Confidential, unpublished property of CIGNA.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]
Confidential, unpublished property of CIGNA.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Confidential, unpublished property of CIGNA.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?
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA
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
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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:
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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 = 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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
Visa Support
Pre-Trip Healthcare
Provider Listing
ICE Strategy
Security Procedures
Contingency Plans
TravelerTraveler
CDCCDC
WHOWHOSecuritySecurity
Risk MgtRisk Mgt
NewsNews MedicalMedical
TravelTravel
HRHR
State DeptState Dept
Global Traveler Checklist
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
Total Medical Cost
US Networks Global Wellness Tools
Global Network
Medical Cost Savings
INITIATIVE
Networks 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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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.
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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 PlansNew Plans New and Grandfathered PlansNew and Grandfathered Plans
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
ImplicationsImplications
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
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 non-citizens residing outside the United States.
– Don’t forget other issues like Massachusetts Credible Coverage Minimums
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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 Risk
Medium Risk
Low 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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
Level 3
NO
Condition Management: Diabetes Triage Logic
YESDo 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
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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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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)
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA
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…
►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
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