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Global Wellness in the Healthcare Reform Era: Is The World Curved or Flat? ISCEBS Global Wellness in the Healthcare Reform Era: Is The World Curved or Flat? ISCEBS NYC 14 September 2011 Presented by: Allen Koski, CEBS 302 -797 -3300 allen. [email protected] com Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

4 Years Ago (2007) § Apple Introduces the i. Phone § Price of Gold 4 Years Ago (2007) § Apple Introduces the i. Phone § Price of Gold was $630/ounce § Final Harry Potter Book Released § World Stock Markets Plummet § Daimler sells Chrysler to an Equity Fund § Peru earthquake leads to Tsunami Warnings § Bulgaria and Romania join the European Union § Tiger Woods wins Thirteenth Major (will win only one more) § Time magazine in 2007 calling the Aztek one of the worst cars of all time Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

New Diseases since 1973 § 1973 Rotavirus: Infantile Diarrhea § 1977 Ebola: Hemorrhagic Fever New Diseases since 1973 § 1973 Rotavirus: Infantile Diarrhea § 1977 Ebola: Hemorrhagic Fever § 1981 Staphylococcus aureus: Toxic Shock Syndrome § 1982 Borrelia burgdorferi: Lyme Disease § 1983 HIV: AIDS § 1989 Hepatitis C: Parentally Transmitted Liver Infection § 1993 Hantavirus: Adult Respiratory Distress Syndrome § 1995 Ehrlichiosis: Severe Arthritis § 1996 nv. CJD: Creutzfeldt-Jacob Disease § 1997 H 5 N 1: Influenza § 1999 Nipah: Severe Encephalitis § 2000 s: Methicillin-resistant staph (MRSA) § 2009: H 1 N 1 Flu Epidemic? Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Evolution of the Global Health Care Management Model The Goal: High Quality Care Worldwide, Evolution of the Global Health Care Management Model The Goal: High Quality Care Worldwide, integrated health care delivery system providing the highest quality of care available in any given locale and bringing together worldwide best practices. Member Beware Network Global Health & Patient Risk Protection Advocacy Development Wellness Only [ WHAT WAS ][ ] BUILDING OUT Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA

What Will Change 4 Years Hence: § Networks a mile wide and a few What Will Change 4 Years Hence: § Networks a mile wide and a few facilities deep: care in countries where no networks or pre-arranged payment systems exist and Medical CPI (200 Countries) § Widen the Circle of Care: Post treatment coordination and recuperative care § Managing dynamic change in global healthcare, IEAP, dental, and disability § Local insurance requirements to support VISA concerns and Healthcare Reform § Corporate Global Wellness Initiatives § Expatriate population continues to age and get more diverse § Great “Black Swan” event planning § Medical Tourism or Regional Options Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Tri-State Depot and Global Inc. Number of employees = 500 employees vs. 50 expat Tri-State Depot and Global Inc. Number of employees = 500 employees vs. 50 expat employees Location of employees = 50 miles from store vs. World Wide (30 different countries) Number of Hospital = = 5 to 10 local Hospitals vs. 1, 000+ Possible Hospitals Number of Providers 200 in-network/500 out vs. 100, 000 Worldwide Providers Location of Dependents = For locals, most families live together vs. internationally, many spouses may not live in same location, and students tend to go to colleges in different countries Type of care available = For locals, care is similar across providers vs. internationally, care can be very advanced to primitive Currency = = = US dollars only vs. any currency available State compliance ID Card Claim Adjudication Financial 3 or 4 US states vs. 200 different countries 1 -800 number vs. Global Call Collect Auto adjudication vs. Direct Pay or Pay and Claim Self Insured versus Insured Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

