Self Funding Magazine january 2011

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Self Funding Magazine

TABLE OF CONTENTS

SPECIALTY PHARMACEUTICAL RISK MITIGATIONby Eric Hill, Vice President of BioRx,

This Issue ~ For Your Health

Copyright © 2011 Self Funding Magazine. All rights reserved. Self Funding Magazine is published monthly by. Material in this publication may not be reproduced in any way without express permission from Self Funding Magazine. Requests for permission may be directed to [email protected]. Self Funding Magazine is in no way responsible for the content of our advertisers or authors.

ARE YOU OFFERING THE RIGHT BENEFITS?by Alex Piper

LETTER FROM THE EDITOR2011- A New Road Lies Aheadby Jonathan Edelheit

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SFF EMPLOYERSELF FUNDINGHEALTHCARE & WORKERS COMPENSATION CONFERENCE

3rd Annual

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8 IS AN OVERWEIGHT EMPLOYEE MORE LIKELY TO BE INJURED ON THE JOB?”by Craig Halls, MBA, LAT, CEES & Dwight Gaal is CEO/CFO of The Industrial Athlete, Inc

10By Don Duford,, CEO, One Call Medical

THE URGENT NEED TO MANAGE DIAGNOSTIC RADIOLOGY

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Jonathan EdelheitJohn Springer


By Zubiller, Vice President, Advanced Diagnostics, McKesson Health Solutions

KILLING GRANNY?by Victor S. Dorodny, M.D., N.D., Ph.D., M.P.H.

WELLNESS PROGRAMS WORK BY ATTRACTION NOT PROMOTIONby Neil Treitman, founding partner of Cambium Wellness, LLC

A.R.M. YOUR EMPLOYEESby Jay Young

VOLUNTARY BENEFITS HELP LOWER THE RISK OF SELF-FUNDED BUSINESS MODELS

RETIREE DRUG OPTION GIVES BROKERS OPPORTUNITY TO RIDE Samuel H. Fleet is President of AmWINS Group Benefits

LET THE THIEF NO LONGER STEAL!By Tony Dale

FOLLOW US ON:

TABLE OF CONTENTS

By Don Duford,, CEO, One Call Medical

THE URGENT NEED TO MANAGE DIAGNOSTIC RADIOLOGY

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SUBSTANCE ABUSE, AGING, AND BABY BOOMERS: NOT A PRETTY PICTUREby Ken Bachrach, Ph.D

MANAGING THE ADVANCED DIAGNOSTIC TESTING BOOM

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by Michael Naumann

RED FLAGS IN THE MORNING, BUSINESSES TAKE WARNINGby By Lewis D. Bivona, Jr., CPA, AFE

THE TOOTH, THE WHOLE TOOTH, AND NOTHING BUT THE TOOTH.by Mark Roberts

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CATCH THE NEXT WAVE IN VOLUNTARY BENEFITS!by Wayne Morris

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TAKE THESE STEPS TO EAT HEALTHIER DURING THE HOLIDAY SEASON.by Jody LaMarca-Lowry, RD, CDN

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Self Funding Magazine LETTER FROM THE EDITOR

2011~ A New Road Lies AheadAs we enter the New Year many of us are eager to leave behind the troublesome and complicated tribulations that 2010 brought. This past year has been one of the most difficult years for employers, insurance companies, agents and other healthcare and health insurance industry stakeholders. Healthcare reform has been a wild and bumpy roller coaster ride that has yet to stop. It seemed every-one was forced to stop in their tracks, and put on hold new initiatives and inno-vative programs to focus on understanding what healthcare reform meant and the implications it would have on their enterprise, learning not only how it would

affect them, but how they would need to comply with it. Just when everyone started feeling comfort-able and felt like they had a good grasp of healthcare reform and its provisions, the republicans swept in with a huge win in the fall elections, winning the House and reducing the Democratic majority in the Senate. With Republicans vowing to cut off funding for healthcare reform and its implementation, and one Federal Court striking down the individual mandate, no one knows when or better yet, how this roller coaster will really end.

Unfortunately, one negative effect of healthcare reform is that it has caused insurers, employers and agents to sit back and wait. It is now time for action. Employers and insurers need to start implement-ing those new programs they had previously set aside for the last year and start putting them into place so that they can reduce their healthcare costs and make healthcare consumers more price/quality con-scious. A focus should be put on corporate wellness and health and wellness initiatives, valued based benefits design, consumer driven plans, and innovative new pharmacy and specialty drug programs. Voluntary Benefits will be the lifeline that keeps many insurance agents in business as insurers elimi-nate their commissions or reduce them to unsustainable levels. Employers will turn toward self fund-ing their healthcare benefits as a way to lower healthcare costs. It’s a year of ACTION and the New Year is a time that marks resolutions and plans for a fresh new start!

As the government gets more organized and develops better infrastructure to deal with healthcare reform, hopefully they will provide more insight and guidance and in a much more timely fashion go-ing forward. 2011 will be a very interesting year. There will be challenges, but along with challenges come opportunities and new paths to venture on. I wish everyone a very successful year.

Jonathan Edelheit

Are You Offering The Right Benefits?

No one can dispute the fact that times keep changing. Take a look at your history books or Google history of the U.S. and you will see that there have been many distinct historical periods in the U.S. Today’s generations can certainly point to historical facts such as Nine Eleven (September 11, 2002), Iraq, Afghanistan and the Obama Economic bailout, as some of these distinct historical memories. Times also affect the U.S. public and the U.S. labor force. One of these effects is in how they protect themselves against unforeseen occurrences.Unforeseen occurrences can include both personal and non personal occurrences. The number one non-

personal occurrence is financial in nature. Aside from traumatic accidents that can have lasting psychological effects, the main result of accidents is financial in nature. Therefore, Americans always seek a way to minimize the adverse financial effects of accidents and are willing to invest in that effort. While all this information may seem very basic in nature to readers, it is necessary to show the background against which this article will elaborate.The major benefits are group health, dental, vision, life, accidental death and dismemberment, and long term care. We are all familiar with these in some shape or form. They account for the majority of the

by Alex Piper



cost of benefits to U.S. households. For the most part, these coverages are tried and proven. In other words, they’ve been around for a long time. Therefore, they are very, very competitive in price and features. In other words, they do not differ much from one provider to the next. The relevance of this observation is that insureds and employees are not likely to be swayed much by the small differences that exist amongst these benefits from one provider to the next.One way in which self-insured plan owners can influence the impact of these major benefits to their employees is in the cost. Note that we are referring to the cost, not the price. The price, as the previous paragraph noted, is not likely to be very different from one product to the next. Therefore, the price is not likely to offer a major advantage or disadvantage to the plan owner. The cost of the benefits, for purposes of this article, is the amount of money that the plan owner passes on to the employees. Different employers cover the cost of the benefits to different extents. Based on the actuarial of the offering, it’s common to see employers cover between Fifty percent (50%) and Ninety percent (90%) of the overall cost. The higher the enrollment, the less cost per employee. This is one reason why plans strive for high enrollments; it makes the cost to the employee more bearable. It’s common in the market place to hear employees say that large employers “have better benefits”.In fact larger employers, with over 50,000 employees for example, are able to spread the cost of the benefits over a much larger head count than smaller employers. Therefore, the cost of the benefits is less, and employees interpret that benefit of a lower cost as if the benefits were better. Regardless of the cost of the benefits, employers can design the benefits package that they offer their employees. What this article is referring to when it talks about the benefits package design is the actual benefits that are offered. This is different from what is commonly referred to as “plan design”. Plan design is commonly attributed to the actual features of a benefit. These features contain some distinct factors. But for the most part,

the plan design refers to the participants, eligibility, coverage and cost.Participants are very important because they cover part of the plan costs. Employers are very careful who they extend coverage to. They manage who is covered and who is not covered through eligibility. Note the subtle difference between participants and eligibility. Participants are the plan members who pay and have out of pocket costs. Eligibility refers to other covered persons. The more the eligibility the higher the plan cost and the higher the payments that the participants have to make. Employers who want their employees to cover more of the plan costs can choose to extend coverage to more persons or, increase eligibility. Of course, in the true sense of the word, eligibility covers much more than who is covered and who is not covered. However who is covered and who is not covered is the specific distinction that this article wishes to make regarding eligibility.Coverage simply refers to the conditions, ailments, and treatments that the plan can be used to defray some of the cost. The cost refers to the extent to which the coverage defrays the cost, because the balance, or uncovered costs, is charged to the participant as out


of pocket costs. Plan design is much more intricate and complex than this article insinuates, but for purposes of this article we can limit our understanding of plan design to participants, eligibility, coverage and cost.Now let’s review what we’ve talked about thus far. We’ve taken a look at the major benefits that comprise a benefits package. We’ve examined how the major benefits packages do not differ from each other substantially enough to constitute a major competitive advantage, or to make an appreciable difference to the employees. We’ve also taken a look at some plan design features in terms of participants, eligibility, coverage and cost. Now let’s take a look at the benefits package design. The specific benefits that comprise a benefits package are called the benefits package design. Unavoidably, our discussion of benefits package design will also touch on some plan design. This will occur so that we may address our topic in as robust a manner as is possible.To start off the discussion of actual benefits package design, I want to list some benefits, and then focus on some of them to make this article’s point. The major benefits mentioned in the third paragraph are group health, dental, vision, life, accidental death and dismemberment, and long term care. The benefits that can be added to these in order to create a package that is very attractive to employees in today’s market place are as follows. Flextime, vacation, holidays, sick days, work from home, internet access, breaks, lunch, day care, discount cards, and parking.This list may seem intuitive for the most part to the readers of this article. However, we’ll see that their selection AND their design can make a difference. First, let’s examine the makeup of most U.S. households. Ten or twenty years ago the acronym DINKs was very popular. It referred to families with Double Income and No Kids. The phrase “Yuppies” was also very popular. It referred to Young, Urban, Professionals. Offshoot of the phrase such as “Buppies” or “Black Urban Professionals”, also were common. Regardless of the acronyms or the phrases, they were a sign of times of wealth and individualism or small households. The fact that today, U.S. households are larger and more

interdependent is a major sign of the current times. How does this affect benefits package design? Let’s take a look.The term “head of household” in today’s household, is a shared responsibility. And because of the size of today’s household, employees need time to be able to take care of a more diverse household. Household members range now from the very young to the very old. Therefore their needs are very different from each other. In order to meet their responsibilities, head of households, who are the household wage earners, need time and resources. They need a flexible work schedule (Flextime), more time off (vacation, holidays, sick days), time at home ( work from home), ability to solve problems from wherever they are located (internet access, breaks, lunch breaks, day care) and ways to save money (discount cards). Here’s a good one. They also need to be able to jet in and out of work as needed (parking), and quickly, so they can run errands for the household. Starting to make sense?Whereas the major benefits that comprise a benefits package are instrumental in attracting a productive work force, it is the design of the benefits package that is instrumental in the retention of that productive workforce. Otherwise, the employees are not able to be happy in employment with a poorly designed benefits package. Of course, the plan design itself is also very important. For example, what exactly constitutes flextime? Is it a flexible workday or a flexible work week, or a flexible pay period? In other words, do employees have flexibility by the day, by the week, or by the pay period? This is the sort of plan design that this article considers to be important when assessing whether you are offering the right benefits.In my opinion, employers with the right benefits will always have a long line of candidates who are applying for jobs at their company. However, they will also be the ones that are conducting large numbers of interviews for job applicants because they have a high employee turnover. The employers with the right benefits package design will be the ones who are conducting less job interviews because their turnover is low.



Is an overweight employee more likely to be injured on the job?

According to two studies the answer is “YES!” One study performed by the Duke Health and Safety Surveillance System found a clear relationship between body mass index (BMI, which is a measurement used to classify individuals as overweight or obese) and the rate of injury claims. Another study, performed by researchers at the John Hopkins Bloomberg School of Public Health’s Center for Injury Research and Policy, obese workers do have more injuries. The study looked at 7,690 workers and out of this group, 85% of them were classified as overweight or obese.

by Craig Halls & Dwight Gaal


There are a number of options, and some need to be considered more carefully than others due to legal and liability issues in order to avoid discrimination based on height and weight, which is currently illegal.

Some suggestions include:

• Develop or maintain onsite wellness program, such as a pre-work or lunch time walking group• Implement an incentive/challenge program using a pedometer• Do a “Biggest Loser” challenge with • Provide onsite weight loss classes, such as Weight Watchers at Work• Providing gym memberships• Analyze vending machines and allow employees healthier options, such as a fruit bowl in the lunch room• Distribute literature or create a bulletin board that has information on weight loss (risks of being overweight, how to start an exercise program, how to eat healthier, etc)• Post-offer pre-employment physicals that ensure the employee has the physical capabilities to perform the job tasks• Use an “industrial athlete” approach to implement injury prevention and injury management programs• Perform ergonomic analysis and see if there is a way to make the workstations saferThe Urgent Need to Manage Diagnostic Radiology

So what’s an employer to do?

Craig Halls, MBA, LAT, CEES is the Wellness Manager at Aurora Health Care. He has over 14-years of consulting experience with developing and managing onsite programs for employers, such as injury prevention, rehabilitation, ergonomics, and wellness. Craig obtained his Bachelor’s of Science in Human Kinesiology from UW-Milwaukee and MBA from Cardinal Stritch University. He has spoken multiple times at the National Safety Council Annual Meeting and the National Athletic Trainers’ Association Annual Meeting has authored numerous articles related to onsite employee health-related programs. Contact Craig at [email protected] or [email protected].

