The Best Laid Plans
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
Hale Everson disliked silence and wasn’t bothered by visible distractions. A natural multitasker, he liked to keep D.C. Span, the 24-hour news channel devoted to Washington politics, on his office TV.
As the Human Resources director for the Southern operations of Fuego Motors, a leading European car maker, Hale had been working for years to create a state-of-the-art health care monitoring system for the automobile manufacturing plant’s employees.
On the computer monitor in front of him, there were no less than 10 open spreadsheets.
Hale loved data and along with the auto plant’s risk manager, he had compiled plenty of it.
Hale paused at his keyboard and shifted his attention to his TV set. The U.S. Senate was voting on the passage of the Patient Protection and Affordable Care Act.
“Come on boys, come on,” he said, as he watched the “yes” votes pile up. Hale wasn’t worried about the outcome of the vote. He’d been preparing for this day for years.
When it came to what he required to work well, Brady Heller, the CFO for Apex Care, a regional hospital, was a door-shut type, even though he had a corner office. Brady hated any sort of distraction.
It wasn’t until he got home late that night and watched the 11 o’clock news that Brady found out the Affordable Care Act had passed. Brady watched impassively as his wife sat next to him.
Always keeping his cards close to his vest, Brady quietly calculated what Apex Care had spent over the past four years to acquire numerous specialty practices to build a state-of-the art Accountable Care Organization.
Brady wasn’t worried about the outcome of the vote either. He’d also been preparing for this day for years.
Brady and Hale, friends since college, were walking down the fourth fairway at the local country club when the two community leaders, key members of the local chamber of commerce, put their well-disciplined heads together.
“Nice job picking up Neil Zane’s cardiac practice buddy,” Hale said to his friend with a smile.
“Thanks,” Brady said, as he scanned the grassy rise for his golf ball.
“From what I can tell, you’ve got all the pieces in place,” Hale said.
“I sure hope I do. Cost us enough,” Brady said as he turned to set up a 2-iron shot.
“Brady, hold on just second,” Hale said. Brady turned and looked soberly at Hale, alert to the business-like tone Hale had switched to.
“I think I’ve got all my pieces in place too, and I don’t want to wait ‘til the wind changes. I want to bring my entire workforce to Apex on a direct contract. I’ve got all the data…”
“I bet you do,” Brady said.
“And with my documentation we can get this done sooner rather than later,” Hale said.
“You got everybody ready?” Brady asked.
“I’ve got everybody on board, from Turin to where we’re standing right here,” Hale said, and Brady could tell that Hale meant every word.
Within three weeks, the local business weekly ran a story under the following headline and subhead.
“Fuego and Apex Ink Healthcare Pact”
“Savings and better quality of care in focus in multi-million-dollar arrangement”
The story featured a picture of Brady and Hale shaking hands over a conference table.
Under the direct contract with Apex, Fuego’s workers and their dependents would receive exclusive health care at the regional health giant for three years. The contract was set to renew as long as costs didn’t deviate more than five percent on an annual basis from projections.
Seven months after the direct contract deal was announced, Serge Bernstein, head of Apex’s high-profile bariatric medicine and weight loss clinic, requested a face-to-face meeting with Brady.
“I have to ask you, did you have access to Fuego’s health care data before you agreed to this deal?” Dr. Bernstein asked Brady.
“I know as a matter of fact that the company keeps excellent records,” Brady said as an opening defense.
“Well, I keep pretty good data on my end as well,” Dr. Bernstein said, as he expertly swiped his digital tablet to bring ups some figures.
“The contract with Fuego says costs can’t deviate more than five percent from projections,” he said.
“That’s correct,” Brady said.
“What would you say if I told you that I am seeing instances of diabetes in that population at about 250 percent of projections?” Dr. Bernstein said.
“I’d be very concerned,” Brady said.
“Then you should be very concerned,” Dr. Bernstein said.
Two weeks later it was the hospital system’s head of orthopedics, Krishnan Gilani, who was sitting in Brady’s office.
