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Copyright © 2011 Global Benefits Magazine. All rights reserved. Global Benefits Magazine is published monthly. Material in this publication may not be reproduced in any way without express permission from Global Benefits Magazine. Requests for permission may be directed to [email protected]. Global Benefits Magazine is in no way responsible for the content of our advertisers or authors.

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Jonathan Edelheit

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By Matthew Zubiller, Vice President, Advanced Diagnostics

CORPORATE DUTY OF CARE AND RISK MITIGATION IN EMERGING MARKETS AND THE DEVELOPING WORLD:by John M Quinn and Lola May

DUTY OF CARE VS DUTY OF DOLLAR

RESPONSIBILITIES AT TIME OF SALE by Paul Reed, Legal Counsel, GlobalExcel

MANAGING THE ADVANCED DIAGNOSTIC TESTING BOOM

by Shawn Austin

By Jim Webb

HAVING AN ANTI-JERK POLICY AS PART OF YOUR CORPORATE WELLNESS STRATEGY

by Arthur Tacchino, J.D.

HOW TO DRIVE VALUE CREATION IN THE C-SUITE

THE CHANGING FACE OF HEALTHCARE: UNDERSTANDING THE MEDICAL LOSS RATIO

by LaShanda Blissett, MS and Rachel

HEALTH INSURANCE FOR EXPATRIATES IN SPAIN

By Les C. Meyer, MBA and Ronald Parton, MD, MPH

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PHARMA REFORM &WORLD TRADEby Melvin J. Howard

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by Fredric Havens

ARE YOU AND YOUR COMPANYREADY TO TRAVEL?16

GLOBALBENEFITSMAGAZINE An International Benefits, Expatriate and Travel Insurance Magazine



Jonathan Edelheit

In today’s global world, many employers are growing and opening up new offices in different parts of the world. Some employers are closing down offices in the developed part of the world and moving offices and manufacturing to developing parts of the world where the costs for doing business are much more affordable. The Global Benefits space, all benefits offered globally whether to local employees or expats is expected to become one of the fastest growing “niches” within the healthcare and employee

benefits space and many of the big insurance companies are positioning themselves for this space. Insurance companies, consulting firms and industry service providers are investing in their infrastructure for what the future will bring. Global Benefits is all encompassing, it covers all benefits offering multi-nationally, whether insurance, non-insurance, employee benefits or non-employee benefits. It includes expat benefits, travel insurance and everything that employers offer as international benefits. We are committed to expanding our coverage of this industry and looking forward to spending the upcoming year getting to know each and everyone of you better, and bringing this industry much closer together.

Jonathan Edelheit is Editor-in-Chief of the Global Benefits Magazine, the first and only dedicated magazine for Global Benefits, expatriate healthcare, travel insurance and International Benefits, with a heavy focus on employers, agents and consulting firms with international operations. Mr. Edelheit is considered an expert international healthcare. He is editor of five employee benefits magazines, healthcare and formerly ran a national healthcare administrator where he implemented many cutting edge healthcare programs and voluntary benefits. Mr. Edelheit has been featured or mentioned in hundreds of magazines and newspapers throughout his ten years and last February was featured as a visionary in US healthcare by Executive Managed Healthcare Magazine.

Mr. Edelheit works with large international insurance companies, governments, employers, health insurance agents and consulting firms in areas of implementing new cutting edge healthcare

Jonathan Edelheit

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Global Benefits an Industry in Growth Mode



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Corporate Duty of Care and Risk Mitigation in emerging markets and the developing world: medical evacuation and outpatient care for employees By John M Quinn and Lola May Coker

Across all sectors and industries, the developing world has continued to see market growth and significant foreign direct investment (FDI). Despite recent economic stagnation, and in some sectors, decline in the developed world, developing nations offer great opportunities in manufacturing, construction, and various services in the growing field of peace and stability operations. War, conflict and general political and social instability continue to plague these dynamic environments, and in many regions these are on the rise. Risk for the many companies sending workers abroad and hiring local national staff is rising as well. Transnational companies, especially

those in the public sphere, have a responsibility to offer Duty of Care to their employees. This Duty of Care applies not only for emergency and medical evacuation situations but also for sub-acute and even chronic medical conditions for employees traveling and working abroad. Identifying risk for employees traveling to the developing and least developed world, mitigating risk for the corporation once in-country and managing risk once exposed are basic principles for any management team with personnel abroad. Health risk assessment for any foreign operation working abroad involves medical best practices, due diligence, health economics and cost effective analysis. This article seeks to better define the risks undertaken by corporations deploying to the developing world, define the risks associated with utilizing both self-insurance and underwritten

January 2011



insurance and examine best practices in mitigating the risks involved with medical evacuations and assistance providers. And finally, we define the responsibilities that corporations must meet and exceed to fulfill Duty of Care towards their employees.

Duty of Care

The concept of Duty of Care in the corporate sector has grown exponentially in recent years. The basic concept in both English and American common law is that the Duty of Care falling within corporate responsibility includes basic health and safety standards and practices for employees. This means that corporations must apply duty of care for employees traveling for work abroad and for basic work in all corners of the globe. We have seen in recent years that this unclear definition has started to apply even to situations when gross acts of negligence by the employee causes them harm. For businesses working in international settings today, Duty of Care includes medical evacuation and medical treatment for workers when they fall ill and need a standard of care. Additionally, “the duty of care addresses the attentiveness and prudence of managers in performing their decision-making and supervisory functions.” This ‘business judgment rule’ presumes that directors (and officers) carry out their functions in good faith, after sufficient investigation, and for acceptable reasons. In sum, major companies are increasingly being held responsible for the medical evacuation and other medical treatment costs for their employees working abroad – regardless of the contract and insurance cover prior to the incident. The risk that serious medical injury and emergency increases while traveling and working is severe. , ,

Save Money: Self-Insure?

Most large corporations have found it cost effective to self-insure for the medical calamities

that may befall their employees while traveling abroad or otherwise on the job. Self-insurance is a decision to retain risk within the company, as opposed to transferring the risk to a third party. In self-insurance cases, an amount of money is set aside to compensate for the potential future loss (medical evacuation, extreme medical costs or any other associated loss) by the company. If self-insurance is approached as a serious risk management technique, the money set aside must be enough to cover future and uncertain losses, and actions taken to reduce the probability of the risk occurring, and its impact should it occur. This amount is calculated using the actuarial and pre-existing insurance information of the company. The underlying goal behind self-insurance is provision of a necessary service to defined levels at the optimum price, and cost containment through the elimination of annual insurance fees. Purchasing an annual insurance policy (healthcare, medical evacuation or ‘other’ travel medical insurance policy) will cover, subject to Terms and Conditions of the policy, the loss incurred less certain “excesses” which are the amounts that the company will pay on certain types of claims. The real decision is which will cost less, an annual insurance policy or self-insurance? To minimize the impact of litigation loss from user groups, firms can use a number of risk management approaches, including self-protection, self-insurance, or market insurance. Self-protection involves measures to minimize the occurrence of litigation, including screening clients for high-risk behavior prior to acceptance and continuation. , The risk that is associated with self-insurance is clear. Many countries have differing legislation for transnational companies that prefer the self-insure option. In sum, for many companies operating globally, the debate continues to self-insure or not and many decisions fluctuate to fit different markets and dynamic sectors.




The case for purchasing an annual insurance policy is not as clear as a financial decision and as a risk mitigation tool. The cost of an annual insurance policy will not only cover the patient’s evacuation and medical treatment but may remove a great portion or even all indemnity and liability from the employer, shifting it to a Third Party Administrator (TPA) or Assistance companies. The TPA is usually an organization that can process

insurance claims and handle certain aspects of any employee benefit plans for a separate entity; this can include medical evacuation and coordination. The cost of international health insurance from the large assistance companies and insurance brokers throughout the world has risen significantly in the past ten years. This rise in cost has forced many companies to review their policies and to opt for self-insurance, sometimes without disclosing such directional changes for the health and safety of their staff. The initial cost savings of self-insurance can be quite large, however hidden costs including self-administration (i.e. selecting appropriate care packages, negotiating fixed tariffs, and handling claims), can lead to unforeseen financial losses and legal exposure. One such small mechanism that can help mitigate this loss is purchasing a “stop loss” insurance policy to pay amounts that exceed pre set claim limits. Stop loss policies are sometimes less expensive than standard health insurance plans and can help to pay for large loss claims. Despite such stop loss policies, Duty of Care may not be fulfilled and exposure not entirely mitigated. This is seen in recent litigation cases. These range from companies not providing appropriate medical or emergency cover for the employees working abroad, companies not reacting promptly to medical emergencies causing injury or loss of life to companies being ill equipped to deal with political and social upheavals. Taking out adequate private Insurance can mitigate all of the above.

Self-insurance often results in a fiscal struggle between a positive balance sheet versus patient care. The endless strive for cost containment reduces patient care, decreases medical standards and eliminates continuity of care. All this jeopardizes the corporations’ Duty Of Care towards its employees. True mitigation of risk can easily be lost with the company’s first medical evacuation or death of an employee working overseas. Indeed, while self-insurance


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can lead to immediate financial gain, the strive for cost saving measures may inversely effect medical treatment standards and ultimately employee satisfaction and tenure.