International Benefits versus Domestic (US) Benefits § Medical, Dental, and Prescription Drug: Transactional § International Benefits versus Domestic (US) Benefits § Medical, Dental, and Prescription Drug: Transactional § Life and AD&D: Commodity § Evacuation and Repatriation, Employee Assistance Program (EAP): Duty of Care Important § Long Term Disability (LTD): Hybrid Transactional and Commodity § Short Term Disability (STD): Salary Continuation Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Plan Design Differences § International is Insured, Domestic is often Self-Insured § Location of Plan Design Differences § International is Insured, Domestic is often Self-Insured § Location of Assignment and Dependent Location § Location where the Plan will be Monitored and Maintained § Specific Subgroup Requirements § Country Specific Minimum Requirements § State Minimum Creditable Coverage (MCC) – Out of Pocket limited to $5, 000/10, 000 in Massachusetts Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Domestic vs. International Cost Projections Domestic Trends= Cost X Utilization International Trends = Cost Domestic vs. International Cost Projections Domestic Trends= Cost X Utilization International Trends = Cost X Locations X Fx X CPI X Movement of Members X Medical Advances X Utilization International plans tend to less expensive overall but have higher trend Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Country Specific Variations: § Dubai: Need a local plan number § UK: A Surgeon Country Specific Variations: § Dubai: Need a local plan number § UK: A Surgeon in “Mister” § France: 3/5/09 is 5/3/09 § Japan: 96 hour maternity is the norm § China: No screened blood supply § Germany: Alternative Therapy § Singapore: Ritalin is a “Controlled Substance” § Global: Hardware versus Software § US: Cost, Access, Quality § UK: Employer benefits contributions are taxed to Employee Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Global Traveler Checklist Travel Security WHO HR CDC Traveler Risk Mgt State Dept News Global Traveler Checklist Travel Security WHO HR CDC Traveler Risk Mgt State Dept News Visa Support Pre-Trip Healthcare Provider Listing ICE Strategy Security Procedures Medical Contingency Plans Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Health Care Challenges Multitudes of clinical protocols and dangers: – Post treatment coordination and Health Care Challenges Multitudes of clinical protocols and dangers: – Post treatment coordination and recuperative care – Avoid counterfeit prescription medications – Dealing with local traditional non-medical treatments – Medical evacuation protocols, post treatment options – Unscreened blood supplies Difficult administrative issues – “Hardware” and “Software” match – Paying for emergency care in countries where no networks or pre-arranged payment systems exist – Local insurance requirements to support VISA concerns – Payment using any type of currency available Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Total Medical Cost Global Network Medical Cost Savings Global Wellness Tools US Networks INITIATIVE Total Medical Cost Global Network Medical Cost Savings Global Wellness Tools US Networks INITIATIVE Networks Improve Health & Productivity Return on Investment Local Networks Direct Payment Networks Early risk reduction and intervention Direct individuals to programs and high efficiency providers Employee Initiatives Employer Initiatives Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Summary of Differences § Recognize that international assignment demands are more complex and require Summary of Differences § Recognize that international assignment demands are more complex and require specialized attention – Medical capabilities are variable country to country § Global service partners must improve business performance – By delivering services that reduce the administrative burden of health care and associated costs § Protect the investment made in human capital and allow international assignees to focus on what matters most within their respective businesses § Do not forget everything is multiplied in complexity when someone is facing a new situation § Work within different cultural norms Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA

Challenge Question: What Matters To You Most In a Program? 1. Designing a Globally Challenge Question: What Matters To You Most In a Program? 1. Designing a Globally Compliant Solution 2. Cost Effective, Comprehensive Coverage 3. Easy Member Experience 4. Unrivaled Global Network 5. Wellness Tools to Improve Health Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Mod 2: Overview of the Impact of Health Care Reform on Global Employees § Mod 2: Overview of the Impact of Health Care Reform on Global Employees § Many Governments around the world have changed their view about medical coverage (Locals and Expats). – – UAE: Expats are now required to show proof of coverage before getting a work visa, Czech Republic now requires Locals and Expats to get minimum coverage levels thru a non-government insurance company, Russia requires a minimum level of medical coverage, with any insurance company, Some national systems require all employers to pay into one system for both Locals and Expats. Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Delivering Global Benefits is Complicated: Legal Middle East Australia – – – Illegal for Delivering Global Benefits is Complicated: Legal Middle East Australia – – – Illegal for any non-registered health fund to pay claims for Medicare eligible Australians Having private health insurance with an AUS registered health fund allows Australia taxpayers to claim exemption from 1% Medicare Levy Surcharge, if eligible Minimum benefits are required to allow for 457 Visa Letters to be issued for non-Australians working in Australia Saudi Arabia Coverage has to be provided by a locally-admitted carrier • Minimum coverage requirements (CCHI) United Arab Emirates • Coverage has to be provided by a locally-admitted carrier • Plans must be filed with local authorities (HAAD) • Impact on obtaining a visa • Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