“I’ve got a four-week waiting list for initial non-emergency evaluations,” Dr. Gilani said.
“Why?” Brady said.
“Have you heard of the Affordable Care Act? This autoworker population requires a lot of care. Many of them are overweight, which complicates treatment. I’ve also got a threefold increase in overall caseload due to all the previously uninsureds coming on board under the new law,” Dr. Gilani said.
“Wow,” Brady said.
“Wow indeed, Mr. Heller,” Dr. Gilani said. “These are substantially out of whack figures and of great concern,” Dr. Gilani said.
Hale and Brady were mostly silent as Hale lined up a putt and the two of them digested the information that the increased number of insureds coming in for treatment was threatening to broadside their direct contracting arrangement.
“It’s the first year of the program,” Hale said after his putt lipped out. “I’m sure the numbers will settle down in years two and three.”
“You’re probably right,” Brady said as he stood over his putt.
“You’re probably right.”
Hale’s view of his in-office television screen is obscured by the bulk of the autoworkers’ union vice president. To the vice president’s left is the union president. Neither of them looks healthy and neither of them looks especially pleased.
“Eighteen months ago you sold this hospital deal to us, saying it would be better for the workers and their families. You said we’d get better treatment, cheaper, and better access to treatment,” the union president said.
“I did say that, that’s true,” Hale said
“None of that was true,” the vice president said.
“We got a guy on the line, he twists his back trying to keep an engine compartment bonnet in place. You know how long it takes him to see a back specialist?”
“I don’t…” Hale begins.
“How about five weeks?” the vice president said. “Five weeks!”
“And this is the only hospital we can go to,” the president said.
“I thought health care reform was about choice. You know what? We have no choice,” the union president said.
“Am I in Russia now because I feel like I’m in Russia,” the union vice president says to the union president.
The quarterly meetings between hospital management and the medical team leaders have become so fraught with tension for Brady Heller that they begin to feel like out-of-body experiences.
Dr. Bernstein, Dr. Gilani and Dr. Helen Beers, chair of the cardiac unit, have Brady in their cross-hairs.
“When you brought my practice into your system, I was assured that I could maintain my care standards, that my cost of risk would be reduced by 20 percent and that my revenues would increase by 30 percent,” Dr. Beers begins.
“None of that has happened,” she said, fixing formidable steel blue eyes on Brady through her titanium eyeglass frames.
“Instead I’m seeing delays in payment. I am seeing care standards that I never would have tolerated independently, and I am seeing this across a number of departments, not just my own,” she said.
“We want access to full financial documentation under the terms of our contracts or we are walking, I am not kidding you,” Dr. Bernstein said.
Brady looked from Dr. Bernstein to Dr. Gilani to Dr. Beers. Nowhere was there mercy or understanding.
Hale has a board meeting of his own to attend.
“If we pay them this $3 million that they’re asking for,” the CFO for North America says to Hale.
“On top of the contracted amount,” he says, looking around the table for emphasis, to make sure everyone is getting his point.
“On top of the contracted amount,” he says yet again, unmercifully.
“What assurances do we have that we’re not going to be shelling out another $3 million in six months to a year from now?” the CFO asks.
“I’m not sure that I can offer you any assurances,” Hale says.
“We’re seeing treatment delays and co-morbidities that are beyond the scope of our projections,” he adds.
“I thought this was the best health care money could buy,” the CFO says.
“It may be,” says the North American CEO, who has made a special point to be at this meeting.
“The issue is we didn’t know it would take this much money to buy it.”
The CEO fires Hale Everson that very evening.
A sizable regional employer and a large health care system come to grief when their directly contracted health care arrangement is blind-sided by health care reform implementation. The planners of the deal fail to take into account the delays in treatment that large numbers of previously uninsured patients coming into the system will create. Contrary to their promises, standards of health care deteriorate and key stakeholders become alienated.
1. The importance of good data: Data is only actionable if it is good data. Fuego Motors thought it had adequately measured the health care risks inherent in its employee population, but events proved it to be woefully wrong. The advent of the Affordable Care Act is going to impact medical treatment and loss projections are going to have to be altered.
