Deep Discounts on Transplant Program Fees

Deeply discounted transplant access fees are available through our new Platinum Rewards program, an enhanced OptumHealth Care Solutions (formerly United Resource Networks) program. This program is available only to Summit Re’s clients. Under our previous program, you received a 5% discount on network access fees, an additional 5% discount if you agreed only to use OptumHealth’s networks, and up to 10% based on Summit Re’s total volume of business with OptumHealth. The third discount was calculated retrospectively.

These three potential discounts are now bundled into one substantial discount. The program is easier to use and easier to understand. You will be able to realize the total savings we've negotiated “up front” through reduced access fees.

The savings from the Platinum Rewards program can be significant, as shown in the chart. Based on our historical case mix, the Platinum Rewards program represents an effective 27% discount off standard OptumHealth fees.

To be eligible for Platinum Rewards, you must agree only to use the OptumHealth networks for your transplants, although you can still “carve out” facilities with which you have your own contracts.

The new program is effective on January 1, 2008. You will need to execute a new Payer Access Agreement, selecting either the fees for the Platinum Rewards program or the standard access fees.

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Platinum Rewards Frequently Asked Questions

Which of the OptumHealth programs will be subject to the reduced fees?

The reduced fees apply to the Transplant Resource Services’ Centers of Excellence program and the Transplant Access Program for business that is reinsured through Summit Re. All other OptumHealth program fees remain unchanged.

Do the reduced fees apply to both adult and pediatric transplants?

Yes, the reduced fees apply to adult and pediatric transplants.

How will the Platinum Rewards program affect the OptumHealth transplant facility contracts and services?

The new program has the same facility contracts and services contained under the current OptumHealth programs.

Will I be able to “carve out” a specific facility from the OptumHealth contract and use my own contract at that OptumHealth facility?

You will still have the capability of carving out a facility or facilities from the OptumHealth agreement. Those facilities should be listed on Exhibit C of the Payer Access Agreement.

What happens if I want to use another transplant network in addition to OptumHealth?

You may use another network in addition to OptumHealth. However, if you do so, you will not be eligible for the reduced fees available through the Platinum Rewards program. You will pay OptumHealth’s standard access fees.

What do I need to do to initiate the new program?

If you are currently accessing OptumHealth through Summit Re, you will need to sign a new Payer Access Agreement. New Payer Access Agreements will be mailed to Summit Re clients. Be sure to indicate if you intend to use the OptumHealth network only or if you will use another network in addition to OptumHealth’s network.

Will I still receive this year’s discount based on Summit Re’s total volume of business with OptumHealth?

You will still be eligible for the discount for 2007 based on Summit Re’s total volume of business with OptumHealth, provided you are a Summit Re client at the time the refund is paid. OptumHealth has committed to paying this refund within 60 days after the end of the calendar year.

Cover transplants from first dollar

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. A typical HMO excess coverage provides risk protection for all catastrophic events—traumas, transplants, neonatal cases, and other complex medical claims. Some plans, however, prefer to "carve out" certain risks from their medical excess coverage and have specific coverage for the given risk on a first dollar basis. Organ and bone marrow transplant carve-out coverage is such an example.

The need

ABC Health Plan is a public hospital board authorized by statute to operate a hospital service plan in its state. Because the plan desired predictability and the plan's hospital owner is not a major tertiary provider for organ transplants (excluding kidneys), the plan was interested in having organ transplants carved out from its risk.

The solution

Summit Re provided ABC Health Plan an organ transplant carve-out through United HealthCare Insurance Company, part of OptumHealth Care Solutions’ (formerly United Resource Networks) family of transplant programs. Summit Re still provides the medical excess coverage to ABC Health Plan in excess of its $90,000 deductible with an appropriate credit for the organ transplant carve-out now reinsured by United.

The result

ABC Health Plan has renewed the program for several years with predictable renewals and has access to excellent organ transplant case management and provider contracts. A typical premium for this type of coverage is $2.00-$4.00 per member per month, depending on the parameters of the risk.

