Surgeon A handled Surgeon B’s neck patients, and Surgeon B handled Surgeon A’s back patients.

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Doctors aren’t all good or all bad. They’re good at some things, and not so good at others. These analytics find out what they’re good at and exploit it to everyone’s advantage.

BETTER CARE AT LOWER COSTS

By sending the plan members to the doctors that achieve the best outcomes‒claims will go down. Good healthcare costs less overall than bad healthcare as 30% of claims are unnecessary, the result of poor or ineffective care. The best doctors deliver superior care for less, wringing out those excess costs. Absence costs will go down too because the best doctors return employees to work faster. And maybe most importantly of all, now everyone will receive better care.

Scott Roloff is the President of IntegerHealth Technologies, which combines advanced analytics with medical expertise to quantify healthcare outcomes for health plans and workers’ compensation programs Driving down the costs, while improving the care. Scott can be reached at (817) 849-9402 and sroloff@integerhealth.com.

INNOVATIVE STOP LOSS AND ANCILLARY SOLUTIONS At BenefitMall, we know that employer groups benefit most from treating their health plan as an investment rather than an expense. Our team of self funded consultants can help you succeed by offering: • Reporting, Compliance Services and Plan Document Review • Billing and Premium Collection • Ancillary Products and Services

• Unbiased Expertise and Review • Initial Placement, Implementation and Renewal of Coverage • Claims Audit, Submission, Tracking, and Resolution Services

©2020 BenefitMall. All rights reserved.

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888.248.8952

ENDEAVORS

SIIA ENDEAVORS UPCOMING SIIA EVENTS SIIA ENGAGEMENT SERIES

Join us on Thursday, September 10th at 3:00PM EDT for the next event in SIIA’s Congressional Town Hall Series, featuring U.S. Congressman Tim Walberg (R-MI-07).

Tim Walberg

As a member of the House Committees on Education & Labor and Energy & Commerce, Congressman Walberg will discuss and interact with SIIA members on health, tax and other top of mind policy issues, including the upcoming 2020 election.

This event will be exclusively hosted as a live video conferencing call, providing you with the opportunity to engage directly with the Congressman.

Registration Fees: SIIA Member - Free Non-Member - $125

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ENDEAVORS If you have any questions, please contact djackson@siia.org.

Please note participation for this webinar will be limited so register for it right away if you want to listen live. For membership information, please contact Jennifer Ivy at jivy@siia.org.

SIIA VIRTUAL NATIONAL

EDUCATIONAL CONFERENCE & EXPO

The event will also feature a virtual exhibit hall with more than 100 companies showcasing their products and services. The SIIA platform is extremely user friendly with significant functionality designed to easily connect attendees with exhibitors.

For information about how your company can participate as an exhibitor or sponsor, please contact Justin Miller at jmiller@siia.org.

Rounding out the conference will be multiple opportunities for attendees to connect and engage with each other, both in group and in private settings. While there is no substitute to “being there,” SIIA is creating the next best thing. These details will be previewed closer to the date.

Complete event details can be accessed on-line at www.siiaconferences.org or by calling (800) 851-7789.

We look forward to sharing this unique SIIA experience with you soon.

SIIA Virtual National Educational Conference & Expo will be live soon and plans are well underway to provide participants with valuable educational and connection opportunities.

Scheduled for October 12-15, 2020, the world’s largest self-insurance event has extended its reach even further with the new format, which will allow industry professionals to experience SIIA from wherever they are.

With nearly 50 educational sessions planned – several live with an interactive format and others available on-demand – this will be the largest collection of self-insurance educational content ever offered as part of a single event.

With registration fees now as low as $395 and zero travel cost, this event is a truly unique opportunity for organizations to involve multiple team members who would benefit by staying current with the latest industry information and developments.

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No Guarantee of Results – Outcomes depend upon many factors and no attorney can guarantee a particular outcome or similar positive result in any particular case.

Connect in New Ways through HCAA As an association leader in transforming the self-funding industry, and one that focuses heavily on The Value of Connection, HCAA education, advocacy and networking has not stopped. We’ve just found new and creative ways to connect, engage and educate during this time. The HCAA Experience is unlike any other, and we challenge you to discover the value it brings to your self-funding career.

Learn more about the many benefits HCAA membership offers to the self-funding industry at hcaa.org/page/membership.