Conventional Means: less than conventional health outcomes

A word of warning for corporations that purchase private Insurance, while the insurance industry is heavily regulated, no regulatory body exercises control over Assistance providers. It is up to an Insurer to conduct its own due diligence when selecting an Assistance company. Unfortunately there are not many assistance experts within the Insurance industry to be able to distinguish the capabilities of one provider versus another. An Insurer may have their own set of criteria to fulfill when selecting an Assistance provider such as language capabilities, geographical locations, medical expertise, fees or cost containment capabilities and while most Assistance providers can fulfill these requirements there are no formal regulations in place to ensure the provider does not misrepresent its capabilities.

Most Assistance companies claim to be offering a comprehensive one stop-shop solution when in fact most outsource work to a number of external providers. It remains up to the Assistance companies to vet these providers to their internal standards and requirements, if they have any, or and this is often the case, to select them without prior investigation and true due diligence. While subcontracting is necessary, as no one company has the capabilities to run a case without the assistance of an external provider, be it a taxi company or a ground ambulance provider there is need for greater transparency and control within the Assistance industry.

Mitigation of Risk

Regulatory compliance with local and international laws of Duty of Care is required for all companies operating abroad. In a recent risk management article printed in the Journal of Peace and stability Operations, Jasbir Dhillon argues that it is critical for organizations to ensure that they have a robust policy for their employees outlining how they may travel safely. It is important for any firm working abroad to ensure that their teams are covered on any short or long term work related trips and to ensure that the location and specific travel are covered on the policy. In 2003, for example, many companies that had purchased insurance before the Iraq War found that their policies did not cover their immediate and emergency workers when first deploying to Iraq. Many companies also lacked standard operating procedures for disasters, including essential contact information and procedural guidelines; some even opted out of drafting a basic travel and work safety policy while operating in war and conflict zones. These negligent actions are not in compliance with the Duty of Care concept, to which companies must adhere. ,

Progressive Means: unconventional health outcomes There are many Assistance providers to choose from, most claim to be the leading industry specialist, to have the most comprehensive suite of services and to offer the fairest pricing structure. The market is saturated with Assistance providers and while some are more experienced, diverse and known than others none can claim to be industry leaders.

For an Assistance provider to be truly an industry leader, it would need to set precedence and seek to establish a regulatory governing body to ensure that all Assistance companies




financial risks.

The Assistance industry is long overdue a transformation to address the shortcomings described above. Likewise the Insurance industry needs to review its selection criteria and on-going audit function of their Assistance Service Providers. In the current economical climate Insurance companies tend to change Assistance providers as a money saving exercise and whilst for some this is a must rather than an option it is crucial to conduct a comprehensive due diligence prior to making a move to avoid legal as well as financial exposure.

Corporate Scrutiny

Despite the many medical programs and travel assistance solutions that corporations have employed for their staff and subcontractors throughout the developing world, many governments such as the United States and the United Kingdom hold ever increasing standards for implementation. Adequate insurance must support the health and safety of workers and may provide liability protection when crises such as natural disasters, unanticipated conflict and war and acts of war occur. This paper does not attempt to address all aspects of corporate compliance and duty of care law across borders. Civil law and occupational health and safety laws require significant due diligence practices by all major companies for expatriate and local workers. After all, the imbalance of power between the legislative requirements of companies and the corporation as an entity is explained by the Draconian consequences of an indictment and the elastic notions of corporate criminal liability. ConclusionOpportunities for work in the developing world are growing and are abundant at present with few signs of diminishing. Corporations continue to deploy workers abroad and hire an increasing

number of local employees both in peaceful as well as politically unstable parts of the world. The developing world offers great opportunity for transnational corporations and start-up companies alike, but will only be truly successful when approached with calculated risk. Corporations hold implicit responsibilities towards their employees; Duty of Care is not only the provision of emergency and medical evacuations but also basic medical coverage while traveling and working abroad. Companies must decide whether to self-insure for the provision of medical evacuations and care or to purchase an annual insurance policy to fulfill Duty of Care and mitigate risk. Gone are the days of unaccountable corporate risk exposure.

1. Kahler, M, Walter, B, Territoriality and Conflict in an Era of Globalization, (ISBN-13: 9780521675031 | ISBN-10: 0521675030)

2. Echevarria , LTC Antulio J. GLOBALIZATION AND THE NATURE OF WAR, US Army War College, Strategic Studies Institute, March 2003 ISBN 1-58487-118-0 9, accessed August 12th 2010: http://www.strategicstudiesinstitute.army.mil/pdffiles/PUB215.pdf

3. Ritzer, G, The Blackwell Companion to Globalization, Wiley-Blackwell, August 2007 ISBN: 978-1-4051-3274-9

4. Alan R. Palmiter, Corporations: Examples and Explanations, 5th ed. (New York: Aspen Publishers, 2006), 192

5. Prociv P. Deaths of Australian travellers overseas. Med J Aust 1995; 163: 27-30.

6. Leggat PA, Carne J, Kedjarune U. Travel Insurance and health. J Travel Med 1999; 6: 243-248.

7. Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travellers: an analysis of deaths related to international travel. Ann Emerg Med 1991; 20: 622-626.

8. Huss, H.F. and Jacobs, F.A. “Risk Containment: Exploring Auditor Decisions in the Engagement Process”. Auditing: A Journal of Practice and Theory, Fall 1991: 16-32.

9. Johnstone, Karla M. “Client Acceptance Decisaion: Simultaneous Effects of Client Business Risk, Audit Risk, Auditor Business Risk, and Risk Adaptation”. Auditing: A Journal of Practice and Theory, Spring 2000.

10. Jason, T, Global Implications of Admitted, Non-Admitted and Self-Insurance, Risk Management, Saturday October 1st, 2005

11. Kreuze, J, Newell, G, Langsam, S, Self-insurance: Should corporations make disclosures? Journal of Corporate Accounting & Finance, Volume 8,Issue 2, pages 133 – 138, Winter 1997, DOI: 10.1002/jcaf.3970080211

12. WILSON v. REBSAMEN INSURANCE INC, O’Neal WILSON, Appellant, v. REBSAMEN INSURANCE, INC. d/b/a Insurisk Insurance Services, Jim Moorhead, and John Doe, Appellees. No. 97-14. December 04, 1997

13. Actuarial Standard Board, Actuarial Standard of Practice No. 12 , Risk Classification (for all areas of practice) Developed by the Task Force to Revise ASOP No. 12 of the General Committee of the Actuarial Standards Board, Adopted by the Actuarial Standards Board December 2005 Doc. No. 101 (accessed August 12th 2010: http://www.actuarialstandardsboard.org/pdf/asops/asop012_101.pdf)

14. Saltanat Berdikeeva, Journal of International Peace Operations, Volume 6, Number 1 – July – August 2010, page 9 [available at: http://web.peaceops.com/pdf/journal_2010_0708.pdf]

15. Keith, N, Walsh, G, International Corporate Criminal Liability in the Workplace, Serving the Specialist of the Safety, Health and Environmental (SH&E) Profession. Also Available at http://www.asse.org/practicespecialties/docs/CoPSArticleoftheMonth8-09.pdf and http://www.asse.org/practicespecialties viewed September 14th 2010.

16. Carel H. T., Contracting for helicopter emergency transport services. Healthcare Financial Management, Sunday, August 1 1993.

17. Bagshaw, Roderick; McBride, Nicholas (2008). Tort Law. Longman. ISBN 1405859490

18. Jonathan N. Rosen, Journal of International Peace Operations, Volume 6, Number 1 – July – August 2010, page 19 [available at: http://web.peaceops.com/pdf/journal_2010_0708.pdf]


January 2011



Responsibilitiesat Time of Sale

By Paul Reed, Legal Counsel, GlobalExcel

Insurance professionals know that medically underwritten rates and policy exclusions are essential to the availability and affordability of travel insurance and other health insurance products. However, enforcing these coverage terms

often l e a d s

to accusations of hiding behind the

small print to avoid paying claims. Indeed, when a claim is

denied based on an exclusion or a failure to disclose material information during the application process, policyholders seldom agree with the decision. They might react by contacting the media, filing complaints with insurance regulators and sometimes initiating legal proceedings. These are uncomfortable situations for any insurance carrier, broker or health plan, particularly because of the reputational damage they can cause. One suggestion to minimize the risk of this happening is to review your sales or enrolment process and ensure that it includes mandatory notices to make applicants aware of, and accept the



on age and health. While most applicants understand the importance of obtaining coverage for medical emergencies before travelling, many do not realize the severity of their duty to disclose accurate information when applying for insurance. This situation can lead to omissions on application forms and consequently invalidate the corresponding insurance policies. When this happens the results can seem unfair and extreme to the policyholder, particularly at time of claim. But this general rule about disclosure is a fundamental principle of insurance and can easily be explained to applicants: in order to effectively calculate risk, insurance companies must be able to rely on the information they obtain during the application process, and applicants are therefore responsible for providing complete and accurate information. If they do not fulfil this obligation, the insurance company is not obligated to fulfil the contract of insurance, which it would not have issued under the same conditions if the applicant’s disclosure had been complete.

If a retroactive premium adjustment were the

only consequence for misrepresenting relevant information on a health insurance application, there would be an incentive to withhold or misstate facts when applying for coverage. Everyone would “qualify” for the best plan by withholding relevant information, knowing that in case of a claim they would simply need to make an additional premium payment. This would be like applying for insurance after experiencing a loss and it would prevent insurance companies from effectively calculating risk. They would be unable to collect enough premiums to pay for claims and it would ultimately lead to insurance coverage becoming unavailable.

As for exclusions, which specify events or circumstances that result in there being no coverage, they are necessary and enforceable, because they ensure that coverage is available and affordable for all situations that are not excluded.