Dwight Gaal is CEO/CFO of The Industrial Athlete, Inc. TIA is a national leader in providing employees to implement the Sports Medicine Model for industrial and manufacturing companies. TIA’s proprietary SMART System has saved their clients millions of dollars as it reduces insurance and out-of-pocket healthcare expenses, and lowers DART (Days Away, Restricted Duty and Transfers) rates and OSHA (Occupational Health and Safety Administration) recordable injuries. At the same time it helps prevent injuries and gets employees back to work sooner with less chance of an injury reoccurrence. Contact Dwight at [email protected] or for a free analysis of your current occupational health and safety program, email [email protected].

Bio



Today, there is a new category of escalating medical costs—diagnostic radiology—that requires effective cost-containment solutions. Diagnostic radiology services, which include magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) scans, have improved the medical community’s ability to detect, diagnose, and treat medical conditions and injuries. With these diagnostic tools, physicians can peer into the human body with increased power and capability. Yet

left unmanaged, diagnostic radiology costs will continue to skyrocket, negatively impacting the bottom line for many self-funded health programs, as well as healthcare consumers. With spending in this area increasing so dramatically, diagnostic radiology is now the new frontier that self-funded health plans need to manage. In this article, we discuss the key challenges and cost drivers, as well as outline sensible solutions that deliver proven savings and quality outcomes.

The Urgent Need to Manage Diagnostic RadiologyBy Don Duford


Diagnostic Radiology: Three Key Concerns Today, diagnostic radiology presents three key challenges to self-funded programs:

• How do we control skyrocketing radiology costs? With its 20 percent growth rate, diagnostic radiology is now the fastest rising area of medical expense, increasing at twice the rate of prescription drugs and faster than overall healthcare spending, which is rising at only 10 percent each year. According to a report by the Association of Health Insurance Plans, almost $100 billion a year is spent on imaging in the U.S. and these costs are expected to double in just four years.

• Howdoweidentifyandutilizequalifiedradiologyproviders? Today, there are many imaging facilities to choose from. The number of providers has grown 52 percent between 1999 and 2005, and providers differ in regards to their impact on cost and quality. As a result, self-funded programs need a means to identify and utilize only the best, most qualified, and credentialed radiology providers.

• How do we effectively service patients’ diagnostic imaging needs? The growing popularity of consumer-driven benefits means patients are paying more out-of-pocket expenses to meet their healthcare needs. Consequently, they have a greater stake in making wise purchasing decisions. However, patients often do not have sufficient pricing information for diagnostic services, nor do they have the ability to verify that providers will perform tests promptly and appropriately. As a result, advocacy services are in high demand to meet patient needs, as the primary consumers of these services.

Three Types of Providers: The Impact on Cost & Quality The key factor driving increased utilization is that diagnostic radiology leads to better medicine. Advanced imaging provides fast, comprehensive information on which to base an accurate diagnosis. It enables physicians

to create an effective treatment plan, which ultimately leads to improved quality of care for patients. Although diagnostic radiology may be on the rise, tests can lead to an overall reduction in healthcare costs, if imaging is performed appropriately. And therein lies the challenge. There are generally three types of providers of radiology services, and each impacts costs and quality differently:

• Hospitals. Upwards of 80 percent of imaging exams are performed in an outpatient hospital setting. These services are generally high in quality, but also very expensive, charging the highest per-scan cost of any other imaging facility. Often the same test can be performed with identical equipment and equally experienced clinical staff, but at a more cost-efficient facility.

• Physician Offices. In the past, high-tech imaging equipment was found in a limited setting. Today, physician offices can easily purchase or lease the same equipment, although it is very expensive. Studies suggest that physicians who have acquired this technology have a strong incentive to recoup their investment over time. As a result, many order tests for financial reasons rather than medical necessity.

For example, the U.S. General Accountability Office (GAO) recently documented a dramatic increase in the number of physician offices that “self-refer” patients for imaging performed on scanners they own or profit from. Self-referring physicians use these services as much as 3.2 times more than physicians who referred patients to independent radiologists. This trend leads to inappropriate utilization and soaring radiology costs.

• Freestanding Imaging Centers. Today, most of the U.S. population has access to one of the thousands of freestanding imaging centers across the country. The challenge is in identifying the facilities that consistently perform quality tests, provide prompt service, and deliver accurate test interpretations.



With the popularity of consumer-driven health plans, it’s often the patients who must pay for a majority of the imaging cost, and who are responsible for shopping around to find the best facility. And as previously discussed, consumers often lack the information to make informed decisions on where to go to obtain quality testing.

Diagnostic Specialty Networks

Most plans will experience approximately 200 to 250 scans per 1,000 members per year. Up until this point, self-funded programs have relied solely on traditional PPO networks to access radiology providers. However, with increasing utilization, these programs must consider a more specialized approach to effectively contain costs and ensure patients schedule tests with quality providers.

Use of diagnostic specialty networks is a proven and increasingly popular management strategy. Specialty networks have close partnerships with radiology providers, and therefore, can offer savings of 50 to 60 percent per scan, depending on the geographic region and the type of provider who

would have otherwise performed the test. These networks also use several methods to ensure the quality

of their contracted providers, which leads to more accurate imaging and interpretations.

A specialty network consists of freestanding imaging centers and reading radiologists, and it also has access to a vast number of sub-specialists, who are available for second reads or specialized image interpretations. The network’s contracted providers have undergone a rigorous credentialing process, which meets or exceeds the National Committee for Quality Assurance (NCQA) standards, and uses the American Medical Association (AMA) and National Practitioner Data Bank (NPDB) to verify provider credentials, licensure, and memberships.

Providers must also adhere to national quality guidelines established by associations like American College of Radiology (ACR). Most specialty networks ensure that a vast majority of its contracted providers—three out of four—are ACR accredited. This ensures that the physicians who are supervising and interpreting diagnostic imaging tests have met stringent educational and training standards. For facilities that


are not ACR accredited, a specialty network requires a sample film review to ensure quality test results.

Managing Diagnostic Spending in Consumer-Driven Health Plans

Mike Kovaleski, vice president of business development at Employee Plans, spoke about diagnostic management among his clients: “Self-funded employers have always valued cost-containment programs because of the money they can save, but for the first time, these programs are also grabbing the attention of employees. Since they shoulder more out-of-pocket expenses, they’re willing to understand how these value-added programs work and how to make more cost-effective medical decisions.”Employee Plans recently began to offer a diagnostic specialty network to its clients to help control advanced radiology expenses. “In my opinion, this type of program is what healthcare reform is all about. It actually impacts the cost curve and forces overall spending to go down, and that’s what everyone’s looking for,” said Kovaleski.

Case in Point: Ten Cate Enbi

“Ten Cate Enbi was our first client to implement the diagnostic specialty network,” said Kovaleski. “With this program, the company has been able to offer its employees a more cost-effective option for diagnostic imaging. Instead of having a scan performed at the local hospital, employees travel a short distance to a freestanding imaging center, and save 50 to 65 percent per scan. If employees have not yet met their deductibles, they could experience immediate out-of-pocket savings.”

“At one time, our health plan was fully insured,” said Laureen Zola, administration manager at Ten Cate Enbi. “In August 2008, we decided to self fund to better control costs, so we are open to new programs that can help us reduce spending. At first, when I heard about this diagnostic management program, I was skeptical. If the service is cheaper, I thought there must be a catch,

so I set out to do my homework. What the research, program implementation, and employee experience of the service revealed was the network was first rate, and could actually save money for our company, as well as our employees.”

Ten Cate Enbi experienced the following key benefits:

• Dramatic Savings. A diagnostic specialty network has close partnerships with imaging facilities, and therefore, offers significant savings on imaging services. “The regional hospital charges approximately $1,800 for an MRI,” said Zola. “Through the diagnostic specialty network, our employees receive the same service for about $700. As a result, we’re really starting to see savings from the program.”

• Quality Providers. Network providers have undergone a rigorous credentialing process to ensure their qualifications, and they adhere to national quality guidelines established by associations like the American College of Radiology (ACR). “We have a couple patients with serious medical conditions,” said Zola. “They receive ongoing CT scans to monitor their condition. We asked them about the network’s diagnostic imaging; they and their physicians confirmed that the quality of the scans was on target.”

• Excellent Patient Service. Through the network’s patient advocacy center, care coordinators help patients schedule diagnostic radiology exams. “Employee feedback has been positive,” said Zola. “They find it’s easy to schedule an appointment through the call center, and I’ve trained employees to fully leverage program savings and services. For example, the diagnostic specialty network provides instant three-way communication between their care coordinator, our employee, and the imaging facility, which helps to get everyone on the same page.”

• Ease of Implementation. The process of implementing a diagnostic specialty network is relatively simple. Ten Cate Enbi added the toll-free number of the



network’s call center to member ID cards. Employees also received educational material and training about the benefits of scheduling their imaging services through the call center. “Now, if employees need diagnostic imaging, they know to question the site of service, the coverage, and the final cost to them,” said Zola.

• Flexible Benefit Design. Self-funded employers have a lot of flexibility and control over how they want to structure their diagnostic savings program. “In general, our program design gives employees the incentive to utilize the more cost-effective option, and it gets them more involved in their healthcare decisions,” said Zola.

“Our coverage for diagnostic imaging is 90/10. This means we cover 90 percent of the scan, and the employee pays the other 10 percent. If employees get imaging done at the hospital, not only is the cost higher but also coverage is 75/25, so their portion is higher. Of course, when it’s an emergency, we tell our employees to just get the scan done as quickly as possible, and it will be paid at the 90/10 percentages. In the end, if employees help us to keep costs down, we pass those savings on to them,” concluded Zola.

Immediate, Substantial Results

By utilizing a diagnostic specialty network, self-funded program can immediately and substantially impact radiology costs. In addition, employees have access to the best, most qualified, and credentialed radiology providers. In turn, these best-in-class radiologists deliver accurate tests and test interpretations, which lead to an appropriate diagnosis, effective treatment, and quality care for patients. At the same time, plan members enjoy prompt scheduling of radiology services as well as decreased out-of-pocket expenses. Overall, it’s a win-win proposal for all parties.

Don Duford is CEO of One Call Medical (www.onecallmedical.com), a leader in innovative diagnostic management solutions. He can be reached at [email protected]. One Call Medical (OCM) offers a nationwide network of fully credentialed high quality facilities and reduced cost for radiology and neurodiagnostic services. OCM customers realize significant cost savings, receive exceptional scheduling and medical report turnaround services and are confident in knowing that their patients obtain the best quality diagnostic testing in credentialed facilities. OCM’s customers include the nation’s leading group healththird-party administrators, as well as self-funded employers.

Mr. Duford brings nearly 30 years of experience in delivering specialized managed care services to Work Comp, Healthcare, and Group Disability plan administrators. Prior to joining OCM, Mr. Duford was President of CIGNA Integrated Care, a subsidiary created to deliver integrated services across all disability and health benefit plans. Other positions of note held by Mr. Duford include President of Intracorp, a national case management company, and Senior Vice President of Cigna’s HealthCare National Accounts unit.

Bio


SpecialtyPharmaceutical Risk Mitigation

Nationwide, specialty drug spending continues to grow by double digits – 15% to 20% in 2009, and an estimated 22% to 25% in 2010. Total drug

spending in the United States in 2009 was just over $300 billion, with specialty drugs representing 21% of the total, or approximately $63 billion. Important to understand is that only 1% to 2% of the population accounts for this spending. By isolating a smaller bucket of risk – namely the population vs. the spending category – self-funded plans can more effectively protect against identifiable risk factors.

Risk Management vs. Risk Mitigation

Standard measures used to manage specialty drug spending include member cost-sharing, step therapy, pre-authorization, evidence-based coverage

guidelines, and various case management and utilization management programs. While necessary to manage the growth in spending, each of these tools fails to predict which drug(s) or member(s) are more likely to scrape the boundaries of affordable risk. In real terms, these measures can be characterized as reactionary attempts to minimize an already-born risk. Indeed, they do not minimize the risk itself or adequately account for its foreseeable cost. The majority of specialty drug spending resides in the large therapeutic categories of cancer, multiple sclerosis and inflammatory conditions. But it is in rarer therapeutic categories where unpredictable “blips” (or “left hooks” depending on the size of the plan) in spending are more likely to threaten existing risk management protections, and thereby present true financial risk. Drugs for the rarest diseases inevitably carry a higher per-patient price tag, but spending “blips” can also be due to fewer drugs being available within a therapeutic class (limiting formulary or

by Eric Hill


step-therapy options), the uncurable nature of a disease (resulting in few, if any, treatment alternatives), the unpredictable duration of therapy (limiting standard authorization guidelines), or the existence of limited drug distribution network (affecting negotiated price discounts). Each therapy category presents its own unique opportunity for risk mitigation, but the smaller the therapy population, the more precise (and effective) your mitigation strategies will usually be.