Contact us (888) 637-1605 hcaainfo@hcaa.org

NEWS

NEWS FROM SIIA MEMBERS 2020 SEPTEMBER MEMBER NEWS SIIA Diamond, Gold & Silver Member News SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to membernews@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 at jivy@siia.org.

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NEWS DIAMOND MEMBERS

About The Phia Group

THE PHIA GROUP ANNOUNCES

The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive services, designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Visit www.

PhiaGroup.com.

PROMOTION OF JASON DAVIS TO SENIOR VICE-PRESIDENT OF PROVIDER RELATIONS

Canton, MA - The Phia Group LLC, the health benefit industry’s leading costcontainment service provider, announces the promotion of Jason C. Davis to the role of Senior Vice-President of Provider Relations.

“Jason has been partnered with The Phia Group for nearly 7 years, and we have grown tremendously during this time; we now want to highlight and reward his contributions with a seat at the executive table” stated Adam Russo, CEO of The Phia Group. “Jason has proven himself to me and our clients as a person of intelligence and integrity, and I believe he is the right person to lead our Provider Relations department to the next level.”

Prior to partnering with The Phia Group in 2014, Jason Davis was VicePresident US Markets for Global Excel Management, where for nearly 10 years he contributed at various levels of claim settlement, dispute resolution, R&D, product development, sales, and leadership. “I believe in The Phia Group’s mission to lower healthcare costs for all, and so I am thrilled to be part of the Phia family and to build on our success,” added Jason Davis.

For more information regarding The Phia Group, please contact Vice President of Sales and Marketing, Tim Callender, by email at tcallender@phiagroup.com or by phone at 781-535-5631.

TOKIO MARINE HCC - STOP LOSS GROUP INTRODUCES CHRISTINE CARLSON AS SENIOR VICE PRESIDENT OF CLAIMS

TMHCC, a leading provider of medical stop loss insurance, announced that Christine Carlson has accepted the position of Senior Vice President of Claims. Ms. Carlson brings to TMHCC over 15 years of industry experience in leading change management, optimization, innovation, customer experience, and team building.

Prior to joining TMHCC, Christine held a variety of claims operations leadership positions at Blue Cross and Blue Shield of Minnesota, most recently as a Senior Director.

Christine holds a Bachelor of Science degree in Business from the University of Wisconsin.

Jay Ritchie, President of TMHCC’s Stop Loss Group said “We are excited and confident that Christine will be a major contributor to our company’s success and an important part of our leadership team going forward.” Beata Madey, Executive Vice President, Stop Loss Group added that “TMHCC is well positioned to build upon our excellent customer experience and operational excellence by adding Christine’s leadership within our organization. ” If you have any questions or need additional information, please contact Christine directly at (770) 693-6582 or email her at ccarlson1@tmhcc.com.

About Tokio Marine HCC – Stop Loss Group For more than 45 years, HCC Life Insurance Company, operating as Tokio Marine HCC – Stop Loss Group, has been leading the way in medical stop loss insurance for employers and plans who self-fund their benefit plans. Rated A++ (Superior) by A.M. Best Company, Tokio Marine HCC – Stop Loss Group is backed by the financial stability of its parent company, Tokio Marine HCC. Visit tmhcc.com.

Tokio Marine HCC – Stop Loss Group delivers competitive coverage through exceptional customer service. Our team of underwriters, claim specialists, actuaries and medical professionals provides personal service and professional expertise to a network of producers. Visit tmhcc.com/en-us/groups/stop-loss-group.

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NEWS VĀLENZ RANKS NO. 2065 ON INC. 5000 LIST OF FASTEST-

GROWING PRIVATE COMPANIES PHOENIX, AZ — Inc. magazine announced that Vālenz™ ranks No. 2065 on the annual Inc. 5000 list, the most prestigious ranking of America’s fastest-growing private companies.

The Inc. 5000 list represents a unique look at America’s most successful independent small businesses. Over the years it has included such leading-edge organizations as Microsoft, Vizio, Intuit, Oracle, Zappos.com and many others.

“We are honored to be recognized as one of the fastest-growing companies in America, and it reinforces what our clients already know – that controlling health plan costs, serving the plan member and helping the employer group are all connected,” said Rob Gelb, Chief Executive Officer at Valenz. “Our rapid growth is a function of everything we do to control costs, deliver quality, and create new paths of opportunity

for employers, TPAs, and brokers to improve plan design, reduce plan spend, and enhance member lives.”

