Transcript Global Health Care Management

Global Wellness in the Healthcare Reform Era:
Is The World Curved or Flat?
ISCEBS NYC 14 September 2011
Presented by:
Allen Koski, CEBS
302-797-3300 [email protected]
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
4 Years Ago (2007)
 Apple Introduces the iPhone
 Price of Gold was $630/ounce
 Final Harry Potter Book Released
 World Stock Markets Plummet
 Daimler sells Chrysler to an Equity Fund
 Peru earthquake leads to Tsunami Warnings
 Bulgaria and Romania join the European Union
 Tiger Woods wins Thirteenth Major (will win only one more)
 Time magazine in 2007 calling the Aztek one of the worst cars
of all time
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
New Diseases since 1973
 1973 Rotavirus: Infantile Diarrhea
 1977 Ebola: Hemorrhagic Fever
 1981 Staphylococcus aureus: Toxic Shock Syndrome
 1982 Borrelia burgdorferi: Lyme Disease
 1983 HIV: AIDS
 1989 Hepatitis C: Parentally Transmitted Liver Infection
 1993 Hantavirus: Adult Respiratory Distress Syndrome
 1995 Ehrlichiosis: Severe Arthritis
 1996 nvCJD: Creutzfeldt-Jacob Disease
 1997 H5N1: Influenza
 1999 Nipah: Severe Encephalitis
 2000s: Methicillin-resistant staph (MRSA)
 2009: H1N1 Flu Epidemic?
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Evolution of the Global Health Care
Management Model
The Goal: High Quality Care
Worldwide, integrated health care delivery system providing the
highest quality of care available in any given locale and bringing
together worldwide best practices.
Member
[
Member Beware
Risk Protection
Only
WHAT WAS
Patient
Advocacy
][
Network
Global Health &
Development
Wellness
BUILDING OUT
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]
What Will Change 4 Years Hence:
 Networks a mile wide and a few facilities deep: care in countries where no
networks or pre-arranged payment systems exist and Medical CPI (200 Countries)
 Widen the Circle of Care: Post treatment coordination and recuperative care
 Managing dynamic change in global healthcare, IEAP, dental, and disability
 Local insurance requirements to support VISA concerns and Healthcare Reform
 Corporate Global Wellness Initiatives
 Expatriate population continues to age and get more diverse
 Great “Black Swan” event planning
 Medical Tourism or Regional Options
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Tri-State Depot and Global Inc.
Number of employees
=
500 employees vs. 50 expat employees
Location of employees
=
50 miles from store vs. World Wide (30 different
countries)
Number of Hospital
=
=
5 to 10 local Hospitals vs. 1,000+ Possible Hospitals
Number of Providers
200 in-network/500 out vs. 100,000 Worldwide Providers
Location of Dependents
=
For locals, most families live together vs. internationally,
many spouses may not live in same location, and
students tend to go to colleges in different countries
Type of care available
=
For locals, care is similar across providers vs.
