Multihospital Group Owned Captive: Optimizing the Captive and Services in the New Landscape of Healthcare Reform in the

1. Multihospital Group Owned Captive: Optimizing the Captive and Services in the New Landscape of Healthcare Reform in the USA Cayman Captive Forum December 4, 2013

2. Panel

3. Cone HealthGreesboro, NC Tim Rice President and CEO

4. Cone Health • NFP Healthcare System: Serves a 5 county region in central North Carolina, covering approximately 1,000,000 lives • 6 Acute Care Hospitals, Behavioral Health Hospital, Regional Cancer Center • 1273 beds • 1176 physicians; 2799 RNs • 100 locations including 3 urgent care and 71 physician practices • Net Patient Revenue: $1.4 billion (FY2013) • Became an Accountable Care Organization- Triad Healthcare Network – July 2013: 700 healthcare providers, covers 40,000 lives and 30,000 more in Medicare Advantage

5. Tallahassee Memorial HealthCareTallahassee, FL Mark O’Bryant President and CEO

6. Tallahassee Memorial HealthCare • NFP Healthcare System: Serving 17 counties in North Florida and South Georgia • 772 bed Acute Care Hospital; Behavioral Health Hospital, Rehabilitation Hospital, Regional Cancer Center • 570+ physicians; 1200+ RNs • Region’s only state designated Trauma Center; Region’s first Freestanding Emergency Center • Net Patient Revenue: $480,815,000 (FY2012) • Expanding residency programs and research with Florida State University College of Medicine

7. Health Care Casualty Insurance LimitedandHealth Care Casualty RRG, Inc. Providing Financial Protection and Enhanced Patient Safety For Member Healthcare Systems

8. Introduction • In 2002, a group of healthcare providers determined that it was strategically advantageous for them to take control of their medical malpractice insurance • The IOM report on medical error was fresh and activity to enhance patient safety was accelerating • The insurance marketplace was expensive … and services were minimal • Moving from purchasinginsurance to using an insurance vehicle in concert with quality and safety efforts became important

9. Fast Forward to 2013 • Two companies have been formed … both owned by the Healthcare organizations • A group owned captive insurance company for the hospital excess coverage: Health Care Casualty Insurance Limited (HCCI) • A group owned RRG for the physician coverage, and hospital excess coverage: Health Care Casualty RRG, Inc. (HCCR) • The Owners (Members) • Health First, Inc., Rockledge, FL • Cone Health, Greensboro, NC • Tallahassee Memorial HealthCare, Tallahassee, FL • Unity Health System, Rochester, NY

10. How do the programs work? Hospital Program • Captive Insurance Company domiciled in the Cayman Islands • Provides a $20 Million excess layer of insurance • Special coverages are endorsed onto the policy • Each Member retains a minimum of $1Million in a self-insured layer • Policy is written as claims made coverage for professional liability, and occurrence coverage for general liability • Reimbursement policy … claims control remains with the Member, supported by Clarity resources • Reinsurance in place

11. How do the programs work? Physician and Physician Extender Program • Risk Retention Group domiciled in Washington, D.C. • Insures Employed, Contracted and Voluntary Medical Staff • Full underwriting, policyholder services and first dollar claims management are done by Clarity, the Company’s Operations Manager • Reinsurance in place

12. National RQS Advisory Committee • Comprised of physician leadership, nursing and risk/quality/safety professionals from the Member organizations • Focus the RQS services agenda • Drive the education agenda • Support RQS initiatives within their organizations Helps assure RQS coordination among the Members’ healthcare systems and staff

13. Services Enjoyed by the Members • Risk – Quality – Safety Management • Tailored on-site consultation • Educational programming- webinars, in-person • Continuous access to professional consultants • Shared data • Current focus on RQS in Ambulatory Settings – Coordination with the hospital • External Peer Review Program • System – wide Data and Event Management • Web-based data collection system that penetrates all aspects of the organization … enables immediate consultation on events and in-depth knowledge to get to action quickly – All Members use this product system-wide

14. Services Enjoyed by the Members • Claims Advisory and Management Services • Continuous access to professional consultants for best practices and consultation on difficult cases and full cooperation with on-site Risk Managers • First dollar claims management of physician cases • Web-based state-of-the-art claims management system • Annual Audit to review claims managed within the Member’s self insured retention • Quality and Safety Support and Data Protection under the Patient Safety and Quality Improvement Act • Patient Safety Organization – All Members participate in Clarity PSO, A Division of Clarity Group, Inc.

15. Services Enjoyed by the Members • Insurance Products that respond to the changing landscape of healthcare delivery … particularly with the advancement of the Affordable Care Act and ACO formations • Flexible coverage options • Ability to add service structures, for – profit entities and joint ventures • Flexible physician coverage options and insurance structure options • Useful for recruiting / acquisition of physician groups … no need to purchase tail from prior carrier • Useful for employed physician groups • Focus on coordination with hospital RQS programs • Cyberliability protection: Hospital network and physicians … including participation in HIEs

16. Questions to the Panel • What have been the most significant changes to your organization in the last 5 years? • How has your ownership and participation in HCCI and HCCR supported the changes you made? • What impact does your ownership and participation in HCCI and HCCR have on how risk-quality and safety are managed in your organization? • How would describe the overall benefits to your organization of your ownership and participation in these group owned captive facilities?

17. In Summary… • Benefits of the programs go beyond insurance coverage … • Leadership …like minded organizations and leaders who focus on quality and community benefit • Openness …ability to share issues and learn from each other • Controlled cost… reduced costs for hospital liability insurance each year since inception • Physician alignment … physician insurance program has been a vehicle for both employed and non-employed physicians • Resource support … RQS, Claims, and PSO services have worked in concert with internal resources and are now being financed by the insurance companies

18. Why is this a good strategy for the future? • Healthcare reform is creating new reimbursement structures and integrating resources… • Hospital – physician alignment is essential … medical malpractice insurance is a good tool to help seal the alignment • Clinical integration requires incentives to do the right thing … working through the services in both the hospital and physician insurance companies can support this process • As organizations get more extensive services to manage the population’s health … issues of consistency and evidenced based care across the organization will arise … the web-based event management system, the insurance products and the Patient Safety Organization are vehicles to help control cost and quality Control and coordination of practices … leads to control of resources and management of potential medical error

19. Multihospital Group Owned Captive: Optimizing the Captive and Services in the New Landscape of Healthcare Reform in the USA Cayman Captive Forum December 4, 2013