Examples of Risk Mitigation Strategies

A good example is hemophilia – a $2 billion category of annual drug spending incurred by approximately 17,000 people nationwide. Inherent within any hemophilia population is stratifiable financial risk – based on disease type, severity, age, weight, and other factors. While the average cost of anti-hemophilic clotting factor medication is approximately $130,000 per patient per year, the median spending is closer to $40,000. Depending on the combination of risk factors, a hemophilia patient’s use of clotting factor medication may cost as little as $1,000 per year, or as much as $3 million or more. In some cases, the drug cost for one individual with hemophilia can swing hundreds of thousands of dollars per year. A small self-funded plan with four hemophiliac members could estimate average annual costs of $130,000 per patient per year, but may fail to recognize that one of those members is likely to develop an inhibitor (antibody) to clotting factor which could increase predicted factor therapy costs three-fold. By mapping this population according to its risk parameters, a self-funded plan can uncover opportunities to either capitate or share risk, or take proactive steps toward cost-prevention, such as “off schedule” pricing or various patient education and adherence training initiatives on the front-end. Immunoglobulin (Ig) therapy is another example, with an estimated $4 billion drug category affecting approximately 1 in 4,000 lives. With an average annual cost of $40,000 per patient, Ig therapy has been used to treat over 100 acute and chronic conditions, including



primary immune deficiencies, secondary immune deficiencies, autoimmune disorders and neurological disorders. Average spending among the different disease groups ranges between $10,000 and $1 million per year. Ig has been safely and reliably infused in a homecare setting for decades, yet the vast majority continues to be infused in the more costly setting of a hospital or outpatient infusion center. With the wide variety of conditions treated with Ig, the financial risk of the therapy cannot be reliably predicted based on a pure diagnostic population analysis. However, future expenditures for existing Ig therapy “outliers” often can be predicted. This involves an analysis of an Ig patient’s risk profile, including diagnosis(es), site of care, age, weight, and previous treatment history. It is a member’s risk profile that predicts the anticipated frequency and volume of drug to be used, the payable drug price (based on plan design and site of care), the anticipated duration of therapy, and the likely outcome of treatment – all important elements to establishing the boundaries of financial risk and instituting cost avoidance measures where they will have the greatest impact. These measures might include options such as case-rate (single member) capitation, “off schedule” drug pricing and rebates, or targeted disease management strategies and provider partnerships where high-dose Ig prescribing is the norm.

Summary

Self-funded plans – especially small- and medium-sized – can be better prepared with a specialized review of their specialty drug populations. In contrast to standard pharmacy and medical management efforts to control the rising cost of specialty pharmaceuticals, by proactively analyzing their specialty drug populations, self-funded plans can explore unique opportunities to prevent unnecessary risk and/or cap predictable drug expenditures – a true risk mitigation strategy. Waiting until a pharmacy calls for pre-authorization is not the time to recognize the extent of your future

drug spending. A risk mitigation strategy attempts to undermine predictable catastrophic expenditures. With even a small dent in a high-cost member’s claims, self-funded plans can quickly save hundreds of thousands, if not millions, of dollars per year.

Eric Hill is Vice President of BioRx, LLC, a specialized provider of pharmacy and infusion services targeted at extremely high cost, low prevalence, chronic diseases – typically with an annual drug spend of greater than $50,000, but up to $1 million or more. Mr. Hill has more than 20 years experience in the specialty pharmacy/infusion industry. Under his leadership, BioRx has created innovative pricing and risk assumption strategies for catastrophic specialty pharmacy patients, including single-patient case rates and capitation agreements.BioRx employs a centralized drug distribution model coupled with decentralized customer and clinical service. This combination delivers high-touch, therapy-specific services to the patients who need it most, while ensuring consistent quality pharmacy service and clinical care. The company’s core areas of focus include hemophilia clotting factor, immunoglobulin, C1 esterase inhibitors (for hereditary angioedema), alpha-1 proteinase inhibitors (for alpha-1 antitrypsin deficiency), and parenteral nutrition. Email: [email protected]: www.biorx.netPhone: 866.442.4679

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Substance Abuse,Aging, and Baby Boomers:

Not a Pretty Picture The number of Americans age 50 years or older in need of substance abuse treatment is expected to nearly triple over the

next 20 years, from 1.7 million in 2000 to 4.4 million in 2020. These findings were published in 2003 by Joseph Gfroerer and colleagues in the journal, Drug and Alcohol Dependence, based on an analysis of data from the National Household Survey on Drug Abuse. This not-so-pretty picture is not solely due to the aging of the baby boomer generation, which refers to individuals born between 1946 and 1964. (Baby boomers will swell the 50 and over group of Americans from 75 million in 2000 to 113 million in 2020.) The percentage of these older individuals in need of substance abuse treatment will increase from 2.3% in 2000 to 3.9% in 2020. This will require healthcare providers to pay more attention to the treatment of older adults with substance use disorders. It will also increase the costs of healthcare for employers and insurers, since substance abusers have higher than average health care costs and are prone to develop chronic medical disorders with long-term, continued use. People with substance abuse problems have higher health care costs, but these costs are significantly reduced by treatment. A 14-year study, by Holder and Blose (1992) of 3,729 alcoholics, found that their health care costs decreased from 23% to 55% following treatment. People often don’t connect these higher costs directly with substance abuse, since these costs show-up as higher rates of hypertension, liver disease, workplace injuries, and co-occurring mental disorders.

by Ken Bachrach

As adults get older, they need to be careful as to how much alcohol they consume. Most adults find that as they age, they can’t drink the same amount of alcohol they used to consume, due to a greater sensitivity and decreased tolerance to alcohol. This is because as lean body mass decreases with age, total body water also decreases while fat increases. Since alcohol is water-soluble and not fat-soluble, this change in body water means that, for a given dose of alcohol, the concentration of alcohol in the blood system is greater in an older person than in a younger person. Also, alcohol is metabolized more slowly with age, so the alcohol stays in the body for a longer period of time. Consumption of alcohol in older adults can trigger or exacerbate serious medical conditions, including high blood pressure, ulcers, liver and heart disease, and diabetes. Adults report poorer memory as they get older, and alcohol can only make this problem worse. Sleep disturbances are made worse by drinking alcohol. Slips and falls, including fractured hips, increase with alcohol consumption. Most problematic may be the mixing of prescription drugs with alcohol, since the average person over the age of 65 takes at least two medications daily. Increased fatigue and drowsiness can occur and serious medical problems can result, even when mixing alcohol with some over-the-counter drugs on a regular basis. Older adults who abuse alcohol are more likely to misuse prescription medications. The two classes of addictive medications often misused and abused are tranquilizers (known as benzodiazepines) used for sleep or to reduce anxiety. Included in this group of medications are Valium, Xanax, Ativan, and Klonopin. The other major misused and abused medication group is opiates, often used to control pain. Medications that fall into this group include Vicodin, Oxycotin, Codeine, and Darvon. Small amounts of alcohol can provide some health benefits, but it is important to always add that abstinence is recommended for anyone who: (1)


Biohas a history of alcoholism or drug abuse; (2) who is taking certain medications that adversely interact with alcohol; or (3) is diagnosed with certain chronic diseases such as diabetes or congestive heart failure. Studies based primarily on male samples show that consuming one or two drinks per day may reduce the risks of coronary heart disease. However, this cardiovascular benefit may not apply to adults already diagnosed with heart disease. Also, heavy drinking will greatly increase the risk of cardiovascular disease, including coronary heart disease. Research shows that alcoholics tend to misinterpret these recommendations, by in a sense saying “if one drink is good, five drinks must be better!” Loss of a spouse or loved one can often trigger the misuse and abuse of alcohol and prescription medications. People may drink or turn to medications to deal with both depression and anxiety. As people age, they usually will lose close friends and eventually their spouse, have more medical problems, and decreased mobility. As a result, they will become more isolated. They may turn to drinking and medication misuse when alone, and it may be more difficult to even know there is a problem until they have an accident or medical crisis. Education and awareness of these risks can go a long way in preventing problems with alcohol and prescription medications. A small percentage of older adults will need help with substance abuse problems, and this percentage will grow as the Baby Boomer generation ages. If you would like more information about substance abuse treatment for a family member, friend, or employee, please contact Hank Seiden, Director of Business Development at 800-996-1051, via e-mail at [email protected] or visit us at www.TarzanaTC.org.

Ken Bachrach, Ph.D. is a licensed clinical psychologist. Since 1987 he has been Clinical Director of Tarzana Treatment Centers, one of the largest providers of substance abuse and integrated behavioral health services to adults and youth in California. He has over 25 years of experience in the treatment of individuals with substance use disorders and those with co-occurring psychological disorders, and regularly trains substance abuse and mental health professionals in this area. He coordinates TTC’s activities in NIDA’s Clinical Trials Network. Dr. Bachrach is the President and founder of Professional Psych Seminars, which offers live, online, and home study continuing education programs to mental health professionals locally and nationally. Established in 1972, Tarzana Treatment Centers (www.tarzanatc.org) is one of the leading integrated health care organizations in California serving more than 13,000 persons annually. TTC provides services in the Los Angeles County areas of—Lancaster, Tarzana, Long Beach, Palmdale, Reseda and Northridge, and now serves all areas of California via Telehealth. Services include HIV/AIDS medical care; primary medical care; specialty care for substance use disorders including inpatient detoxification, residential, day treatment and intensive outpatient services. TTC also offers specialty psychiatric and mental health care on an inpatient and outpatient basis. Tarzana Treatment Centers contracts with all major insurance companies and with federal, state, county and city agencies. For additional information on Tarzana Treatment Centers and any of our services please call our toll-free number 800-996-1051. Information can also be found by visiting us at our website www.TarzanaTC.org.



Red Flags in the Morning, Businesses Take Warning

By Lewis D. Bivona, Jr., CPA, AFE

The Federal Trade Commission (FTC) announced on May 28th that it would further delay its enforcement of the Red Flags Rule through December 31, 2010. The delay is intended to

give Congress time to consider legislation that would limit the scope of businesses covered by the rule. Senators John Thune (R-SD) and Mark Begich (D-AK) introduced S 3416, a bill that amends the Fair Credit Reporting Act to provide for an exclusion from Red Flags rules for certain businesses, including physicians and accountants. As reported previously, a similar bill, HR 3763 sponsored by Congressman John Adler, passed the House unanimously late last year, but there has been no action in the Senate until now. HR3673 amends the Fair Credit Reporting Act with respect to the duties of users of consumer reports who take adverse actions on the basis of information contained in such reports; it excludes any health care practice, accounting practice, or legal practice with 20 or fewer employees from the meaning of creditor subject to Red Flag Guidelines regarding identity theft promulgated by the proper federal financial regulatory agency. It also excludes any other business which the Federal Trade Commission (FTC) determines: (1) knows all its customers or clients individually; (2) only performs services in or around the residences of its customers; or (3) has not experienced incidents of identity theft, and identity theft is rare for businesses of that type There is an old saying, “red sky in the morning sailors take warning”, which means that rough seas are

usually anticipated. The Red Flags Rules were set up as a requirement to force businesses and organizations to develop and implement a written Identity Theft Prevention Program that would detect the warning signs or “red flags” that would identify possible issues as they arose in the day to day conduct of their business. While the June 1 deadline to comply has just been extended to 12/31/2010, it would be wise to prepare for the rule just in case waivers for certain small businesses and professions do not get relief from the act. While it seems counterintuitive that you would prepare for a regulation that does not apply to you, you need to remember that almost every state in the Union requires data security prevention, detection and reporting in their consumer protection laws. The other important thing to remember is that the biggest risk to your company, next to the cost of responding/remediating damages and the attendant legal costs from breeches, may be damage to its reputation; TJ Maxx set aside over $200 Million to deal with potential liabilities arising from its breeched client data base but also suffered incalculable damages in loss revenue from the incident. So, how should a business go about preventing identify theft of its customers? The FTC has provided some simple tools and very clear guidance for businesses from large to small. Generally the smaller the business the easier it is to assess and implement the components to protect itself from non-compliance with the “red flag” rules. Large to mid-size companies may find that the sophistication of their systems require them to secure help from an entity that has a history of performing IT vulnerability evaluations and implementation of best practices to resolve any found IT


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security deficiencies; if you don’t have an appreciation for how all encompassing these requirements and attendant testing can be, take a look at the Payment Card Industry Data Security Standards for an indicator of how complex and time consuming compliance can be. For most businesses, the easiest way to understand the “red flags” requirements is to review the FTC guidance at http://www.ftc.gov, but for your reading ease I have excerpted some guidance from one of the FTC’s public access documents below: First, your Program must include reasonable policies and procedures to identify the “red flags” of identity theft you may run across in the day-to-day operation of your business. Red flags are suspicious patterns or practices, or specific activities, that indicate the possibility of identity theft. For example, if a customer has to provide some form of identification to open an account with your company, an ID that looks like it might be fake would be a “red flag” for your business. Second, your Program must be designed to detect the red flags you’ve identified. For example, if you’ve identified fake IDs as a red flag, you must have procedures in place to detect possible fake, forged, or altered identification. Third, your Program must spell out appropriate actions you’ll take when you detect red flags. Fourth, because identity theft is an ever-changing threat, you must address how you will re-evaluate your Program periodically to reflect new risks from this crime. Just getting something down on paper won’t reduce the risk of identity theft. That’s why the Red Flags Rule sets out requirements on how to incorporate your Program into the daily operations of your business. Your board of directors (or a committee of the board) has to approve your first written Program. If you don’t have a board, approval is up to an appropriate senior-level employee. Your Program must state who’s responsible for implementing and administering it effectively. Because your employees have a role to play in preventing and detecting identity theft, your Program also must include appropriate staff

training. If you outsource or subcontract parts of your operations that would be covered by the Rule, your Program also must address how you’ll monitor your contractors’ compliance There are also several good free tools that businesses can use to help them and their employees to develop a baseline understanding of the “Red Flags” rule at the following addresshttp://ftc.gov/bcp/edu/microsites/redflagsrule/resources.shtm . You will find tools that will describe the rule and its compliance requirements, a video that you can use to educate you employees and a “Do-It-Yourself” template for businesses that are at low risk for identity theft. For more complex companies that are medium to high risk entities, we would be more than happy to help you with your needs.

Lewis (Lew) is the Insurance Practice Leader for the Firm and has over 32 years of experience in the healthcare and insurance industries,. The depth of his experience has been garnered from high-level positions within the public accounting, HMO, consulting and hospital industries as well as a period in HMO regulation. Lew has been the team leader on many financial condition examinations on behalf of the New Jersey Department Banking and Insurance including the Examinations of AmeriChoice of New Jersey, Inc., Aetna Health Inc. of New Jersey, American Preferred Provider Plan, Health Net of New Jersey, Cigna Healthcare of New Jersey, United Healthcare of New Jersey, Horizon Health Plan, CURE of NJ, Horizon Healthcare Services (the first risk based examination in New Jersey), Horizon Health Plan and Oxford Health Plan. He managed the limited scope examinations of Palisades Insurance Company and HealthFirst NJ. Lew is also responsible for coordinating both on and off examination training of service team members in NAIC/NJDOBI accepted examination techniques and practices. In addition, Lew has been in leadership positions on audits of P&C and L&H companies throughout the United States.



