3 New Unintended Consequences of Health Care Reform
As the Affordable Care Act (ACA) continues its gradual and bumpy rollout, health care providers are utilizing various strategies to comply and adapt. Many of these approaches, some of which include M&A activity, IT upgrades and shared service agreements are now creating new risks of their own.
1. Continuity of Care
Many aspects of the ACA and other healthcare trends are driving M&A or shared service agreements among hospitals, physicians and other providers. These new relationships can present serious challenges for managing a patient’s treatment across different organizations.
“There’s a risk that one organization might not provide care consistent with the other,” said Dan Nash, national healthcare practice leader, Zurich in North America. “Oftentimes, it’s not contractually required for them to do so.”
Patients being transferred from system to system might be exposed to different approaches to care and different levels of treatment.
Care managers can do a lot to help alleviate risks associated with continuity of care. Having a “concierge” that knows how each system operates can make transitions much easier for patients and explain why treatments differ from system to system.
“There’s a risk that one organization will not provide care consistent with the standards of the other. Oftentimes, it’s not contractually required for them to do so.”
– Dan Nash, National Healthcare Practice Leader, Zurich North America
“It creates a feeling that they’re working together,” said Dan Nash, national healthcare practice leader, Zurich in North America. “If you have a care manager through the process, it can give the patient a level of comfort that takes away anxiousness,” said Nash. “Then they feel like they’re being taken care of.”
Between the Health Insurance Portability and Accountability Act, the U.S. Department of Health and Human Services and a long list of other government organizations and mandates, there are serious demands on health systems.
“Real estate may be all about location, location, location but healthcare is all about compliance, compliance, compliance,” said Nash.
A lot of risk managers are focused on digital-related exposures, but a significant amount of serious data breaches are still the result of “paper losses.”
“One example happened on a subway in 2009 when a hospital worker left records for 192 patients on a train,” said Nash about an incident involving a mid-Atlantic hospital “It led to the hospital paying $1 million to the government in 2011 to settle the potential HIPAA violations.”
Despite the risks, health care providers are still reluctant to buy coverage around it.
“People used to look at banks with an eye toward their brick-and-mortar locations. ‘My money is safe because it’s housed within those walls,’ they’d think. While that thinking is antiquated when dealing with finances, it still rings true in the health care world,” said Nash.
“Often customers we talk to say it’s important, but not in budget this year,” said Nash. Furthermore, their IT departments seem to think they’ve got the problem figured out on the digital side and companies generally don’t pay enough attention to the possibility of paper losses.
To help combat the risk, Zurich offers to qualified customers a Breach Coach consulting service, during which an experienced cyber breach risk engineering consultant can assess where businesses are most vulnerable to a data loss.
3. Outpatient Treatment
Currently, 60% of hospital services are delivered inpatient with 40% of care delivered through outpatient facilities. Under the Affordable Care Act, the proportion will likely be reversed, so that 60% of care is delivered through outpatient facilities.
“It’s risky because patients generally see hospitals as places where they are safer in the event of an adverse reaction,” said Nash. “They might not have that same sense of security with an outpatient facility.
Nash compared that notion to the way many Americans thought about banks 20 or 30 years ago.
“People used to look at banks with an eye toward their brick-and-mortar locations. ‘My money is safe because it’s housed within those walls,’ they’d think. While that thinking is antiquated when dealing with finances, it still rings true in the health care world,” said Nash. “People feel safer and think they’re getting better care if they’re in a large hospital. At an outpatient facility, that comfort level isn’t the same.”
Another risk of having more outpatient procedures is that the health care provider has less time for observing patients. With patients going home after their procedure, it becomes even more important for the patient to carefully follow instructions: like taking medicine at scheduled times and doing proper rehab. Any health care provider can tell you that’s never guaranteed. But even if they don’t follow the care instructions, the hospital is still responsible.
This article was produced by Zurich and not the Risk & Insurance® editorial team.
Note: This content is provided for informational purposes only. Please consult with qualified legal counsel to address your particular circumstances and needs. Neither Risk & Insurance® nor Zurich are providing legal advice and assume no liability concerning the information set forth above.
