1999 CAS SEMINAR ON HEALTH AND MANAGED CARE Health Care Provider Excess Insurance

1. This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation • In Slide Show, click on the right mouse button • Select “Meeting Minder” • Select the “Action Items” tab • Type in action items as they come up • Click OK to dismiss this box • This will automatically create an Action Item slide at the end of your presentation with your points entered. 1999 CAS SEMINAR ON HEALTH AND MANAGED CAREHealth Care Provider Excess Insurance Prepared By: Milliman & Robertson, Inc. Arthur L. Wilmes, FSA, MAAA

2. Prospective Trends in Healthcare • Healthcare Providers Need to Consider Strategies That Increase Efficiency • Forces in the Healthcare Market Will Make It Very Difficult for Status Quo Providers to Compete Effectively • Healthcare Providers Will Need to Develop Their Patient Management Processes as if They Are Being Paid Under Capitation

3. Health Care Delivery Systems • Independent Practice Associations (IPAs) • Physician Practice Management Companies (PPMCs) • Group Practice Without Walls • Medical Group Practice • Physician Hospital Organizations (PHOs) • Medical Service Organization (MSOs) • Foundation Model

4. Independent Practice Associations • Umbrella Contracting Entity for Multi-Specialty or Single Specialty Physicians • Individual Physicians Reimbursed by the IPA • Composed of Independent Physicians With Only Central Contracting Being Common • Not Necessarily a Lean Mean Fighting Machine • Some States will Regulate Like MCOs

5. Physician Practice Management Companies • Tend to Be Venture Capitalized Public Companies • Last Two Years Have Not Been Kind to PPMCs • Continue to Be a Force in Healthcare Market • Approximately 27 Publicly Traded PPMCs • Combined Equity Value Declined 49.3% During 1998 • Several High Profile Collapses

6. PPMCs Have Experienced Some Recent Equity Improvement • At the End of 1998, the Aggregate Stock Value of PPMCs is Up 12.8% Over the Last Six Months of 1998. • S&P Rose 7.5% During the Same Period. • Total Capitalization of PPMCs was Estimated at Approximately $4.8 Billion. • Some of the Largest PPMCs Continue to Have Difficulties. • Medpartners • FPA Medical Management

7. Group Practice Without Walls • Independent Physicians That Aggregate Their Practices Into a Single Legal Entity • Legal Merging of All Assets of the Individual Physicians • Individual Physician Incomes are Affected by the Performance of the GPWW as a Whole • Independent Nature of Practices Within GPWW Means Independent Action • Difficult to Align Incentives • Weak Capitalization

8. Medical Group Practice Model • Like the GPWW, but Physicians Become a Fully Integrated Medical Group • No Multi-Site Independent Practice Groups • Tends to be More Integrated Than a GPWW • Be Wary of Top Heavy Groups

9. Physician Hospital Organizations • Joint Hospital and Physician Entity That is Primarily a Negotiating Vehicle • Integration Tends to Be Weak • Trial Courtship Before a Serious Relationship • Open vs. Closed PHOs • MCOs tend to View PHOs as Ugly Cousins

10. Medical Service Organizations • Service Bureau and Contracting Entity for Physicians • Physicians Remain in Independent Practice • MSO may purchase all or Some of the Physician’s Assets • Also Viewed as an Ugly Cousin by MCOs • Purpose Tends to Be Centralized Common Services

11. Foundation Model • Generally Created as a Not-For-Profit Organization Which Purchases Physician’s Practices • Must Provide a Substantial Community Value/Benefit • Not Generally Formed With an Eye Towards Planned Resources • Loose Control Over Physician Behavior

12. Physician Compensation • Fee-For-Service • Capitation • Withholds and Risk/Bonus Provisions • Carve-Outs • PCP vs. Specialist vs. Hospital • Individual vs. Pooled Risk • Affecting Physician Behavior • Product

13. Reimbursement is Key Underwriting Factor • Usual and Customary Fees • FFS and Discounts • Relative Value Schedules (RVS) • Capitation • Diagnosis-Related Groups (DRGs) • Per Diems (With and Without Outliers) • Case Rates • Ambulatory Patient Groups (APGs)

14. Example of Effect of Reimbursement on CPDs • Prudential • The Travelers • NYL Care

15. Example of Effect of Reimbursement on CPDs • Prudential • The Travelers • NYL Care

16. Case Study - Scope of Engagement • Feasibility of Offering Stop-Loss Coverage to PCPs for Institutional Services • 12 PCP Care Councils (Practice Groups) • $100,000 Excess Maintained by MGA • Care Councils Going to Full Risk, Want Lower Excess Limits

17. Historic Costs and Variability

18. Developing a Claims Probability Distribution • Combined Individual Distributions of Historic Claims • Trended Historic Costs by Assumed Incurred Trend • Assumed a Piece-Wise Lognormal Distribution Developed by Minimum Distance Method

19. Empirical vs. Lognormal Distribution

20. Effect of Age and Gender

21. Effect of Group Size and Confidence Intervals

22. Putting it All Together