Moving forward, the company is poised for future growth. As the innovators behind an ecosystem that combines health data analytics with healthcare service delivery across the entire lifecycle of every claim, Valenz is laser-focused on changing the trajectory of healthcare costs – which they call lowering the Claim Cost Arc – for the self-insured industry.

Data and information flow through the Valenz ecosystem from the company’s core products, clients, platform partners and industry sources, and in doing so, it fuels ever-expanding analytic and predictive capabilities. That data-driven decision enablement, coupled with member- and client-centric service delivery, creates continuous value for every individual and organization within the ecosystem.

“If you are excited about what Valenz has accomplished for your business in the three years since we first envisioned our ecosystem, you will be very pleased with what the future holds,” said Gelb. “By engaging early and often for smarter, better, faster healthcare, we are continuously creating new opportunities for self-insurers to target the small percentage of claims that drive their majority of health plan costs.”

“From health and software to media and hospitality, the 2020 list proves that no matter the sector, incredible growth is based on the foundations of tenacity and opportunism,” said Inc. editor-in-chief Scott Omelianuk.

Together, the companies in the 2020 Inc. 5000 achieved three-year average growth of more than 500 percent and a median rate of 165 percent, with aggregate revenue accounting for more than 1 million jobs in the same time frame. Complete results of the Inc. 5000 can be found at www.inc.com/inc5000.

INTRODUCING HPGPS Mobile App and Website for H.H.C. Group RBP Plans

User friendly Health Plan GPS (HPGPS) is designed to increase member engagement and satisfaction while reducing plan and member healthcare costs for H.H.C Group Reference Based Pricing Plans.

HPGPS is ideal for secure member engagement, communications, steerage to safe harbor providers, balance bill appeal support, e-payments to providers and much more…

Contact Stella Chung for a HPGPS demo | schung@hhcgroup.com, 301-963-0762 ext. 130 Claims Negotiation & Repricing | Claims Editing | Medical Bill Review (Audit) | Reference-Based Pricing DRG Validation | Utilization Reviews and Independent Reviews | Independent Medical Examinations

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NEWS About Valenz Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem.

Visit valenzhealth.com. Valenz is backed

by Great Point Partners.

About Great Point Partners Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Visit www.gppfunds.com.

About Inc. Media The world’s most trusted businessmedia brand, Inc. offers entrepreneurs the knowledge, tools, connections, and community to build great companies.

Its award-winning multiplatform content reaches more than 50 million people each month across a variety of channels including websites, newsletters, social media, podcasts, and print. Its prestigious Inc. 5000 list, produced every year since 1982, analyzes company data to recognize the fastestgrowing privately held businesses in the United States. Visit www.inc.com.

BERKLEY ACCIDENT AND HEALTH ANNOUNCES 2020 WINNER OF FIRST-EVER BERKLEY EDGE EXCELLENCE IN HEALTH RISK MANAGEMENT AWARD

Hamilton Square, NJ – Berkley Accident and Health, a Berkley Company, is proud to announce BevCap Health as the winner of our first-ever Berkley Edge Excellence in Health Risk Management award. The Excellence in Health Risk Management award recognizes a stop loss group captive program that has demonstrated strong health risk management strategies and best practices over the past year.

BevCap manages multiple health captives, including both heterogenous and homogenous captive programs. This year’s award goes to BevCap’s single-industry, homogenous captive focusing on beer distribution companies. BevCap’s goal this year was to increase usage of surgical center medical tourism during 2019.

In the first quarter of 2019, surgical center medical tourism usage among health plan participants was at 30%. In an effort to encourage utilization, the members made adjustments to their plan documents, and none of the changes included penalties to their employees.

As a result, usage of surgical center medical tourism jumped to 50% in the second quarter of 2019. In addition, the captive members had estimated savings of almost $1 million in the first 6 months.

“We’re very honored to win this award. Our members are truly committed to employee health and well-being, so this recognition is a tribute to all the hard work they’ve done,” said Jason Dixon, Partner at BevCap. “We’ve seen our hard work really pay off this year, and we look forward to further improvements in the years to come.”

About Berkley Accident and Health Berkley Accident and Health is a member company of W. R. Berkley Corporation, a Fortune 500® company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captives, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident. The company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. Visit www.BerkleyAH.com and connect with us at Contact@BerkleyAH.com.

