AON Health Care Report

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2012 U.S. Industry ReportHealth Care

Aon Risk Solutions


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2012 Health Care Report Aon Risk Solutions 1

Table o Contents

Foreword 2Executive Summary 3

Risk Insights 5Top 10 Risks 5

Risk Preparedness or the Top 10 Risks 6

Loss o Income Associated With Top 10 Risks 7

Ident i icat ion and Assessment o Major Risks 8

External Drivers Strengthening Risk Management

(past two years) 9

Claim Frequency and Severity 9

Emerging Risks 11

Client Insights 14Priorities in Choice o Insurer 14

Desired Property and Casualty Market Changes 15

Risk Management Department 16

Market Insights 17Medical Proessional Liability 17

Managed Care Errors and Omissions 18

Managed Care HMO Reinsurance, Excess-o-Loss and Provider

Excess 19

Workers Compensation 21

Directors and O icers Liability 21Property 23

Use o Captives 24Demographics 24

Coverages Insured by Captive 25

Financial Perormance 26

Methodology, Notes and Discla imers 27

Aon at a Glance 28

Key Contacts 29


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ForewordAon is pleased to present you the ndings o our 2012 Health Care Industry Report.

The health care sector continues to ace many risks and challenges, which aect the way

companies view and prioritize their resources in response to risk.

Even though it is not known at this point to what degree the health care reorm will impact

the traditional lines o property and casualty coverage, we can be certain there will be an

impact on medical proessional liability, as hospital providers employ more physicians, and

ACOs assume some o the nancial risk o providing care. Consequently reorm may also

have an eect on vicarious liability and antitrust exposures. When more physicians are

employed, we anticipate the underwriting o those physicians to be more rigorous, including

not only the traditional criteria o specialty and losses but also non-traditional underwriting

criteria such as inection rates, readmission rates and other quality indicators. At this point we

also believe that reorm will aect some o the traditional coverage lines such as D&O and

workers compensation.

In additional we would also like to highlight a ew key ndings and observations to guide you

through an array o interesting risk management acts and gures within the report.

When you look at the top 10 risks as a whole, there is an undeniable interdependence

among many o these risks. It is more important than ever or organizations to embrace an

enterprise-wide approach to managing risk, and optimize their strategies on a holistic basis.

Regulatory/legislative changes remain the top risk or the health care sector as

respondents are concerned over the broader implications and impacts o the new

health care reorm laws and legislation.

Increasing competition is ranked as the second top risk. Considering the tremendous

amount o mergers and acquisitions taking place in the health care industry, we expect

this will remain to be a high priority or health care organizations.

The nations slow economic recovery continues to weigh heavily on the minds o

survey respondents who have ranked economic slowdown as the third top risk.

The next on the list is ailure to attract or retain top talent. As baby boomers start to retire

in the next three to ve years, the ederal government is predicting that by 2020, there will

be a shortage o nearly 24,000 doctors and close to one million nurses in the U.S. In addition

to potential sta shortages, the health care industry must also contend with training and

deployment ineciencies, which could lead to declining health care quality and accessibility.

History provides only a partial understanding o risk or the uture. To eectively manage risks,

organizations must assess the likelihood and potential impact o all viable risk events in order to

be prepared or the next challenges while maximizing uture growth opportunities.

I you have any comments or questions about the survey, or wish to discuss the ndings

urther, please contact your Aon account executive.

Best regards,

Ron Calhoun Dominic Colaizzo

Managing Director Chairman

Aon Risk Solutions Aon Risk Solutions

Health Care Practice Health Care Practice


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Executive SummaryOrganizational sustainability in the health care industry demands

proactive understanding and management o risk In the current andstill evolving economic, legal and regulatory landscape, health care

companies risk proles can change quickly Recent challenges such as

health care reorm laws and legislation, as well as actual and potential

pandemics, killer tornadoes and unprecedented ooding remind us that

threats to organizations come rom all directions and in many dierent

orms The ability to manage these risks is key to survival and success

Staying ully inormed and up-to-date with the latest trends around risk

is the best way to remain competitive and relevant in the evolving global

market We provide this report to clients or this very reason to help

you understand the emerging issues and to learn what your peers and

competitors are doing to manage risks, overcome challenges and capture

opportunities

The report is comprised o our main components:

Risk insights include top 10 risks aced, reported readiness, loss o income related to risks, how

organizations are identiying and assessing risks, external drivers aecting risk management, claim

requency and severity and emerging risks.

Client insights include priorities in choice o insurer, desired market changes and risk management

departments.

Market insights include discussions o coverage terms and conditions, retentions, limits and

premium rates or the major property and casualty lines o coverage purchased by health care

providers.

Use o captives include coverages insured by captive and nancial perormance, expense ratios, and

premium-to-surplus ratios.


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Key Findings

Risk Insights Greatest risks At a time when the countrys health

care reorm laws are being implemented and continue

to dominate political debates, it is no surprise that

respondents to Aons 2011 Global Risk Management

Survey indicate regulatory/legislative changes as the top

risk or the health care sector.

Risk preparedness or the top 10 risks Health care

respondents report the lowest levels o preparedness

or two o the most complex and dicult to control risks

economic slowdown (64 percent state they are not

prepared) and political risks/uncertainties (57 percent).

Loss o income associated with top risks For the health

care industry, economic slowdown tops the list o risks withthe most income loss in the past 12 months, at 77 percent.

Identication and assessment o major risks

Respondents have cited senior managements intuition

and experience as the primary method used to identiy

and assess major risks acing their organization. In

practice, organizations typically utilize a combination o

risk registers, a structured enterprise-wide approach and

senior managements intuition.

External drivers strengthening risk management

Increased scrutiny rom regulators and economic volatility

remain the most important external drivers strengthening

risk management or the health care sector.

