It is clear that the outline agreement 2018 (Hoofdlijnen Akkoord 2018) is starting to crack. Slowing down the growth of medical-specialist care expenses to zero percent has not yet proved feasible in practice. Demographic developments, among other things, are causing demand for care to rise, but the parties are unable to realize the intended transition from hospital care to primary care at the same pace. In the mean time, however, insurers want to stick to the zero percent goal while hospitals do not want to turn patients away. In some arrangements, particularly those involving “effective care”, care provided in excess of the agreed amount is still (partly) reimbursed.

NECESSARY INVESTMENTS

As for the hospitals, in addition to the increase in demand for care, more money is needed. The recent CAO agreements are not covered by the regular agreements with the health insurer. Furthermore, it is common knowledge that the level of investment has lagged behind in recent years. Hospitals cannot continue to postpone the necessary investments in renovation, electronic patient files and further automation. Room must be created in operations to be able to bear the extra financing costs (interest and depreciation) in the long run.

"The hospital’s business case, with a projection of new investments, can no longer be made on the basis of the outcome of the negotiations with the health insurer."

Delivering care for the right remuneration has therefore become an increasingly delicate balancing act. The question is how the hospital will succeed in doing this within its operations and continue to comply with its financing ratios. The transition does not result in any cuts. Savings must come from the application of new concepts that lead to greater efficiency and a lower demand for second-line care. However, these developments take place at a slower pace than desired. Until then, hospitals feel, health insurers should step in. At least, as mentioned above, by reimbursing “effective care” above the agreed amount. The alternative is to raise the rates where there is still some room. So P or Q.

FINANCIAL BUSINESS CASE

The hospital’s business case, with a projection of new investments, can no longer be made on the basis of the outcome of the negotiations with the health insurer. Instead, during the negotiation process the person who controls the multi-year budget model – the treasurer – must be involved in the process. This gives the hospital more insight into the financial consequences. Sharing these insights with the health insurer can better substantiate the hospital’s arguments and thus provide more insight during negotiations. This way, the insurer becomes more directly involved in the long-term prognosis and the long-term financial health of the hospital. It thereby becomes a joint objective to achieve affordable care in the long term.

An important part of the financial business case is shaped during negotiations with the insurer. During the negotiations, the hospital wants to be able to steer the long-term impact of the outcomes. This is the only way to ensure that a proposition emerges that is financeable for banks and secure for the WfZ (Guarantee Fund for the Health Care Sector), and that the hospital is able to comply with the financing ratios in the long term. It will remain a balancing act, but one with a more solid basis.

Traditionally the company insures events that can lead to huge losses, such as natural disasters. Two years ago, this reinsurer decided to further strengthen its payment processes. Swiss Re has engaged the support of Zanders, in several areas, since 2012. At first, this was mainly related to Group Treasury’s balance sheet management and risk reporting processes. Among others, a new liquidity risk measurement and reporting system was put in place using a combination of an in-house built data warehouse, a vendor risk management system and modern business intelligence (BI) technology.

Connectivity ‘on par’

At the time, account manager Jeroen van der Heide was already Group Treasury’s main point of contact. “Since 2017, we’ve also been helping Swiss Re to improve their operational treasury processes,” Van der Heide says. In early 2017, the reinsurer organized several workshops on bank connectivity. “We participated in those workshops and provided our point of view assessment on their as-is. Swiss Re’s connectivity demonstrated to be ‘on par’ with the market standard. However, our other feedback during those workshops strengthened their resolve to work towards a new central financial messaging hub in the medium term. We were chosen to support them in the realization of that ambition.”

Single source of truth

A central financial messaging hub is a considerable undertaking, given that the company has at least a dozen different systems from which payments are initiated and where bank statements are consumed. Like many big financial multinationals, Swiss Re has grown substantially over the years, partially through acquisitions. One of Zanders’ first tasks was to analyze the presence of bank account information in the various systems – and the consistencies and inconsistencies between them. This analysis then served as the basis for a blueprint of the 'to be' data model.

It’s crucial to designate a single source of truth for different types of master data, simply because that avoids getting stuck in master data reconciliation, it really is the starting point for any move towards operational excellence.

Nicolas Andres, head of Group Finance Transformation at Swiss Re

SWIFT network

In the fall of 2017, the focus shifted to connectivity with the SWIFT network. Zanders made sure that compliance with the Customer Security Programme (CSP) was achieved without problems and, with an eye on improving business continuity, an initial analysis was carried out on the SWIFT Alliance Lifeline program. Then it was time to support the switchover to a new SWIFT Service Bureau (SSB). Zanders provided both the project management and subject matter expertise to support the requirements analysis, drafted the RfP document and guided the selection process towards choosing a new SSB. Throughout this process, special consideration was given to complementary services, which a new hub could benefit from. Andres explains: “As the single exit point towards the wider financial system, the hub is naturally well-suited for complementary controls, for example to detect payment fraud.”