SUN LIFE MAKES IN-PERSON BENEFITS ENROLLMENT A VIRTUAL REALITY

WELLESLEY, Mass. – As benefits enrollment season approaches and the pandemic continues, insurance providers and self-funded employers need to evolve to ensure that all enrollment needs can be met while maintaining everyone’s health and safety.

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NEWS Sun Life’s virtual enrollment capability provides employers and employees with the tools they need to understand and choose their benefits without in-person meetings.

Through remote technologies, Sun Life benefits counselors engage directly with employees at the 1:1 or small group level, offering individualized guidance and support, open Q & A sessions, and even facilitating the complete enrollment process.

So far demand for Sun Life’s fully digital enrollment services has increased significantly, with more than half (54 percent) of enrollment clients engaging in the virtual enrollment process this year.

“Enrollment season is already a challenging time for employees, as there are many benefit options to consider and a lot of decisions to make,” said David Healy, senior vice president of Group Benefits at Sun Life U.S. “We recently expanded our technology solutions to provide more customized options for digital benefits enrollment, and we are constantly innovating to continue to improve this support in the future.”

Sun Life also provides a customized landing page for the employer, giving employees a familiar, company-branded portal to navigate.

The landing page offers live or recorded informational sessions with a benefits counselor, informational videos, the employer’s enrollment materials and a link to their enrollment page. Interest in the customized landing pages has increased dramatically during the pandemic, as employers seek engaging digital options to replace traditional on-site meetings. Approximately 98 percent of employees who register for their employer’s landing page utilize it for enrollment.

“We expect even more interest in virtual enrollment as we get closer to enrollment season in the fall,” added Healy. “The way people engage with their benefits is changing, and now more than ever it’s important for us to serve employers and employees where they are.”

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NEWS For employers already using a dedicated benefits administration platform, Sun Life still provides benefits communication and enrollment support, and employees can reach a benefits counselor 24/7 via phone.

Telephonic enrollment for Sun Life clients has increased 16 percent since the pandemic began. Enrollment support is also available through Sun Life’s own digital benefits administration platform, Sun Life + Maxwell Health.

For all of Sun Life’s virtual enrollment resources, visit Sun Life’s enrollment services page on www.sunlife.com/us.

About Sun Life Sun Life is a leading international financial services organization providing insurance, wealth and asset management solutions to individual and corporate Clients. Sun Life has operations in a number of markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, Australia, Singapore, Vietnam, Malaysia and Bermuda. As of June 30, 2020, Sun Life had total assets under management of C$1,122 billion. Visit www.sunlife.com.

GOLD MEMBERS AMPS ANNOUNCES BRUCE RALSTON JOINS SENIOR LEADERSHIP

TEAM AS CHIEF TECHNOLOGY OFFICER AND CHIEF INFORMATION SECURITY OFFICER

PHOENIX – Advanced Medical Pricing Solutions (AMPS), a pioneer in cost management for the self-insurance industry, announces the appointment of Bruce Ralston as Chief Technology Officer and Chief Information Security Officer.

Mr. Ralston’s technology leadership is an ideal fit within AMPS, a technology-driven company. He brings a mixture of experience, spanning healthcare insurance, security, architecture, and engineering.

“We’ve given Bruce a tall order; now that our services are fully cloud enabled, his initial focus will be extending our data insights and capabilities beyond our four walls, empowering our partners and self-insured groups, while maintaining a strong security posture. Bruce’s expertise in workflow, claims processing and information security will play a large role in our new mobile enablement efforts and member services,” stated Kirk Fallbacher, President and Chief Executive Officer at AMPS. Ralston’s Insight: Technology Trends and Industry Advancements Mr. Ralston will also lead AMPS efforts with partners to contribute to the overall advancement of technology in the healthcare insurance industry by enabling a more integrated and secure experience for employer-sponsored plans and the members they serve through:

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1. Secure information sharing to enable increased cost transparency of provider services

2. Mobile enablement of direct member access to healthcare benefits and claims information

3. Transparent bundled pricing, resulting in savings for both the plan and member expected out of pocket expenses

4. ‘Zero-trust’ security controls that address weaknesses of legacy network security paradigms Mr. Ralston brings to AMPS a career dedicated to leading software development teams across the healthcare, travel, and financial services industries. His prior roles included managing security for six (6) hospital campuses and 125 clinics at HonorHealth; serving as Director of Architecture at Pegasus, leading engineers, developers, and quality assurance; and leading technology at Eldorado as Chief Technology Officer, responsible for engineering, quality assurance, and business analysis.