Claim requency and severity Aons 2011 Hospital

Proessional Liability and Physician Liability Benchmark

Analysis shows that the requency o medical proessional

liability has stabilized, growing at a 1 percent annual rate,

while severity continues to grow at a constant infationary

trend.

Emerging risks The health care sector aces many

unknowns, most o which stem rom the global economic

uncertainties as well as health care reorms. We nd

that health care organizations are coping with these

challenges in a range o ways. One prominent trend is theemployment o more physicians.

Client Insights Priorities in choice o insurer Health care respondents

rank value or money/price as the most important

standard in selecting an insurer, ollowed by nancialstability/rating and claims service. These are the same

two top priorities stated by health care providers in 2009,

when nancial responsibility was rated number one and

value or money/price number two.

Desired market changes Surveyed health care

organizations are looking or increased ability to recognize

internal risk management through lower premiums and

broader coverage/better terms and conditions.

Risk management department Seventy-our percent

o health care respondents indicate that they have a

ormal risk management department. Among those, 29

percent say their risk management department reportsto the CFO/Finance and 29 percent report to the General

Counsel. In the case where no ormal risk management

department exists, 43 percent say their CFO handles risk

management.

Market Insights Market conditions In 2011 most o the major lines

o coverage or the health care sector experienced no

market changes, except or property premiums which

began to see an upward trend in the second hal o the

year. In 2012, we expect to see fat to increasing rates. For

medical proessional liability, we anticipate a continuationo the current stable market, with some rate reductions.

Retentions, deductibles, limits and coverage terms and

conditions should remain airly stable.

Use o Captives Coverages insured by captive While medical

proessional liability continues to be the major line o

coverage or a health care captive, Aons 2011 Health

Care Captive Benchmark Study shows that captives are

assuming a range o new exposures, such as employed

physicians, auto liability, workers compensation, medical

stop loss and directors and ocers liability.


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Risk Insights

General Introduction

In todays global environment, health care organizations are acing increasingly complex challenges

extensive regulatory oversight and the increasing cost o compliance, rising litigation, and technology

ailures that could potentially disrupt businesses. The stakes or organizations are high. It has never

been more critical or businesses to access accurate and the most up-to-date inormation and

proactively address business risks at every level o the organization. Within this section o the report

we provide industry-specic insight into:

Top 10 Risks

Risk Preparedness or Top 10 Risks

Losses o Income Associated with Top 10 Risks

Identication and Assessment o Major Risks

External Drivers Strengthening Risk Management

Claim Frequency and Severity

Emerging Risks

Top 10 RisksRespondents are provided a list o 49 risks and asked to select 10 that they believe to be the top risks acing their

organizations. Given the controversy surrounding the current debate on health care reorms, it is not surprising that

surveyed companies have chosen regulatory/legislative changes as the top risk category or the health care sector.

Ranked second on the list is increased competition, which continues to be a key concern or the health care sector,

particularly in local markets and markets with low barr iers to entry. The industry is going through a signicant number o

mergers and acquisitions. Hospitals and health care systems are merging and expanding their physician workorce by either

hiring on an individual basis or acquiring physician practices. In addition, there are increased eorts among health care

organizations to align more closely with physicians and physician practices through insurance programs, electronic health

record systems and management service organizations.

The economic slowdown remains a key concern or health care organizations, most likely ueled by uncertainties in theglobal economy and the potential or urther deterioration. At the same time, organizations have to grapple with the rising

cost associated with capital, reduced levels o reimbursements, accessing and hiring adequate proessional sta and a range

o technology upgrades, as well as meeting the increasing regulatory and legislative demands.


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Survey participants list ailure to attract or retain top talent as the ourth top risk. In the next three to ve years, a large

number o baby boomers will be retiring. The ederal government is predicting that by 2020, nurse and physician

retirements will contribute to a shortage o at least 24,000 doctors and close to one million nurses. Moreover, the aging

population and the addition o over 30 million newly insured individuals under health care reorm will urther exacerbate

the situation. Besides, the training and deployment ineciencies could also lead to declining health care quality and

accessibility.

When you look at the top 10 risks as a whole, there is an undeniable interdependence among many o these risks. It is

more important than ever or organizations to embrace an enterprise-wide approach to managing risk, and optimize their

strategy on a global basis

Top 10 Risks - Health Care

Rank Health Care 2011 Top 10 Risks

1 Regulatory/legislative changes

2 Increasing competition3 Economic slowdown

4 Failure to attract or retain top talent

5 Pandemic risk/health crises

5 Damage to reputation/brand

5 Capital availability/credit risk

8 Political risk/uncertainties

8 Proessional indemnity/errors and omissions liability

8 Lack o technology inrastructure to suppor t business needs

Data Source: 2011 Global Risk Management SurveyWhere ranking numbers are duplicated that indicates a tie

Risk Preparedness or the Top 10 Risks

Preparedness or risk means having a plan in place to address the risk or having undertaken a ormal review o that risk.

Health care respondents report the lowest levels o preparedness or two major risks economic slowdown (64 percent)

and political risk/uncertainties (57 percent). These two risks, typically more complex and dicult to control, carry a higher

degree o unpredictability and are enterprise-wide.

As risk management is becoming more embedded in an organizations culture and with additional demands or improved

quality outcomes, we expect to see an upward trend in risk preparedness over the nex t two years.


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Top 10 Risks Reported Readiness - Health Care

0% 20% 40% 60% 80%

77%

83%

73%

70%

86%

64%

82%

76%

76%

57%

100%

Political risk/uncertainties

Professional indemnity/

errors and omissions liability

Lack of technology infrastructure tosupport business needs

Pandemic risk/health crises

Damage to reputation/brand

Capital availability/credit risk

Failure to attract or retain top talent

Economic slowdown

Increasing competition

Regulatory/legislative changes

Loss o Income Associated With Top 10 Risks

Among the top 10 risks, economic slowdown is cited by the health care sector as causing the most loss o income in the past

12 months, at 77 percent.