Coverage details

Covered organ transplant procedures include liver, kidney, heart, lung, heart/lung, double lung, pancreas or simultaneous pancreas/kidney. Digestive transplants are covered only when performed by a facility that participates in the transplant network. Coinsurance is higher for services provided by non-network facilities.

Transplant services include all medically necessary services resulting from and/or directly related to an organ or bone marrow transplant procedure, including:

• Services provided by the transplant facility
• Hospital or skilled nursing facility services
• Physician services
• Nursing services
• Outpatient treatment and follow-up
• Speech, physical and occupational therapy
• Anesthesia and anesthesia services
• Radiology
• Laboratory services
• Oxygen
• Durable medical equipment
• Blood and blood products
• Dressings
• Harvesting and acquisition expense
• Transportation, lodging and meals for transplant candidate and one companion

Typical services NOT covered include:

• Services received before or after the benefit period, other than services for bone marrow harvesting, transplant evaluation, living donor organ procurement, air ambulance or transportation, lodging or meals related to the covered transplant procedure
• Organ or tissue transplants performed prior to the member’s effective date
• Services not related to the covered transplant procedure
• Services unrelated to the diagnosis or treatment of the transplant procedure
• Drugs that are investigational or have not been approved for general sale by the FDA
• Items which are not medically necessary

“No Floors” Transplant Network

The most important consideration when choosing a transplant network should always be the quality of care delivered. A secondary but important consideration is the cost effectiveness of the network. Contracts for the U.R.N. Transplant Centers of Excellence network and Transplant Access Program (TAP) are structured in a variety of ways, allowing Summit Re customers referral options based on their desire for cost predictability. In order to assist in the contract selection process, U.R.N. has identified a subset of network contracts without floors and aggregated them into a “No Floors” network.

The U.R.N. "No Floors" network consists of programs with transplant contracts that eliminate the possibility of a transplant being paid at a percent of billed charges. This network consists of 51 centers and 237 transplant programs and increases the transparency of network providers without minimum payment provisions. This provides you with greater transplant cost predictability when using a “No Floors” network facility.

Information regarding the “No Floors” network, including a listing of the facilities, can be found on the U.R.N. website (www.urnweb.com) or you can contact Debbie Stubbs, RN, MS, CCM at 260-407-3979 or at dstubbs@summit-re.com.

But what if you have no transplant contract?

Most health plans have contracts with hospitals or medical centers that perform organ and tissue transplants. And, through Summit Re, clients have access to U.R.N.’s Transplant Resource Networks and Transplant Access Program. Most reinsurance agreements provide more favorable coverage for organ and tissue transplants performed in “approved” facilities than for those performed in "unapproved" facilities. The health plan typically submits its contracted rates to the reinsurer during the underwriting process and the reinsurer determines if the contracts will be “approved” or not.

Standard approach

At Summit Re/Swiss Re, that’s our standard approach as well. We usually provide 90% coinsurance for approved contracts (we use the term “scheduled”) and 50% or 60% for unapproved or unscheduled contracts. We list the scheduled contracts on Exhibit A, part of our reinsurance agreement. We consider U.R.N.’s transplant network facility contracts to be scheduled. Usually those contracts our clients hold directly are also scheduled if they are similar to U.R.N.’s.

A potential problem

But what if a member needs to go to a facility that isn’t part of U.R.N.’s network and with which the health plan has no contract for transplants? When the plan tries to negotiate a rate for that member, how will the plan know how the reinsurer will view the arrangement?

Usually the plan won’t know unless the terms are submitted to the reinsurer for review in advance of the transplant, each and every time such a situation arises. This can be frustrating for the health plan and means additional work for the reinsurer.

Summit’s solution

At Summit Re, we recognized this issue early on and took steps to make things easier for you. We developed another exhibit, Exhibit B, which helps our clients determine their reinsurance overage for unscheduled transplants up front.

We list specific case rates we consider to be scheduled for each type of transplant. We show rates for inpatient hospital services only and rates that include professional services. We show a separate set of rates for children and a set for adults. We include rates for all three types of bone marrow/stem cell transplants – even those performed on an outpatient basis.