For these reasons, insurance companies verify the answers provided on applications for insurance, and the law in most jurisdictions allows them to


void the insurance policy when the application contains a material misrepresentation. For certain types of coverage (e.g. travel insurance) this verification is done when a claim is received as it would be impractical or impossible to do so during the application process. The cost of doing so for every application could also make coverage much less affordable and the applicability of exclusions to the facts of a claim can only be verified after the claim has been made. Nonetheless, in the vast majority of cases the verification confirms that the application is complete and accurate, the policy is valid and the claim is payable. But when the information disclosed on the application is materially different from the insured person’s medical records, or when anexclusion is triggered by the circumstances surrounding the incident, the claim will be denied. The resulting consequences can be devastating, especially because of the incredible costs often charged for healthcare services.

To minimize the risk of this happening, we

must strive to produce clear application forms and eliminate the possibility of innocent misrepresentations. We must provide ongoing product training to our distribution networks and emphasize the importance of accurate and complete disclosure to applicants. Warnings about the consequences of misrepresentation should also be prominently displayed on application forms and other insurance material. Finally, we must ensure that applicants are instructed to read their policy and pay particular attention to the limitations and exclusions.

Misrepresentations and the resulting denial of claims will inevitably continue to arise, but continually raising awareness of this issue will surely have a positive impact. Encourage your distribution networks to tirelessly spread the message to applicants: make sure you disclose all relevant information accurately and completely when applying for travel or health insurance; if you are not sure about what to answer, do not take a chance, ask your doctor!


Advanced diagnostics, including molecular and genetic tests, is one of the fastest growing diagnostic areas – and one that

brings with it tremendous complexity, cost and quality issues for employee health and self-funded insurers. Molecular diagnostics, which includes infectious disease assays, pharmacogenomics and genetic tests, has grown from $1.4 billion in 2005 to $6.2 billion in annual medical costs in the U.S. for a 28% compounded annual growth

rate, according to a Washington G-2 Reports 2010 survey. At $300-3,000 per test, the survey predicts that molecular tests will soon comprise one third of all diagnostic testing costs.

There are many key drivers fueling the growth of these advanced diagnostic tests including:

• Rapidly decreasing costs of DNA sequencing and related technologies

• Our aging population coupled with consumerism increasing the demand for the most innovative new tests

• Faster time-to-market for new molecular tests

Managing The Advanced Diagnostic Testing Boom

By Matthew Zubiller, Vice President, Advanced Diagnostics



Managing The Advanced Diagnostic Testing Boom

However, the greatest factor may be the growing interest in personalized medicine, which is the practice of using genetic profiling to tailor medical care to an individual’s needs. A case-in-point is the chemotherapy drug Herceptin. Approved by the FDA in 1998, it became widely prescribed to treat breast cancer, with annual costs in the range of $50,000-100,000 per patient. Herceptin was known to work only for women whose tumors overproduced a protein called HER2/Neu, which occurs in perhaps 20-25% of all cases. By 2006, genetic-level HER2 testing became a recommended standard of care for all patients with invasive breast cancer, thus indicating the 75-80% of breast cancer cases for which the $50-100K arduous therapy could be avoided. This example illustrates how a molecular test can dramatically reduce unnecessary medical costs, as well as unnecessary delays and anguish associated with improper treatment.

As the era of personalized medicine moves to the forefront, the complexity of managing the advanced diagnostics component of employee health is likely to increase exponentially. For example, today physicians often review about 10-15 variables to diagnose a patient, such as a physical exam, a CBC, etc. Over the next few years, there may be 1,000 or more variables, including results of advanced diagnostics, for physicians to analyze. They will need to look at and synthesize a much larger stream of complex data including genetics, genomics, sub-typing, proteins that drive how patients will respond, and much more.

Until recently, if a patient’s HDL was too low, the physician would probably start the patient on a statin. We are now finding that it is not just the HDL level we need to measure, but that we also need to look at sub-typing to identify the size and density of the HDL particles. If we know that the patient has large HDL particles that help

clean out the arteries, this may totally change the diagnosis and treatment plan and a statin may not be necessary. More and more, physicians will be trying to assimilate hundreds and thousands of relevant data points on molecular and genetic diagnostics, biologics and other factors. With the projected PCP shortage, physicians will have even less time to analyze this avalanche of data. In this new healthcare landscape, which brings with it a new paradigm for diagnosis and for managing employee health, self-funded insurers will need to determine how best to manage within the context of personalized medicine.

Impacts of Managing What Can’t be Measured

As diagnostic testing is said to influence 70% of all health care decisions, it is critical to understand the impact of these advanced tests on the total cost of care, which includes therapies, surgeries and admissions, as well as the quality of employee health. But effectively managing the utilization of these tests is a daunting task as there are only a couple dozen CPT billing codes for the 2,000 or so molecular tests. As a result, there’s little appropriate data on how many and what kinds of molecular tests have been paid for or should have been paid for. In fact, McKesson analysis of data from health plans representing over 100 million claims shows at least 1/3 of the advanced diagnostic spend is unidentifiable due to inadequate CPT codes.

How can self-funded insurers develop strategies to manage the cost of care when it’s not possible to distinguish one molecular test from another because they all use non-specific billing codes? With new molecular and genetic tests coming to market virtually every day, this problem is going to grow exponentially.

Compounding the measurement problem are utilization management processes that are unnecessarily expensive, time-consuming and




incomplete. Even if molecular testing spend were well-identified, insurers and their benefit management vendors find it difficult to enable processes to help ensure appropriate molecular test selection and reimbursement. For example, the following are just a few of the system gaps today:

• Manual, time-intensive authorization processes, resulting in payor costs of $50 or more per test authorization, turnarounds that may take several days due to manual medical reviews, and inappropriate care and medical cost from inconsistent decision-making.

• Non-specific coverage and network rules, such as incomplete coverage information not specific to encounters, unknown payment responsibility for employees pre-service and leakage to high-cost, out of network clinical labs. McKesson analysis shows that molecular tests cost two to four times more when performed out of network.

• Insufficient data for targeted utilization and network management, including unclear identification of specific medical services rendered – and delayed, incomplete data on provider ordering trends. Claims data is not clear on what test was conducted by which lab, or ordered by which clinician. That data is also often 60-120 days delayed in analysis.

It Takes Automated Intelligence at the Point of Care

For self-funded plans to effectively manage the booming area of advanced diagnostics, they need to ensure intelligent, automated decision support tools are in place at the point of care that enable transparent, immediate access to coverage information and medically appropriate rules. This foundation is necessary for driving optimal provider practice patterns and employee utilization behaviors, which are critical success factors in

lowering administrative and medical costs, while more effectively engaging ordering providers and labs. Through automated intelligence within the clinical workflow, we can drive toward a prospective, collaborative, exception-based approach to managing utilization and performance.

These types of solutions are now available and self-funded plans should be aware of the most essential aspects of these systems:

• Automated “advanced” notification and authorization –Automates medical appropriateness review and authorizations with evidence-based clinical decision support. This can lower utilization management administrative costs 40+% while helping to ensure appropriate, evidence-based utilization by identifying lower cost, medically appropriate alternatives. It also enforces consistent rules and with its greater automation and intelligence provides much higher ROI than “basic” utilization management portal solutions.

• Redirection to appropriate in-network labs. – Builds upon analysis across plans to provide physicians with the most appropriate, in-network labs to perform the genetic test. From our own experience with plans representing 50M covered lives, out-of-network or “non-par” orders can cost two to four times the amount of the same order in-network. Providing the right lab choices via automated decision support helps drive lower medical costs and more optimal care.

• Policy and outcomes optimization to measure and manage utilization – Provides a real-time, detailed understanding and measurement of which tests are being ordered, by whom, and by which labs they are being performed. As such, plans can measure performance and quality, against which they can place appropriate incentives and scorecards to ensure effective reimbursement policies with clear engagement from their providers and labs.


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These new solutions reduce administrative costs and inappropriate medical spend by connecting key stakeholders and automating real-time clinical and financial decision-making at the point of care. They enable transparent, immediate access to coverage, medical appropriateness and network rules while driving consistent application of evidence-based medical policy. They also help self-funded plans manage cost and quality by providing timely, complete data on utilization and leakage trends – while supporting real-time, targeted provider interventions and providing a model for performance-based utilization management and value-based reimbursement.

Educating Physicians and Patients

Because genetic-level medicine is such a new science, and interpretation of results can have many consequences for patients, consider enabling genetic counseling services for your covered employees. Certified genetic counselors can advise both physicians and patients on the appropriateness of specific tests, what to expect as potential results and consequences, and can help in interpreting the results and assessing treatment options. These services can more than pay for themselves—up to 33% of cases that initially meet coverage policy criteria are deemed inappropriate after expert genetics review.

Managing Advanced Diagnostics is a “Now” Issue

With the lack of CPT codes, most insurers, including self-funded plans, are unable to identify their advanced diagnostic spend and determine if it is medically appropriate for its employees. Without the right tools, management of this spend

is even trickier. Industry data shows that the costs for these tests are significant and ramping at an aggressive rate. The good news is that innovative new solutions are now available at low cost relative to manual alternatives that can reduce inappropriate medical spend by connecting key stakeholders and automating real-time clinical and financial decision-making at the point of care. These solutions also empower self-funded insurers to drive care quality by coordinating post-testing care management and treatment plans. Those self-insurers that act now will be in the best position to address the fast emerging challenge of personalized medicine and can do so while better managing overall employee health.