The addition of Mr. Ralston at AMPS follows the continued expansion of its executive team, which recently added several healthcare and health insurance industry veterans to its leadership team.

The addition of these industry-seasoned leaders, who together bring decades of experience in bending the cost curve to control the skyrocketing cost of healthcare, will help AMPS greatly enhance its ability to serve self-funded employer groups, brokers, third-party administrators and, most importantly, members.

Simplify Your Health Benefits Administration

We’re a leading third party administrator for self-funded employers of all sizes, in all industries. Driven by the unique needs of our employers and brokers, our proprietary technology systems give you the flexibility of customized plan design combined with the utmost in data security and online tools.

In addition to claims and benefits administration, we offer pharmacy benefit management, health management and wellness programs, stop-loss insurance, and print and payment solutions.

We offer a broader range of services and customized plans compared with other TPAs and have the flexibility of seamlessly integrating our solutions with your vendors.

See What Pinnacle Can Do For You 866.930.PCMI

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NEWS

About AMPS Advanced Medical Pricing Solutions (AMPS) provides market leading healthcare cost containment services for self-funded employers, public entities, brokers, TPAs, and reinsurers. AMPS mission is to help clients attain their goals of reducing healthcare costs while keeping members satisfied with quality healthcare benefits. AMPS leverages 15 years of experience in auditing and pricing medical claims to deliver “fair for all” pricing both pre-care and post-care. AMPS offers innovative dashboards and analytics to provide clients with insights based on Plan performance. Contact Amanda Hertig, Marketing, at ahertig@advancedpricing.com and visit www.advancedpricing.com.

SILVER MEMBERS NOVA HEALTHCARE ADMINISTRATORS RECOGNIZED AS ONE OF THE BEST PLACES TO WORK IN HEALTHCARE IN 2020

Chicago, IL – Nova Healthcare Administrators (Nova) has been selected by Modern Healthcare as one of the 2020 Best Places to Work in Healthcare. The complete list of this year’s winners, in alphabetical order, is available at ModernHealthcare.com/ bestplaceslist.

Modern Healthcare will publish a special supplement featuring a ranked list of all the winners along with the October 12 issue.

Nova is an innovative health plan solutions company headquartered in Buffalo, New York. With over three decades of experience, they work with organizations to build custom health plans that create better outcomes for their clients and their members.

“It has been an especially trying year for the world, and healthcare in particular as COVID-19 ravages our communities and your workplaces,” said Aurora Aguilar, Modern Healthcare’s editor. “But the organizations recognized on this year’s list rose to the top and continued to be a source of strength for their teammates. They have seen their colleagues fall ill to the virus and struggled with the economic impact of the pandemic. The loyalty and trust between employers and their workers is being put to the test now more than ever. We congratulate the Best Places to Work in Healthcare for continuing to serve their workforce and communities during such an unprecedented time.”

“There is no doubt 2020 has been a trying year. However, it has highlighted the importance that every associate plays in day-to-day operations and achieving our mission. We have spent this year focusing on making adjustments to a variety of

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internal initiatives to reinforce our sincere appreciation for their work and emphasize the fact that the value of workplace culture isn’t about a physical location but rather an overall approach to work, and living our core values,” noted Nova’s President, Jim Walleshauser.

This award program identifies and recognizes outstanding employers in the healthcare industry nationwide. Modern Healthcare partners with the Best Companies Group on the assessment process, which includes an extensive employee survey.

Nova will find out their ranking on the Best Places list and be celebrated at the 2020 Best Places to Work in Healthcare awards gala taking place virtually on October 8 in conjunction with the Workplace of the Future Conference. Information on the award celebration and conference is available at ModernHealthcare.com/WOTF. For more information or questions on the 2020 Best Places to Work in Healthcare recognition program or awards gala, please contact Jodi Sniegocki, Director, Education and Events, at jsniegocki@ modernhealthcare.com and 312.649.5459.

About Nova Evolving over the last 30 years, Nova aims to manage trend to reduce health care spend and improve selffunded health plan performance.