Feasibility study

On this topic, Zanders was asked to assess the benefit of leveraging modern machine learning techniques on the traffic to and from the SSB gateway. “Nowadays, advances in machine learning and artificial intelligence receive attention nearly on a daily basis,” says Van der Heide. “Vendors have been quick to take advantage of this development, and they promise a lot.” Andres continues: “We were curious to what extent these techniques would actually bring us forward. We know Zanders prefers to segregate hype from benefit. Plus they’re well acquainted with our infrastructure and have relevant experience from their risk advisory practice, so they were the natural partner to ask this question.”

Zanders' advice on what to do next, and particularly on what not to do, was totally appropriate.

Nicolas Andres, head of Group Finance Transformation at Swiss Re

Electronic banking tools

Meanwhile, as the SSB selection project slowly drew to a conclusion, an analysis was made of the various electronic banking tools that had worked their way into the organization over the years. “The analysis was an important step in the preparation process for the financial messaging hub. It turned out there were quite a few more tools in use than expected.” concedes Andres. “The vast majority are actually only used to collect statements from individual banking partners. That confirmed our viewpoint that proper bank statement distribution would be an important feature of the new 'to be' solution.”

Webservice-centric approach

At the start of 2019, the implementation of the new financial messaging hub finally kicked off. “An important benefit of the 'to be' solution is that we move from a batch-centric approach to a webservice-centric approach. This means that upstream systems can basically deliver their messages whenever they want,” says Andres. The first step of the project includes implementing the switchover to the new SSB, finding an adequate compliance-filtering solution, rationalizing the Bank Identifier Codes (BICs), implementing the SWIFT Alliance Lifeline and putting the first REST APIs in place. Two years later, Zanders is still involved, coordinating progress surrounding the six workflows and ensuring that all stakeholders are adequately involved.

Trust

When asked what makes the collaboration work, Andres says: “I believe in resourceful and intelligent junior consultants, supported by pragmatic experts where needed. Zanders offers both.” Jeroen feels the relationship is largely built on trust – and that is something that works both ways. “Nicolas trusts me on the quality we provide. That is something I am proud of and we are pulling out all the stops to ensure we continue to justify that.” Andres summarizes: “It is the engagement and skill shown to get the job done after the initial Powerpoints that convinces.”

In the 150 years of its existence, Swiss Re has grown to be one of the world’s largest providers of reinsurance and insurance-based forms of risk transfer. Reinsurers are mostly associated with insurance for extreme loss events, such as natural catastrophes. However, Swiss Re’s services cover the entire insurance spectrum: Swiss Re is the counterparty to risks which primary insurance companies and large corporates decide to mitigate.

Liquidity risk

Usually, liquidity is not the first topic that comes to mind as a key risk for reinsurance companies. “The general view was, and kind of still is, that reinsurance companies do not run a lot of liquidity risk, like a bank,” Martin Ramseyer says. For banks, the main driver of liquidity risk is a sudden customer run on deposits. The risk for reinsurers is rather that claims can reach the order of billions, sometimes to be paid out at short notice relative to the magnitude. If sufficient assets cannot be liquidated at a reasonable price within the required time frame, the company not only puts its reputation at stake but also risks bankruptcy – regardless of its solvency or profitability.

From a capital perspective, expanding services across businesses yields a risk diversification benefit. But that benefit does not extend to liquidity, Ramseyer clarifies: “There are many legal limitations imposed by different jurisdictions that limit our abilities to move assets between subsidiaries within the group.” A joint effort of risk and treasury was initiated several years ago to create a framework to measure and manage funding liquidity risk. Initially, the primary objective was to identify potential liquidity constraints for the major legal entities. Calculations gradually grew more extensive, and the framework evolved into an important scenario analysis mechanism used to support executive management decisions. Its execution had become time-consuming, and the operational risk inherent in manual calculations increasingly relevant. The time was ripe to streamline and automate liquidity risk analysis and the reporting process. Andreas Tonn became the business project manager for the system selection and implementation.

Implementation

The choice was made for a vendor solution. “The core advantage is that they provide a framework, which reduces implementation time and facilitates the translation of needs into requirements,” Tonn says. “But as you will never find the perfect tool, it is important to have a clear focus.” Liquidity risk measurement models for the insurance business in vendor systems are still in evolution phase. Flexibility was therefore a key priority for Swiss Re, as the majority of the logic needed to be implemented from scratch. Swiss Re embarked on an intensive proof-of-concept phase, and asked vendors to provide a working demonstration that addressed all aspects of its liquidity risk framework. They chose Wolters Kluwer’s RiskPro, as it proved both mature and sufficiently flexible at the same time.

A phased implementation approach was chosen to gradually introduce the solution into the reporting cycle. However, after the first release, it became apparent the project team would need additional business support if it was to cover all the aspects thoroughly within the stated time frame. “Our internal resources were too committed to other tasks and could not provide support to the extent an intensive project requires,” Tonn says, “but external resources are actually only beneficial to a project if they bring the right expertise to the table.” There were very positive experiences with Zanders on other treasury projects so a request was made for support.

Jeroen van der Heide from Zanders was asked to join the project team: “His ample experience with functional design of various systems across risk domains convinced us that he would indeed accelerate our project.”