About The Author

Matt Zubiller, business leader for Advanced Diagnostics Management, is responsible for leading initiatives that advance McKesson’s role in the realm of personalized medicine, genetics and molecular diagnostics. Before joining McKesson, he worked for a global strategy consulting firm in London, co-founded a spin-off from a leading Enterprise Resource Planning software and services vendor, and then founded and sold a boutique consulting practice working with early stage technology companies, entrepreneurs and venture capitalists in the US, UK, and India. He holds an MBA from London Business School, and a management of technology degree from the Berkeley College of Engineering and the Haas Business School. He can be contacted via email at [email protected]. To learn more about McKesson, please visit www.McKesson.com.


A R E Y O U A N D Y O U R C O M P A N Y

READY TO TRAVEL?by Fredric Havens

Is travel insurance really necessary and worth the added expense? According to the leading travel website Expedia, 19% of every traveler cancels or postpones their plans because of work-related reasons. A survey conducted by the Insurance Information Institute corroborated this trend by finding that 17% of travelers, one out of every six, file some type of claim during their business travels or vacations. Are you ready to travel? Travel insurance is widely regarded as the best way to protect travelers against a wide range of situations, well beyond emergency illness or injury. Even if your company group health plan covers typical medical circumstances, a business traveler would be well advised to upgrade to a comprehensive travel insurance policy for additional overseas business protection. The first step should be to check with the HR Department about your group coverage. Examine the policy to see what is, or what is not, covered. Does “healthcare abroad” appear in the policy? How about “medical evacuation?” If you company has an HAS or a Section 125 pre-tax plan, payment for this upgraded coverage would qualify. Don’t rely on the common misconception that credit cards give adequate travel coverage. The vast majority offer protections so narrow that they may as well have none at all. The same is true for domestic health insurance companies. Most do not cover foreign travel, nor do they have the logistics to help with most emergencies away from home. They may reimburse for emergency medical procedures incurred while traveling, but what about the rest? Medical evacuation is ruinously expensive and almost never covered. Terror delays are no longer as rare

travel risks that many employees travelers typically underestimate:

• foreign auto accidents

• legal help needed unexpectedly

• evacuation due to weather or natural disasters

• medical evacuation often costing as much as $100,000

• air ambulance from a remote local to a city large enough to host a modern hospital

• repatriation, whether for a health crisis, a lost passport or a military coup

• terror evacuation or kidnap/ransom protection for dangerous hotspots

• sudden departure prompted by a work-related emergency

• embassy referrals from experts on the ground

as in the past. Who hasn’t heard about a friend losing their passport at the most inconvenient moment? What if your need translation for a crucial prescription refill and you’re in Outer Mongolia? A typical comprehensive plan should provide a wide range of assisted services.The risk of travel delays should not be underestimated. In these unforeseen instances, who pays for the hotel and meals? Who finds the accommodations? Without travel insurance, you do.What about lost luggage?

That brand new business suit for the important meeting might have to be replaced overseas. Replacing a stolen laptop could deplete your traveling funds. The important documents in your carryon may have to be emergency couriered at a high price tag. Traveling abroad should be exciting and adventuresome. Having the foresight to insure away these risks with a comprehensive travel policy helps make this happen.


DUTY OF CAREVersus

“DUTY OF DOLLAR”by Shawn Austin


January 2011


DUTY OF CARE Globalization has brought today’s travelers to new, far-flung locations that they would not have visited even just a decade ago. From engineers and doctors to information technology specialists and banking financial executives, more and more people in a myriad of industries are traveling around the globe. Companies are also expandingoperations internationally, with a growing population of expatriates stationed around the world. At the same time that worldwide business travel is increasing, so is the frequency of natural disasters, political unrest, and terrorist incidents affecting travelers and expatriates. Disasters – both natural and manmade – pose a host of health, security, safety, and risk concerns for individuals traveling on business. For instance, a medical evacuation can cost at least $10,000, according to the U.S. Department of State, and can easily have a pricetag in excess of $100,000 in more remote areas of the world. Now, more than ever, employers are faced with the challenge to control costs. At the same time, employers have a legal, fiduciary, and moral Duty of Care for their

employees. This responsibility extends globally and must apply to employees stationed in all corners of the world. Meeting this very important and essential Duty of Care obligation is more challenging than ever. The question becomes: “How can employers balance the need to send employees overseas and protect these employees, while still keeping an eye on the bottom line?” One solution is a comprehensive travel risk management program that incorporates extensive international security and medical assistance services available on a 24/7 basis for overseas travelers and expatriates. Benefits of such a program include: protecting the health and safety of traveling employees, mitigating potential legal and financial liability, protecting the company’s brand and reputation, fulfilling corporate social

responsibilities, meeting shareholder and stakeholder expectations, and contributing to the recruitment and retention of key employees. Even in times when increasing

How HR and Risk Professionals Can Still Care for Employees While Watching Their Costs



emerging regions of the world – human resource directors, risk managers, and travel managers still need to watch expenses. HR professionals are tasked with evaluating and selecting a cost-effective benefits program for their employees. Increasingly, they are being called upon to provide, evaluate, and select comprehensive travel risk management programs that incorporate extensive international security and medical assistance services. When evaluating travel risk management options, company decision makers should look for a provider that offers cost management solutions, while continuing to provide high-quality service. These solutions should also take into account and help address Duty of Care requirements. Since no two organizations are the same, you want a program that can be customized to meet the unique needs of your organization. For instance, you may want a program that has assistance and insurance benefits integrated into one solution or you may want a program that has assistance services that can be fully integrated with your existing insurance approach. For example, if the assistance program is fully integrated with a company’s travel management program and there arises the need to provide last-minute or business class travel for an injured or ill executive, the costs could be substantially lowered. Also, you want a travel risk management program that provides travel alerts and warnings for high-risk destinations. When speaking to potential travel assistance providers, make sure to ask how they will keep your employees informed on up-to-date health and safety information while your employees are traveling. Some providers maintain dedicated customer or member web sites and/or

provide the capability to send e-mail alerts and text messages with the latest updates. In addition, examine the cost drivers once you have fully assessed a provider’s quality.

Ask these questions: • Is there a fee for service? • Is there a mark-up for third-party expenses? If you currently have a program, but you’re not sure if it’s working as efficiently as it possibly could or providing all the services your company needs, request that an assessment be performed. Some providers will do this free of charge, and it is a great way to compare your program to industry best practices so that you get an objective view of your company’s travel risk practices. Make sure that the assessment takes a look at such items as your travel medical policy, travel security policy, pandemic policy, expense patterns, crisis response plans, governance and strategic development and team


January 2011


composition. Lastly, but possibly most vital, is that once you’ve selected a provider and have a program in place, make sure you communicate this information to your employees on an ongoing basis. It doesn’t do your employees any good if you have a great travel risk management program that they are not aware of when they travel. Offer this information in your company newsletter. Also, consider sending internal e-mail blasts that are repeated and instruct department heads to brief their staffers about this program. Communication and understanding of these programs are essential, if they are to be utilized to their fullest potential and greatest benefit to travelers within your company.

Knowing this important information in advance is a key component in being able to contain costs and manage an efficient and well-developed travel program. And, at the same time, you can provide Duty of Care and quality care for employees who are venturing out to the far reaching corners of the globe.

Shawn Austin is the Senior Vice President, Employer Markets at the Accident & Health Division of Chartis




The Changing Face of Healthcare: Understanding the Medical Loss Ratio

By Arthur Tacchino, J.D.

The Affordable Care Act created a new regulation designed to bring down the cost of healthcare through the use of a new medical

loss ratio standard. This is an extremely complex regulation and this article will spell out what it actually required of the various parties it regulates. Essentially, this is a new reporting and rebate requirement for health insurance issuers. Generally speaking, insurance issuers will be required to submit reports for the large group, small group, and individual markets in each state

the issuer does business. In each market, a medical loss ratio standard is set. For individual and small group markets (groups of 100 or fewer employees), issuers must spend 80 percent of premiums on “medical care”. In large group markets (groups of 101 or more employees), issuers must spend 85 percent of premiums on “medical care”. If the medical loss ratio standards are not met for any market, issuers must rebate premiums to all plan enrollees on a pro rata basis. The regulation allows the Secretary of HHS to adjust the MLR standards for a state’s individual market if it is likely that the MLR standard will destabilize that market. Under the MLR regulation, HHS also may impose



civil monetary penalties on noncompliant health insurance issuers. It is also important to note that States can set higher MLR Standards for their markets than required by these regulations. The term “medical care” was at the heart of the MLR debate. The National Association of Insurance Commissioners (NAIC) was charged with creating uniform definitions of activities reported under this requirement and standardized methodologies for calculating the medical loss ratio. HHS has adopted the NAIC’s final MLR regulations. These new regulations apply to health insurance

issuers offering group or individual health insurance coverage. The regulations create special rules for expatriate plans, “mini-med plans”, and newer plans due to their special circumstances.

Issuer’s Reporting Requirements

The MLR regulations require issuers to submit an annual report to the Secretary of HHS for each plan year (note that plan year is defined as a MLR reporting year). The report must contain information related to earned premiums and expenditures in various categories, including:



• Reimbursements paid for clinical services provided to enrollees,

• Activities that improve healthcare quality, and

• All other non-claims costs, including an explanation of the nature of such costs, but excluding federal and state taxes and licensing or regulatory fees.