Headquartered in Buffalo, NY, Nova is a wholly-owned affiliate of Independent Health. One size does not fit all. We work with flexibility to provide the solutions you need in the way you need them including medical, dental, vision, COBRA, reimbursement account

NEWS administration, and private-labeled partnerships. Nova provides clients with unique reimbursement pricing arrangements, customized strategies and personalized service. Visit novahealthcare.com.

H.H.C. GROUP NOW REPRICES

WORKERS’ COMP CLAIMS IN 40 STATES

H.H.C. Group (HHC) announced that it has begun repricing Workers’ Comp claims to the fee schedule for the states of Washington, Oregon, Hawaii and Idaho.

This brings to 40 the number of fee schedule states for which HHC reprices Workers’ Comp claims. Additionally, HHC will negotiate with providers and accesses multiple Workers’ Comp Preferred Provider Organization networks to secure discounts below fee schedule in these four states, as it does in all fee schedule states.

“Our proprietary software reprices claims based on specific provider data and our Workers’ Comp Compliance Officer makes sure all claims are being repriced utilizing the latest available fee schedules to ensure repricing accuracy.

Consequently, providers challenge our calculations

less than 1% of the time.” said Dr. Bruce D. Roffe’, HHC’s President and CEO. “Very importantly, we’re able to turnaround the repriced claims with the discounts below fee schedule in 3 days or less. Our clients tell us our turnaround is faster and our repricing accuracy better than the companies they used before switching to HHC.” About H.H.C. Group H.H.C. Group provides containment solutions for Insurers, Third Party Administrators, Self-Insured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA and Government Health Plans. H.H.C. Group utilizes a combination of highly skilled professionals and advanced information technology tools to consistently deliver targeted solutions, significant savings and exceptional client service.

H.H.C. Group’s services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Reviews/Independent Reviews, Independent Medical Examinations (IME), and Pharmacy Consulting. H.H.C. Group is an URAC accredited Independent Review Organization for Internal and External Reviews. Contact Bob Serber at rserber@hhcgroup.com, 301-963-0762 ext. 163 and visit www. hhcgroup.com.

PAYER COMPASS LAUNCHES COMPASSCONNECT: TRANSPARENCY FOR HEALTH PLANS AND MEMBERS

Plano, TX – Payer Compass, a leading provider of healthcare cost control solutions, announces the launch of CompassConnect, a transparency tool that will reshape the healthcare experience for third-party administrators, brokers, self-funded employer groups and plan members.

Using data intelligence from proprietary and multiple outside data sources, such as CMS and Physician Compare, CompassConnect is designed to drive increased plan utilization and healthier outcomes through transparency.

The platform contains an array of provider data – general contact info, specialty, cost, geographic location and quality ratings. Users have the freedom to compare and select physicians, ultimately giving the plan members control over how they spend their healthcare dollars.

The tool makes it easier to comprehend member health benefits through the dashboard feature that will show a full view of the member’s utilization summary, individual claim history and overall plan terms.

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NEWS The app was designed with the user experience in mind, keeping information easily digestible. Providers are identified in written and visual, color-coded form based on their level of acceptance for reference based pricing plans, ranging from “Safe Harbor Providers” to those that are not RBP friendly.

Employers’ costs for plan benefits are driven by employees and their insured family members. To generate operational efficiencies and design a plan that best fits the members, CompassConnect gathers member data that is shared with the plan administrator.

This firsthand insight helps the plan admin or advisor identify high utilization members, design programs for them and specify terms to meet members with the care they need. Plans can also take this data to address member engagement, build trust, and ideally improve the organization’s population health.

“CompassConnect is our next step in delivering the most innovate and client-centric solutions, supporting our mission to control the cost of care. The current state of healthcare – the accessibility and out-of-pocket-cost for the members – is so crucial at this time, and we feel like we have something that will genuinely make a difference,” says Greg Everett, President and CEO of Payer Compass.

Early results of the solution’s impact show noticeable results – groups are seeing an uptick in plan utilization and more cases of plan acceptance by providers. It is proving to be helpful for members located in rural or remote areas where care options are limited by specialty or geographic location.

CompassConnect is an add-on solution for clients already integrated with our full reference-based pricing program, Innovate360, but it can also function as a standalone solution.

For additional information, please view CompassConnect video and the solutionspecific page.