internationally, care can be very advanced to primitive
Currency
=
=
=
=
=
US dollars only vs. any currency available
State compliance
ID Card
Claim Adjudication
Financial
3 or 4 US states vs. 200 different countries
1-800 number vs. Global Call Collect
Auto adjudication vs. Direct Pay or Pay and Claim
Self Insured versus Insured
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International Benefits versus Domestic
(US) Benefits
 Medical, Dental, and Prescription Drug:
Transactional
 Life and AD&D:
Commodity
 Evacuation and Repatriation, Employee Assistance
Program (EAP):
Duty of Care Important
 Long Term Disability (LTD):
Hybrid Transactional and Commodity
 Short Term Disability (STD):
Salary Continuation
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Plan Design Differences
 International is Insured, Domestic is often Self-Insured
 Location of Assignment and Dependent Location
 Location where the Plan will be Monitored and
Maintained
 Specific Subgroup Requirements
 Country Specific Minimum Requirements
 State Minimum Creditable Coverage (MCC)
– Out of Pocket limited to $5,000/10,000 in
Massachusetts
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Domestic vs. International Cost Projections
Domestic Trends= Cost X Utilization
International Trends = Cost
X Locations
X Fx
X CPI
X Movement of Members
X Medical Advances
X Utilization
International plans tend to less expensive overall but have higher trend
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Country Specific Variations:
 Dubai: Need a local plan number
 UK: A Surgeon in “Mister”
 France: 3/5/09 is 5/3/09
 Japan: 96 hour maternity is the norm
 China: No screened blood supply
 Germany: Alternative Therapy
 Singapore: Ritalin is a “Controlled Substance”
 Global: Hardware versus Software
 US: Cost, Access, Quality
 UK: Employer benefits contributions are taxed
to Employee
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Global Traveler Checklist
Travel
Security
WHO
HR
CDC
Traveler
Risk Mgt
State Dept
News
Visa Support
Pre-Trip Healthcare
Provider Listing
ICE Strategy
Security Procedures
Medical
Contingency Plans
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Health Care Challenges
Multitudes of clinical protocols and dangers:
– Post treatment coordination and recuperative care
– Avoid counterfeit prescription medications
– Dealing with local traditional non-medical treatments
– Medical evacuation protocols, post treatment options
– Unscreened blood supplies
Difficult administrative issues
– “Hardware” and “Software” match
– Paying for emergency care in countries where no
networks or pre-arranged payment systems exist
– Local insurance requirements to support VISA
concerns
– Payment using any type of currency available
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Total Medical Cost
Global Network
Medical Cost
Savings
Global Wellness
Tools
US Networks
INITIATIVE
Networks
Improve Health &
Productivity
Return on Investment
Local Networks
Direct Payment Networks
Early risk reduction and
intervention
Direct individuals to programs
and high efficiency providers
Employee Initiatives
Employer Initiatives
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Summary of Differences
 Recognize that international assignment demands are
more complex and require specialized attention
– Medical capabilities are variable country to country
 Global service partners must improve business performance
– By delivering services that reduce the administrative
burden of health care and associated costs
 Protect the investment made in human capital and allow
international assignees to focus on what matters most within
their respective businesses
 Do not forget everything is multiplied in complexity when
someone is facing a new situation
 Work within different cultural norms
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Challenge Question: What Matters To
You Most In a Program?
1. Designing a Globally Compliant Solution
2. Cost Effective, Comprehensive Coverage
3. Easy Member Experience
4. Unrivaled Global Network
5. Wellness Tools to Improve Health
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Mod 2: Overview of the Impact of Health
Care Reform on Global Employees
 Many Governments around the world have changed their view
about medical coverage (Locals and Expats).
– UAE: Expats are now required to show proof of coverage
before getting a work visa,
– Czech Republic now requires Locals and Expats to get
minimum coverage levels thru a non-government insurance
company,
– Russia requires a minimum level of medical coverage, with
any insurance company,
– Some national systems require all employers to pay into
one system for both Locals and Expats.
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Delivering Global Benefits is Complicated: Legal
Middle East
Australia
– Illegal for any non-registered health
fund to pay claims for Medicare
eligible Australians
– Having private health insurance with
an AUS registered health fund
allows Australia taxpayers to claim
exemption from 1% Medicare Levy
Surcharge, if eligible
– Minimum benefits are required to
allow for 457 Visa Letters to be
issued for non-Australians working
in Australia
Saudi Arabia
• Coverage has to be provided by
a locally-admitted carrier
• Minimum coverage requirements
(CCHI)
United Arab Emirates
• Coverage has to be provided by
a locally-admitted carrier
• Plans must be filed with local
authorities (HAAD)
• Impact on obtaining a visa
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US: Patient Protection and Affordable Care (PPACA) Act of 2010
New Plans
New and Grandfathered Plans
 Must follow rating limitations.
 Guaranteed issue.
 No preexisting condition
exclusions.
 Guaranteed renewability.
 Waiting period limited to 90 days.
 No discrimination based on
health status.
 No discrimination against health
care providers acting within
scope of their license.
 Must cover essential benefits.
 Must follow cost-sharing limits.
 Must cover clinical trials without
additional conditions.