If the health plan can negotiate case rates that are equal to or are better than the ones shown on Exhibit B, then the claim is reimbursed at the higher coinsurance level. There’s no need to send anything to us for “approval.” You already know the level of coinsurance that applies.

Not a cap

There’s one more very important point to remember, though. The rates listed on Exhibit B do not represent limits on what we consider to be eligible amounts under the reinsurance agreement.  They do not represent caps on case rates. Amounts in excess of the listed case rates are not excluded. If a health plan simply can’t negotiate a rate that is equal to or lower than the Exhibit B rate, it just means the claim would be reimbursed at the lower coinsurance level.

This is just another example of Summit Re’s putting into practice its “fairness” Founding Principle to produce balance sheet stability for you.

Information-Based Decisions with TransAdvise

URN’s TransAdvise is a new complimentary service for our clients who have contracts with URN. TransAdvise clinical consultants can assist you and your members by providing information about transplant-related diagnoses and treatment options. A dedicated team of transplant nurse experts who work with more than 12,000 transplants each year are available to provide:

• Transplant program performance information (e.g. annual volumes and outcomes) to help patients make more informed decisions about their transplant care.
• Information about relevant clinical trials and treatment protocols based on diagnosis or underlying condition.
• Assistance in referral to Transplant Centers of Excellence Network programs to maximize clinical and financial outcomes.

These services help you and your members make more informed decisions about transplant care with the goal of better outcomes.

Access to TransAdvise is direct, flexible, easy, and free to our clients. Simply call (800) 343-4305 to speak with a TransAdvise clinical consultant or provide this number directly to your members. TransAdvise clinical consultants are available from 7:00 a.m. to 6:00 p.m. CST, Monday through Friday. Conference calls with a TransAdvise clinical consultant are also available for you and your members.

Summit Re/URN Transplant Program

The Fall (October) 2005 edition of Summit Perspectives detailed Summit Re’s new transplant program features with United Resources Networks (URN). Some key points to keep in mind regarding the program are:

• URN access fees are discounted for transplant services on business reinsured through Summit Re. These discounts are not available by directly contracting with URN or through any other reinsurer.
• URN will extend the Summit Re discount fee arrangements to a new Summit Re client who was using URN through another reinsurer.
• A Summit Re client does not have to use URN exclusively in order to obtain the discounted access fees for transplant services where URN is utilized on business reinsured through Summit Re.
• Zero Access Fees (ZAP) is an exclusive URN arrangement with Summit Re. It provides for alternative transplant facility terms with no access fees. These terms can be elected on a case-by-case basis at the time of each transplant referral.

Please contact Debbie Stubbs RN, MS, CCM at dstubbs@summit-re. com if you have any questions or would like additional information concerning the Summit Re/URN Transplant Program.

Manage Your Transplant Risk More Effectively with New Program

Selecting a Network The most important consideration when choosing a transplant network should always be the quality of care delivered.  A secondary but important consideration is the cost effectiveness of the network.  A network that charges access fees but has greater net savings overall due to more favorable negotiated arrangements with network facilities is preferable to a transplant network that charges no access fees but has less effective contracts.

New Program

Summit Re recently conducted a thorough assessment of three transplant networks. (See table on page 3.)   As a result of that assessment, we concluded that United Resource Networks (U.R.N.)  provided the best overall value.  Therefore, we agreed to enter into an exclusive arrangement with U.R.N. for the provision of transplant services for our clients.  We have been able to negotiate lower access fees because of this exclusive relationship.

Access Fees

Under the new program, our clients will have their access fees for each transplant reduced by 5% due to Summit Re’s exclusivity with U.R.N.  An additional 5% reduction can be realized if clients incorporate certain benefit incentives into their plan designs for the use of U.R.N. facilities and use them exclusively.  A third discount is based on Summit Re’s total volume of business with U.R.N.