This report also must include information regarding any rebates to plan enrollee’s that the issuer was required to make because of failure to meet the MLR standards. These reports give a level of transparency that is unprecedented. HHS will post these reports on a website where consumers can see how their premium dollars are being spent. The due date of this new reporting requirement will be the June 1st that follows the MLR reporting year. This means that for the 2011 MLR reporting year, reports must be submitted to the Secretary by June 1, 2012. This allows issuers to report claims for services provided during the MLR reporting year that are processed and paid

in the three months following the end of the MLR reporting year. It also gives issuers another two months to compile and submit the required data.

Activities that Improve Health Care Quality

One of the main questions arising from the MLR debate was: “What is included in the “activities that improve healthcare quality” portion of the medical loss ratio?” Parties from both sides lobbied for various definitions of the equation that would favor either the insurance issuers or the consumers. In the end, most observers agree that consumers defeated the issuers in the fight. The final MLR regulation allows non-claims expenses incurred by a health issuer to be counted as a quality improvement activity only if the activity meets all of the following requirements. The activity must be: • Designed to improve health quality;• Designed to increase the likelihood of

desired health outcomes in ways that can



be objectively measured and that produce verifiable results and achievements;

• Directed toward individual enrollees, for the benefit of specified segments of enrollees, or provide health improvements to the population beyond those enrolled in coverage (as long as no additional costs are incurred due to the non-enrollees); and

• Grounded in evidence-based medicine, widely accepted best clinical practice, or criteria issued by recognized professional medical associations, accreditation bodies, government agencies or other nationally recognized health care quality organizations.

Generally, any health information technology expenditure that clearly improves healthcare, prevents hospital readmissions, improves patient safety, reduces errors, or promotes health activities and wellness will also be classified as a quality improvement activity.

Activities that are NOT to be reported as quality improvement activities are:

• Those activities designed primarily to control or contain costs;

• Concurrent and retrospective Utilization Review;

• Fraud Prevention Activities; • Development, execution, and management of

a provider network;• Provider credentialing; • Marketing expenses;• Costs associated with calculating/

administering individual enrollee or employee incentives;

• Clinical data collection without any subsequent data analysis;

• Establishment and/or maintenance of a claims adjudication system; and

• 24-hour customer service/or health care

professional hotline addressing non-clinical member questions

It is important to note, that despite a strong attempt by brokers and agents, commissions were excluded from this category of “activities that improve healthcare quality”, essentially excluding them from the medical care portion of the equation. This will greatly impact how agent and broker compensation will be structured and paid by insurance issuers. It will likely mean downsizing of agents and brokers by insurance companies purely due to fee structure and budgetary concerns.

“Special Circumstance” Plan’s Reporting Requirements

As previously mentioned, the MLR regulations also created separate reporting requirements for so-called “special circumstance” plans. These plans include expatriate plans, “mini-med” plans, and newer experience plans.

Expatriate Plans & “Mini-med” Plans

Expatriate plans generally cover employees working outside their country of citizenship, and employees working outside the employer’s country of domicile. “Mini-med” plans often cover the same types of medical services as comprehensive medical plans but have unusually low annual benefit limits. Due to these plans’ special circumstances, issuers of these plans will report their experience separately from the other markets. Reporting will be on a quarterly basis, and the medical loss ratio calculation of claims and quality-improving activities is multiplied by a factor of two, to add credibility to the ratio. This special separate reporting requirement will last only in 2011 at which time HHS will determine what is appropriate for 2012.




Newer Experience

Due to unique circumstances for plans with newer experience, issuers can defer both the premium and claims experience, as well as the life-years, for policies first issued after the start of the MLR reporting period (after January 1, 2011) to the next MLR reporting year. That is, if these policies account for more than half of the issuer’s experience in a market segment for an individual state. This rule was created to alleviate the issue of unpredictable claims.

Calculating and Providing the Rebate Calculating the MLR and rebate employs a complex equation developed by the NAIC. Insurance issuers will be responsible to make this calculation. The calculation allows issuers to apply credibility adjustments to partially credible

groups. A credibility adjustment modifies the reported MLR of an issuer by adding reliability to an otherwise unreliable statistic. Partially credible groups are those that have between 1,000 and 75,000 life years. A life year is the number of member months divided by 12. Groups with 75,000 life years are considered fully credible and will not be allowed to make a credibility adjustment. Groups with 1,000 or fewer life years are not credible and therefore are not required to rebate premiums to plan enrollees.

Rebating Premium if MLR Standard is not Met

The MLR regulations require that if the medical loss ratio standard is not met for a market, premium rebates must be made to plan enrollees. Notice of rebates to enrollees is required only if issuers have not met the MLR standard. The



rebate paid to each enrollee is based on the earned premium paid by (or on behalf of) the enrollee, minus taxes and other permissible adjustments taken by the issuer. Rebates are made on a pro rata basis. There are special rules for de minimis rebates, unclaimed rebates, and situations where rebates may force an issuer into insolvency. Rebates must be made annually and paid by the August 1st following the MLR reporting year, which means the first rebates are due by August 1, 2012. Issuers can choose the form of rebate for current employees, but not for former employees. For former employees, issuers must disburse checks to enrollees. For current employees, the issuer can disburse rebates as either a premium credit or a cash lump sum. This lets the issuer decide which form is less of an administrative burden.

Simplified Example of Rebate Calculation:

Assume a plan has 200 participants. Each participant pays $9,000 dollars each in premiums (we assume participants pay equal amounts, even though that is generally not true). The total premiums would be $1,800,000. Since this plan is in the large group market, it would be subject to the 85 percent MLR standard (we assume this plan is fully credible, but a credibility adjustment could make this much more complicated). That means that $1,530,000 (85% of $1.8 million) must be spent on medical care, as defined by the NAIC. Now, assume the issuer only spends $1,200,000 for the plan year on medical care. This means that $330,000 ($1,530,000 - $1,200,000) must be rebated to plan enrollees. Since plan enrollees paid equal amounts of premiums, they would each receive a rebate of $1,650 ($330,000 divided by 200 plan participants). Note that rebates are paid on a pro rata basis, so enrollees that pay higher premiums are entitled to higher rebates.

Impact of MLR Regulations:

This example should give a taste of how important this regulation is to both issuers and consumers. It will radically change how insurance issuers operate in the industry. This article has been an overview of the basic requirements of this complex new regulation. MLR regulations will subject issuers to greater transparency and complex spending requirements. The practical effect of this regulation on health insurance issuers will be a squeeze on their business. Some issuers are already operating at a high level and will have no problem satisfying these new spending requirements. Others will struggle to meet these new MLR standards. We will likely see several insurance issuers merge to streamline their business models and adapt to these new requirements. Only time will tell what effect the new MLR requirements will have on health insurance issuers, agents, and brokers in the healthcare industry.

About the Author:

Arthur Tacchino is an Assistant Professor of Health Insurance at The American College. Arthur received his J.D. from Widener School of Law and his B.S. of Economics from Susquehanna University. Arthur is currently designing courses for The American College’s new premier healthcare designation, the Chartered Healthcare Consultant™ (ChHC™). Professionals who want to learn more about the MLR and other aspects of healthcare reform can reserve a place in the ten-week webinar course Essentials of Healthcare Reform by visiting TheAmericanCollege.edu/healthcare. The courses of the ChHC™ curriculum provide a competitive advantage for benefits consultants and other industry leaders who want to differentiate themselves in the complex new world of healthcare reform.




Having an Anti-Jerk Policy as Part of your Corporate Wellness Strategy:

Defining the Problem and the Impact of Workplace Bullying

by LaShanda Blissett, MS and Rachel Levine, PhD, MSPH

This is the first article in a series addressing workplace bullying. The article below defines the problem and its consequences. Next month we will explore strategies to improve this problem. When budgets are tight and the risk of programs being cut is high, what elements of an employee wellness strategy should be retained? For many corporations, the answer is fairly simple: those programs that increase the levels of employee engagement and satisfaction. Current research on this topic confirms this theory. According to Barry Hall, a Principal with Buck Consultants and the global leader of Buck’s

wellness research, “Our 2010 global wellness survey indicates that employers are putting additional focus on improving employee morale and engagement, likely due to concerns that employees have become disengaged throughout the recession. Employers recognize that retaining workers will become increasingly challenging as the job market is revitalized, and being a good place to work with a healthy culture will help them keep their best employees.” The difference between a “good” place to work and a “not-so-good” one often boils down to the relationships our workers have with their bosses and their peers. A phenomenon that has received a lot of popular press lately is the notion of workplace bullying – which is the antithesis of what happens in a healthy office setting. Workplace bullying is repeated harassing behavior that is deliberately



intended to cause harm to individuals and prevent them from excelling at work. It is a form of emotional harassment that is frequently targeted at competent employees, by their peers and, often, by managers and supervisors. Literature consistently reveals that workplace bullying, done deliberately or unconsciously, clearly causes humiliation, offense, distress, interferes with job performance, and contributes to an unpleasant working environment (Heames and Harvey, 2006). When negative comments and intentional acts of targeted mistreatment of employees persists; organizations risk being sued, developing a negative reputation for permitting uncivil behavior, and losing the overall respect of competent employees who would otherwise be loyal and productive contributors (Heames and Harvey, 2006). In 2007, the Workplace Bullying Institute (WBI) conducted a Zogby survey, and reported an estimated 37% of employees in the United States had been bullied at work. Since the onset of the economic recession in September of 2008, the problem has gotten worse (WBI, 2010). Employees have reported this issue is a direct cause of their individual dissatisfaction on the job, high stress levels, high absentee rates, and emotional illnesses that even lead to depression. Knowing that over 80% of bullied employees leave their jobs (Marie, 2010), which costs organizations an estimated $180 million dollars in lost productivity each year (Heames and Harvey, 2006; Farrell, 2002), creating an anti-jerk policy combined with a workplace bullying prevention program could be a key to saving a corporate wellness program. Within organizations where bullying is ignored or little to nothing is done to stop or prevent it, the targets end up accruing a variety of costs that can range from ill health, tarnished professional reputations, and reduced productivity from high absenteeism (Farrell, 2002; Heames and Harvey,