Coping with Cancellations
Airlines typically can offset revenue losses for cancellations due to bad weather either by saving on fuel and salary costs or rerouting passengers on other flights, but this year’s revenue losses from the worst winter storm season in years might be too much for traditional measures.
At least one broker said the time may be right for airlines to consider crafting custom insurance programs to account for such devastating seasons.
For a good part of the country, including many parts of the Southeast, snow and ice storms have wreaked havoc on flight cancellations, with a mid-February storm being the worst of all. On Feb. 13, a snowstorm from Virginia to Maine caused airlines to scrub 7,561 U.S. flights, more than the 7,400 cancelled flights due to Hurricane Sandy, according to MasFlight, industry data tracker based in Bethesda, Md.
Roughly 100,000 flights have been canceled since Dec. 1, MasFlight said.
Just United, alone, the world’s second-largest airline, reported that it had cancelled 22,500 flights in January and February, 2014, according to Bloomberg. The airline’s completed regional flights was 87.1 percent, which was “an extraordinarily low level,” and almost 9 percentage points below its mainline operations, it reported.
And another potentially heavy snowfall was forecast for last weekend, from California to New England.
The sheer amount of cancellations this winter are likely straining airlines’ bottom lines, said Katie Connell, a spokeswoman for Airlines for America, a trade group for major U.S. airline companies.
“The airline industry’s fixed costs are high, therefore the majority of operating costs will still be incurred by airlines, even for canceled flights,” Connell wrote in an email. “If a flight is canceled due to weather, the only significant cost that the airline avoids is fuel; otherwise, it must still pay ownership costs for aircraft and ground equipment, maintenance costs and overhead and most crew costs. Extended storms and other sources of irregular operations are clear reminders of the industry’s operational and financial vulnerability to factors outside its control.”
Bob Mann, an independent airline analyst and consultant who is principal of R.W. Mann & Co. Inc. in Port Washington, N.Y., said that two-thirds of costs — fuel and labor — are short-term variable costs, but that fixed charges are “unfortunately incurred.” Airlines just typically absorb those costs.
“I am not aware of any airline that has considered taking out business interruption insurance for weather-related disruptions; it is simply a part of the business,” Mann said.
Chuck Cederroth, managing director at Aon Risk Solutions’ aviation practice, said carriers would probably not want to insure airlines against cancellations because airlines have control over whether a flight will be canceled, particularly if they don’t want to risk being fined up to $27,500 for each passenger by the Federal Aviation Administration when passengers are stuck on a tarmac for hours.
“How could an insurance product work when the insured is the one who controls the trigger?” Cederroth asked. “I think it would be a product that insurance companies would probably have a hard time providing.”
But Brad Meinhardt, U.S. aviation practice leader, for Arthur J. Gallagher & Co., said now may be the best time for airlines — and insurance carriers — to think about crafting a specialized insurance program to cover fluke years like this one.
“I would be stunned if this subject hasn’t made its way up into the C-suites of major and mid-sized airlines,” Meinhardt said. “When these events happen, people tend to look over their shoulder and ask if there is a solution for such events.”
Airlines often hedge losses from unknown variables such as varying fuel costs or interest rate fluctuations using derivatives, but those tools may not be enough for severe winters such as this year’s, he said. While products like business interruption insurance may not be used for airlines, they could look at weather-related insurance products that have very specific triggers.
For example, airlines could designate a period of time for such a “tough winter policy,” say from the period of November to March, in which they can manage cancellations due to 10 days of heavy snowfall, Meinhardt said. That amount could be designated their retention in such a policy, and anything in excess of the designated snowfall days could be a defined benefit that a carrier could pay if the policy is triggered. Possibly, the trigger would be inches of snowfall. “Custom solutions are the idea,” he said.
“Airlines are not likely buying any of these types of products now, but I think there’s probably some thinking along those lines right now as many might have to take losses as write-downs on their quarterly earnings and hope this doesn’t happen again,” he said. “There probably needs to be one airline making a trailblazing action on an insurance or derivative product — something that gets people talking about how to hedge against those losses in the future.”
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.