2. Assess your contract: Direct contracts to provide health care services to employers might make a lot of strategic sense, but they can turn into straightjackets if not written with enough flexibility to account for increasing health care costs and the unknowns of health care reform.
3. Medical practice acquisition is fraught with perils: Bigger is not necessarily better when it comes to health care business management. Conflicting work cultures and compensation and quality of care expectations can lead to disagreements, litigation or worse if contractual provisions aren’t spelled out adequately.
4. Health care regulation is in conflict: Federal health care reform is not the only wind sweeping the waters. There are numerous federal and state entities regulating health care and their missions and mandates are not in step with each other. Understanding the full lay of the land moving forward is a must.
5. Move with measured steps: There is so much going on in health care practice and regulation right now that the unknowns outnumber the knowns. Look at acquisition targets with more caution than ever before.
6. Be fully transparent: Both sides thought they had all the data they needed. But in the end, their failure to completely share with their data with their respective teams created unpleasant surprises. Being fully candid about all risks is the best strategy in this unsure environment.
The issues covered in this scenario were in part based on the impact of health care reform. This follow-up webinar focused on specific changes to the health care market in the wake of Affordable Care Act implementation and presented actions insureds can take to prepare themselves moving forward.
The Fury of Anais
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
Buddy Welch, an analyst with the National Hurricane Center at Florida International University in Miami, is finishing his second cup of coffee on the morning of August 22, 2017 as he monitors a tropical wave formation off of the western coast of Africa.
Buddy looks over to his colleague Jonathan Schell.
“Hey Jon, will you come look at this a second?”
“Sure, what is it?” Schell says before walking over to Buddy’s desk and looking over his shoulder.
“Look at that,” Welch says, pointing to the satellite images on his monitor.
“That’s a very strong wave,” Schell says, watching the evidence of the strong tropical wave moving off of the coast of Africa.
“Could be the strongest thing we’ve seen all summer,” echoes Buddy.
“By far,” the two scientists say at the same time.
“We’ve got very warm water in the Atlantic right now,” Jonathan adds.
He and Buddy continue to monitor the tropical wave for signs of strengthening and possible convection. Forecast models indicate that conditions are ripe for the wave to organize quickly into a tropical storm and thereafter, a hurricane.
The tropical wave does become a tropical storm, dubbed “Anais,” and bolstered by unusually warm ocean water, it intensifies as it moves across the tropical Atlantic toward the Caribbean and the United States.
On August 26, Anais is upgraded to a hurricane in the tropical Atlantic, east of the Eastern Caribbean.
As the hurricane moves through the Caribbean, past Hispaniola, the National Hurricane Center notifies residents and emergency managers up and down the Eastern Seaboard that Anais poses a very real and severe threat.
Several days later, on the 1st, Anais buffets the Bahamas with high winds. It spares the Bahamas a direct hit and instead veers north- northwest and, now classified as a Cat 4, with maximum sustained winds of 150 mph, takes dead aim at the coast of North Carolina.
Ray Bonner, risk manager for the City of Norfolk, Va. is one of those who takes heed.
Bonner immediately convenes Norfolk’s crisis management team, which is more sophisticated than many because it has a “business resilience” subcommittee that is dedicated to coordinating with municipal officials in the event of a natural catastrophe. The committee’s mandate is to help businesses open as soon as possible in the aftermath of a major storm.
“This hurricane could hit every coastal city from Wilmington, N.C. to Boston,” Bonner tells his assembled crisis management team.
“We can’t be sure that we’ll get much help from neighboring emergency responders if that’s the case,” he tells the committee.
On Labor Day, September 4, Anais strikes Wilmington, N.C. as a Cat 4. The storm cripples the Wilmington power grid and causes 13 deaths.
All Fall Down
Despite the damage done by Anais in Wilmington, Bonner and other members of Norfolk’s crisis management team are frustrated by what they see as a lack of sense of urgency in some quarters to evacuate as necessary and take proper precautions. Perhaps distractions due to end-of–summer Labor Day plans are partially to blame, they reason.