2006; WBI, 2010), and in some cases suicide. A recent example is Kevin Morrissey’s publicly debated suicide, which is suspected to be a result of him enduring ongoing stress from workplace bullying at the Virginia Quarterly Review (Wilson, 2010). Many of the indirect costs to individual targets add up to become organizational problems, such as toxic work environments in which employees lack the




basic level of trust needed for teams to successfully work and produce together. So, what can be done to prevent workplace bullies in the first place, or keep them at bay? Dr. David Ballard, the head of the American Psychological Association’s Healthy Workplace Program suggests, “Organizational leaders can promote a psychologically healthy workplace by modeling desired behaviors, rewarding pro-social conduct and training managers to identify and address counter-productive interactions. Formal policies regarding bullying and incivility can also help communicate clear expectations and promote a culture of trust and respect. “ The creation of a psychologically healthy workplace is not a new idea in corporate wellness, but it is often ignored in favor of other initiatives such as weight management, nutrition, and health screenings. The American Psychological Association (APA) hosts a resource-rich program c a l l e d

“The Psychologically Healthy Workplace Program.” In the creation of a Psychologically Healthy Workplace, the APA advocates for five types of workplace practices that contribute to a psychologically healthy work environment, including: employee involvement, work-life balance, employee growth and development, health and safety, and employee recognition (Psychologically Healthy Workplace Program, 2010). Focusing on employee “health and safety”, the APA broadens the typical notion of occupational safety to include efforts that improve physical and mental health, reduce health risks, and manage stress effectively. If programs that address those goals are implemented correctly, a company could benefit from greater productivity, reductions in: healthcare costs, absenteeism, and accident and injury rates (Psychologically Healthy


January 2011



Workplace Program, 2010). Workplace “bullying” creates a toxic environment for employees, and is one example of what a comprehensive mental health strategy could address. The notion of “bullies” or “jerks” is nothing new – but the measurement of their effects on our people is astounding, which is why Gold’s Gym, Washington Mutual, Berkshire Hathaway, and Mozilla are a few of the firms that maintain a “no jerk policy” to sustain a healthy work environment (Sutton ,2010). They know bullies affect the bottom line and create toxic environments in which employees become ill and disgruntled. Corporate Wellness needs to be redefined, to include comprehensive mental health programs and strategies. As an industry, it is essential to focus time and attention on the widespread workplace bullying phenomenon and develop new ways of teaching employees this behavior is unacceptable. One suggestion is for the different parts of an organization to communicate with each other. If human resources, Employee Assistance Programs, and wellness Directors were all part of a universal plan to prevent bullying and other uncivil behavior among supervisors and peers, perhaps we would all be better off!

LaShanda Blissett is a PhD student at Capella University, working toward a Doctorate in Education with a specialty in Training and Performance Improvement. She is the Principal Consultant with The Blissett Group, Corp, a management consulting firm based out of Rockville, MD, near Washington, DC. She has over 19 years of professional experience, over 15 of which has been in training and performance improvement on federal government contracts. Her roles have ranged from instructional design consultant to training manager. LaShanda can be

reached via email at [email protected] or by phone at (301) 442-7788. Rachel Permuth-Levine, PhD, MSPH, is a public health practitioner and an expert in worksite health promotion. As a health behavior theorist, she strives to use evidence-based programs that produce the best results for her employees. Rachel is also a yoga and fitness instructor. Rachel can be reached via email at [email protected].

ReferencesFarrell, L. (2002). Workplace bullying’s high cost: $180M in lost time, productivity. Orlando Business Journal. US: March 15, 2002. Retrieved on September 4, 2010, from http://orlando.bizjournals.com/orlando/stories/2002/03/18/focus1.html#ixzz0ynFODaOO.Heames, J., Harvey, J. (2006). Workplace bullying: a cross-level assessment. Management Decision. London: 2006. Vol. 44, Iss. 9; pg. 1214.Kesten, G., Savino, K. (2010). The 2010 implementation awards. Speech Technology. Medford: Jul/Aug 2010. Vol. 15, Iss. 4; pg. 32, 5 pgs.Know Bull! Australia. (2010). http://www.know-bull.com Marie, S. (2010). Reacting to abusive managerial behavior: A qualitative phenomenological study. Dissertation, University of Phoenix: Phoenix, AZ, 201 pages; AAT 3415970Workplace Bullying Institute (WBI). (2010). WBI Zogby Survey Results. The Workplace Bullying Institute. Retrieved on September 5, 2010, from http://www.workplacebullying.org/research/WBI-Zogby2007Survey.html.New South Wales Court docket. Nationwide News Pty Ltd v Naidu & Anor; ISS Security Pty Ltd v Naidu & Anor [2007] NSWCA 377. Retrieved September 5, 2010, from http://www.austlii.edu.au/au/cases/nsw/NSWCA/2007/377.html.Sutton, B. lashanda – which article do you want cited and how?Wilson, R. (2010). What Killed Kevin Morrissey? How the death of an editor threatens the future of the University of Virginia’s prestigious literary review. The Chronicle of Higher Education: August 12, 2010. Workplace Bullying Institute. (2010). Retrieved October 4, 2010, from http://www.workplacebullying.org/research/wbi-studies.html.Young, L. (2008). Bullying worse than sexual harassment: Study. Canadian HR Reporter. Toronto: April 7, 2008. Vol. 21, Iss. 7; pg. 1, 2 pgsLaShanda and Rachel welcome your feedback for future articles on this topic. Please write to Ms. Blissett at the email below.

Bio





Health policies are sold in Spain in two modalities. The first one provides healthcare services through a closed list of doctors and hospitals that have agreed to work with them. The second one permits free access to any doctor or hospital. The company reimburses the cost of the service to a percentage afterwards. Both types present a time limit of three months when covering healthcare assistance abroad. So, when a family has to move to a foreign country for a long period or has to send the kids to study abroad, the healthcare problem arises for there are very few countries that have a public and universal heath service like Spain or that have

exchange agreements for mutual service. INESE, the Spanish insurance publishing division of Reed Business Information, published in 2008 an in depth study that compares the different healthcare products for expatriates available in the country. The study clearly sets two groups of actors in this market: health insurance companies -that provide higher capital limits for hospital and out-patients care- and travel insurance companies. Health insurance policies, as a hole, are structured in modules that permit multiple combinations of the different types of healthcare: hospitalization, out-patient assistance and

by Cristina García




maternity, which permit the insured to choose covers according to his/her needs. Capital levels for hospital services in these policies range between 500,000 and 7 million Euros, enough to face the costs of any pathology, as serious as it might be. In this point, it gets important to get acquainted with the health system of the country of destination as well as with the different contingencies that might arise during a recovery process. If all this is known beforehand, the insured will be able to purchase a policy that meets his/her needs. For an executive that travels a lot to foreign countries, travel insurance policies would suit him/her perfectly,

for he/she will most probably get coverage at a very good price without having to make a second policy. Besides, travel insurance policies usually include other interesting covers like the one that sends a deputy executive to replace the one that gets ill, allowing the company to reduce the cost of sending a replacement. The difference between health and travel insurance policies for expatriates also reflects in premiums. They depend on the amount of capital offered for each cover, the geographical area of the country of destination and the size of the group to insure.


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By Les C. Meyer, MBA and Ronald Parton, MD, MPH

Gentlemen, Start Your Engines!

In the eyes of a CEO, businesses create jobs, innovate, manufacture and provide the services that drive economic growth. Yet lack of inertia along the frontier of health and performance improvement (HPI), continuous value enhancement, is significantly restricting Corporate America’s ability to accelerate growth to achieve a sustainable global competitive advantage.

Imagine the Unimaginable

CEOs view the meaningful use of health improvement as a strategic imperative and serious economic strategy. They also demand that C-Suite

executives optimize the total economic impact of employee health to maximize an individual’s health achievement potential and job satisfaction expectations through personal and organizational performance results.

Their population health framework focuses on improved health, enhanced on-the-job professional experiences, proactive meaningful productive interactions and reduced per capita cost of a company’s defined population, which includes employee satisfaction and total rewards initiatives that enable employees to define their own needs and expectations as distinct choices.

In order to yield hard returns on employee and family population health programs and “bend the health care cost curve”, CEOs must lead by example and steer cross-functional work teams toward relentlessly fostering a value-centric culture of health, which becomes a self-


perpetuating competitive advantage. This is accomplished by engaging disengaged employees, embracing meaningful use of health achievement benchmarks and metrics, creating C-Suite visibility for innovative health and wellbeing indices, supporting individual financial security aspirations, aligning meaningful incentives and helping people get the best out of life.

Transformation Life Cycle at Work

Sounds great. So why hasn’t the worksite wellness industry taken off? Something is amiss. CEO’s are not accelerating the meaningful use of health improvement best practices and transforming their work force into thriving wellbeing people that yield triumphs in on-the-job engagement rates, declines in presenteeism, accolades in health and wellbeing index resiliency scores and upticks in profits.