US: Patient Protection and Affordable Care (PPACA) Act of 2010 New Plans New and US: Patient Protection and Affordable Care (PPACA) Act of 2010 New Plans New and Grandfathered Plans § Must follow rating limitations. § No preexisting condition exclusions. § Guaranteed issue. § Waiting period limited to 90 days. § Guaranteed renewability. § No discrimination based on health status. § No discrimination against health care providers acting within scope of their license. § Must cover essential benefits. § Must follow cost-sharing limits. § Must cover clinical trials without additional conditions. 2010 2011 2012 2013 2014 2015 2016 2017 2018 18 Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

PPACA: Provisions Phased in until 2018 Implications § No discrimination in favor of highly PPACA: Provisions Phased in until 2018 Implications § No discrimination in favor of highly compensated individuals. § Dependent age rises to 26 years § Minimum loss ratio requirements (80%/85%) § Broker commission in/out of the program? § Is the individual mandate legal or not? § 2018: Introduction to high value plans ($11, 200/$27, 500) § What waivers will be granted? What state requirements? § Will insurers withdraw from markets? § Will Americans be allowed on “offshore” plans after 2014? 2010 2011 2012 2013 2014 2015 2016 2017 2018 19 Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Global Plan Options: Post Healthcare Reform (PPACA) § It appears that domestically sitused expatriate Global Plan Options: Post Healthcare Reform (PPACA) § It appears that domestically sitused expatriate plans will be subject to some of the new law provisions. – – – leave US citizens on a US PPACA compliant plan but cover the TCN/KLNs under a separate “offshore” policy, again assuming the US employer has a place of business in a location where a local policy can be legally issued; OR create a sub-group under the US policy made up of only TCNs and KLNs with cover that differs from the PPACA compliant cover provided to the other group on the principles that (a) these groups could be grandfathered (if renewing), and (b) presumably the PPACA was not intended to require certain types of cover for non US citizens based outside the United States and thus a client is willing to assume the risk that it is unlikely that the government would pursue non-PPACA-compliant levels of cover for noncitizens residing outside the United States. Don’t forget other issues like Massachusetts Credible Coverage Minimums Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Mod 3: Business Plan on Deploying International Wellness Programs Multi-national workforce means varied health Mod 3: Business Plan on Deploying International Wellness Programs Multi-national workforce means varied health and wellness concerns: Europe: Productivity, Reducing Presenteeism & Morale/Engagement Canada: Productivity, Reducing Presenteeism & Morale/Engagement United States: Reducing Health Care Costs & Productivity, Reducing Presenteeism Latin America: Productivity, Reducing Presenteeism & Maintaining Work Ability Asia: Morale/Engagement & Productivity, Reducing Presenteeism Africa: Productivity, Reducing Presenteeism & Absence Management Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA Australia: Productivity, Reducing Presenteeism & Absence Management

A Different Way of Thinking Addressing health care demand spending from both sides of A Different Way of Thinking Addressing health care demand spending from both sides of the problem Annual Patient Cost $ Case Management Earliest interventions help prevent costly medical events Q-12 Q-10 Q-8 Q-6 Disease Management Utilization Management Q-4 Q-2 Q 0 Q 2 Q 4 Q 6 Traditional medical management responds to disease/illness Q 8 Q 10 Preventing/Slowing Responding/Reversing • Health Promotion & Wellness • Lifestyle Behavior Modification • Chronic Condition Support • Disease Management • Acute Care Coordination Original chart source: Musich, Schultz, Burton, Edington. DM&HO. 12(5): 299 -326, 2004 Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA Q 12

Condition Management § Chronic condition support & management: A comprehensive approach to managing the Condition Management § Chronic condition support & management: A comprehensive approach to managing the course and impact of chronic conditions – Look for active versus passive program • • Proactive identification of high risk patients Program with consistent service experience, regardless of patient location Holistic patient management, not just managing events of treatment – “health, family, and life management” not just medical management Outreach for the purpose of education and intervention, so as to change behavior and manage compliance Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA

Condition Management: Diabetes Triage Logic DIABETES? YES Do You Take Insulin? YES Level 3 Condition Management: Diabetes Triage Logic DIABETES? YES Do You Take Insulin? YES Level 3 NO NO / Next Do You Know Your Hemoglobin A 1 C Levels? YES Is it Above 7? YES NO NO Level 3 Do You Take 2 or More Meds a Day for Diabetes? Level 3 YES NO Level 1 if Low Risk country; Level 3 if High risk country Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA Level 3