Make the Change

This program replaces the previous benefit that Summit Re had negotiated with U.R.N. – namely, a waiver of the 35%-of-savings fee U.R.N. normally charges for cases that access U.R.N. facilities but do not result in transplantation.  The current program is still available to existing Summit Re clients who access U.R.N., but we recommend the new program.  Summit Re will contact current clients to discuss the program in greater detail.

Access Fee Discount	Source
5% discount	Summit Re’s exclusive marketing of U.R.N. for transplant services
5% discount	Client’s exclusivity agreement and benefit differentials
Up to 10%	Summit Re’s total volume of business with U.R.N.*
Total Discount: Up to 20%

*This portion of the discounts will be calculated retrospectively by U.R.N. on an annual basis.  The discount is available to clients who have reinsurance coverage through Summit Re that is in effect on the date of the payment to Summit Re.

Transplant Facts: Costs and Incidence

The cost of transplantation can be staggering and continues to rise as new technology and pharmacology become available.  

Incidence of Transplants

According to the United Organ Sharing Network (UNOS), there are currently over 89,000 patients listed for a transplant.  The breakdown of types of transplants as a percentage of the total is shown in the chart below.  There continues to be a disparity between the number of transplants requested and the number of organs available. Only 40% of the patients waiting for a solid organ transplant will get one. To view the current wait list statistics and the number of transplants completed and organs donated, please go to www.unos.org.

Comparison of Transplant Programs

Summit Re engaged in a stringent due diligence process prior to making the decision to enter into an exclusive agreement with United Resource Networks (U.R.N.) for transplant management. Below you will find a comparison of the type of information we considered:

Size & Scope	U.R.N.	INTERLINK	LifeTrac
Covered lives	46 million	20 million	15 million
Annual transplant referrals	10,000+	900	1,800
Centers available	108+	44	47
Average network discount across all five phases	43%	31%	31%
Dedicated personnel (excluding claims repricing):Licensed medical / clinical staff Support staff Total	86 97 183	2 10 12	3 6 9
Pricing
Per diem for all phases of care in most contracts	Yes	No	No
Organ & bone marrow acquisition included in all case rates	Yes	Some	Some
Access Fees	$3,500 - $20,000	$3,000 - $13,000	None
Services
Complete utilization & financial reporting	Yes	Yes	Unknown
Web access to comprehensive medical center data	Yes	No	Yes
Transplant case-management services available	Yes	No	No
Quality & Credentialing
Physician advisory panels	4	No	No
Education
Annual education conferences	5+, on-line CEUs	On-line CEUs	No
Annual client conference	Yes	No	Unknown
Other Products
Able to take or share economic risk for transplants	Yes	No	No
Specialized pediatric credentialing and network	Yes	No	Yes
Congenital heart disease program and network	Yes	No	No

Disclaimer – Competitor information is based on data available through a variety of sources. Specific detailed information should be sought directly from each competitor to ensure reliable comparison data.

Zero Access Fees (ZAP) Available on Case-by-Case Basis

If you access U.R.N. through Summit Re, you also have access to ZAP. You can elect at the time of each transplant referral to use U.R.N.’s traditional facility terms, which have the access fee, or use the ZAP contract and not pay an access fee. Your actual transplant costs will be determined based on the terms you have chosen. Generally, the traditional terms will provide for a lower cost, even with consideration of the access fee, if the transplant situation turns out to be average or worse than average. On the other hand, the ZAP terms will generally perform better if it turns out that the transplant situation is much better than average.

ZAP provides contract terms which U.R.N. believes are superior to their competitors. While U.R.N. does not guarantee to always beat the competition, it is U.R.N.’s intent to maintain the best contracts as compared to its competitors, regardless of which U.R.N. option is selected.

Reinsurance incentives for the use of either U.R.N. program are available. For clients who choose the traditional access fee product, the access fee will continue to be treated as a claim cost. Summit Re receives no incentive payments for offering these network products to our clients. Our interest is to bring you effective programs and services to help manage your catastrophic risk. Please note that this program is only available through Summit Re.