The Tooth, the Whole Tooth, and Nothing but the Tooth.ByMark roberts


Witnesses brought into court must take an oath to tell the truth, and they are sworn to uphold their testimony. Often, they are coaxed by counsel to answer questions that give more emphasis on particular points in

favor of their respective case. Telling the truth can hurt, but it is the right thing to do—always. Dealing with health care issues has similar results and consequences. Truthfully, the employer that wants the best results from his workers provides the best options when benefits are examined and offered within the overall context of the company’s available funds allotted to health care. The winners are employers who have healthy employees pleased with their benefit compensation, and who use their plan effectively to maintain a higher standard of health within the workplace and their community. Additionally, judgment in this case is also awarded to employees that understand that serving their company well, in addition to doing great work, means staying healthy. Dental benefits, health coverage, meeting

the bottom line – every day, employers are making tough decisions about what they can and can’t provide employees. In a down economy with health care costs rising, employers are struggling to provide employees with adequate benefits coverage and at times making the decision to cut some or all employee benefits, according to Tampa Bay Online News. The dramatic escalation of employee health care costs has prompted many CFOs and HR managers to look for new ways to gain control over premium expenditures and vendor fees, according to the Society for Human Resource Management (SHRM). Self-funded employee health care insurance plans are one alternative that can allow firms to reduce and manage their health care costs and improve cash flow while still delivering the health coverage they desire for their workforce. In self-funded plans, the employer takes on the financial risk of funding their health plan from its assets and becomes responsible for managing and administering the benefit plan. Self-funded plans are governed by the Employer Retirement Income Security Act (ERISA) and are appealing to employers because



of the greater level of flexibility that comes with being able to tailor the plan to their needs with fewer state-mandated features. While firms take on additional financial risk, they are able to limit their total risk through the purchase of a stop-loss policy and benefit from the increased cost savings typical of the self-funded model. Under a self-funded arrangement, the employer assumes the health plan liability and risk in exchange for more significant control over the plan’s administration and funding levels, according to SHRM. This differs from traditional fully insured plans where the insurance company assumes the risk, controls the plan administration, establishes reserve capital levels and manages other major decisions concerning the health care coverage provided to company employees and dependents. When a company elects to self-fund its health plan, it can purchase excess insurance coverage to protect itself from extreme claims and utilization levels. This excess insurance is called employer stop-loss (ESL) coverage. In addition to covering the potential losses inherent with any group benefit plan, ESL coverage provides protection for the entire covered group, reimbursement for medical expenses above a specified dollar amount, and cover for catastrophic and high dollar claims such as transplants, leukemia, renal failure and premature births. To obtain ESL coverage, employers should be prepared to provide the following information to an insurer:

• A census of covered employees (noting age, gender, dependent status and location).

• Claim history, with two years of group-level history and two years of individual catastrophic claims history.

• Current and proposed plan of benefits.Once the employer secures excess coverage from an insurance carrier, it may contract with a third party administrator (TPA) for claims adjudication, benefit plan administration, oversight of managed care networks (e.g. PPOs) and management of service vendors such as pharmacy benefit managers and disease and case management firms. The following key objectives are

common to companies seeking to self-fund their health care plans: • Gain control over how insurance premiums are spent, potentially improve cash flow and maintain company health plan reserves for investment.

• Reduce plan operating costs.

• Tailor a health benefit plan to the needs of the company, thus enabling it to attract and retain employees.

Paramount with establishing a great medical plan for self funded groups is the need to have stellar ancillary services included in your benefits program--including wellness, vision, dental, telemedicine, urgent care, and more. Dental in particular is the most requested benefit after medical for employee health plans. Employers who include this specialty item as a key ingredient to medical health are very smart. Poor dental hygiene is the gateway to more significant health issues and leads to potentially other medical issues. According to OraMedica, incorporating dental health education into workplace wellness promotion notably mitigates the risks for heart disease, diabetes, pregnancy


complications, cancer, and pain. Wellness coordinators who understand and support the dental-systemic health links impart significant dollar savings in employee health costs, absenteeism, healthcare premiums, workers’ compensation, and other healthcare-related expenditures. Lost time, lack of productivity, employee health, and reduced revenues are all critical reasons to make sure that employers should encourage workers to maintain good oral health. Providing access to a quality a dental plan at affordable rates will help reduce the problems associated with employees who have problems related to poor oral health. A quality dental plan can be a valuable benefit to help keep employees at work. When it comes to dental insurance most companies need a flexible plan, as dental procedures are predictable and rarely catastrophic, according to Tampa Bay Online News. But rather than giving up on dental insurance, employers can implement an affordable alternative to traditional insurance plans. Self-funded, dollar-based dental programs are not a new concept – they have been around since the mid-1970s. The freedom of self-funded plans allows the flexibility of choosing any dentist and the convenience of full coverage on all non-cosmetic procedures. Employers can tailor the plan to fit their employees’ specific needs, no matter the company size. Self-funded plans allow employers to easily administer coverage, eliminating the high costs correlated with dental insurance. Employees enjoy freedom of choice, with no network of “approved” providers limiting their choices. And dentists are able to provide the best quality care and treatment without any limitations. Businesses are trying to make their dollars go as far as possible without leaving employees in the cold without benefits. Self-funded plans offer substantial savings with minimal risk to the employer. Patients are able to choose the best dentist and the dentist to choose the best treatment. However, when a dental PPO network is part of your self-funded plan, the economies of scale for saving money improve when employees visit participating dentists. Claims are paid based on a set fee schedule, and the employer saves money based on

this type of fee for service model. Networks offering access include Dentemax, Aetna, DNOA, Careington, and a few others. By moving their current dental and vision plans to a self-funded program, employers can save anywhere from 10 to 20 percent in health care costs. Essentially, they are cutting out the overhead and profit that a fully insured carrier must include in their rates, according to Business Smart Online. Here are a few FAQ’s, especially focusing on dental and vision coverage. Why are business owners taking advantage of and implementing self-funded plans?

Employers are fed up with unjustified increases from their traditional fully insured programs that lack reporting data to back them up. By implementing a self-funded program, employers gain control of their plan designs and reporting capabilities and also have the opportunity to lower costs dramatically. These self-funded plans help offset high and rising medical costs and are easy to set up and administer with the help of a broker.

How do self-funded vision and dental plans work compared to a fully insured plan?

The self-funded vision plan is a reimbursement program. You may utilize any licensed eye care provider. A typical vision plan would reimburse an employee $50 for an exam and $100 for glasses or contacts. This level of benefit matches the plan designs offered by the fully insured market but at a much lower cost. A fully insured PPO dental plan can cost between $30 and $40 a month for single coverage. The self-funded dental plan with the same benefit level runs nearly half of that, between $15 and $20 (including the administration fees). Vision programs are approximately $6 to $10 per employee per month. The monthly cost for a self-funded vision plan for single coverage is in the $2 to $3 dollar range.

How does a business owner operate a self-funded health plan?



The employer hires a third-party administrator to process claims and administer the plan. The most cost-effective pricing is generated by putting the dental and vision benefit into one plan. That keeps your admin costs to a minimum. Some employers add a dental PPO network to save in additional costs, but the discounts must outweigh the access fee charged by the dental PPO. However, most offer a simple traditional dental plan with no network, offering the flexibility for employees to use any dentist.

Areallbusinessownersqualifiedtoself-funddental and vision plans? Yes, however, it is not recommended for companies with less than 50 employees.

What are the risks associated with self-funding?

The claim risks associated with self-funding have limits or maximums that the employer can choose, putting a roof or ceiling on their risk. If set up properly by your broker, your plan’s maximum liability, especially on a dental and vision plan, can be quite low, relatively speaking.

Will employees notice a change in their coverage if the plan becomes self-funded?

No. As long as the program is set up and communicated properly by the broker and employer, the changes can be minimal, if non-existent.In the current hyper-competitive marketplace, it is essential that companies explore every avenue for reducing expenses. Shifting to self-funded health plans is one of those opportunities that provides significant savings without any reduction in employee benefits. In fact, because self-funding offers an almost significant flexibility in benefit design, often benefits can be improved increasing employee satisfaction and loyalty while still delivering substantial cost savings.

By funding claims directly, employers avoid the cost of claim reserves; they also eliminate the insurance company’s administrative costs, profit margin, risk charges, premium taxes and contingencies, which are added to the cost of expected claims in the insured premium. Program benefits can be designed to encourage healthy behavior from employees and preventative care encouraged by employers, thereby reducing overall benefits costs. If self-funding is feasible, long-range planning and decisions about plan design, administration, investment of funds, plan documentation, etc. should be made before the employer takes over the plan’s funding. There are more details about self-funded plans, especially those that include dental. That’s the tooth, the whole tooth, and nothing but the tooth.

Mark Roberts is a 30-year sales veteran and is a licensed life and health agent based in the US, and has published numerous articles on voluntary benefits and health topics. Mark works with clients, agents and groups in the US and the UK; he can be contacted at [email protected] .

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Managing The Advanced Diagnostic Testing Boom

By Matthew Zubiller

Advanced diagnostics, including molecular and genetic tests, is one of the fastest growing diagnostic areas – and one that brings with it tremendous

complexity, cost and quality issues for employee health and self-funded insurers. Molecular diagnostics, which includes infectious disease assays, pharmacogenomics and genetic tests, has grown from $1.4 billion in 2005 to $6.2 billion in annual medical costs in the U.S. for a 28% compounded annual growth rate, according to a Washington G-2 Reports 2010 survey. At $300-3,000

per test, the survey predicts that molecular tests will soon comprise one third of all diagnostic testing costs.

There are many key drivers fueling the growth of these advanced diagnostic tests including:

• Rapidly decreasing costs of DNA sequencing and related technologies• Our aging population coupled with consumerism increasing the demand for the most innovative new tests• Faster time-to-market for new molecular tests that receive less rigorous oversight from the FDA than do pharmaceuticals



However, the greatest factor may be the growing interest in personalized medicine, which is the practice of using genetic profiling to tailor medical care to an individual’s needs. A case-in-point is the chemotherapy drug Herceptin. Approved by the FDA in 1998, it became widely prescribed to treat breast cancer, with annual costs in the range of $50,000-100,000 per patient. Herceptin was known to work only for women whose tumors overproduced a protein called HER2/Neu, which occurs in perhaps 20-25% of all cases. By 2006, genetic-level HER2 testing became a recommended standard of care for all patients with invasive breast cancer, thus indicating the 75-80% of breast cancer cases for which the $50-100K arduous therapy could be avoided. This example illustrates how a molecular test can dramatically reduce unnecessary medical costs, as well as unnecessary delays and anguish associated with improper treatment. As the era of personalized medicine moves to the forefront, the complexity of managing the advanced diagnostics component of employee health is likely to increase exponentially. For example, today physicians often review about 10-15 variables to diagnose a

patient, such as a physical exam, a CBC, etc. Over the next few years, there may be 1,000 or more variables, including results of advanced diagnostics, for physicians to analyze. They will need to look at and synthesize a much larger stream of complex data including genetics, genomics, sub-typing, proteins that drive how patients will respond, and much more. Until recently, if a patient’s HDL was too low, the physician would probably start the patient on a statin. We are now finding that it is not just the HDL level we need to measure, but that we also need to look at sub-typing to identify the size and density of the HDL particles. If we know that the patient has large HDL particles that help clean out the arteries, this may totally change the diagnosis and treatment plan and a statin may not be necessary. More and more, physicians will be trying to assimilate hundreds and thousands of relevant data points on molecular and genetic diagnostics, biologics and other factors. With the projected PCP shortage, physicians will have even less time to analyze this avalanche of data. In this new healthcare landscape, which brings with it a new paradigm for diagnosis and for managing employee health, self-funded insurers will need to determine how best to manage within the context of personalized medicine.

Impacts of Managing What Can’t be Measured

As diagnostic testing is said to influence 70% of all health care decisions, it is critical to understand the impact of these advanced tests on the total cost of care, which includes therapies, surgeries and admissions, as well as the quality of employee health. But effectively managing the utilization of these tests is a daunting task as there are only a couple dozen CPT billing codes for the 2,000 or so molecular tests. As a result, there’s little appropriate data on how many and what kinds of molecular tests have been paid for or should have been paid for. In fact, McKesson analysis of data from health plans representing over 100 million claims shows at least 1/3 of the advanced diagnostic spend is unidentifiable


due to inadequate CPT codes. How can self-funded insurers develop strategies to manage the cost of care when it’s not possible to distinguish one molecular test from another because they all use non-specific billing codes? With new molecular and genetic tests coming to market virtually every day, this problem is going to grow exponentially. Compounding the measurement problem are utilization management processes that are unnecessarily expensive, time-consuming and incomplete. Even if molecular testing spend were well-identified, insurers and their benefit management vendors find it difficult to enable processes to help ensure appropriate molecular test selection and reimbursement. For example, the following are just a few of the system gaps today:

• Manual, time-intensive authorization processes, resulting in payor costs of $50 or more per test authorization, turnarounds that may take several days due to manual medical reviews, and inappropriate care and medical cost from inconsistent decision-making. • Non-specific coverage and network rules, such as incomplete coverage information not specific to encounters, unknown payment responsibility for employees pre-service and leakage to high-cost, out of network clinical labs. McKesson analysis shows that molecular tests cost two to four times more when performed out of network.• Insufficient data for targeted utilization and network management, including unclear identification of specific medical services rendered –and delayed, incomplete data on provider ordering trends. Claims data is not clear on what test was conducted by which lab, or ordered by which clinician. That data is also often 60-120 days delayed in analysis.