Well before the hurricane made landfall, Bonner and risk managers from other East Coast cities got on a conference call to discuss the storm’s potential impact and how each city might coordinate with the other to assist in recovery.
“This could end up being every bit as bad as Hurricane Sandy,” said Elizabeth Acres, the risk manager for Boston, Mass.
“Or worse,” said Jay Baker, the risk manager for New York City.
“You ever heard of the Norfolk/Long Island Hurricane of 1821?” Baker says.
“No,” says Acres and others simultaneously.
“I’ll send you the link,” he says. “Path of Anais looks very similar to the path of that 1821 hurricane.”
On September 5, Anais, still a Cat 4, hits Norfolk. Without losing strength, the hurricane continues north, striking Cape May, N.J., New York City and Connecticut in turn.
The storm is every bit as damaging as Hurricane Sandy was, and causes historical levels of wind and flood damage throughout the Washington, D.C. to Boston megalopolis.
Back in Norfolk, Bonner, along with the city’s emergency response coordinator Jim Christopher, is touring flooded sections of the city on September 7 in a zodiac that’s equipped as an emergency response boat.
They’re touring one of the city’s business districts, which is still inundated with three feet of water. The zodiac reaches the end of a block and Christopher eases off on the throttle.
The two men stare at the devastation in the deserted business district in silence. They can see dresses and hats floating, half-submerged in the gray flood waters, through one of the few intact store windows.
“I don’t see when these businesses can re-open,” Bonner says.
“I don’t see when we even get into these shops to have a look at them,” Christopher says.
On September 12, Bonner again gets on a conference call with his fellow risk managers from cities in the Northeast. Accompanying them on the call is Ray Harbridge, a Northeast Regional Director for the Federal Emergency Management Agency.
Boston’s Elizabeth Acres leads the dialogue with Harbridge.
“Ray, can you update us on the timeline for any funding assistance we might get from Washington?” Acres says for openers.
“We have no answers in that area Liz,” Harbridge says.
“We’re dealing with an unprecedented level of damage to the six largest cities in the East,” Harbridge said.
“First impressions are that we have millions of people affected,” he said.
“And that’s not even getting into the business impact,” Bonner said.
“That’s correct,” Harbridge said.
“We’ve got to concentrate on housing and medical care for those most vulnerable and those displaced,” he said.
“I know you’ve got plenty of worries on your end, but you’re going to have to rely on your own resources for the foreseeable future. I really don’t know when we see a way clear of all this,” he said.
“Let’s face facts folks,” New York’s Jay Baker said after Harbridge, extremely pressed for time, hung up.
“We still haven’t received federal reimbursement for Hurricane Sandy damage and expenses in some cases, and we’re five years out from that.”
“We’re going to be at this a long time,” Boston’s Acre said.
“You can take that five years from Sandy and double it,” Baker said.
Ever since he heard the first indication from the National Hurricane Center that Anais should be watched, back in late August, Ray Bonner’s mind had been turning on something.
When Hurricane Sandy struck New Jersey and flooded Lower Manhattan in 2012, it caused a permanent shift in Bonner’s thinking.
Before Sandy, the idea that a major hurricane would come near enough to cause substantial damage in New York was thought to be a “Black Swan” event, something with an extremely low possibility, albeit having potentially devastating consequences.
After Sandy, Bonner began to think about ways to mitigate the costs of a major hurricane strike. He’d begun discussions with the City’s budget director and its finance committee on the possible purchase of layers of reinsurance that could help the city defray not only the costs associated with hurricane clean-up and repair, but the lost property tax and business income tax revenue should the region’s homes and businesses take a big hit.
Presentations Bonner made on the Norfolk/Long Island Hurricane of 1821 to city finance officials left them unmoved, though. It wasn’t that city leaders were callous to Bonner’s concerns. But pressing matters like negotiations with unionized police and firefighters took up most of their attention.
