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These Three Trends Could Dramatically Drive Up Healthcare Liability Rates

Healthcare organizations under cost-containment pressure don’t want to see premiums rise, but increased risk, costly claims, and stagnant rates threaten to destabilize the insurance market.
By: | July 2, 2018 • 5 min read

In an environment shaped by shifting economics and uncertainty surrounding the fate of the Affordable Care Act, hospitals and health care providers of every size and type are under pressure to deliver high quality care at the lowest cost. The carriers who insure them have to offer coverage that meets providers’ expanding needs, all while facing similar economic constraints — in addition to ongoing soft market conditions.

No one wants to see their rates go up, especially hospitals and health care providers with good loss histories. But even the best-managed risk is not immune to macro market trends.

“Healthcare organizations understandably don’t want to see premium increase, and insurers are eager to retain business despite rising losses and increasing exposure. That pattern is not sustainable over the long term,” said Lainie Dorneker, president of IronHealth, Ironshore’s healthcare unit.

The struggle to profitability underwrite health care professional liability risk has already driven a few large insurers to exit the market, leaving fewer choices for customers.  Without meaningful pricing correction across the board, the market risks destabilization.

Three trends in particular make rising healthcare liability rates a necessity:

1. Health care providers’ changing risk profiles make them more difficult to insure.

Consolidation, advancing technology and longer patient lifespans all introduce more risk for healthcare organizations.

According to consulting firm Kaufman Hall, a record 115 health system mergers or acquisitions took place in 2017, and 30 have already taken place in the first quarter of 2018. Hospital mergers, acquisitions of independent physician and specialty practices, and strategic partnerships across the healthcare sector help those organizations stay competitive, but they also build aggregate risk for insurers.

“Such actions have served to heighten the duration and magnitude of health care organizations’ risk profile,” Dorneker said.

Healthcare facilities now carry more risk than ever before.  Hospitals continue to expand their scope of services, and they also employing more and more physicians.  This increased exposure growth, on its own, puts pressure on hospital’s self-insured retentions.   But the fact that the physicians’ independent insurance limits are no longer available effectively erodes the attachment point of commercial insurance.  Moreover, the cost of medical care, which is the fundamental measure in life-care plans, has increased approximately 4 percent.

“Even with significant exposure increase and the rising cost of medical care, self-insured retentions have remained relatively constant since 2002. This erodes the utility of the retention and increases the coverage demand on the organization’s lead liability insurer,” Dorneker said.

2. Severe claims are happening much more frequently.

Lainie Dorneker, President of IronHealth, Ironshore’s Healthcare Unit

While claim frequency has remained fairly stable, severity is trending upward.

“The frequency of claim severity, especially related to eight-figure losses, has risen dramatically,” Dorneker said.

Savvier plaintiffs’ bars, jurors’ lottery mentality, litigation funding, batch claims, and advanced medical technologies are all factors converging to drive up claim costs. Average payouts for medical professional liability claims have reached an all-time high; the highest settlements have reached more than $100 million.

“Plaintiffs’ attorneys will often use a ‘profits over people’ argument to foster the idea that healthcare providers care more about saving money than they do about saving lives. They position their client as the victim of a greedy corporation in order to garner higher settlements or awards,” Dorneker said.

Ironshore’s recent study of hospital professional liability loss trends indicates that the frequency of closed claim counts with financial greater than $5 million is increasing by 10 percent every year, while the frequency of closed claims with financials greater than $10 million has risen 7 percent.

While the overall frequency of claims relating to a single incident has remained stable, the frequency of related claims — or “batch claims” — is on the rise. Batch claims result from separate but similar incidents that injure multiple patients and are attributable to the same act, error, or omission or to related acts, errors, or omissions.

Allegations may involve a single surgeon who performed dozens of unnecessary procedures “for profit,” or a single piece of malfunctioning equipment that caused harm to multiple patients. Ultimately, juries may find healthcare organization to be directly negligent or vicariously liable for such incidents.

3. Eroding loss ratios threaten the viability of some health care liability carriers.

As claims with paid indemnity increase, the allocated loss adjustment expenses (ALAE) have increased as well. According to Ironshore’s analysis of healthcare liability claims, “claims with indemnity reflected 55 percent of total claims in 2006 and reached 66 percent of total claims in 2013.  Comparatively, the paid ALAE ratio was 24.5 percent in 2012, a 2.9-point increase from 21.6 percent in 2006.”

Inflation is partly responsible for the rising costs of adjustment expenses. The overall consumer price index for medical care has increased by about 2 percent annually, while the cost of medical care has increased by about 4 percent. Combined with the resistance to raising premium rates, higher ALAE have contributed to poorer loss ratios.

“Many hospital professional liability carriers’ gross ultimate loss ratios are over 100 percent on a current accident year basis,” Dorneker said.  “Many healthcare providers’ premium rates have not been adjusted for general inflation, much less medical cost inflation. So even rates that have remained flat have, in effect, decreased. That trend is not sustainable in today’s environment.”

Work with Best-In-Class Insurers for Long-Term Success

Challenges facing the healthcare professional liability market reflect the broader insurance industry landscape. The triple-threat of Hurricanes Harvey, Irma and Maria, the California wildfires, and a devastating earthquake made 2017 the costliest year on record. Event-related claims could be as high $135 billion.

In the traditional insurance cycle, rates typically rise after such a CAT-heavy season. But the traditional cycle is broken. With very few exceptions, rates across all lines have barely budged.

“Prior-year reserves are drying up, and calendar-year losses are impacting balance sheets,” Dorneker said.

Given these challenges, hospitals and health care organizations need insurers that are in it for the long haul. Carriers will need to work directly with brokers and clients to educate them about trends that may impact their premiums, prepare them for changes, and reaffirm the strength of coverage and services they’ll receive in exchange.

“Through proactive management of our portfolio and a diverse suite of products, IronHealth is well-positioned to navigate these challenges,” Dorneker said. “We aim to provide best in class products and claims services along with market stability that benefits both insurers and insureds in the long run.”

To learn more, visit http://www.ironshore.com/healthcare/


This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Ironshore. The editorial staff of Risk & Insurance had no role in its preparation.


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More from Risk & Insurance

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Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.


Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.

R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.


We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?


Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.


Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now and where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.


More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

The R&I Editorial Team can be reached at [email protected]