It Takes Automated Intelligence at the Point of Care

For self-funded plans to effectively manage the booming area of advanced diagnostics, they need to ensure intelligent, automated decision support tools

are in place at the point of care that enable transparent, immediate access to coverage information and medically appropriate rules. This foundation is necessary for driving optimal provider practice patterns and employee utilization behaviors, which are critical success factors in lowering administrative and medical costs, while more effectively engaging ordering providers and labs. Through automated intelligence within the clinical workflow, we can drive toward a prospective, collaborative, exception-based approach to managing utilization and performance. These types of solutions are now available and self-funded plans should be aware of the most essential aspects of these systems:

• Automated “advanced” notification andauthorization–Automates medical appropriateness review and authorizations with evidence-based clinical decision support. This can lower utilization management administrative costs 40+% while helping to ensure appropriate, evidence-based utilization by identifying lower cost, medically appropriate alternatives. It also enforces consistent rules and with its greater automation and intelligence provides much higher ROI than “basic” utilization management portal solutions.• Redirection to appropriate in-network labs. – Builds upon analysis across plans to provide physicians with the most appropriate, in-network labs to perform the genetic test. From our own experience with plans representing 50M covered lives, out-of-network or “non-par” orders can cost two to four times the amount of the same order in-network. Providing the right lab choices via automated decision support helps drive lower medical costs and more optimal care. • Policy and outcomes optimization to measure and manage utilization – Provides a real-time, detailed understanding and measurement of which tests are being ordered, by whom, and by which labs they are being performed. As such, plans can measure performance and quality, against which they can place appropriate incentives and scorecards to ensure effective reimbursement policies with clear engagement from



their providers and labs. These new solutions reduce administrative costs and inappropriate medical spend by connecting key stakeholders and automating real-time clinical and financial decision-making at the point of care. They enable transparent, immediate access to coverage, medical appropriateness and network rules while driving consistent application of evidence-based medical policy. They also help self-funded plans manage cost and quality by providing timely, complete data on utilization and leakage trends – while supporting real-time, targeted provider interventions and providing a model for performance-based utilization management and value-based reimbursement.

Educating Physicians and Patients

Because genetic-level medicine is such a new science, and interpretation of results can have many consequences for patients, consider enabling genetic counseling services for your covered employees. Certified genetic counselors can advise both physicians and patients on the appropriateness of specific tests, what to expect as potential results and consequences, and can help in interpreting the results and assessing treatment options. These services can more than pay for themselves—up to 33% of cases that initially meet coverage policy criteria are deemed inappropriate after expert genetics review.

Managing Advanced Diagnostics is a “Now” Issue With the lack of CPT codes, most insurers, including self-funded plans, are unable to identify their advanced diagnostic spend and determine if it is medically appropriate for its employees. Without the right tools, management of this spend is even trickier. Industry data shows that the costs for these tests are significant and ramping at an aggressive rate. The good news is that innovative new solutions are now

available at low cost relative to manual alternatives that can reduce inappropriate medical spend by connecting key stakeholders and automating real-time clinical and financial decision-making at the point of care. These solutions also empower self-funded insurers to drive care quality by coordinating post-testing care management and treatment plans. Those self-insurers that act now will be in the best position to address the fast emerging challenge of personalized medicine and can do so while better managing overall employee health.

Matt Zubiller, business leader for Advanced Diagnostics Management, is responsible for leading initiatives that advance McKesson’s role in the realm of personalized medicine, genetics and molecular diagnostics. Before joining McKesson, he worked for a global strategy consulting firm in London, co-founded a spin-off from a leading Enterprise Resource Planning software and services vendor, and then founded and sold a boutique consulting practice working with early stage technology companies, entrepreneurs and venture capitalists in the US, UK, and India. He holds an MBA from London Business School, and a management of technology degree from the Berkeley College of Engineering and the Haas Business School. He can be contacted via email at [email protected]. To learn more about McKesson, please visit www.McKesson.com.

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Voluntary BenefitsHelp Lower the Risk of Self-FundedBusiness Models

Ask any benefits decision-maker of a self-funded company what keeps him or her up at night, and he or she would likely respond, “An unplanned rise in high-ticket illnesses or accidents.”

Even with the best forecasting, modeling and actuaries at your disposal, self-funded companies are all susceptible to that inherent risk — a jump in the number of employees falling victim to high-cost health events, such as cancer, heart attack or stroke. That is one reason why self-funding is considered by some to be a high-risk, high-reward model.

There is little argument as to the potential rewards, both in hard and soft costs that can be gleaned from a self-funded insurance model. The ability to highly customize insurance plans based on employee populations at a much more competitive rate from providers is just one reason why many self-funded businesses are able to significantly reduce insurance costs, while establishing a reputation for running a quality benefits program.

Yet, if it was as easy as simply reaping the rewards, arguably every business would be jumping at self-

funding. At its basic level, self-funding could be described as a highly sophisticated guessing game. And with anything seeped with some form of guesswork, there are no guarantees. But what if there was a potential solution to help reduce the risk side of the equation? Voluntary benefits plans may offer just that.

Major Health Events Can Unravel the Best of Self-Funded Plans

Perhaps the greatest factor in whether a company succeeds or falls short in self-funding is its ability to accurately forecast claim activity based on employee demographics, job functions, prescreening questions, etc. There is, however, no guarantee that employees have honestly provided health history, or to ensure 100 percent compliance in completing health screenings or wellness initiatives, which leaves companies vulnerable to unplanned increases in catastrophic health events and skyrocketing claim costs.

However, when you self-insure, you have the freedom to design a health plan around the needs of the employee population and in a way that fosters cost savings to offset and plan for potential claim increases.

By Michael Naumann



One way is to lower costs to the plan by raising the out-of-pocket expenses for certain events, such as long-term care or hospitalization, and offering voluntary insurance policies to help with those out-of-pocket costs for employees.

Voluntary Insurance Can Supplement Insurance for Self-Funded Plans

More and more businesses are turning to voluntary benefits solutions as an important part of a two-pronged strategy to lowering the risk of their self-insured major medical plans. Voluntary insurance benefits, also called supplemental insurance, represent a variety of insurance policies made available to and paid for by employees as a voluntary option. These plans provide a wide range of coverage choices, including short-term disability, life, dental, and vision insurance policies. But perhaps most relevant to self-funded companies are voluntary critical illness, hospital indemnity and accident insurance plans that can provide much-needed cash benefits to policyholders faced with high out-of-pocket expenses associated with these health events. For example, a business comprised of an employee population made up largely by young females may decide to lower the out-of-pocket expenses relating to prenatal care, so as to reduce the number of at-risk pregnancies — a goal that not only helps safeguard against high medical costs, but that also helps to promote the major medical plan within the organization. Similarly, the same company can further reduce the cost to the plan by increasing the out-of-pocket limits for certain events, such as prostate cancer, while offering voluntary insurance plans as a way for employees to retain adequate insurance and financial protection.

As more and more organizations consider self-funding as an effective, creative model for their benefits program, voluntary insurance can help drive an effective strategy that accomplishes two vital goals. First, it

enables companies to cushion themselves against the potential risk of unexpected high-deductible claims. Second, voluntary benefits also deliver protection to workers against the high out-of-pocket costs that can accompany serious illnesses or accidents and offer the insurance options workers need.Many benefits decision-makers rest easier at night knowing they have the option of earmarking the cost savings they achieve through high-deductible components of their major medical plans to offset higher-than-expected claim activity in a given year. All the while, having the confidence that the voluntary insurance plans they have in place will provide protection for their valued employees and only enhance their overall benefits programs.

Michael Naumann, market vice president of Broker and Market Development at Aflac, is responsible for developing and implementing sales strategies to support Aflac’s field force in acquiring new accounts through relationships developed with national brokers, achieving targeted sales volume, maximizing market potential, and helping design and implement marketing and sales strategies for Aflac products. Before joining Aflac in December 2008, Mr. Naumann was national sales director, group division, for Guarantee Trust Life Insurance Company in Glenview, IL. Previously, he also served as vice president of sales for National Benefit Consultants in Milwaukee, Wis. Prior to that position, he was sales manager for Bay Alarm Company in California, where he had earlier served as a police officer for the Oakland Police Department. Mr. Naumann is a veteran of the U.S. Coast Guard Reserve. He holds a bachelor of science degree in business from Marquette University in Milwaukee, Wis. Mr. Naumann is a member of the National Association of Health Underwriters and Council of Insurance Advisors and Brokers.Visit aflacforbrokers.com or call 1-888-861-0251.

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Wellness Programs Work by Attraction Not Promotion

Recently, I was talking with the director of a self insured group who told me they decided to hold a “health

and wellness fair” to encourage employees. The fair, organized by their ASO, was to be held for a few hours on a Saturday. A flyer describing the event, detailing the event’s offering including flu shots, blood pressure readings, and a cholesterol screenings, was mailed to the 2,500 team members to elicit RSVP responses. To the Director’s surprise, and in spite of a grand prize drawing of a high definition, flat screen TV, the flyer yielded only 4 positive responses! What’s wrong with this picture? The promoters of this event were taking a one-size fits all approach to their health and wellness program; a recipe for low participation. The promoters don’t understand that their team members wouldn’t give up four hours on a Saturday to come in for a dermatology analysis and to enjoy a 10 minute chair massage. Sure, everybody should be concerned about their own health and wellness, but who wants to give up their day off to attend a smoking cessation consultation? In order for health and wellness programs to work, the programs need to be fun and engaging to get the employee to try them and to stick with them until their goals are reached. Additionally, there needs to be a properly structured incentive program to get, and keep, employees interested. Experience has taught me that the lure of a raffle prize, combined with an offer of free health screenings, is woefully inadequate to excite people on their day off to leave the comfort of their home.

Creating and maintaining participant interest has been shown to be on of the most difficult aspects of employer sponsored wellness programs. While independent studies have confirmed that for every dollar invested by the employer in properly organized and executed health and wellness programs, there is a five dollar return in increased employee productivity and decreased health care costs. It has also been demonstrated that the most difficult task facing the providers of employee health and wellness programs is instilling a consistent level of participation by the employees to foster participation and achieve these goals. In order to work, wellness programs need to be fun and engaging. The program should encourage participation and the program design should invoke healthy behavior and the incentives must be meaningful. I spent some time and reviewed a number of studies to see what our competitors and colleagues found to be beneficial. I have found that Employee Wellness Incentive Programs (or”EWIP”) are a key component to the success of a wellness program. An EWIP that not only encourages participation, but also provides an enhanced menu of rewards to encourage positive behavior changes, will better achieve the goal of a healthier, more productive workforce than those EWIP’s that do not distinguish between simply being involved, as in filling out an HRA and achieving a health related result, and active engagement, for instance seeing better numbers on a blood test. One of the most common elements of a successful EWIP is the availability of reduced medical plan payments or co-pays. According to a study

By Neil Treitman



undertaken by American Healthways, a simple reduction of $25 in employee contributions for medical coverage will foster higher employee participation. This is true motivation for employees and an employer can expect a significant increase in the number of employees participating in the plan. The study also found other incentives work as well, including employer funded contributions to an employee medical Flexible Spending Accounts and access to a more comprehensive medical plan offering a higher level of coverage than is available to employees who opt out of participating in the wellness

program. A subject survey of employers conducted by Watson Wyatt on EWIPs found that 52% of the respondents offered no rewards and incentives for employee participation in the wellness programs. It was found that of the 47% of employers that offered EWIPs: i) 29% offered monetary incentives; ii) 15% offered reduced medical co-payments; and iii) 30% provided employee reimbursements for the cost of the program. Interestingly, 48% provided a wide range of incentives including employer contributions to FSAs, raffle give-


a-ways, gift certificates, free health screenings and tests, additional vacation time, company sponsored health and wellness coaching and massage, and many others. Some employers are even taking their EWIP to another level altogether. This involves combining the incentives offered by the EWIP to actual verifiable results, including weight loss and blood pressure reduction. However, going this route is not without potential problems. It is important that EWIPs tied to specific results do not violate HIPAA non-discrimination statutes. It is essential that your EWIP be in strict compliance with the HIPAA structures pertaining to a bona-fide wellness program. Using an HRA can provide a measurable goal. If the result of an employee’s Health Risk Assessment screening determines that the employee is at “high risk,” the employer can create a cash incentive for the employee to participate in a targeted program, but if penalties are involved like higher deductibles or co-pays, most likely the high risk employee would opt out of participating. And money may not be well spent if your wellness program only targets those who are high risk. It is easier and much more cost effective for employers to encourage their team members to remain healthy than it is to encourage them to get healthy. More than ever before, it is imperative, from both cost and productivity standpoints, for employers to prevent employees from becoming high. Assessing a penalty for an employee’s inability to make the lifestyle changes necessary to effect change will simply not work. The employee must actively decide to implement a change and pursue the necessary course of action to have a positive result. When starting an employee wellness program, the employer needs to carefully consider the manner in which incentives are offered, as carrots (incentives) work better than sticks (penalties). Also, to be most effective, the method taken should be consistent with the employer’s culture. This brings us to another approach by which the wellness program is connected to incentives based on participation: the manner in which an employee participates becomes the basis for the incentive structure. Businesses that adhere to this approach firmly believe