Loss o Income From Top 10 Risks - Health Care

0 10 20 30

30%

21%

77%

13%

27%

9%

14%

10%

38%

33%

40 50 60 70 80

Political risk/uncertainties

Professional indemnity/errors and omissions liability

Lack of technology infrastructure tosupport business needs

Pandemic risk/health crises

Damage to reputation/brand

Capital availability/credit risk

Failure to attract or retain top talent

Economic slowdown

Increasing competition

Regulatory/legislative changes

Data Source: 2011 Global Risk Management Survey


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Identication and Assessment o Major Risks

Survey participants cite senior managements intuition and experience as the primary method used to identiy and assess

major risks acing their organizations. In practice, organizations typically utilize a combination o risk registers, a structured

enterprise-wide approach and senior managements intuition.

Should organizations relying predominantly or exclusively on management experience and intuition or their major risk

decisions be concerned?

In todays ast evolving business environment, where the past may not always be the best predicator o the uture, exclusive

reliance on senior managements intuition and experience to identiy and assess risks could result in a signicant loss to an

organization.

Some o the reasons include the ollowing:

Risk identication based on experience tend to miss emerging or new risks.

Risk identication based on intuition may not be consistent and may not be given credence by others.

There may be a tendency toward risk aversion by managers with the view better sae than sorry.

On the contrary, the use o risk registers, quantitative analysis and an enterprise-wide approach to identiying and assessing

risk is desirable, adding consistency to the process and enabling the organization to more eectively assess the potential

impact o an identied risk on the organization so it can deploy appropriate resources or treatment.

As risks increase in complexity, health care organizations must integrate intuition and experience with sophisticated

analytics to make the most inormed objective and predictive decisions.

Identication o Major Risks Assessment o Major Risks

Other

6%Structured enterprise-wideapproach

13%

External serviceprovider/advisor

2%

Business unit riskregisters or key riskindicator worksheets

9%Senior management

intuition and experience64%

Board level discussion andanalysis

6%

Other5%Structured enterprise-wide

approach13%

Consult with externalservice provider/advisor

13%

Business unit quantitativeanalysis

28%

Senior managementintuition and experience

36%

Board level quantitativeanalysis

4%



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External Drivers Strengthening Risk Management (past two years)

Increased scrutiny rom regulators and economic volatility remain the most important external drivers strengthening risk

management or the health care sector, one o the most regulated industries in the world. Organizations in this sector are

exposed to a myriad o regulations, and ace a great deal o uncertainties relating to the health care reorm laws - even

though many o the provisions and mandates are being challenged in ederal courts. It is important to keep in mind that

reorm is inevitable and will continue to occur with or without legislation or any Supreme Court decision. Health care

providers have to continue providing services while trying to plan or the unknowns in the uture.

External Drivers Strengthening Risk Management (past two years)

0% 10%

19%14%

33%19%

13%13%

7%6%

19%18%

6%22%

7%14%

19%11%

41%50%

48%38%

20% 30% 40% 50% 60%

All IndustriesHealth Care

Increased focus from regulators

Economic volatility

Political uncertainty

Natural weather events

Demand from investors forgreater disclosure and

accountability

Pressure from customers

Pressure from suppliers/vendors

Workforce issues

Large third party liabilitylosses/litigation

Other


Claim Frequency and Severity

Based on Aons 2011 Hospital Proessional Liability and Physician Liability Benchmark Analysis released in October 2011, the

requency o medical proessional liability has stabilized, growing at an annual rate o 1 percent. Claim severity, including

both indemnity and deense costs, increase at a consistent rate and is projected to rise 4 percent annually (subject to a USD

2,000,000 per occurrence limit).

Since 2006, claim requency has been growing at a modest but steady pace. Even though the impact may not be eltyet, the period o declining claim requency appears to have ended. We have entered a period o modest growth. See a

snapshot o requency fuctuations between 2000 and 2010 on the ollowing page.


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Hospital Proessional Liability Benchmark Frequency per OBE

Accident Year

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

20112010200920082007200620052004

0.77%0.74% 0.73% 0.73% 0.77% 0.77% 0.78%

0.79%

1.21%1.16% 1.10% 1.14% 1.17% 1.16% 1.17%

1.18%

1.98%1.90%

1.83% 1.87%1.94% 1.93% 1.95% 1.97%

Indemnity Claims Expense Claims

Source: Aons Hospital and Physician Proessional Liability 2011 Benchmark Analysis

Hospital Proessional Liability Benchmark Claim Severity Limited to $2M per Occurrence

Accident Year

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000

20112010200920082007200620052004

$125,000

$138,000$143,000 $146,000

$152,000$158,000

$164,000$171,000

Data Source: Aons Hospital and Physician Proessional Liabili ty 2011 Benchmark Analysis

Claim severity (average cost per claim) has been subject to a constant infationary trend throughout the historical period

shown above. The severity amounts shown in the graph have been limited to USD 2,000,000 to minimize the eect o ver y

large outlier events. The amounts are comparable to typical sel-insurance retention levels.


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Emerging Risks

1. Health Care Reorm:

A shift in the health care delivery marketplace One o the primary objectives o the health care delivery and

reimbursement reorms under the Patient Protection and Aordable Care Act (PPACA) is to promote better outcomes

and drive greater eciencies within the Medicare and Medicaid marketplace. However, the PPACA has changed the way

care is being managed and delivered to the commercial (non-Medicare/Medicaid) marketplace. A undamental shit

rom volume-based to outcomes-based reimbursements currently under way, is driving the evolution o commercial

ACOs (Accountable Care Organizations).

Emerging risk management needs related to health care reorm ACOs have the potential or driving better outcomes

while reducing costs. However, achieving these goals will require changes in organizational structure and operational

workfow. In some cases, depending on the current state o the organization, this transition will require a major cultural

transormation. Additionally, providers must digest and manage ununded regulatory requirements not seen in the past.