Norfolk’s finances were basically sound. Bonner’s attempts to sway city leaders to a different way beyond floating bonds and raising taxes on the back end in the event of a catastrophe just couldn’t gain any traction. City officials felt that they had things under control and didn’t want to start piling on new expenses like insurance premiums.
Six months after Anais struck, analysts released data that showed the storm caused $40 billion in wind damage and $70 billion in storm surge damage to cities and towns from Wilmington, N.C. to Boston.
What Bonner considered a real threat after Sandy struck turned out to be true after Anais. Norfolk city finances, which had previously been solid, began to deteriorate.
Twenty percent of the Norfolk/Virginia Beach region’s housing stock was rendered uninhabitable by Anais. Reductions in property tax revenue, coupled with business tax revenue reductions, were creating budget deficits in Norfolk and in every other city that was hit by Anais.
That public sector pain was being repeated in the private sector. Loss of mortgage interest and principle payments, a lynchpin of the banking system, led to the failures of dozens of regional banks and severe limitations on the revenue of the larger banks.
In 2021, four years after Anais hit, the Rand Corporation released a study, titled “The Anais Effect” which estimated that the economic damage from Anais restricted growth in the Northeast by seven percent from 2017 to 2021.
Rand Corp. researchers estimated that by 2027, 10 years after the storm, an “Anais Recession” — the first ever regional economic recession connected to a natural catastrophe — would limit growth on an annual basis in the Northeast by five percent.
Risk & Insurance® partnered with Swiss Re Corporate Solutions to produce this scenario. Below are Swiss Re Corporate Solutions’ recommendations on urban and corporate resilience, and a reminder about the company’s global expertise in the areas of Nat Cat modeling and disaster preparedness. This perspective is not an editorial opinion of Risk & Insurance®.
The 1821 hurricane struck the mid-Atlantic and Northeast United States at a time in history when human population and concentration of value were dramatically lower than present day. In fact, only 136,000 people lived in Washington and New York at the time. If a major catastrophic event like the 1821 Norfolk Long Island Hurricane was to happen today, it would cause 50% more damage than Sandy and potentially cause more than $100 billion in property losses stemming from wind damage and flooding from storm surge.
That’s just one part of the story, however. Taking into consideration lost tax revenue due to destroyed homes and business, lower real estate values and other economic considerations, the broader economic impact would grow to over $150 billion. That’s well above the aggregate losses of all storms which recently impacted the Eastern United States, including Hurricane Sandy.
With an eye toward a future event that could dwarf Sandy in terms of insured and economic losses, Swiss Re has published a new report that analyzes the 1821 hurricane and how a repeat event would impact the region today. Download the report at: http://media.swissre.com/documents/the_big_one_us_hurricane_web2.pdf
To prepare for such a future event, large scale urban resilience must be at the forefront of the risk management community. Of course, protecting lives should be the highest priority for city authorities seeking to improve their disaster preparedness. Beyond that, municipalities and businesses – large and small – must work together to ensure critical infrastructure and supply chain redundancy. This can be accomplished, in part, by more fully understanding the geographic hazards via advanced modeling techniques using Swiss Re’s CatNet® tool.
CatNet® – Advanced Modeling
Combining satellite imagery with Google MapsTM and Swiss Re’s proprietary historical data, CatNet® allows risk management professionals to analyze worldwide natural hazard exposures. CatNet® features:
- Natural hazard atlas
- Country-specific insurance data
- Disaster statistics
This allows risk managers to prepare local, regional and cross-regional risk profiles to assist management in disaster preparedness. The result is a more informed viewpoint about a company’s or city’s insurance considerations and potential enterprise risk management gaps. An organization’s disaster preparedness can be further enhanced by partnering with local authorities, businesses and municipal leaders to ensure community-wide resilience.
Contractors Face Complex Insurance Scenario
With today’s expanding global marketplace, U.S.-based construction companies naturally seek growth opportunities in foreign countries. For instance, China has been on a decades-long building spree. Middle Eastern nations continue to invest in massive developments. Cross-border construction activity among developed countries, particularly in Europe and Japan, remains robust.