Why? CEO’s don’t’ believe the pitch. To make matters worse, the business case doesn’t resonate with disengaged employees, many of whom resent being told just how healthy, productive, well, at-risk, flexible, disengaged, or empowered they should be in a climate of substantive cost-shifting and work-life imbalance.

The term ”value creation” can be a misnomer, but for CEOs it is simple: delivering additional value to the bottom line through a new wave of breakthrough ideas that empower people to improve decision-making and business performance. Value is in the creation of getting things done. Savvy

CEOs focus on execution and breakthrough ideas that create real-time meaningful distinctions in their companies and promote team achievement and insightful exchange of information for sound decision making.

CEOs believe value is built on four essential elements: trustworthiness and trust, engagement and incentive alignment, relevant information and distinct choices. According to a recent study of the Informed Opinion Leadership Action Group – Employer Market Sector, value creation is defined as meaningful productive interactions and personalized experiences of employees, their families and caregivers. Population HPI means that consumers will have greater control over decisions affecting their health affairs and be inspired and motivated by the aforementioned four essential elements. [See Table 1]

Higher profits from a healthier work force elude most CEOs, because they don’t have a straightforward C-Suite measurement of value scorecard to improve their day-to-day worksite wellness monitoring system to sustain a competitive advantage. The complexity lies in drawing that value out of evidence-based approaches to meaningful use of work life health and wellbeing scorecards, dashboards and cockpits that contend with real-world settings. CEOs are faced with an overabundance of tangible and intangible metrics, as well as distinctive secondary employee benefits data, that challenge health and human capital executives.


January 2011


New Era of Population Health Population health is an employer-employee collaborative that seeks to realign the neighborhood health care delivery system, which is widely recognized as fragmented, ineffective, poorly managed, wasteful and economically inequitable. The IOLAG: Employer Market Sector report recently profiled its population health vision in interviews with 20 informed opinion leaders:

Table 1




Table 2

Putting the needs of employees and their families first in the context of neighborhood health assurance will potentially unleash disruptive improvement in the workplace and will drive “The Triple Aim” advocated by Dr. Donald Berwick when he was president of the Institute for Healthcare Improvement. What do population health and the Triple Aim have in common?

A focus on the improved health and wellbeing of employees, enhanced worksite engagement, personalized experiences of employees with their trusted family clinician and reduced per capita health benefit costs, as well as employee satisfaction and wellbeing benchmarks through which employees define their own personal needs and concerns as a core component. [See Table 2]


January 2011



The Triple Aim business model engages the foresight of the definition of optimal health. More importantly, the population health triad ap-proach to employer cost avoidance of health bene-fits trend, evidence-based care coordination while reducing the per capita costs of an employer’s benefits costs resonates nicely with CEOs who are scrambling to bend the cost curve.

Accelerating Rules of the Road

Industry experts and researchers agree that today’s No. 1 critical business issue is to initiate and maintain employee population health and in-centive programs without putting significant fi-nancial burden on the company. It’s all about ex-ecution and C-Suite strategy to increase employee satisfaction and retention, bend the cost curve and recruit and retain people who meet or exceed both pay-for-performance and personal objectives — thus, creating aligned incentives for employee and employer, alike. Any organization’s healthy per-formance strategy requires a strong commitment from the C-Suite to optimize the total economic impact of employee health, as well as clinical and functional outcomes.

The next generation of population health programs should be built around the meaningful use of health benefits design and total wellbeing that pinpoints healthy living and working strate-gies, as well as designates healthy performance best practices to improve individual and corporate performance. Employers must focus in order to foster a caring corporate culture that enables em-ployees to achieve these results, regardless of per-sonal health status or multiple risk factors.

Innovative business coalitions and savvy employers have found that the creative and in-tensive use of population health programs and other tools, techniques and best practices can help prevent many chronic conditions and delay the onslaught of mortality, as well as improve out-

comes and quality of life. New consumer-centered “neighborhood culture of health” programs are emerging worldwide and occur when a proactive population or community of covered lives bands together to make the right lifestyle, health and wellness choices as a result of a convergence of in-terests and alignment of employer, employee and provider support systems, structures and processes for the benefit of employees and their families.

With the emphasis on consumerism and the associated cost and risk shifting to the employ-ee, the idea is to embrace a business approach that satisfies what matters most across each diverse talent pool: employee health, job satisfaction and pay for performance. Executives that utilize these employee-centric, population health improve-ment initiatives also must recognize that the cost of absenteeism and lost productivity, including impaired performance on the job, is much bigger than the cost of health benefits in terms of having an impact on organization-wide results.

The thinking behind this new popula-tion health strategic imperative and serious eco-nomic strategy is to implement a built-in culture of health enabling benefits design and integrated employee health interventions that include a per-formance-driven focus on the recruitment, reten-




tion, engagement, deployment and optimization of all involved. Employee health and optimal per-formance has more to do with a conducive envi-ronment, healthy behaviors, beliefs, attitudes, job satisfaction, compensation and work-life balance than solely affordable access to health insurance benefits.

The overarching goal is to foster the vision that keeping people healthy is a community-based, economic imperative and business strategy for employers, employees, government and taxpayers alike. Employers must step up to protect, engage sustain and promote the health and well being of their employees, as well as reward healthy be-haviors and optimal individual performance. As a result of consistently taking care of their people, employers will benefit from thriving wellbeing people via better on-the-job engagement rates, execution-centric human capital deployments to achieve company goals, rewarding corporate train-ing investments in people opportunities, appropri-ate retention levels and improved profits for the company. In order for this new thinking to really pay off, employees must also benefit from their in-vestment in their improved personal performance and the economic wellbeing of their employer of choice.

All Aboard Next-generation population health ini-tiatives require a collaborative effort that includes an employer employee partnership, array of pro-viders, value-focused vendors and community re-source groups. The role of the employee is vital in terms of creating health and performance-based talent management programs, since these are the very people who need to be engaged in order to live healthier and to personally perform at optimal levels at work and home.

The key to success in an increasingly com-petitive global economy will be integrating a mod-

el with performance-focused talent-management strategies that lay the groundwork for a wiser in-vestment in human capital. What attracts employ-ees to jobs and keeps them from looking elsewhere also results in improved health outcomes and op-timized job performance. It’s more than healthy people equating to healthy bottom lines. It’s rec-ognizing that people should be paid for better per-formance. And when they feel better, they perform better. When they perform better, everybody wins.

How can current worksite wellness programs be retooled to inspire healthier living and peak perfor-mance to yield both personal and corporate gain? It is not easy to change organizational cultures and to achieve sustainable health improvement. The time has come, however, to acknowledge in the C-Suite that population health is the silver bullet we have been hoping for all along. CEOs view the meaningful use of health improvement as a stra-tegic imperative and serious economic strategy. It will take a nation to raise population health to the next level.

Les C. Meyer, MBA, a seasoned health care strategist and vice president of HealthNEXT, se-nior fellow, Jefferson School of Population Health, Thomas Jefferson University, chairman, Informed Opinion Leadership Action Group (IOLAG): Employ-er Market Sector, and can be reached at (303) 916-0017 or [email protected].

Ron Parton, MD, MPH, is the chief medical officer of Symphony Corporation and is responsible for steering the direction of Symphony’s capabilities and service offerings in the healthcare sector. With over 20 years of operational experience, Dr. Parton is a physi-cian executive with a proven track record for innova-tion in population health improvement and improving quality that results in lowered healthcare costs. He is leading the development of the new Symphony Care Management System, designed to interface with elec-tronic health records and help accountable care orga-nizations and health plans target high risk populations, improve care and reduce unnecessary medical costs. Dr. Parton can be reached at (608) 237-7890 or [email protected].


January 2011



By Melvin J. Howard

There is an industry that in the past has been more profitable than the commercial banking sector. Can you guess which one? It has been the pharmaceutical industry.

You can’t have meaningful health care reform without pharma reform. From the never-ending search for the elusive “Blockbuster Drug”, to the ongoing need for more increasing shelf space, we have allowed the capital markets and the patented medicine model to dominate decision-making when it comes to our health care. The pursuit of finding remedies for the human illness is a noble cause and one that has made

life bearable and some diseases curable. But if we continue with this same model unchecked it may very well end how the capital markets work as we know it, giving them an incurable disease that could be terminal. Capital that flows into drug research and development is obsessed with a couple of issues that are mostly monetary in nature. The industry is failing to notice something far more menacing just over the horizon. The global HIV/AIDS crisis, already striking at the very thing the capital markets need to survive market players.

As the epidemic rips into Africa, China, and India, will the U.S. be able to continue its low level support for this crisis of the developing world? Or will the threat to the labor force of our major trading partners provide the shock necessary to remind us

PHARMA REFORM&WORLD TRADE



that illness prevention and cure is a social service that does not fit well into the confines of 20 to 30 year patent monopolies. Will the exponential growth of HIV/AIDS in Eastern Europe and the former Soviet states, right on the doorstep of the European Union, wake up the rest of the West to the need to either act now, or risk losing their global marketplace? There are many arguments both for and against the patent model for pharmaceutical development; I shall touch on just a few.

As in most industries, the capital markets drive the classic predator-prey dynamics; the pharmaceutical sector is no different. As the fictional character of Gordon Gecko of Wall Street fame said, “You either eat or you get eaten!” Let’s go back to 1995 when much of the mega-merger business in the pharmaceutical industry was just getting underway;

• Glaxo Holdings gobbled up Wellcome Plc to form Glaxo-Wellcome

• Novartis was formed out of the merger of Ciba-Geigy and Sandoz

• 1998 saw the creation of Aventis out of the fusion of smaller drug companies

• AstraZeneca from Astra and Zeneca

• Pharmacia & Upjohn scooped up Monsanto, the controversial agribusiness

• In 1999 Pfizer swallowed Warner-Lambert Glaxo-Wellcome

• Smith-Kline-Beecham were fused together to form GlaxoSmithKline in 2000.