Health Programs: Virtual Second Opinions Access to internationally-recognized experts for confirmation of life-threatening/life-altering diagnoses Health Programs: Virtual Second Opinions Access to internationally-recognized experts for confirmation of life-threatening/life-altering diagnoses and treatment recommendations, without requiring the expat to travel or incur out-of-pocket expenses. Look for: • • Utilization of a specific world-class vendor (recognized expertise) Intended for use for serious illness, complex cases Provision of more treatment options beyond what’s available locally Receive world-class opinions without the cost/disruption of traveling Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Health Programs: International Employee Assistance Program Immediate access to confidential services for behavioral health Health Programs: International Employee Assistance Program Immediate access to confidential services for behavioral health assessment. Have three levels: Telephonic, Face-to-Face and Work/Life Support. Look for: • Service Level: 24/7 with multiple access points: telephonic, email, online chat or SMS Text. • Telephonic triage and crisis intervention services • Local language Face-to-Face Sessions • Work/Life Support: Child and Senior Care • Local language access (23 Regions) • Structure telephonic counseling (170 Countries) Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Wellness Program: Health Assessment § Collects individuals’ health information by asking a series of Wellness Program: Health Assessment § Collects individuals’ health information by asking a series of questions: § Personalized health risk report to make changes to unhealthy lifestyle habits: – – – Behavior modification to instill healthy habits before condition appears Self-directed, online programs available in many languages and culturally adapted Targets four key areas of modifiable health risks: • Sleep Habits • Stress Management • Healthy Eating • Physical activity Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2010 CIGNA

Challenge Question: What Wellness Program Will Have the Greatest Inpact? 1. Health Risk Assessment Challenge Question: What Wellness Program Will Have the Greatest Inpact? 1. Health Risk Assessment for Expatriates 2. Health Risk Assessment for Locals 3. Condition Management Program 4. Virtual Second Opinion 5. International Employee Assistance Program Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Business Plan § Prepare for “Black Swan” Events (ICE Strategy) § Gap Analysis between Business Plan § Prepare for “Black Swan” Events (ICE Strategy) § Gap Analysis between Healthcare Provider, Workers Compensation Provider, Evacuation Vendor § Harmonize Medical Evacuation and Security Evacuation § Review Legal Requirements at Local and Global Country Level § Have Global Dental and EAP Providers § More Local Options Before Evacuation § Screen Chronic Conditions Before Deployment § Have Regional Options in Place § Understand Healthcare Reform Initiatives by Country § Offer Wellness and Pre-Departure Tools § Consider Segmented Expatriate and Third Country National Plans § Recognize Corporate Duty of Care Requirements Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

“Sometimes I'm confused by what I think is really obvious. But what I think “Sometimes I'm confused by what I think is really obvious. But what I think is really obviously isn't obvious. . . ” Michael Stipe, Lead Singer REM Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

Questions to Ask § Are global health plan higher or lower than domestic? § Questions to Ask § Are global health plan higher or lower than domestic? § Are there any downsides to putting in a plan? § How is eligibility handled? § Can you do VISA letters to help with immigration requirements? § What reporting in offered? § Are there countries where the program does not work? § Should we purchase war risk or terrorism coverage? § Discuss employer contribution strategies for expats, TCNs and Key Locals? § How do you do implementation meetings? § How does healthcare reform(s) affect our global benefit levels? § How should we handle short term assignments? § How does HR and Risk Management manage multiple vendors? § Does the evacuation, healthcare or workers compensation vendor take the lead on medical emergencies? § What do you think about multinational pooling? Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA

CIGNA International Expatriate Benefits – A Market Leader in Global Healthcare What we offer… CIGNA International Expatriate Benefits – A Market Leader in Global Healthcare What we offer… access to quality health care coupled with integrated products and very personalized service Leadership Statistics ►Global ► 30+ years of experience Our products… ►Medical, dental, vision, behavioral, pharmacy, life insurance, personal accident, disability, business travel and wellness programs ►Leverage CIGNA Health. Care’s capabilities, where applicable ►Focus on consumer through global access to quality health care and personalized service ►Multi-lingual customer service representatives, 24/7/365 ►Global networks with Direct-to-provider payment system with more than 150 countries How we distribute… ►Primarily through benefits brokers and consultants to multinational organizations with employees serving on long- and short-term international assignments ► 49% of Fortune 100 companies are customers ► 4. 8 million policyholders worldwide ►Actively selling in 27 countries and jurisdictions with service capabilities in virtually any country ►A global workforce of 4, 000 experienced professionals ► 30 different healthcare licenses worldwide Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2011 CIGNA