These dynamics have related nancial and operational risks that will require unique risk mitigation strategies.

Additional challenges acing academic medicine As the health care delivery system are migrating away rom ee

or service and toward outcomes based reimbursements, there will be winners and losers within the academic medical

center (AMC) community. In the absence o a cogent Medicare/Medicaid reimbursement carve-out strategy, AMCs will

be competing with regional integrated delivery systems in the commercial ACO marketplace. This creates a unique set

o challenges or AMCs, given that their mission and related expense structures are undamentally dierent rom the

integrated delivery systems. Those AMCs that are building around current or emerging brands in pursuit o additional

market share (either directly or via strategic alliances) will continue to be the winners in this new era.

Employment o physicians Whether the current legislation stays in its current orm, health care reorm in one way or

another is here to stay. For example, health care organizations are already making organizational changes. Aons Hospital

and Physician Proessional Liability 2011 Benchmark Analysis has conrmed the trend o hospitals hiring more physicians,

and integrating physicians into their sel-insurance programs. The graph below shows the current composition oemployed physician rosters or non-university systems. The astest growing specialty or non-university systems is

hospitalist. Other ast growing specialties include neurology, neurosurgery, orthopedics, pulmonary disease, radiation

oncology, and emergency medicine. When hospitals team up with physicians, they have eectively minimized medical

proessional liability risk.

Specialty Distribution o Employed Physicians

Anesthesiology

Pediatrics

General Surgery

All Other Surgeons

Emergency Medicine

OBGYN Surgery

Internal Med/Fam Practice/Hospitalist

Other NonSurgical Specialties29%

9%

16%

4%

5%

8%3%

25%

Data Source: Hospital and Physician Proessional Liability 2011 Benchmark Analysis


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Accountable Care Organizations The health care reorm legislation enacted in March 2010 authorizes the Medicare

program to contract with ACOs - networks o physicians and other providers that could work together to improve the

quality o health care ser vices and reduce costs or a dened patient population. In theory, ACOs provide nancial

incentives or health care organizations to reduce costs and improve quality. In reality, given the complexity o the

existing system, health care providers are acing more challenges than ever beore. The new health care landscape will

be characterized by:

Center or Medicare and Medicaid Services (CMS) is moving to tiered risk payments and per ormance-based

quality care.

New alignments will be developed across all providers and care settings, and among multi-hospital and

multi-physician groups.

Payer-provider links will promote risk sharing, data integration and patient management.

Accountable care will be driven by quality metrics and eciency rather than volume and unit pricing.

Financial and data transparency, IT inrastructure and process improvement will be keys to success.

Health care providers will be required to become both clinically and nancially accountable.

2. Physician Payments Sunshine Act. This part o the Aordable Care Act is intended to limit the infuence o drug and

medical equipment manuacturers and supplies on physician or hospitals practices. The law requires manuacturers to

report payments or transers o value to physicians or academic medical centers and teaching hospitals by January 1,

2012. However, there is little guidance on what inormation to be provided. Both providers and industry leaders are

concerned about how it will be interpreted by payers and the public. CMS was asked to issue regulations speci ying

what was needed and in what ormat no later than October 1, 2011 so ar nothing has been done yet.

3. Reimbursement changes pay-or-perormance (P4P) and non payment or never events. The need to ensure

appropriate reimbursement or services provided has always been a challenge but it is getting ar more dicult in a

number o ways. For example, P4P, also known as value-based purchasing, is a payment model that rewards physicians

and hospitals or meeting certain perormance measures or quality and eciency. Under the new law, CMS and many

commercial carriers will essentially stop paying the treatment costs o preventable medical complications or neverevents.

4.Focus on patient saety and quality. Closely related to the above reimbursement challenges and transparency issues

is the ongoing ocus on patient saety. This area has been a prior ity or all health care organizations, but clearly, the

pressures will continue to escalate. Hospital providers are awaiting several key decisions rom the Centers or Medicare

& Medicaid Services over how the agency intends to interpret and apply penalties against hospitals that have higher

than expected rates o 30-day readmissions in three disease categories: heart ailure, hear t attack and pneumonia.

[Health Leaders, November 21, 2011]. The providers perormances are being closely scrutinized and audited, rewarded

or punished in a broader range o ways.

5.Medicare secondary-payer mandatory reporting Known as MMSEA section 111in reerence to the section o

the Medicare, Medicaid, and SCHIP Extension Act, where the issue is addressedthe mandatory reporting program

requires organizations to report payments, settlements, and awards involving Medicare beneciaries. Medicare, sinceits inception in 1965, has been a secondary payer or workers compensation programs, including the ederal black-lung

benets program. In 1980, the Medicare Secondary Payer Statute expanded the program to include liability, automobile,

and no-ault programs. The intent o the Medicare secondary-payer program is to protect the Medicare trust und by

identiying situations in which the Medicare program should not be the primary payer to the beneciary. The new

provision in MMSEA mandates reporting, with penalties o USD 1,000 per claimant per day or noncompliance.


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6. Electronic Medical Records (EMR) and Electronic Health Records (EHR): Health care providers are being oered

a plethora o options or electronic inormation technology. While they are required to network with other providers

and publish outcomes, they also have to keep the inormation entirely private. The ramication o a breach in privacy &

security may include:

The duty to notiy potentially aected individuals

HIPAA (Health Insurance Portability and Accountability Act) ne

Protected Health Inormation (PHI) regulations

Regulatory action

Class action potential

Reputational damage

7. Shortage o health care proessionals: As baby boomers start to retire in the next three to ve years, the ederal

government is predicting that by 2020, retirements will contribute to a shortage o nearly 24,000 doctors and close to

one million nurses. In addition, the health care industry must also contend with training and deployment ineciencies

which may result in the r isk o declining health care quality and accessibility.

