presented by: allen koski, cebs 302-797-3300 allen.koski@cigna

Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

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]

mailto:[email protected]


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

http://en.wikipedia.org/wiki/TIME_Magazine

http://en.wikipedia.org/wiki/File:2002-05_Pontiac_Aztek.jpg


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?

http://www.webmd.com/skin-problems-and-treatments/understanding-mrsa-methicillin-resistant-staphylococcus-aureus


Evolution of the Global Health Care Management Model

The Goal: High Quality CareWorldwide, integrated health care delivery system providing the highest quality of care available in any given locale and bringing together worldwide best practices.

Patient Advocacy

Network Development

Global Health & Wellness

Member BewareRisk Protection

Only[ ]WHAT WAS [ ]BUILDING OUT

Member


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

What Will Change 4 Years Hence:


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 = 3 or 4 US states vs. 200 different countries

ID Card = 1-800 number vs. Global Call Collect

Claim Adjudication = Auto adjudication vs. Direct Pay or Pay and Claim

Financial = Self Insured versus Insured


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


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


Domestic vs. International Cost Projections

Domestic Trends= Cost X Utilization

International Trends = Cost X Locations

X Fx X CPI X Movement of MembersX Medical Advances X Utilization

International plans tend to less expensive overall but have higher trend


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


Visa Support

Pre-Trip Healthcare

Provider Listing

ICE Strategy

Security Procedures

Contingency Plans

TravelerCDC

WHOSecurity

Risk Mgt

News Medical

Travel

HR

State Dept

Global Traveler Checklist


Health Care Challenges

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

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


Total Medical Cost

US Networks Global Wellness Tools

Global Network

Medical Cost Savings

INITIATIVENetworks Local Networks Direct Payment Networks

Improve Health & Productivity

Early risk reduction and intervention

Direct individuals to programs and high efficiency providers

Return on Investment Employee Initiatives Employer Initiatives


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


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


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.


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

Middle East

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

Delivering Global Benefits is Complicated: Legal


US: Patient Protection and Affordable Care (PPACA) Act of 2010

No preexisting condition exclusions.

Waiting period limited to 90 days.

Must follow rating limitations. Guaranteed issue. Guaranteed renewability. 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.

18

2010 2012 2014 2016 20182011 2013 2015 2017

New Plans New and Grandfathered Plans


Implications

PPACA: Provisions Phased in until 2018

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?

19

2010 2012 2014 2016 20182011 2013 2015 2017


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 non-citizens residing outside the United States.

– Don’t forget other issues like Massachusetts Credible Coverage Minimums


Mod 3: Business Plan on Deploying International Wellness Programs

Multi-national workforce means varied health and wellness concerns:

Africa:Productivity, Reducing Presenteeism & Absence Management

Latin America:Productivity, Reducing Presenteeism & Maintaining Work Ability

Asia:Morale/Engagement & Productivity, Reducing Presenteeism

Europe:Productivity, Reducing Presenteeism & Morale/Engagement

Canada:Productivity, Reducing Presenteeism & Morale/Engagement

United States:Reducing Health Care Costs & Productivity, Reducing Presenteeism

Australia:Productivity, Reducing Presenteeism & Absence Management


A Different Way of Thinking

$

Q4

Disease Management

Annual Patient Cost

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Q_12 Q_10 Q_8 Q_6 Q_4 Q_2 Q0 Q2 Q4 Q6 Q8 Q10 Q12

High RiskMedium RiskLow RiskCase

Management

Utilization Management

Traditional medical management responds

to disease/illness

Q-12 Q-10 Q-8 Q-6 Q-4 Q-2 Q0 Q2 Q4 Q6 Q8 Q10 Q12

Original chart source: Musich,Schultz,Burton,Edington. DM&HO. 12(5):299-326, 2004

Earliest interventions help prevent costly medical events

Disease Management

Addressing health care demand and spending from both sides of the problem

Preventing/Slowing Responding/Reversing•Health Promotion & Wellness•Lifestyle Behavior Modification

•Chronic Condition Support•Disease Management•Acute Care Coordination


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


Level 3

NO

Condition Management: Diabetes Triage Logic

YES Do You Take Insulin?

NO

Do You Know Your Hemoglobin A1C

Levels?NO / Next

DIABETES? YES Level 3

YES

NO

Level 3

Is it Above 7?

NO

Level 3

Do You Take 2 or MoreMeds a Day for

Diabetes?

Level 1 if Low Risk country; Level 3 if High risk country

YES

YES


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


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)


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


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


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


“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


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?


CIGNA International Expatriate Benefits – A Market Leader in Global Healthcare

What we offer…

►Global access to quality health care coupled with integrated products and very personalized service

Our products…

►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

How we distribute…

►Primarily through benefits brokers and consultants to multinational organizations with employees serving on long- and short-term international assignments

Leadership Statistics

►30+ years of experience

►49% 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

►30 different healthcare licenses worldwide

presented by: allen koski, cebs 302-797-3300 allen.koski@cigna

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