that the catalyst for change stems from the individual employee. For the employee to lose weight, control their diabetes, or stop smoking, the employee must truly commit to make such a change. Simply telling them a list of actions they have to do will not work. Simply explaining to them that their lifestyle choices are ill-conceived and unhealthy will have no effect. Only when the employee makes a conscious decision to change their behavior will there be a positive result. That is why wellness coaches are essential. To assess an employee’s readiness for change and to create that generative moment, a moment of clarity when the individual can recognize that their quality of life, productivity, and wellbeing will improve with each positive step made. We design programs to meet the employee in their present space and move step–by-step to their own vision of wellness, relying on the facts from their own health assessments. By using EWIPs, we reinforce motivation by offering the employees external rewards for taking steps to improve their health and wellness. EWIP incentives range from recognition of the participant’s achievements in the employee wellness newsletter to small monetary rewards for achieving a beneficial health goal, such as losing weight or stopping smoking. Many of our programs incorporate electronic devices and applications that track various different health related measures, from the number of steps taken, to an employee’s heart rate, or the nutritional values of a meal an employee eats. The devices eliminate the need for manual record keeping and make the tracking of reward points fun and interactive. It is important that the incentive is meaningful to the employee in order to motivate the employee to create positive lifestyle and health changes. The fact is that most people suffer from boredom which precludes them from taking the steps necessary to make the positive changes needed. If motivation were not an overriding factor, wellness programs would be unnecessary. Creating a program that is fun will go a long way towards overcoming the boredom and motivation challenges that beset the majority of people. In order to realize the benefits of a productive and beneficial wellness program, it will be necessary for the employer to spend a significant portion of its wellness

budget on incentives. Healthier employees equal lower health care related costs; so, it is money well spent if properly incorporated into the employee’s program as it will support their vision as well as yours. At Cambium Wellness, LLC, we utilize six different platforms to appeal to a greater number of individuals within each client organization. The data from an employee’s daily or weekly wellness related activity is refined and translated into a numeric value. The values are then aggregated through a customized portal for each client creating a unique set of tools for each participating employee. Our objective is to deliver a summarized and actionable information to our participants about how they are treating their bodies, and how they are progressing on their wellness goals. In doing so, we accentuate the circumstances related to each participant’s interest providing the motivation and guidance to achieve their goals. The Cambium Wellness programs use online calculators to deliver results based on the participant’s biometric information. We calculate the set point in a number of health areas that provide the information necessary to allocate incentives based on efforts and results. We provide an efficient, measureable, focused path for success, helping the employee every step of the way toward better health and wellbeing. Cambium encourages the use of electronic

and mobile devices to more efficiently collect the data to provide these customized programs. Our devices include a Bluetooth enabled Glucometer, heart monitors, and three-dimensional accelerometers which assist in calculating the caloric burn of program participants. Our unique software integrates the results of the data collected into our proprietary health risk assessment platform enabling our software to create a real-time display projecting how today’s activity affects the overall well-being of the participant. In most cases, a wellness coach is paired with a participant to help establish realistic and measurable goals, and to provide support along the way. The wellness programs created by Cambium Wellness, LLC, incorporate state-of-the-art technology to build online platforms that encourage employee participation and improve employee health and wellness while increasing productivity. The result is a more effective workforce and lower health care costs for the employer.A well-constructed, properly implemented wellness program with appropriate incentives has the potential to help companies reduce their health care costs dramatically. Along with this direct benefit there are also a number indirect benefits – lower turnover rates, fewer days lost to absenteeism, and better performance, to name just a few. www.cambiumwellness.com


Retiree Drug Option Gives Brokers Opportunity to Ride to the Rescue

By Samuel H. Fleet

As the countdown to the full implementation of the Patient Protection and Affordable Care Act continues, so many parts are still in

motion that many employers are uncertain where they will stand when everything falls into place. Should they continue with their current health benefits? Should they look for alternatives that give them more flexibility? Should they drop their plans entirely? As the old adage makes clear, however, one thing is always certain: taxes, and in this case an increase in taxes. This has been particularly true for employers who took the federal government up on its offer of a 28 percent Retiree Drug Subsidy to keep retired workers who already had benefits from flooding the then-new Medicare Part D program. Under health reform, employers will no longer be able to write off the 28 percent of their pharmaceutical costs that are covered by the subsidy. In addition, the administrative costs associated with the Retiree Drug Subsidy will no longer be deductible.

Although these changes will not take effect until the 2013 tax year, the repercussions for businesses were immediate because of accounting standards that require reporting now about future cost increases. Just days after the law was enacted, a number of companies ratcheted their future earnings downward. For AT&T, it was a $1 billion change; Verizon came in at $970 million; Deere & Co. took a $150 million charge; and 3M Co. listed an $85 million to $90 million charge. As a result of the decreased value of the Retiree Drug Subsidy, many employers are considering alternatives. According to a recent survey conducted by the National Business Group on Health, 69 percent of large companies have the Medicare Part D subsidy issue “under review.” With financial losses like these looming, brokers have an opportunity to rescue employers who are exploring their options. By bringing employers solutions that address their concerns, brokers can demonstrate the value they bring to the table that goes well beyond auto-pilot annual renewals. But what are those options that brokers should be offering? While implementing Medicare Part D can

By Samuel H. Fleet



be complex, one of the best ways to make it simple for employers is to explain the advantages of an Employer Group Waiver Plan – known by the acronym EGWP, and often called Egg Whip.

Back to the Beginning

To help employers understand EGWP, brokers should first make sure they are well grounded in the history of the Retiree Drug Subsidy. For many employers, the Retiree Drug Subsidy was a great deal. The federal government paid for up to 28 percent of the costs for covered retiree drugs. The benefit came with burdensome administrative requirements, but the subsidy was worth it to many. Not only did companies receive the tax-free 28 percent subsidy, but they also were able to add it to their costs and potentially write off 100 percent of their parmaceutical costs. While the tax benefits were almost too good to be true, the federal government had sound financial reasons for offering this incentive. When Medicare Part D was implemented, the government had to do something to prevent scores of employers from terminating their private-plan prescription drug coverage and allowing their employees to instead take advantage of the federal government’s program. Too many plan participants would have been a costly drain on the program. The Retiree Drug Subsidy was the way for the government to encourage employers to continue their own drug coverage. While the benefit came with a heavy paperwork requirement, the subsidy provided employers with an average value estimated at more than $500 per Medicare beneficiary per year. When health reform passed in early 2010, lawmakers had to find ways to fund their plans to overhaul the health system and extend insurance coverage to more people. One way was to change the tax status of the Retiree Drug Subsidy. According to the Employee Benefit Research Institute, the average cost of the subsidy for the government is roughly $665 per person. According to benefits consultant Towers

Watson, more than 3,500 employers received the subsidy in 2008. With the health reform changes to the tax status of the subsidy, Towers Watson estimates increased taxes for employers of $233 per year for each retiree and spouse. The incremental nationwide cost to employers is expected to be roughly $14 billion.

Transitioning to EGWP

Instead of accepting the subsidy to keep their current plans, employers can switch to an EGWP with the help of a knowledgeable broker. At its core, an EGWP allows an employer to become a prescription drug plan sponsor, providing prescription drug benefits to retirees and dealing directly with the federal government for reimbursement. Under this structure, the government uses a nationally based formula to pay the company a capitation fee or predetermined amount per participant. In some cases, the fee paid is as much as $200 per member per year more than the Retiree Drug Subsidy. In fact, experts say the federal government covers 35 percent or more of an employer’s prescription drug costs with EGWPs, compared to roughly 20 percent with the drug subsidy.

The advantages for an employer of an EGWP plan include:• Retaining sponsorship of their retiree benefit plan at a lower net cost.• Maximizing flexibility in regard to contribution options.• Maximizing the Medicare Part D government contribution.• Customizing benefits to match current offerings for retiree group.• Providing the option of including stop-loss insurance (an important provision in today’s world of increasingly expensive specialty drugs).• Minimizing disruption to members during transition through employer control.

Of course, becoming a prescription drug


plan sponsor involves a full layer of administrative functions, including servicing the needs of plan participants, creating networks of providers, processing paperwork and completing government reports. All of these functions involve expertise and costs that employers may wish to avoid. A more appealing strategy may be for employers to engage a third-party administrator with expertise in EGWP solutions. This strategy should sound familiar to self-funded employers, most of who already partner with third parties to carry out the administrative portions of their benefit package. Brokers can play an important role in helping employers find a good fit to administer the EGWP plan. Baseline services provided should include, enrollment and fulfillment; medical underwriting; claims management; eligibility maintenance; billing and collection; customer service; and records management. In addition, brokers can help employers identify third-party administers that have expertise and a documented track record of providing value through extra services. These can include auditing services, custom products, integrated stop-loss insurance, national resources and benefits management processes that target high costs without lowering the quality of patient care. Take Action

While the federal health reform brings with it many unknowns, one thing is clear: It will affect everyone – businesses and individuals – one way or another. In order to best position themselves for doing business in a new healthcare world, employers must monitor the changes taking place that may have a considerable impact on their bottom line. Exploring their options will be critical not only to profitability, but also to the welfare of employees and retirees. Agents and brokers can play a pivotal role in helping employers stay on top of the trends that affect their businesses. They can serve as trusted advisors and knowledgeable partners in wading through these

complex changes. Through relationships with third party experts, agents can provide innovative and cost-saving solutions, like EGWPs, that will help employers protect their bottom lines, as well and the health and wallets of their employees and retirees. Additional Sources:http://www.aishealth.com/Bnow/hbd090310.html

Samuel H. Fleet is President of AmWINS Group Benefits, a leading wholesale broker/TPA of comprehensive group insurance programs and administrative services. With more than 20 years of health and benefit experience, Sam has guided the rapid rise of AmWINS Group Benefits from a small regional organization to one of the most successful wholesalers and group insurance administrators in the country. In the era of the Patient Protection and Affordable Care Act (PPACA), innovative health benefits strategies and industry-leading products will be more important than ever before – and under Fleet’s leadership, AmWINS has proven to be an expert at providing both. These products join a long list of others that AmWINS has specifically created for the group market. While some industry offerings fall short of meeting customer expectations, AmWINS has focused its group benefits business on what truly matters by emphasizing solid plan design, unique distribution and flawless administration. As the founder of the company that became AmWINS Group Benefits, Sam Fleet is frequently sought after for his knowledge and experience as a speaker at conferences of the Council of Insurance Agents and Brokers, the National Association of Life Underwriters and Benefits Selling Expo. His success has been recognized in such prestigious industry publications as Best’s Review, Employee Benefit News, Benefits Selling, Business Insurance and Employee Benefit Adviser.

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Let The Thief No Longer Steal!Thoughts on jobs, wages and limiting health care costs.

The Grinch may not have been able to steal Christmas, but someone or something has managed to steal the jobs, the economy, and even most common sense in the health care debate. This month I want to help us look at these issues and see if we can find out who or what this “thief” is! Jobs will be a good starting place as we explore what works and what does not work (excuse the pun!) Since currently most medical coverage is tied to work, let’s consider the consequences of health coverage being tied to work.

Here are some of the issues:

• The National Center for Policy Analysis, quoting Rich Lowry from the National Review , notes that while Texas created around 119,000 jobs from August 2009 to

August 2009, California managed to pretty much cancel that out by losing 112,000 jobs in the same time period. So how do we keep people at work?• There are often unintended consequences to government actions. The possibility of McDonald’s needing to cancel 30,000 limited benefit health plans that it makes available to its hourly staff is a clear example of this. Apparently no-one had thought through that adjusting the medical loss ratios would impact so many people. Of course waivers have now been given to McDonalds and many other major groups. But what about those not given waivers. Who decides who are the lucky winners or the unlucky losers in this massive national game of health coverage roulette?What about the economy? How can so many economists get it so wrong that trillions of dollars are “stolen” from

By Tony Dale


Let The Thief No Longer Steal! the value of the economy, whether through equity/capital loss in the markets, or through government removing it from our pockets to typically squander it on non-revenue producing social engineering?• Greed and arrogance seem to be at the heart of Wall Street’s part in the collapse of the economy. They would do well to remember the words of Proverbs where it states, “Give me neither poverty nor riches, but give me only my daily bread. Otherwise, I may have too much and disown you and say, ‘Who is the Lord,’ or I may become poor and steal, and so dishonor the name of my God.” • But doesn’t government tend towards the same arrogance when it always assumes that it (i.e. the elites) know best and should show us how to spend the results of our hard labor, rather than leaving those decisions in our hands. Milton Friedman, a Nobel Prize winner in economics, called Adam Smith’s Invisible Hand “the possibility of cooperation without coercion.” I, for one, am grateful that the Tea Party movement is forcing politicians of all stripes to step back and seriously consider that maybe the apparently random action of people, when all added together, is a better regulator of the economy than all of the government’s interventions put together. As Adam Smith famously said, “The real tragedy of the poor is the poverty of their aspirations.” You don’t redistribute that by taxation but by example and by promoting the American Dream. Well, what about the loss of common sense in the whole of the health care debate? Again, I can’t think of a better way to put this than to quote a famous preacher, Dr. Adrian Rogers. “Friend, you cannot legislate the poor into freedom by legislating the wealthy out of freedom. And what one person receives without working for, another person must work for without receiving. The government can’t give to anybody anything that the government does not first take from somebody. And when half of the people get the idea they don’t have to work because the other half’s going to take care of them, and when the other half get the idea it does no good to work because somebody’s going to get what I work for, that, dear friend, is about the end

of any nation.” Isn’t it time that all of us catch these thieves and put them to work!