8. More civil and criminal penalties: The U.S. Department o Justice has invested in new legal tools, added hundreds o

more investigators and increased the budget by USD 350 million over the next 10 years to enhance its capabilities to

combat raud, waste and abuse. The U.S. Health and Human Services is also well positioned to eectively crack down on

health care raud and abuse.

9. Meaningul use: CMS is expected to issue rules dening State II o meaningul use o electronic medical records

or hospitals and doctors in the rst quarter o 2012, but there is continued expectations that the implementation will

be postponed with hospitals hoping or a one-year delay. Meaningul use is a very big deal or hospitals because

theres USD 4 billion in incentive payments or doctors and hospitals, said Don May o the American Heart Association.

The Stage II cr iteria are eared because CMS is expected to signicantly increase the percentage o clinicians who, or

example, are using computerized physician order entry to meet the meaningul use requirements. (Health Leaders,

November 21, 2011)


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Client Insights


The right knowledge at the right time can literally change the world. The health care sector has

capitalized on timely inormation being available or some time. Similarly, the value Aon oers through

content is empowering our clients with analytical, relevant, and timely risk insights that can help them

make not just better decisions but the right ones to achieve their goals. Within this section o the

report, we provide industry-specic insight into:

Priorities in Choice o Insurer

Desired Market Changes

Risk Management Department


Value or money/price is ranked the highest priority among health care respondents ollowed by nancial stability/rating

illustrating the act that concerns over nancial stability o a carrier may be somewhat tempered by competitive pricing. We

expect that value or money/pricing will continue to be an important actor in the oreseeable uture and especially during

the economic recovery, when organizations seek to save money wherever possible.

O interest, the health care industry appears to have lowered the prior ity on long-term relationships, going rom numbertwo in priority ranking during the 2009 survey to number ve in 2011. Long-term relationships do matter to health care

providers, but the ongoing economic challenges and an active competitive market compel them to pay close attention to

the bottom line, making the long-term relationships somewhat less important.


Priorities in choice o insurer 2011 Health Care 2009 Health Care

Value or money/price 1 2

Financial stability/rating 2 1

Industry experience 3 5

Claims service 4 4

Long-term relationship 5 2

Flexibility/innovation/creativity 6 7

Prompt settlement o large claims 7 8

Capacity 8 6

Speed and quality o documentation 9 10

Ability to deliver a global program 10 9



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Desired Property and Casualty Market Changes

When asked what changes health care organizations would most like to see in the insurance market, the majority o

respondents desire:

Recognition o investments in internal risk management eorts through lower premiums

Broader coverage/better terms and conditions

Desired Property and Casualty Market Changes

0% 10% 20% 30% 40% 50%

7%

7%

47%

32%

31%

42%

27%

28%

42%52%

11%

18%

64%

58%

67%

63%

60% 70%

All IndustriesHealth Care

Broader coverage/better terms andconditions

Recognition of investmentsin internal risk management eorts

through lower premiums

Increased capacity

More flexibility

More sophisticated informationtechnology (IT) systems

Better quality of service

More product innovation

Other



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Risk Management Department

Among health care respondents, 74 percent indicate that they have a ormal risk management department. Among those,

29 percent say their risk management department reports to the CFO/Finance and 29 percent to the General Counsel

(The health care sector has the highest percentage o respondents say their risk management department reports to the

General Counsel than any other industry group surveyed). In the case where no ormal risk management department exists,

the greatest majority, 43 percent, also say their CFO handles risk management. Those with an in-house risk management

department typically maintain a sta o one or ve people.

Formal Risk Management Department

No

26%

Yes

74%



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Market Insights


Access to timely insights on policies, premiums and carriers allow health care clients to make aster

and more accurate decisions while seeking to obtain the best coverage and rates. Aon has invested

resources to develop the industry leading research and platorms and ensure our clients have the data

they need, when they need it. Within this section we provide insights into the ollowing coverages:

Medical Proessional Liability

Managed Care Errors and Omissions

Managed Care HMO Reinsurance, Excess-o-Loss and Provider Excess

Workers Compensation

Directors and Ofcers Liability

Property

Even though it is not known at this point to what degree the health care reorm will impact the traditional lines o property

and casualty coverage, we can be certain there will be an impact on medical proessional liability, as hospital providers

employ more physicians, and ACOs assume some o the nancial risk o providing care. Consequently reorm may also have

an eect on vicarious liability and antitrust exposures. When more physicians are employed, we anticipate the underwriting

o those physicians to be more rigorous, including not only the traditional criteria o specialty and losses but also non-

traditional underwriting cr iteria such as inection rates, readmission rates and other quality indicators. At this point we alsobelieve that reorm will aect some o the traditional coverage lines such as D&O and workers compensation.

There will be a more immediate impact on managed care exposures, including medical stop loss and provider stop loss,

as health care providers move in the direction o ACO development and assuming more risk. ACOs will require that the

D&O, privacy, vicarious medical proessional and business risk o ACOs, among other risks, will require consideration in risk

management nancing treatments.

As reorm changes evolve, additional exposures will develop.

Medical Proessional Liability

Category 2011 2012

Pricing

Deductibles/Retentions

Limits

Coverage Terms & Conditions



19/32


Pricing

The medical proessional liability market remains stable, with renewal pricing staying either fat rate or reduced, even in

dicult venues. The market stayed sot through 2011 and we expect the same or 2012. With many insurers writing hospital

business, capacity is plentiul. Redundant reserves (market over-reserving) will continue to provide insurers some margin oprotability. This high level o competition encourages some insurers to decrease pricing in order to retain business.


Retention levels are at historically high levels, but continue to remain stable. Health care providers have become

accustomed to higher retentions as a result o the hard market several years ago. Markets continue to provide aggregate

protection in certain situations.

Limits

For medical proessional liability, limits purchased range rom zero (going bare) to well in excess o USD 100 million. The

question o limits is answered by understanding a range o issues: venue, state liability caps, statutory protection such as

municipal immunity or some health care providers, nancial resources or board attitudes toward risk.