• Pfizer and Pharmacia then announced their merger, to outsize GlaxoSmithKline, to become the biggest kid on the block.

There are still more rumours of even bigger mergers yet to come.

The pharmaceutical industry of today started in the late 1800s when it became possible

to mass-produce compounds such as morphine and cocaine. By the early twentieth century drugs and compounds were patented by various companies to protect their discoveries. A patent on a branded drug or chemical gives the company a monopoly on sales of that chemical for a specified period, enabling them to set high prices in the absence of competition. The argument for patent protection is that it enables the developer to recover their investment in R&D plus a profit, hence providing incentive to private industry to find new cures. However, in order for the company to lure customers into buying such a high priced product, they also need to spend a lot of money on advertising and marketing to convince people that its products are the best.

Today, the brand name drug companies look nothing like their chemical ancestors of the 1800s. New products require large investments in R&D and take a long time to bring to market. The drug giants are dependent on patents, marketing and branding to make a profit. Consequently, the pharmaceutical sector has more in common with the movie industry than with any public service provider. A new drug must become a profitable “Blockbuster”, or it will not be worth the cost of development. In contrast, generic drug companies spend comparatively little on R&D and advertising, existing primarily to compete for market share based on price once a patent on a brand name drug has expired. Once such a patent expires, generic companies can copy the drug and can afford to sell it at a lower price since they don’t have as much R&D and advertising costs to recoup.

that illness prevention and cure is a social service that does not fit well into the confines of 20 to 30 year patent monopolies. Will the exponential growth of HIV/AIDS in Eastern Europe and the former Soviet states, right on the doorstep of the European Union, wake up the rest of the West to the need to either act now, or risk losing their global marketplace?


January 2011



There are many arguments both for and against the patent model for pharmaceutical development; I shall touch on just a few.

As in most industries, the capital markets drive the classic predator-prey dynamics; the pharmaceutical sector is no different. As the fictional character of Gordon Gecko of Wall Street fame said, “You either eat or you get eaten!” Let’s go back to 1995 when much of the mega-merger business in the pharmaceutical industry was just getting underway;

• Glaxo Holdings gobbled up Wellcome Plc to form Glaxo-Wellcome

• Novartis was formed out of the merger of Ciba-Geigy and Sandoz

• 1998 saw the creation of Aventis out of the fusion of smaller drug companies

• AstraZeneca from Astra and Zeneca

• Pharmacia & Upjohn scooped up Monsanto, the controversial agribusiness

• In 1999 Pfizer swallowed Warner-Lambert Glaxo-Wellcome

• Smith-Kline-Beecham were fused together to form GlaxoSmithKline in 2000.

• Pfizer and Pharmacia then announced their merger, to outsize GlaxoSmithKline, to become the biggest kid on the block.

There are still more rumours of even bigger mergers yet to come.

The pharmaceutical industry of today started in the late 1800s when it became possible to mass-produce compounds such as morphine and cocaine. By the early twentieth century drugs and compounds were patented by various companies to protect their discoveries. A patent on a branded drug or chemical gives the company

a monopoly on sales of that chemical for a specified period, enabling them to set high prices in the absence of competition. The argument for patent protection is that it enables the developer to recover their investment in R&D plus a profit, hence providing incentive to private industry to find new cures. However, in order for the company to lure customers into buying such a high priced product, they also need to spend a lot of money on advertising and marketing to convince people that its products are the best.

Today, the brand name drug companies look nothing like their chemical ancestors of the 1800s. New products require large investments in R&D and take a long time to bring to market. The drug giants are dependent on patents, marketing and branding to make a profit. Consequently, the pharmaceutical sector has more in common with the movie industry than with any public service provider. A new drug must become a profitable “Blockbuster”, or it will not be worth the cost of development. In contrast, generic drug companies spend comparatively little on R&D and advertising, existing primarily to compete for market share based on price once a patent on a brand name drug has expired. Once such a patent expires, generic companies can copy the drug and can afford to sell it at a lower price since they don’t have as much R&D and advertising costs to recoup.

After successes and record high profit levels throughout the 1990s, all is not well in the pharma world of blockbuster remedies. The looming patent expires, resulting in competition from generic companies, a drug R&D pipeline that is drying up, and angry governments, corporations, consumers and managed-care companies tired of high drug prices. With health reform there are calls to reform the pharmaceutical industry throughout the U.S.

These common enemies are forcing all these unions amongst the drug giants who hope




that consolidation will allow them to do more of their two favourite things at lower cost. These two things are (1) Advertise and (2) Produce Blockbusters. The future dangers to the general public of all this consolidation is even higher drug prices and more seriously, the lowered ability of the pharmaceutical sector to respond to real illnesses, which are not getting much attention. The latter is reflected not only in the untreated epidemics haunting the developing world, but even here in the U.S., with increasing reports of shortages of basic medicines and vaccines at many hospitals. These problems are all compounded by the fact that drug companies are fighting every way they can to counter the ‘Attack of the Generics’.

The Miracle Drug

Miracle drugs and pervasive drug advertising has been a part of the American diet for both the body and the mind for over a hundred and fifty years.

After more than 30 years of pressure for food and drug safety laws, the year 1906 finally ushered in the landmark Pure Food and Drug Act, amid shocking disclosures of the use of poisonous food additives and cure-all claims for worthless and dangerous patent medicines. In 1927 the Food and Drug Administration (FDA) was formed as the regulatory arm of the government charged with enforcing food and drug law. The pharmaceuticals lost their battle against an overhaul in drug regulation in 1937, after a drug known as the Elixir or Sulfanilamide killed over a 100 people, including many children. This paved the way for the passage of the 1938 Food, Drug and Cosmetic Act, which, among other things, required new drugs to be shown safe before they could be marketed. The Thalidomide scare of the early 1950s put pressure on Congress to further strengthen drug regulation. Still, the brand-name

companies continued to prosper because they could set whatever price they wanted on patented drugs.

The year was 1984 when pharmaceutical companies first started seeing trouble on the way, with the passage of the landmark Hatch-Waxman Act. Prior to this, generic drug companies had to perform the same rigorous testing on generic drugs that the companies with the initial patent had to perform. This made competition from generics virtually a non-issue because the investment required to get regulatory approval could only reasonably be recovered where the producer could charge a sufficiently high price for the drug once approved. In practice, this meant that the pre-Hatch-Waxman regulatory structure was heavily biased in favor of the companies with drug patents - that is, the brand name drug companies.

The 1984 Drug Price Competition and Patent Term Restoration Act (often referred to as the Hatch-Waxman Act) changed the drug competition landscape drastically by lowering the regulatory hurdles for generic companies. It said that rather than the generic companies performing all the safety tests, the original company with the patent carried out, just had to show that the generic drug was chemically the same as the original drug, which had already been


January 2011



tested. Finally, there was a feasible economic model for the generic industry. Once a patent expired on a drug, they could replicate and sell that drug for a lower cost and still make a profit, because their initial costs to get the drug to market were now much lower.

That part of the 1984 law sounds pretty good for the consumer right? But wait. This is one of the oldest tricks in the book! Create a law that looks pretty good to the general public, but with some twists and turns that are not obvious until many years later when the law did more harm than good. I currently experience this personally with our NAFTA Chapter 11 challenge against the Government of Canada. This Trojan horse was allowed into the 1984 regulatory regime. There were a number of methods for the brand-name companies to fight the generics:

1. Extension of patent protection to make up for time lost in the FDA regulatory approval process (hence the term “Patent Restoration”).

2. Ability to get multiple patents on drugs covering not only the chemical itself, but also all kinds of preparation methods and techniques, making it harder for the generics to prove they had the same drug. These patents could be staggered, such that when the patent on the main chemical expired yet the patents on various methods and techniques were still in force. This equals wide-ranging abilities to challenge generic companies in the courts for patent infringement.

These are back door methods available to keep patents going from a major strategy used by the brand-name companies to ward off the threat from generics. It is these very loopholes that coalitions such as “Business for Affordable Medicine” and

many congressional representatives were trying to close.

The World Trade Organization and associated revisions to international trade law further strengthened patent protection of pharmaceuticals. Then, starting in about 1994, the brand name companies launched into exponential growth by way of direct-to-consumer advertising of prescription drugs for reasons that probably have to do with increasing pressure from generic competition and managed-care companies. Meanwhile, in some industrialized nations, provisions of universal healthcare mean that drug prices are largely controlled by those corresponding governments. Drug companies in those countries have not been allowed such freedom to either set prices for patented drugs or to advertise directly to the consumer. Consequently the U.S. consumer ends up not only paying for the privilege of being advertised to by the drug companies at home in the U.S., but also subsidize lower drug costs abroad where prices are regulated by those corresponding governments. Put all these factors together and there’s little mystery as to why prescription drug costs are spiralling out of control in this country.

About The Author

Melvin J. Howard is Principal of the Howard Group a family office that specialize in Founda-tions, Trusts, Limited Partnerships, Private Equity, Capital Markets, and Health Care Trade Issues. We are registered federal lobbyist that pursues eco-nomic and international public policy initiatives on behalf of U.S. companies with interest abroad, more specifically international global health and trade issues. He can be reached at Melvin J. How-ard [email protected] [email protected]




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