1 Thessalonians 4:11 See http://www.nationalreview.com/articles/249868/texas-model-rich-lowry and http://www.ncpa. org/sub/dpd/index.php?Article_ID=19962&utm_source=newsletter&utm_medium=email&utm_ campaign=DPD. Proverbs 30: 8-9 http://en.wikipedia.org/wiki/Invisible_hand http://www.lwf.org/site/PageServer?pagename=lis_quote

The Karis Group is best known for the Patient Advocacy services that it provides to many DMPO and Limited Medical Benefit Plan (LMBP) members around the country. Tony is a passionate defender of all people’s right to access medical care, and their subsequent responsibility to see that the medical provider is adequately compensated for the valuable services rendered. Recognizing that there will often be a tension between the value of the services received, and the ability of any specific patient to cover those costs, patient advocacy from The Karis Group provides a professional and dignified way for members of DMPO and LMBP to receive the help that they need when out of pocket expenses are mounting and benefits are running out!Patient Advocacy from The Karis Group is also an invaluable part of various EAP programs. Even when the employee may have adequate health insurance, there are often family members who are not fully covered. Patient Advocacy provides quality help for employees and their families when medical bills are proving a serious distraction.As well as his entrepreneurial activities with The Karis Group, Tony is also very involved in missions and church work around the world. For more information on The Karis Group see www.thekarisgroup.com.

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Reduce Worker’s CompClaims throughGood Ergonomic PracticesBy Vanessa Friedman

Ergonomics is one of the most important but overlooked tools utilized in preventative health. Employed properly, ergonomics can promote workers’ comfort on the job, increase company revenue through an increase in productivity and reduce worker’s compensation claims. In other words, ergonomics are as important to running your business as hiring capable employees.

An effective and carefully designed ergonomics program in your company can provide:

• High return on investment• Healthier, injury-free employees• Lower worker’s comp claims and costs• Lower employee turnover• Reduced overtime• Elimination of cost to hire new workers to replace injured workers

An irrefutable fact of doing business in the U.S is that when you have employees, you must purchase worker’s comp insurance. It’s also irrefutable that the more worker’s comp claims you file, the more expensive your insurance rates will be. This puts pressure on your bottom line, and these days whatever you can do to improve that number is well worth the effort. Of course, it’s understood that to reduce the number of worker’s comp claims at your business; you must make sure that all safety standards are met and there is consistent follow-through with work place safety procedures. This is when ergonomics enter the picture because there is a direct relationship between introducing good ergonomic practices and equipment to your work place and reduced worker’s compensation claims.

When you consider that most American workers spend nearly 40 hours per week sitting at a desk, keeping


Bio

that worker comfortable and safe is vitally important. Ergonomics have been proven to reduce work place musculoskeletal injuries which account for the majority of worker’s compensation claims. Worker’s compensation claims cost American businesses more than $60 billion each year according to the U.S. Department of Labor. The National Council on Compensation Insurance reports that more than 50% of those claims are for back injuries from lifting, pulling, pushing, keyboarding and straining. Another common work place injury is carpal tunnel syndrome. Carpal tunnel syndrome results in the highest number of days lost among all work related injuries. Almost half of the carpal tunnel cases in the U.S. result in 31 days or more of work loss. In these challenging economic times, time lost means dollars lost to any business. Using ergonomically designed equipment from properly designed chairs and keyboard trays to foot rests and ergonomic computer mice significantly reduces worker

injury, resulting in quantifiable worker’s compensation savings. It is a win-win for your company and your employees.

The Bureau of Labor Statistics calculated the estimated time-lost cost per injury at $26,000 per incident. Medical costs related to work place injuries can be significant. $50,000 is the average cost for back surgery; $30,000 is the average cost for carpal tunnel surgery. But that’s just a portion of the cost of the injury. For every dollar a company spends on an employee’s injury, they’ll spend three to five times that amount on indirect costs such as productivity loss, rehiring, retraining and overtime. These are sobering statistics that represent expenses that your company can ill afford. Prevention of a single injury by implementing use of ergonomically designed equipment results in immediate cost savings. Simple changes and small investments in the health of your work force will mean better health, increased productivity and fewer costs later.

The Obama administration is undertaking a review of the Occupational Safety and Health Association (OSHA) ergonomic standards as they anticipate ordering more stringent workplace safety standards. Any changes that are made in the OSHA regulations will have a direct impact on businesses. A safer work environment guarantees fewer accidents and workers comp claims.

Vanessa Friedman is the owner of Rehab Solutions, a national provider of ergonomic services and equipment, established in 2003. Rehab Solutions helps you find furniture and accessories to enhance your workers’ comfort and aid in preventing injuries. They provide workstation evaluations to identify ways to improve staff effectiveness and prevent injuries. All of their products and services are available through their website: www.ergonomicconnection.com or by contacting them at 818-888-7215.



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Killing Granny?

In the article: “Palin: Obama’s “Death Panel” Could Kill My Down Syndrome Baby” posted on The Huffington Post on August 7,

2009 it’s author Ms. Rachel Weiner makes fun of the Former Alaska Governor Sarah Palin. Earlier that month Gov. Palin posted on her Facebook page that President Obama’s health care plan might kill her child. Her statement came on the heels of renowned economist Thomas Sowell pointing out that, in addition to the fact that this is not a health care reform but a health care insurance/payment reform, goverment reform will not reduce cost—it will simply refuse to pay for costs.

Gov Palin’s prognosticative assertion : “The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evill” at the time was considerd extreme and far fetched even by the criitcs of health payment reform. Flash back to the proceeding of the International Euthanasia Task Force, 1995 where this author, and than the President of the Pacific Division of the National Association of Managed Care Physicians was quoted saying that as the direct result of proliferation on managed care: “Most ominous, is the possibility that facilitated suicide or simply withholding care might

By Victor S. Dorodny

someday be viewed as a cost-cutting measure. I’m sure there will be pressure from the business side to turn to physician-assisted suicide or another form of rationing since something like 70% of expenditures occurs in the last six months of life.” I further asserted that such rationing tools will be applied to the most vulnerable segments s of population: the very young, the sick, the elderly and disabled, to start with. My sentiment at the time was echoed by the Rev. Brad Karelius of Episcopal Church of the Messiah in Santa Ana, an expert on the issues of death and dyeing: “Money will move the decision to kill people” he said. Fast forward to November 14, 2010 when Paul Krugman, the Princeton University professor and New York Times columnist who won the Nobel Prize in economics in 2008, said on November 14, 2010 that “death panels” may be needed to help curb the nation’s budget deficit. “Some years down the pike, we’re going to get the real solution, which is going to be a combination of death panels and sales taxes,” he said. “It’s going to be that we’re actually going to take Medicare under control, and we’re going to have to get some additional revenue, probably from a VAT. But it’s not going to happen now.” “Health care costs will have to be controlled, which will surely require having Medicare and Medicaid decide what they’re willing to pay for — not really death panels, of course, but consideration of medical effectiveness and, at some point, how much we’re willing to spend for extreme care,” he later clarified on his blog. (1) Needles to say , adding approximately 45M patients in to the system, while mandating extended coverage will exponentially increase costs of health care. The system will be further burdened by increased consumption of health care by aging baby-boomers and medical complications of a younger obese generation. The rationing of health resources is here to stay for the foreseeable future! Calling it utilization review, health assets


management, allocation of medical resources, gatekeeper, cost-sharing, means testing are all double talk for health care rationing--limitation of access to or the equitable distribution of medical services, through various controls. Inevitably, difficult decisions will be routinely made based on medical futility or survivability. Futility is a concept that is inextricably bound up with a social understanding of the nature and purpose of the practice of medicine and the nature of the relationship between patient and health care provider. (4) Medical futility refers to the belief that in cases where there is no hope for improvement of an incapacitating condition that no course of treatment is called for. It is distinct from the idea of euthanasia because euthanasia involves active intervention to end life, while withholding futile medical care, in theory, does not encourage, nor speed the natural onset of death. The issue of futile care in clinical medicine generally involves two questions. The first concerns the identification of those clinical scenarios where the care would be futile.

The second concerns the range of ethical options when care is determined to be futile. Some people argue that futile clinical care should be a market commodity that should be able to be purchased just like cruise vacations or luxury automobiles, as long as the purchaser of the clinical services has the necessary funds and as long as other patients are not being denied access to clinical resources as a result.. With rising medical care costs and an increase in extremely expensive new anti-cancer medications, the same issues of equity often arise in treatment of end-stage cancer. (3) Because the issue of control within the physician-patient relationship is often understood in terms of competing or clashing values, there is a strong urge to find a value-free definition of futility.(4) As of today there is no such definition, and each and every Granny can be allowed to pass if she clearly and convincingly meets the existing definitions

of medical futility, or meets the super-stringent criteria for Physician Assisted Suicide. The concept of social utility is also taken into consideration by healthcare providers. Mostly on subconscious level its derived from patient’s real or perceived socio-economic status, physical or mental disability (real or perceived) and other incapacity. In clinical reality it is hard to cleanly separate moral and utilitarian arguments, and in practice they often appear together. Obviously, no human or group of humans can assign social value to another human’s life. Unfortunately, from a practical standpoint, social utility determination process and that of medical futility for a member of hospital’s Board of Directors would be at least “different” if not outright discriminatory than similar condiretion for a severly retarded homeles person sleeping in the hospital’s parking lot. Soon, the issues of social utility will be much easier to resolve, at least in the City of New York. Starting January 2012 New York City will begin charging private hospitals as much as $1 million a year for hospital ambulances dispatched by the city’s 911 system prompting hospitals to stop providing the service. Most of the affected hospitals are in underserved areas and are safety-net providers, operating on razor-thin margins or even running deficits, in vulnerable communities citywide. Once these hospitals drop out of the system patients will suffer because of longer waiting time and lack of access to appropriate timely care. The City of New York will benefit by collecting the exorbitant fees and by not providing proper care to its citizens. It is clear that decision regarding rationing of health care resources should not be left to Mr. Obama’s burecrauts, hospitals or even individual physicians. Such decisions should rest with a thanatology team of experts in death and dying. About 15 years ago I first proposed such team approach for hospice/home management of end-stage cancer and HIV. Thanatology team team should consist of a panel of at least too independent specialist isolated from any



considerations of social utility, patient’s family/primary physician; pain managent expert, home/hospice care provider, social worker, clergy/spititual and legal advisors. Having entrusted physicians with rationing or withholding care from patients that are determined to be medically futile, it is clear to understand my active support and participation in the Global Physician-Assisted Suicide movement. In my presentation and media appearances I am frequently asked of how physicians can reconcile their role as healers and their Hippocratic Oath with participation in physician-assisted suicide and/or lethal injection? Truth be told, the Oath is, and always was, ceremonial only--just like traffic signs in the city of New York, that function only as general guideline. Hence my reasoning for syncretistic approach to the issues of medical futility and physician assisted suicide. The modern version of Hippocratic Oath, written in 1964 by Louis Lasagna, then Academic Dean of the School of Medicine at Tufts University states that a physician “…will apply for the benefit of the sick, all measures (that) are required, avoiding those twin traps of overt treatment and therapeutic nihilism…” Clearly, in cases of chronic debilitating, and frequently fatal diseases, usually associated with intractable pain, one should not over treat and concentrate only on proper pain control and patients comfort, again allowing Granny to pass in comfort and with dignity. The modern version of the Oath also states that “…it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play God…” The recently failed (by a small margin) California Assembly Bill AB 374 (Compassionate Choices Act of 2007) specifically addressed physicians’ responsibility and respect for patients’ right to self-determination and the right-to-die with dignity. More importantly, the modern Hippocratic Oath recognizes

the concept of medical futility. An earlier, “classical”, version of the Oath comes was translated from Greek and interpreted by Ludwig Edelstein in 1943. It is by far more conservative and discriminatory against women than the current one. It starts with a “mini-oath and covenant” of allegiance to:”...Apollo Physician and Asclepius and Hygiea and Panacea and all of the gods and goddesses…”; and promises to teach the art of healing free, but to men only: “…and to regard his offspring’s as equal to my brothers in male lineage and to teach them this art-if they desire to learn it without fee or covenant…” The “classical” version weighs in on some other “hot” health/ethical/legal issues of our society: “…I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give a woman an abortive remedy. In purity and holiness I will guard my life and my art…” Obviously, our medical schools are not “without fee” and allow women. Further, most modern physicians are less than compliant with major covenants of the classic Hippocratic Oath, and very few are close to practicing their art in “purity and holiness”. ? In a mean time, “…May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” and let Granny go if it’s her time , her desire, and her informd decision !the city.

1. New York Times Columnist Says Death Panels Needed to Fix Economy (LifeNews.com) http://www.lifenews.com/2010/11/15/bio-3212

2. Dorodny, V.S. “Piracy of Privacy” January, 1996 Information Security Journal, a publication of the International Computer Security Association (ICSA)

3. Khatcheressian, J; Harrington, SB; et (July 2008). “’Futile Care’: What to Do When Your Patient Insists on Chemotherapy That Likely Won’t Help”. Oncology 22 (8). http://www.cancernetwork.com/cme/article/10165/1168027?pageNumber=1

4. Robert Halliday, “Medical futility and the social context” USA Journal of Medical Ethics 1997; 23: 148-153, Utica College of Syracuse University, New York,

5. http://en.wikipedia.org/wiki/Thanatology


Prof. Dorodny combines a specialist medical degree with over 30 years of clinical and executive experience, as well as a Doctorate in Health Information Technologies (HIT) and over 17 years of hands-on HIT/Telemedicine experience. Prof. Dorodny enjoys international recognition for advancing electronic health record technologies (EHR, EMR, PHR), and promoting confidentiality and security of health information. Having served served as Advisory Board Member of: The Association of Medical Directors of Information Systems (AMDIS); National Association of Managed Care Physicians (NAMCP) and The IPA Association of America (TIPAA), Prof. Dorodny is a member of the American Telemedicine Association ATA) & the Aerospace Medical Association (AMA) He was one of the creators of the current Health Insurance Portability and Accountability Act of 1996 (HIPAA). He conceived, designed, and led development of Knowledge–based Health Information Systems (KbHIS©) operational databases for healthcare organizations. He served as consultant to the Economic and Social Council of the United Nations; Technical Advisor to the United States Department of Justice and the FBI. Prof. Dorodny originated the revolutionary concept of health and pharmaceutical care value (HCV©) that continues to shape emerging health systems. He consults for: the Institute for Alternative he , National Association of Consulting Pharmacists, the Joint Commission for Accreditation of Hospital Organizations (JCAHO), the National Pharmaceutical Council, and the FDA. Prof. Dorodny is an accomplished Healthcare/HIT Physician-Executive and has successfully introduced his concepts into the marketplace as the Director of Health Affairs for Aviant Information Inc., systems integration and consulting services

corporation and a subsidiary of Whittaker Corporation providing products and services to the Department of Defense. (DOD).