2010
2011
2012
2013
2014
2015
2016
2017
2018
18
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
PPACA: Provisions Phased in until 2018
Implications
 No discrimination in favor of highly compensated individuals.
 Dependent age rises to 26 years
 Minimum loss ratio requirements (80%/85%)
 Broker commission in/out of the program?
 Is the individual mandate legal or not?
 2018: Introduction to high value plans ($11,200/$27,500)
 What waivers will be granted? What state requirements?
 Will insurers withdraw from markets?
 Will Americans be allowed on “offshore” plans after 2014?
2010
2011
2012
2013
2014
2015
2016
2017
2018
19
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
Global Plan Options: Post Healthcare Reform (PPACA)
 It appears that domestically sitused expatriate plans will be subject to
some of the new law provisions.
– leave US citizens on a US PPACA compliant plan but cover the TCN/KLNs
under a separate “offshore” policy, again assuming the US employer has a
place of business in a location where a local policy can be legally issued;
OR
– create a sub-group under the US policy made up of only TCNs and KLNs
with cover that differs from the PPACA compliant cover provided to the
other group on the principles that (a) these groups could be grandfathered
(if renewing), and (b) presumably the PPACA was not intended to require
certain types of cover for non US citizens based outside the United States
and thus a client is willing to assume the risk that it is unlikely that the
government would pursue non-PPACA-compliant levels of cover for noncitizens residing outside the United States.
– Don’t forget other issues like Massachusetts Credible Coverage Minimums
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Mod 3: Business Plan on Deploying International
Wellness Programs
Multi-national workforce means varied health and wellness concerns:
Europe:
Productivity, Reducing
Presenteeism &
Morale/Engagement
Canada:
Productivity, Reducing
Presenteeism &
Morale/Engagement
United States:
Reducing Health Care
Costs & Productivity,
Reducing Presenteeism
Latin America:
Productivity, Reducing
Presenteeism &
Maintaining Work Ability
Africa:
Productivity,
Reducing
Presenteeism
& Absence
Management
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Asia:
Morale/Engagement &
Productivity, Reducing
Presenteeism
Australia:
Productivity,
Reducing
Presenteeism
& Absence
Management
A Different Way of Thinking
Addressing health care demand and spending
from both sides of the problem
Annual Patient Cost
High Risk
$
9,000
8,000
Earliest
interventions help
prevent costly
medical events
7,000
6,000
5,000
Medium Risk
Case
Management
Low Risk
Disease
Disease
ManagementUtilization
Management
Management
Traditional medical
management responds
to disease/illness
4,000
3,000
2,000
1,000
0
Q_12
Q-12
Q_10
Q-10
Q_8
Q-8
Q_6
Q-6
Q_4
Q-4
Q_2
Q-2
Q0
Q0
Q2
Q2
Q4
Q4
Q4
Q6
Q6
Q8
Q8
Q10
Q10
Preventing/Slowing
Responding/Reversing
•Health Promotion & Wellness
•Lifestyle Behavior Modification
•Chronic Condition Support
•Disease Management
•Acute Care Coordination
Original chart source: Musich,Schultz,Burton,Edington. DM&HO. 12(5):299-326, 2004
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
Q12
Q12
Condition Management
 Chronic condition support & management: A comprehensive approach
to managing the course and impact of chronic conditions
– Look for active versus passive program
• Proactive identification of high risk patients
• Program with consistent service experience, regardless of
patient location
• Holistic patient management, not just managing events of
treatment
– “health, family, and life management” not just medical
management
• Outreach for the purpose of education and intervention, so as
to change behavior and manage compliance
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Condition Management: Diabetes
Triage Logic
DIABETES?
YES
Do You Take
Insulin?
YES
Level 3
NO
NO / Next
Do You Know Your
Hemoglobin A1C
Levels?
YES
Is it
Above 7?
YES
NO
NO
Level 3
Do You Take 2 or More
Meds a Day for
Diabetes?