Insurers are reporting successul reinsurance renewals that mirror results In insurance pricing. In addition, severalcommercial insurers who ceased to purchase reinsurance report that they may be interested in purchasing reinsurance to

take advantage o avorable pricing. This will serve to urther increase the already abundant medical proessional liability

capacity.


There are some negative trends with claim requency and severity, which may impact rates in the near uture. Aons 2011

Hospital Proessional Liability and Physician Liability Benchmark Analysis, which was released in October 2011 shows a rise

in requency and a continued increase in severity over the past ew years. The data also suggest that there is an average

1 percent increase in the number o reported claims during the past our years.

Managed Care Errors and Omissions

Category 2011 2012

Pricing


Limits


Pricing

Market conditions stayed sot throughout 2011. We anticipate that in 2012, underwriters will hold the line and as a result,

rate reductions could slow to low single-digit or good r isks, and fat to increases or risks with claims or a dicult risk

prole. Furthermore, given the industrys systemic risk, some carr iers have cited current rates as unsustainable, indicating a

stronger stance against any additional rate decreases.


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Retention levels continue to show downward movement, assuming avorable claims experience by the particular client.

Similar to last year, carriers are using this metric to improve its program, in an attempt to avoid urther premium decreases.

Limits

Limits purchased by managed care entities have been relatively fat in 2011. Some entities which have expanded operations,

either organically or via acquisition, have increased their total program limits. As more managed care organizations are

broadening their scopes o services, new exposures are created. They are addressing these new exposures related to areas

such as direct care and wellness programs either via the master program or in separate insurance policies.


Coverage is relatively stable, with some broadening eatures still emerging. Two carriers have recently revised their base

policy orm with clearer and more avorable policy language. While some markets continue to provide some orms o

privacy/security coverage, others push this exposure into a separate policy/program geared exclusively toward the risk.

As more managed care organizations expand into variations o direct care, such as home care and clinics, the question is

to gure out where this exposure should be addressed via the managed care E&O program, or separately in a medical

malpractice policy.

Managed Care HMO Reinsurance, Excess-o-Loss and Provider Excess

Category 2011 2012

Pricing


Limits


Pricing

Leveraged trend (percent o increase in high-cost claim recoveries year-over-year) ranges rom 15 percent to 25 percent

annually. Advances in medicine and medical technology coupled with double-digit increases in the charge masters rom

tertiary and specialty care acilities have caused high cost claims to more than double in the past ve years.

To oset the signicant trend and expense o loss, reinsurers have imposed a greater number o limitations within their

policies, or have increased premiums to levels that have orced clients to purchase higher retentions and co-insurance

alternatives. In response, managed care organizations are seeking variable unding alternatives in order to best improve

their chances or a avorable return/net cost o insurance.

Many reinsurers oer a host o alternatives designed to transer catastrophic risk, support the provider contracting eorts

o their clients and supply value-added services that help mitigate or transer expense. These include care and case

management support, transplant network pricing, and claim auditing to name just a ew. Each can serve as an outsourced

deense to health plans and provider organizations in need o urther back-room support o their current programs.

Most insurers are oering similar coverage line sizes but we anticipate that capacity will increase in the coming year.


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Selected managed care organizations such as managed state Medicaid programs and developing programs or the

uninsured/underinsured appear to be most in need o excess-o-loss cover. State Medicaid programs that transer ull r isk o

neonate exposure to managed care organizations are seeking some orm o catastrophic protection. The rise in this type o

claim has been highly signicant in the past three to ve years.

Delegated risk rom managed care organizations to provider entities is expected to grow rapidly in the next several years as

ACOs along with Medical Homes are gaining popularity. What was once popular in the mid 90s and remained a contracting

strategy in various pockets o the country has resuraced as a v iable method o risk transer and payment to hospitals and

physicians. The health care reorm legislation passed in 2010 should pave the way or more demonstration projects beyond

those existing ones in Massachusetts and other pockets o the country. As provider entities have shi ted their ocus to

maximizing revenues over the past seven to 10 years, it will be dicult to again shit the culture o an organization to be

both clinically and scally accountable or a patients health care while seeking protability under a delegated risk contract.

Nonetheless we are witnessing interest rom specialty providers and acilities that see this strategy as a means to garner

patients and market share.

As requirements rom the new health care reorm laws become clearer in 2012, there will be greater understanding o

the classes and levels o r isk that will enter the current insurance pool. Nearly 30 million uninsured are anticipated to beenrolled within the health insurance market. Much o this r isk class can be considered uninsurable by todays standards.

I this is true then alternative markets must be accessed to cede the poor r isk expense. Conversely, the government may

realize that it must assume the care or the poor, a high risk group in the health care system. They must also nd alternatives

to transer expense as the ederal and state budget decits worsen. All insurers will nd reinsurance imperative as they

begin to explore segmenting risk classes within their own enrolled populations. Sucient worldwide capacity exists today

to accept much o this exposure. However, pricing will rise as demand and leveraged trend continues to gain at a double

digit pace.


We continue to see higher deductibles or this line. Outlier requency increases will orce the need to address

deductible levels.

LimitsHealthcare reorm will require all risk bearing payers to provide unlimited protection to all policyholders within the next

ew years. To this end inquiries have begun on expanding the limits o protection provided within reinsurance policies.

Reinsurers have yet to provide this range o protection, but have put orth policies with annual limits as great as USD 5

Million which appears to be a pragmatic level o cover based on current day provider reimbursement levels.


In recent years we have witnessed subtle changes to the health care reinsurance marketplace, which has balanced a proper

mix o capacity and competition. With the passage o health care reorm in 2010, we are seeing the onset o ur ther change

within the industry as insurers and reinsurers prepare or the evolving exposures anticipated over the next several years.