He later served as the Chief Medical Officer (CMO) of Clark Information Services, Inc., a software, applications and data warehousing company for pharmaceutical industry and other health care organizations; as the Executive VP & Chief Medical Information Officer of Superior Consultant Company, Inc., an integrated health care, pharmaceutical industry and information technology management company; as the Executive VP of Business Development for ICN, Pharmaceuticals, Inc., Eastern Europe.

Prof. Dorodny is Board Certified by the American Academy of Pain Management, Diplomate and Distinguished Fellow of the American College of Ethical Physicians, Associate in Medicine of the American College of Legal Medicine (ACLM), Diplomate and Distinguished Fellow of the American College of Hospital Physicians, graduate of USC Executive Management Institute in Health Care, and Registered Arbitrator.

Prof. Dorodny made significant contributions on diverse topics in major mass media publications, peer review journals and trade publications. He authored monographs and books. Among his editorial board appointments: Managed Healthcare, US Pharmacist, ADVANCE for Health Information Executives. As Reuters Healthcare Expert he often presents at national and international conferences, and guests on national TV and radio.

Bio



Catch the Next Wave in Voluntary Benefits!

by Wayne Morris

Insurance, Financial, HR and Voluntary Benefit Professionals can dramatically increase their income, plus provide valuable services to protect their clients and companies. Legal and Identity Theft Protection will be the next major growth market, due to the rapid increase in awareness and demand by consumers.Legal Protection Pre-Paid Legal plans offered to Individuals, Families or Employer Groups, as part of the HR or Voluntary benefit package with payroll deduction. Plans include a suite of legal services, including: a Free Will, legal consultation, legal correspondence, contract and

business document review and trial defense services.Have you ever...• Been involved in an accident or arrested?• Received a moving violation or speeding ticket? • Been audited by the IRS? • Purchased a home? • Tried to return a defective product or been overcharged? • Had problems with an Insurance claim?• Lost a security deposit? • Signed a contract? • Prepared a will? Even though most people find themselves in


these situations, the majority do not seek the advice or help of a qualified lawyer. Why? It costs $200-$500 per hour and they don’t know who to call.Identity Theft Protection & 24/7 Credit MonitoringIdentity Theft is the fastest growing white collar crime in the U.S. Criminals and Organized Crime rings are constantly finding new ways to obtain your SSN, Drivers License, Credit Cards, Medical Records, PIN codes, etc. The average individual’s personal information is stored in 100’s of databases. It’s not just online purchases that are vulnerable to identity theft. In fact, online transactions are a small majority of identity fraud cases. Numerous companies have had data security breaches, including: Apple, Bank of America, Chase, Citigroup, Countrywide Financial, Humana, Lending Tree, McDonald’s, Starbucks, TJ Maxx, Veteran’s Administration, Wachovia, Wells Fargo and many other businesses of all sizes. In fact, Ben Bernanke, Federal Reserve Chairman and his Wife were recently victims of an organized crime ring that was able to obtain SSN, Drivers License, Bank and Credit Card accounts.It is no longer a matter of whether your identity will be stolen, but when! And, most people don’t find out until it is too late.

New Federal “Red Flag Regulations

Federal laws now mandate that self-employed individuals and companies in the U.S. take specific proactive steps to protect sensitive data and hold mandatory meetings to educate their employees on Identity Theft protection. Most companies are not aware of these new regulations and the potential liability and fines they face for non-compliance.

SummaryofPlanBenefits1. Unlimited Legal Consultations & Advice2. Free Will with Annual Updates3. Traffic Violation Defense4. Automobile-Related Criminal Charges Defense5. Contract & Document Review6. Legal Correspondence & Phone Calls7. Trial Defense Services8. IRS Audit Legal Services9. Identity Theft Protection & Restoration10. 24/7 Credit Monitoring

Wayne Morris founded USA Insurance Brokers in 1999. The company has been recognized for the past 5 years as one of the Top 10 Independent Insurance Brokers in the U.S. by America’s Health Care Professionals. He previously spent 25 years as Vice President Worldwide Sales & Marketing for several industry leading telecommunications firms. Wayne & Dottie have been married for over 35 years with 2 children and 4 grandchildren. They enjoy Tennis, Golf, Scuba Diving, Skiing and Travel. He served in the U.S. Marine Corps from 1965-1969 and is a Vietnam Veteran. After returning to the U.S., he attended Penn State University and graduated from Allegheny College. Association/Organization Membership: America’s Health Care Professionals; Arizona Small Business Association; National Association of Professional Agents; and Trilogy C.C. For additional information, please contact Wayne Morris @ 1-800-591-3920 or E-mail: [email protected]

Bio



by Jody LaMarca

De-Stress: Keep It Simple… and Healthy

• Buy vegetables that are easy to prepare. Pick up pre-washed bags of salad greens and add baby carrots or grape tomatoes for a salad in minutes. Buy packages of veggies such as baby carrots or celery sticks for quick snacks. • Use a microwave to quickly “zap” vegetables. White or sweet potatoes can be baked quickly this way. • Keep a bowl of whole fruit on the table, counter, or in the refrigerator. • Popcorn, a whole grain, can be a healthy snack with little or no added salt and butter. • Freeze leftover cooked brown rice, bulgur, or barley. Heat and serve it later as a quick side dish. • Consider convenience when shopping. Buy pre-cut packages of fruit (such as melon or pineapple chunks) for a healthy snack in seconds. Choose packaged fruits that do not have added sugars. • Dried fruits also make a great snack. They are easy to carry and store well. Because they are dried, ¼ cup is equivalent to ½ cup of other fruits. • Buy fruits that are dried, frozen, and canned (in water or juice) as well as fresh, so that you always have a supply on hand.

Take these stepsto eat healthier during the holiday season.


Eating Out? Make Healthy Choices

• As a beverage choice, ask for water or order fat-free or low-fat milk, unsweetened tea, or other drinks without added sugars. • If you drink cappuccinos or lattes — ask for them with fat-free (skim) milk. • In a restaurant, start your meal with a salad packed with veggies, to help control hunger and feel satisfied sooner. • Ask for salad dressing to be served on the side. Then use only as much as you want. • Add little or no butter to your food. • Order steamed, grilled, or broiled dishes instead of those that are fried or sautéed. • Order foods that do not have creamy sauces or gravies. • Choose main dishes that include vegetables, such as stir fries, kebobs, or pasta with a tomato sauce. • Ask for whole wheat bread for sandwiches. • Order an item from the menu instead of heading for the “all-you-can-eat” buffet.• Choose a “small” or “medium” portion. This includes main dishes, side dishes, and beverages.

If portions at a restaurant are larger than you want, try one of these strategies to keep from overeating:

• Order the appetizer-size portion of your entrée if it’s offered.• Share a main dish with a friend.• If you can chill the extra food right away, take leftovers home in a “doggy bag.”• When your food is delivered, set aside or pack half of it to go immediately.• Resign from the “clean your plate club” – when you’ve eaten enough, leave the rest.

Follow These Tips for Healthy Holiday Cooking

• For gravies or sauces — If you are making pan gravy, first skim the fat off pan drippings. For cream or white sauces, use fat-free (skim) milk and soft tub or liquid margarine. • For dressings or stuffing — Add low-sodium broth or pan drippings with the fat skimmed off instead of lard or butter. Use herbs and spices and a whole grain bread for added flavor. • For biscuits — Use vegetable oil instead of lard or butter and fat-free (skim) milk or 1 percent buttermilk instead of regular milk. • For greens — Use skin-free smoked turkey, liquid smoke, fat-free bacon bits, or low-fat bacon instead of fatty meats. • For sweet potato pie — Mash sweet potato with orange juice concentrate, nutmeg, vanilla, cinnamon, and only one egg. Leave out the butter. • For cakes, cookies, quick breads, and pancakes — Use egg whites or egg substitute instead of whole eggs. Two egg whites can be substituted in many recipes for one whole egg. Use applesauce instead of some of the fat.

For meats and poultry (chicken and turkey)

• Trim away all of the visible fat from meats and poultry before cooking.• Take off poultry skin before eating.• Broil, grill, roast, poach, or boil meat, poultry, or fish instead of frying.• Drain off any fat that appears during cooking.• Chill meat and poultry broth until fat becomes solid. Skim off fat before using the broth• Skip or limit the breading on meat, poultry, or fish. Breading adds fat and calories. It will



also cause the food to soak up more fat during frying.• Choose and prepare foods without high fat sauces or gravies.

Help Your Kids Have a Healthy Holiday

Eat Right • Set a good example for children by eating fruits, vegetables, and whole grains with meals or as snacks. • Let children decide on the dinner vegetables or what goes into salads. • Offer children a choice of fruits for lunch. • Use cut-up vegetables as part of afternoon snacks. • Let children select and help prepare a whole grain side dish. • While shopping, allow children to pick a new fruit or vegetable to try later at home. • Decorate plates or serving dishes with fruit slices. Be Physically Active• Give gifts that encourage physical activity — active games or sporting equipment. • Be active and get your family to join you. Have fun together. Play with the kids or pets. Go for a walk, tumble in the leaves, or play catch. • Instead of sitting through TV commercials, get up and move. Remember to limit TV watching and computer time. Source: USDA MyPyramid.gov


by Jay Young

Stop! Before you call 911, read on…

ARM is an acronym for Attract, Retain, and Motivate!The passage of Health Care Reform has caused many

employers to consider whether or not to continue offering a health insurance program to their

employees once Insurance Exchanges are up and running in 2014. Setting aside all of the misinformation and rhetoric swirling around, ask yourself this one question...How will I continue to attract, retain, and motivate employees without providing a good, comprehensive

benefits program, including health care? Forbes.com recently published an article

on this very subject (TheBestBenefitsPackagefor Small Businesses, August 17, 2010) and

encouraged business owners and entrepreneurs not to abandon offering benefits for employees. They recommend at a minimum to provide health insurance, life insurance, disability coverage, and a retirement plan. While the bottom line is always the bottom line, it takes talent to meet both financial and operational goals. Obviously, I agree but caution you against trying to navigate the road alone! There are so many options available today and with Health Care Reform, not all

of the curves are clearly marked. Plan design plays an integral part in cost but again there are many ways to design a quality, cost-effective benefits plan.

A.R.M.Your Employees



BioSo, back to the basics…Attract by advertising the benefits that you offer to potential employees. It’s not just about salary but what is the total compensation package look like. The time is coming when your pay scale may take second place behind your comprehensive health plan! Employers that offer self-funded plans have design and pricing advantages over those offering fully insure plans.Retain by performing an annual review of your program, as well as some benchmarking against your industry or other local employers. Voluntary benefits are also a great addition to any benefits plan, allowing employees to pick, choose, and pay for the things they need. Providing an employee with the opportunity to save for retirement, set up a college fund for their children, or even buy some inexpensive term life insurance on their dependents. Employee Assistance Programs are also a great way to provide work/life benefits at a very reasonable cost. Many of these benefits will help stop the drain on productivity when an employee brings problems or issues from home to work.Motivate by consistently communicating with your employees on what benefits are provided, how to use them effectively, and their value. Company newsletters, e-mails, and social media all provide opportunities to keep staff members up to date. Total Compensation Statements are a great way to remind employees of the value of your benefits program! Do your due diligence and find a CERTIFIED FINANCIAL PLANNER™ in your area. Arrange for him to spend a “no obligation” hour with each employee to discuss their finances. A lunch & learn on debt, investments, retirement planning or the economy is a great way to stimulate interest.So, now it’s up to you! Will you reach out for help or will you run for cover and hope for the best? Following the recent elections, it’s easy to get caught up in all of the rhetoric and lose focus on what’s important.Having spent the past twenty years working in employee benefits, I find that a pro-active approach combined with a strong communications program will keep your employees engaged and focused on doing the things you hired them to do!

After twenty-four years in Corporate America, Jay formed Belden Benefits in 2010.

As Senior Director, Benefits & Insurance for USA Mobility, Inc., Jay was responsible for all of the company’s employee benefits and insurance programs.He specializes in the areas of administration, analysis, communication, compliance, and design. He is a skilled negotiator.

Prior to USA Mobility, Jay spent eleven years in the health care industry, where he performed due diligence and integration on more than twenty-five acquisitions.

Belden Benefits was formed to support the brokerage community and therefore will not engage in the sale of insurance products. The goal is to provide employers with hands on, cutting edge consulting services at a reasonable price.

Jay produced an extensive overview of Health Care Reform in late March and has conducted seminars for employers and business owners throughout the Baltimore-Washington area. These seminars were designed to assist employers in becoming compliant, in the most cost-effective manner, while continuing to provide quality coverage. He has also authored a number of articles on this important legislation, as well as a number of other topics.

Married for thirty-seven years, Jay & Sherrie make their home in West River, MD. They lead a couples Bible study in their home and are active in the ministry of their local church.


Documents

Self Funding Magazine january 2011