NO
Level 1 if Low Risk country;
Level 3 if High risk country
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Level 3
YES
Level 3
Health Programs: Virtual Second Opinions
Access to internationally-recognized experts for confirmation of
life-threatening/life-altering diagnoses and treatment
recommendations, without requiring the expat to travel or incur
out-of-pocket expenses.
Look for:
• Utilization of a specific world-class vendor
(recognized expertise)
• Intended for use for serious illness, complex cases
• Provision of more treatment options beyond what’s
available locally
• Receive world-class opinions without the
cost/disruption of traveling
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Health Programs: International Employee
Assistance Program
Immediate access to confidential services for behavioral health
assessment. Have three levels: Telephonic, Face-to-Face and
Work/Life Support.
Look for:
• Service Level: 24/7 with multiple access points:
telephonic, email, online chat or SMS Text.
• Telephonic triage and crisis intervention services
• Local language Face-to-Face Sessions
• Work/Life Support: Child and Senior Care
• Local language access (23 Regions)
• Structure telephonic counseling (170 Countries)
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Wellness Program: Health Assessment
 Collects individuals’ health information by asking a series of questions:
 Personalized health risk report to make changes to unhealthy lifestyle
habits:
– Behavior modification to instill healthy habits before condition
appears
– Self-directed, online programs available in many languages and
culturally adapted
– Targets four key areas of modifiable health risks:
• Sleep Habits
• Stress Management
• Healthy Eating
• Physical activity
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Challenge Question: What Wellness
Program Will Have the Greatest Inpact?
1. Health Risk Assessment for Expatriates
2. Health Risk Assessment for Locals
3. Condition Management Program
4. Virtual Second Opinion
5. International Employee Assistance Program
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Business Plan
 Prepare for “Black Swan” Events (ICE Strategy)
 Gap Analysis between Healthcare Provider, Workers
Compensation Provider, Evacuation Vendor
 Harmonize Medical Evacuation and Security Evacuation
 Review Legal Requirements at Local and Global Country Level
 Have Global Dental and EAP Providers
 More Local Options Before Evacuation
 Screen Chronic Conditions Before Deployment
 Have Regional Options in Place
 Understand Healthcare Reform Initiatives by Country
 Offer Wellness and Pre-Departure Tools
 Consider Segmented Expatriate and Third Country National
Plans
 Recognize Corporate Duty of Care Requirements
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“Sometimes I'm confused by what I think is really obvious.
But what I think is really obvious obviously isn't obvious...”
Michael Stipe, Lead Singer REM
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Questions to Ask
 Are global health plan higher or lower than domestic?
 Are there any downsides to putting in a plan?
 How is eligibility handled?
 Can you do VISA letters to help with immigration requirements?
 What reporting in offered?
 Are there countries where the program does not work?
 Should we purchase war risk or terrorism coverage?
 Discuss employer contribution strategies for expats, TCNs and Key Locals?
 How do you do implementation meetings?
 How does healthcare reform(s) affect our global benefit levels?
 How should we handle short term assignments?
 How does HR and Risk Management manage multiple vendors?
 Does the evacuation, healthcare or workers compensation vendor take the
lead on medical emergencies?
 What do you think about multinational pooling?
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CIGNA International Expatriate Benefits –
A Market Leader in Global Healthcare
What we offer…
Leadership Statistics
►Global
access to quality health care coupled with
integrated products and very personalized service
►30+
years of experience
Our products…
►49%
►Medical,
dental, vision, behavioral, pharmacy, life
insurance, personal accident, disability, business travel
and wellness programs
►Leverage
CIGNA HealthCare’s capabilities, where
applicable
►Focus
on consumer through global access to quality
health care and personalized service
►Multi-lingual
customer service representatives, 24/7/365
►Global
networks with Direct-to-provider payment system
with more than 150 countries
of Fortune 100 companies are
customers
►4.8
million policyholders worldwide
►Actively
selling in 27 countries and
jurisdictions with service capabilities in
virtually any country
►A global
workforce of 4,000
experienced professionals
How we distribute…
►Primarily
through benefits brokers and consultants to
multinational organizations with employees serving on
long- and short-term international assignments
►30
different healthcare licenses
worldwide
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