These changes include the interest o new players to explore entrance to the market, and the need or additional capacity

by current insurers as they prepare to address the 30 million o new high-risk members anticipated over the next several

years. Other issues driving the change include:

Expansion o products and oerings rom current markets

New reinsurer entrants in search o at-risk revenues

Anticipated growth in delegated risk contracts

Need or additional capacity to address health care reorm regulation


22/32


Workers Compensation

Category 2011 2012

Pricing



Pricing

Over the past year, workers compensation rates or health care organizations have averaged fat-to-single digit rate

decreases. We expect this stable market conditions to continue or the insureds with a good loss history, benign risk prole,

and limited exposure changes.

The insureds are anticipated to closely scrutinize medical bill charges in an eor t to create additional sources o savings.

Further, state taxes and assessments will continue to go up, as in the case o a recent increase by the state o New York.


Most insureds choose to maintain their deductible/retention levels. For insureds with loss sensitive programs, collateral

requirements continue to impact the overall deductible/retention strategies and the attractiveness o changing primary

markets.


Overall, there has been no signicant change regarding coverage or workers compensation, and we do not anticipate any

major changes in the near uture.

Directors and Ofcers Liability

Category 2011 2012

Pricing


Limits


Pricing

We believe that pricing or D&O will stay sot or most insureds as long as there is ample capacity in the marketplace with

carriers competing or business. While the nal eect o health care reorm laws has not yet been realized, we anticipate

a gradual dierentiation by carriers between those health care acilities that are poised to prosper, and those that will

struggle. With the quality measurements and corresponding reimbursement rates taking eect, along with a myriad o

other nancial and operational pressures acing health care acilities, carriers will be pricing a risk more heavily on the basis

o the acilitys nancial perormance.


23/32



For private/non-prot hospitals, the employment practices liability (EPL) retention, and more specically, a separate

retention or class/mass actions will continue to drive the overall retention levels. Given the prolic employment claim

activity in this space, carriers will zero in on this issue when constructing programs, matching retention levels with bothemployee count and historical employment claim activity. The sot marketplace means that carriers will be inclined to lower

EPL retentions below what their rating model would suggest or a par ticular employee count, as long as the claim/litigation

history or the account supports the decrease. With that said, most carriers are not willing to go below a cer tain minimum,

which is related almost directly to the employment count. It is also important to note that the way a carrier counts par t-

time employees toward the overall employee tally varies. Some count these toward the total count, same as ull-time, while

others include them at a discount rate (i.e. two part-time employees count as one ull-time).

Carriers also approach antitrust retentions dierently. Certain carriers maintain a strict adherence to the underwriting

philosophy that demands a higher retention or this exposure. These carriers cite the catastrophic nature o these types o

claims, as well as the continued prevalence o this litigation in the health care space. Other carriers see this issue as a way

o dierentiating themselves and creating a competitive edge. Despite this variation in the approach, the overall antitrust

retention level has come down over the past ew years rom an average o USD 1 million or higher, or a current average o

USD 500,000 to USD 1 million. The ollowing, taken rom Aons proprietary benchmarking database, provides inormation

on D&O retentions or various sized entities. Keep in mind that programs oten have higher retentions or the EPL and

antitrust portions o the coverage.

Size Category Average Median

Assets $1M - $750M $65,000 $25,000

Assets $750M - $3B $352,188 $250,000

Assets >$3B $1,000,000 $500,000

Employees 100 5000 $99,571 $62,500

Employees 5000 10000 $309,615 $250,000

Employees >10000 $485,385 $250,000

Data Source: Aon FSG Proprietary Databases

Limits

Overall D&O limits purchased by non-prot/private hospitals and health care systems have been on a slight upward trend

year over year. We see many buyers opting to increase the total program limits with Side A excess to insulate the board rom

the potential exhaustion o limits by entity coverage.


As some hospitals and health systems purchase physician practices or doctor groups, there is heightened concern over limit

adequacy or the kick-back and antitrust exposures. Furthermore, theres been continued uptick on EPL claim activity in this

industry, many o which involve nurses and other similar groups o employees.

Coverage continues to evolve as the marketplace stays sot and carriers attempt to hold the line on pricing, but use policy

language as a means to compete. One coverage expansion is with early trigger o coverage on items such as a service

o subpoena, request or witness testimony, document production, or request or an insured person to appear or an

interview. A urther enhancement pertains to the EPL coverage commonly blended with the D&O in these programs. The

EPL enhancement provides late notice orgiveness or situations where an Equal Employment Opportunity Commission


24/32


charge was not reported in a prior policy per iod but evolves to a complaint or other type o claims in the current period.

These new enhancements represent carr iers attempts to not only dierentiate coverage, but also to stabilize and increase

premium, since there is typically an additional premium associated with the enhancements.

Property

Category 2011 2012

Pricing


Limits


Pricing

In the past 12 months we have seen a 1.1 percent average rate reduction or health care accounts, however, mounting

global losses and updates to RMS modeling has led to rate increase pressure. We expect rates will continue to be under

moderate pressure or the near uture. Rate levels should be fat to +15 percent or most renewals. The ull impact o RMS

version 11 still may not be elt until 2012 when most large property accounts renew in the rst hal o the year.


Over 96 percent o health care accounts in our database maintain the same deductibles in last 12 months ending September

30. In general, there continues to be limited pressure rom the majority o markets to change deductibles/retentions unless

specic account experience warrants a change. With upward rate pressure expected, we anticipate some accounts will opt

or higher deductibles/retentions to counter the rate pressure.

LimitsIn the last 12 months, 92 percent o health care accounts have maintained the same or higher limits. We believe that the

percentage o organizations purchasing higher limits may decrease with the anticipated upward rate pressure.


There was no real change in property coverage. Broad coverage will continue to be available. Coverage improvements

were available in 2011 and are expected to remain available in 2012.


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Use o Captives


Captives exist or are created because they ll a niche that cannot be easily, or as eciently, lled by the conventional

insurance marketplace. While not or everyone, captives can be an important part o a proessionally constructed r isk

nancing program that recognizes the value o retaining certain risks in meeting overall corporate nancial objectives.