That’s the good news for U.S. contractors considering or already involved in global projects. On the flip side, it’s critical to realize that international opportunities present different challenges than domestic projects.
Construction services represent a significant portion of global trade. World exports of construction rose 2% (to $115 billion) in 2012, the World Trade Organization estimates. The European Union and Asia represent the major share of that trade. Yet, while international trade in construction is on the rise, every country retains its own laws regarding insurance, so building a multinational insurance program represents a significant challenge.
ACE’s recently published whitepaper, “Global Construction: International Opportunities, Local Risks” focuses on educating risk managers about the complexities of going global.
Key issues for contractors to consider include:
Legally speaking, compliance for U.S. contractors operating outside the U.S. is much more complex than for their domestic operations. For example, by operating in different countries, multinational contractors must adhere to a myriad of local national laws and regulations regarding the “duty of care” they owe to the general public and other third parties. While most of the developed world has established employer duty-of-care legislation, the majority of the countries where many of these new global projects are available have not. A contractor’s insurance program should be flexible enough to handle claims in several different jurisdictions and provide adequate coverage for awards granted in emerging, as well as developed, legal jurisdictions.
Continuity of coverage across borders
For projects in foreign countries, a proactive risk management strategy should not only address the wide range of exposures typical in a given construction project, but also the impact that the differing local laws and regulations may have on the insurance coverage. For example, a contractor may have to obtain local insurance policies for various lines of business to cover the risks associated with its operations and to be compliant with local insurance requirements.
Building multinational solutions
A multinational program using “non-admitted” coverage can be a cost-effective alternative to local coverage. Such non- admitted coverage is usually arranged in the parent company’s home country to insure exposures in other countries. Some countries, however, don’t allow non-admitted coverage, while others may allow it subject to conditions such as prior approval. In the past the threshold question was whether non-admitted insurance could be used, but today companies should also consider potential changes in enforcement practices as well as evolving regulations.
Local services can be crucial
Besides compliance issues, companies should address issues such as how local claims will be handled and paid, and which other local services they may need in the event of a claim or incident. For example, companies building projects in the European Union may want to purchase environmental coverage that responds to the demands of the European Environmental Liability Directive in order to provide proper insurance protection for potential liability associated with damage to the environment or natural resources. On a broader level, catastrophe planning should be part of a global risk management strategy.
Public/private partnerships may bring new risks
Another consideration for contractors revolves around project structure. Typically in the U.S., construction projects have been driven either by the owners or the contractors and the insurance coverage reflected that through an owner- or contractor-controlled insurance program (OCIP/CCIP). Today, while more U.S. projects are being structured as public-private partnerships, because the structure is more common in Europe, U.S. contractors considering projects abroad may encounter it for the first time. Public-private partnerships raise questions about how risks and liabilities are apportioned among the parties, so contractors may find themselves sharing responsibility for risks that are not typically part of a standard project, or have increased exposures for professional liability.
M&As can impact insurance programs
With the growth of the global construction economy, and the rising need for the development or improvement of infrastructure in emerging economies, an increasingly multinational approach has led to consolidation and merger-and-acquisition activity in the construction marketplace. As this trend continues, companies also need to consolidate their insurance programs to achieve better efficiency by individual lines of business and to meet insurance requirements in different countries.
The takeaway: local risks, global solution
For contractors working in more than one country, maintaining consistent insurance coverage across borders while controlling costs clearly presents a number of challenges. By using a controlled master policy and admitted insurance from local carriers, contractors potentially gain greater insight into their claims trends and an increased ability to identify locations experiencing significant losses. With this information, contractors also will be in a better position to take corrective action and reduce losses.
Finally, while varying insurance regulations and markets must be addressed, contractors should evaluate the insurance carrier, its experience and presence in foreign markets and its relationships with local insurers around the world. When it comes to international construction projects, the right insurance coverage will play a crucial role in long-term success.
To learn more about how to manage global contracting risks, read the ACE whitepaper: “Global Construction: International Opportunities, Local Risks.”
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with ACE Group. The editorial staff of Risk & Insurance had no role in its preparation.