About Payer Compass Payer Compass is an innovator in healthcare cost control, developing solutions dedicated to tackling spiraling costs and a lack of price transparency. Offering the most trusted proprietary healthcare reimbursement technology and price transparency solutions, we are dramatically reducing the cost of claims reimbursement for today’s employers. Payer Compass’ solutions – including the company’s core, next-gen pricing platform Visium™ and Innovate360, an end-toend RBP program, are used by a wide variety of customers within the self-funded community to manage any type of plan and the claims supported. As healthcare cost control experts, we deliver solutions needed to regain control of costs.

Additional offerings include predictive plan modeling and data analysis reporting, care management and bundled payments. Contact Ginger Barrientez, Director or Marketing, at GBarrientez@payercompass.com and visit www.payercompass.com.

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THE SELF-INSURER

SIIA 2020 BOARD OF DIRECTORS & COMMITTEE CHAIR ROSTER

CHAIRMAN OF THE BOARD*

DIRECTORS

COMMITTEE CHAIRS

David Wilson President Windsor Strategy Partners, LLC Princeton, NJ

Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston-Salem

PRESIDENT/CEO

Jeffrey K. Simpson Attorney Womble Bond & Dickinson (US) LLP Wilmington, DE

CAPTIVE INSURANCE COMMITTEE John R. Capasso, CPA, CGMA, PFS President & CEO Captive Planning Associates, LLC Medford, NJ

CHAIRMAN ELECT*

Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA

Mike Ferguson SIIA Simpsonville, SC Robert Tierney President StarLine Osterville, MA

TREASURER AND CORPORATE SECRETARY*

Gerald Gates President Stop Loss Insurance Services AmWins Worcester, MA *Also serves as Director

SIEF BOARD OF DIRECTORS Nigel Wallbank Chairman Heidi Leenay President

Thomas Belding President Professional Reinsurance Marketing Services Edmond, OK Laura Hirsch Co-CEO Aither Health Carrollton, TX Lisa Moody President & CEO Renalogic Phoenix, AZ

GOVERNMENT RELATIONS COMMITTEE Steven B. Suter President & CEO Healthcare Management Admtrs., Inc. Bellevue, WA CHAIR, INTERNATIONAL COMMITTEE Liz D. Mariner Ford Senior Vice President Re-Solutions, a Risk Strategies Company Minneapolis, MN CHAIR, SIIA FUTURE LEADERS COMMITTEE Brady Bizarro Director, Healthcare Attorney The Phia Group, LLC CHAIR, TPA BEST PRACTICES TASK FORCE Jerry Castelloe Principal Castelloe Partners, LLC CHAIR, WORKERS’ COMP COMMITTEE Shelly Brotzge Regional Underwriter, Group Self-Insurance Midwest Employers Casualty

Freda Bacon Director Les Boughner Director Alex Giordano Director

SEPTEMBER 2020 67

SIIA NEW MEMBERS SEPTEMBER 2020 REGULAR CORPORATE MEMBERS

REGULAR CORPORATE MEMBERS (CONT.)

John Sbrocco Principal Achieve Health Alliance Madison, NJ

Jeffrey Baker Senior Vice President of Sales Tampa, FL

Eric Bosnyak Vice President New Business Development WellSpark Health Farmington, CT ChoiceLegal Inc.

SILVER CORPORATE MEMBERS

Cara Abraham National Sales Advisor ImpaxRX Boca Raton, FL

Dawn Maloney-Horn Vice President Marketing Medical Review Institute of America (MRIoA) Salt Lake City, UT

Mary Delaney President Vital Incite Indianapolis, IN

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THE SELF-INSURER

Craig Phillips Executive Director AST Risk LLC Scottsdale, AZ

IS 1 TRILLION DOLLARS

in healthcare waste & errors too much?

YES. At Zelis, we listen to what payers and providers want and bring technology, people, expertise, and entrepreneurial energy together to create smart solutions and a better way for the industry. Integrated solutions to price, pay, and explain healthcare on a claim by claim basis, all offered by one trusted company.

Maximized Claim Savings.

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Transparent Explanations.

Contact Zelis today at 888.311.3505 or visit zelis.com to find out how our pre-payment solutions are helping control the rising cost of healthcare.

Better Service. Better Performance.

zelis.com Copyright 2019 Zelis. All rights reserved.

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