Many captive owners benet rom reduced insurance costs, access to reinsurers, an ability to insure the uninsurable and

improved cover and control. Many organizations in the health care industry utilize these alternative risk transer vehicles

as part o their risk management/insurance programs.

To gauge the use o captives in the health care sector, Aon conducted its third annual Health Care Captive Benchmark Study

in early 2011. This study includes inormation rom 113 participating health care captive insurance companies.

Demographics

As is the case with Aons previous study, most o the captives participating in Aons study are not-or-prot hospitals but as

shown in the exhibit below, a number o other types o organizations have also used captives:

Type o Parent

Group3%

Educational8%

Clinic3%

Services6%

Long TermCare Facility

5%

PhysicianPractice

6%

Hospital69%

For Prot Not or Prot Total

Hospital 19 57 76

Educational 0 9 9

Services 4 3 7

Long Term care acility 3 3 6

Physician practice 6 0 6

Group 2 1 3

Clinic 1 2 3

Total 35 75 110

Data Source: 2011 Health Care Captive Benchmark Survey


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Coverages Insured by Captive

According to Aons 2011 Health Care Captive Benchmark Study, medical proessional liability is the most common coverage

line underwritten, at 62 percent. This nding does not come as a surprise because the coverage is typically one o the

largest insurance costs or health care providers, and may not be aordableor the coverage needed in the standard market

may not be oered.

The study also reveals that captives are assuming a range o exposures, such as employed physicians, auto liability, workers

compensation, and medical stop loss and D&O liability.

Coverages Insured by Captives

Environmental

Aviation

Produc

tLiability

Life

/Diability

BusinessInteruption

Crim

e/Fidility

EquipmentsMaintenance

Employer

sLiability

Property

Directors&

Ocers

Liability

MedicalStopLoss

Workers

Comp

ensation

Non-E

mployed

Physicians*

Professional

Indemnity

AutoLiability

Captives

EmployedPhysicians*

Genera

lLiability

Medical

Malpractice

0%

10%

20%

30%

40%

50%

60%

70%

*This is Professional Liability

*D&O does not include Side A

62%

35%

23%

11% 11% 11%

7%6% 5% 4% 4%

2% 1% 1% 1% 1% 1% 1%

Data Source: 2011 Health Care Benchmark Survey


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Financial Perormance

One o the values o orming a captive is lower expense ratios than the commercial markets. The ndings o the captive

benchmark study show that expense ratios o captives and Risk Retention Groups (RRGs) are lower than commercial

insurers, which typically have 25-30 percent or higher loss ratios. The use o captives or RRGs has enabled providers to

prudently keep these costs low.

Expense Ratio

0%

5%

10%

15%

20%

25%

RRGsCaptives

5%

21%

Expense Ratios equals Expenses divided by Net Earned PremiumExpenses limited to $1,000,000Data Source: 2011 Health Care Benchmark Survey

From the study, we also see that health care captives and RRGs are generally healthy, as demonstrated by their premium-to-surplus ratios which shows plenty o surplus in writing coverage at less than one dollar o premium or every one dollar o

surplus.

Average Premium to Surplus Ratio

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80 0.79

0.61

0.90

On ShoreO Shore

Data Source: 2011 Health Care Benchmark Survey


28/32


Methodology, Notes and Disclaimers

This report is based on data rom Aons 2011 Global Risk Management Survey, Aons 2011 Health Care Captive Benchmark

Study, Aons Hospital and Physician Proessional Liability 2011 Benchmark Analysis, Aon Financial Services Group, Aon GRIP

and other proprietary databases.

2011 Global Risk Management Survey Health Care data shown in this report is based on 54 global company responses.

Breakdown o respondent base is a ollows:

Revenue Range % o Respondents Type o Organization % o Respondents

< USD 1B 61% Public 7%

USD 1B USD 49B 22% Private 26%

USD 5B USD 99B 2% Government/Government owned corporation 4%

USD 10B USD 149B 2% Not or prot 63%

USD 15B USD 249B 0% Other 0%

USD 25B+ 0%

Cannot disclose 13%

Along with the support o other Aon insurance and industry specialists, Aon Analytics collects and tabulates results,

provides analysis and interpretation o ndings, and prepares this report.

All summaries o existing law provided in this Industry Report are general in nature and do not constitute legal advice, and

are not intended to orm the basis or a specic course o action by any person or entity. You should consult with your legal,

risk and proessional advisors beore taking any action based upon the laws and regulations summarized in this report.

This report is urnished or inormational purposes only. Do not distribute or copy. Aon has endeavored to conrm

the correctness o the data and opinions expressed in this report, however, neither Aon nor its employees make any

representation or warranty as to the accuracy or completeness o the data or opinions expressed herein. Aon has no

liability to the recipient or any other party resulting rom the use o, or reliance upon, the contents o this report.

Copyright 2012 Aon Corporation.


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Health CareRon Calhoun

Managing Director

Aon Risk Solutions

Health Care Practice

roncalhoun@aoncom

+7043434128

Dominic Colaizzo

Chairman

Aon Risk Solutions


dominiccolaizzo@aoncom

+ 2152551728

Karen Cullinane

Director o Communications

Aon Risk Solutions


karencullinane@ aoncom

+13123814450

Aon Analy ticsGeorge M. Zsolnay IV

Head o Aon Analytics - US

georgezsolnay@aoncom

+13123813955

For Media and Press InquiresKelly Drinkwine

Director o Public Relations

Aon Corporation

kelly_drinkwine@aoncom

+13123812684

ContributorsCathy Gavin

Samantha Burns

Linda Milliken

Kathryn Meyers

Richard Chiocchi

Martha Jacobs

Key Contacts


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Aon Risk Solutions, 2012. All rights reserved.

The inormation contained herein and the statements expressed are o a general nature and are not intended

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Documents

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