2008 Medical Professional Liability Symposium Chicago, Illinois ~ March 11 & 12, 2008 Trends in Healthcare-The Who, What, Where, When and How of Healthcare Delivery in the Future Wednesday, March 12, :00-3:15 p.m.

The Changing Landscape of Healthcare Delivery MODERATOR: Ron Rumin, Vice President, Healthcare, Worldwide Facilities Insurance Services, Inc. John S. Chace, CPCU, Vice President, Fireman's Fund Michael Ragan, DMD, JD, LLM, Partner, Boyd Mustelier, Smith &Parker Dale Van Demark, Esq., Member, Epstein, Becker & Green, P.C.

3 Good Afternoon This session will explore recent trends in the delivery of healthcare such as concierge medicine and medical tourism. We will see how these trends impact Underwriting and the overall healthcare marketplace.

4 Concierge Medicine What is Concierge Medicine? Overview of the trend? Growth since 2004

5 Concierge Models 3 basic Models  Overview of how the modeling was developed

6 The 3 Models Preferred Access Medical Services Access Fee

7 Future of Concierge Medicine Growth Social Impact Affects on Traditional Delivery System

8 Medical Tourism US Industry Overview

9 Medical Tourism Foreign Providers  Business models and quality

10 Medical Tourism Limitations on patient medical malpractice recourse

11 Medical Tourism Market Alternatives to medical malpractice  Current status

12 Underwriting View How does the delivery changes / point of contact affect Underwriting guidelines  Know Foreign Countries - “Medical Tourism” Different laws for Medical PL or also known as “PI” (outside U.S.) Determine Product - Scope of Policy coverage – “Bringing Claim in U.S. versus anywhere in world”. Know the exposures - (type of practitioners?, how does practitioner practice his or her medicine, how does entity operate – like op clinic?)  Know The practitioner and practice “Concierge” Determine Product Know exposures

13 Can you develop a Premium formula How do you develop a rating formula for the medical malpractice exposure of these evolving trends.  How to price for future claims from present acts? We look to past experience and present exposures, loss activity / claims, and other factors to build a loss cost.  Non – Frequency driven risks uses known “class rating models – Usual practice - “Practitioners for Individual PL, OP Visits, OP Surgeries or percentage of PL for entity, per trips, receipts, beds  Frequency driven risks Uses known “Loss rate” or “experience rate”

14 Future of Healthcare Delivery Trends (A few types of Facilities) Dialysis Centers Drug Rehab Home Health Care Residential Group Homes Testing Labs Hospice Surgical-centers Urgent Care Centers Medical Clinics Ambulance Services

15 Future of Healthcare Delivery Trends Emerging Exposures / Allegations (Is determined based on the type of risk and the caregivers at the facility) Failure to diagnosis/misdiagnosis – “All Allied Profess” Improper treatment/standard of care – “All Allied Profess” Improper line feeds related to dialysis treatments Sexual misconduct/physical abuse Instruments left in surgical spot Death/gross negligence Improperly cleaned equipment resulting in infections Methadone use in drug rehab Elopement/wandering Slip/falls – “PT’s” Improper supervision Misfilled RX – “Pharmacy” Failure to Monitor – “PT’s and RN’s”

16 Future of Healthcare Delivery Trends New Markets & Capacity ($ 2 Billion Market – good for the buyer)  Current Market Players – over 30 players not including all Physician carriers today Some Bigger players – AIG (Lex), Allianz (FFIC), C.N.A, Zurich, etc  In 2007 alone US Domestic Carriers – 4 new in last year London Markets – 2 new carriers in last year Bermuda – 2 new in last year  Physicians carriers and Hospital Carriers fall into these classes “naturally” – they are a spin off of physician outpatient clinics or hospital outpatient ventures.

17 Proliferation of current “Known” Markets (in U.S.) U.S. Markets – building out Allianz (FFIC), QBE, Red Mountain, UNG, James River, Colony, Smith Bell, Landmark, The Doctors Company, Michigan Mutual, Evanston, CNA, Zurich, Lexington (AIG), Gen Star, Scottsdale, Western World, Norcal Mutual, Philadelphia Ins Co, Admiral (Berkley), Liberty Mutual, Hudson, Darwin, Chubb, Medical Protective (Berkshire), “Other PIAA Companies” Off Shore (Bermuda / London) – “now onshore or coming on Shore and building out” Bermuda and London Based companies now in US market:  Examples - Beazley, Hiscox, Inc., ACE – USA, Arch, One Beacon, - other Companies

18 Thank you Special Thank You to the Panel Members