Andreas Tonn, business project manager for the system selection and implementation

Challenges

As with many system implementations, getting the data delivered in a systematic fashion was a challenge: different departments have different priorities and downstream reporting is often not on top of their list. Afterwards, the interpretation for modeling was not always clear either as it was complicated by the global reach of the company in which data ownership spans across time zones. For example, intra-group funding was previously measured using a net aggregate approach. With the implementation of RiskPro, the choice made sense to model each debt contract based on its characteristics as booked in the system. Understanding how to calculate the impact of all implicit options automatically for different scenarios required detailed discussions across teams and continents.

The project team has worked relentlessly during the past year in close cooperation with business and IT colleagues. A total of six minor and major releases were accomplished, during which the necessary data and calculations with respect to investments, collateral, reinsurance portfolios, debt, internal cash flows, and contingent funding requirements were added to the system. The RiskPro results were embedded in existing reporting templates, and the change analysis process between reporting dates was partly automated. They were very satisfied with the Zanders support: “Of great benefit was Jeroen’s talent to quickly gain insight out of a huge amount of information, and present the newly created results in such a way to make them understandable to the business user and fit right into existing business processes. That has been a very valuable business contribution.”

Looking towards the future

With the system up and running, the team is able to provide reporting and analytics for the major legal entities within the group and across business segments and branches, rather than only for those with the largest impact from a risk perspective. “It allows us to understand and represent the liquidity dynamics in a more systematic way across the group,” Ramseyer says. The next step is to increase the quantity and quality of the information flow between local business units and treasury. “It will really enhance the risk awareness of local boards and empower them in their active steering efforts. With their feedback they will help improve the framework in return.”

Developments within Treasury Business Services don’t stop there. The system contains the vast majority of Swiss Re’s economic balance sheet down to the transaction and cash flow level. “The vendor software is designed to be an integrated risk system. With the market data and contract data available in full detail, we have a suitable basis to extend the scope of the solution to other domains,” Tonn says. The plan for the next two years, therefore, is to gradually support other analyses, for example with respect to currency risk, funding cost, liquidity planning, and ALM. The consistency between and efficiency of the analyses will improve, enabling the treasury teams to dedicate more time to proactive analysis and steering. Zanders will continue to support these efforts: “Given his successful contribution to the project and his interest to continue to support Swiss Re, we asked Jeroen to manage next year’s project,” Tonn says, “But first things first: we are very much looking forward to the daily use of the implemented solution.”

The St Jacob Foundation provides care and services to the elderly in the Dutch South Kennermerland area, aiming to give them control over their own lives for as long as possible.

Quality of life is key to home care concepts, as St Jacob showed in their business case which was presented in March 2012. The traditional ‘old people’s home’ has given way to a totally different form of care for the elderly. “Most of our premises stem from the early 1970s,” says Rob van der Hulst, program director of Real Estate and Development at the St Jacob Foundation. “With the type of client we have nowadays this is not sustainable. When the premises were built our target client base was the over 65s who liked to be cared for. In the prosperous areas of Haarlem and the surrounding areas there were often no health issues but rather a preference for a worry-free existence coupled with keeping the luxury they were used to. The domestic assistant sometimes moved with them, for example to an attic in the same building.”

External partners

The foundation’s history goes back a long way, as far as the Middle Ages. The current St Jacob arose from the merger of a number of independent residential and care homes in the Haarlem, Heemstede, and Bloemendaal areas. The latest amalgamation dates from early 2000 and today the foundation has nine premises. Anita Louwers has been the director of the St Jacob’s board of trustees since 2006, when they took their first steps towards a marketing approach to care. “From that time on, care and nursing of the elderly has become faster, more intense and more complicated,” she says. “For that reason, we have opted to find partners to deal with everything which is not directly connected to that complex care, such as help within the home and cleaning, but also the expertise we need in the areas of finance and property. We are becoming a leaner organization: in-depth care with a thin layer of overhead for the relevant support personnel.”

This is a significant difference between St Jacob and other institutions in the country, many of which are more autonomous. Van der Hulst adds: “As an organization we want to stay close to our core function; we are good at intramural and extramural complex care, but other parties are better at what has to be done on the sidelines. The target group has changed considerably over the past few years. The senior citizens, those above 65 years, still live at home, travel and play golf twice a week. Those who now occupy our premises are the over-85s, who are also less mobile, but even in this age group we are noticing changes and, with support, a number of them can still live at home. This group of ‘light clients’ no longer use intramural care facilities, so only the clients who require dedicated nursing remain. “And this group is increasing constantly. People are getting older and the numbers with dementia are increasing as well. We are focused on this growth, but also on recovery and revalidation of the aged,” says Van der Hulst.

Living career

The fact that the aged are requiring more complex care has consequences for the employees of care agencies. “We used to be able to employ semi-skilled people but nowadays care is no longer so lightweight,” says Louwers. “Last year we retrained 500 employees to a higher level of competence. Today, employees have to have specific knowledge about various illnesses and they have more to do with psychiatric problems. Also, care at home is much better organized; people who have had treatment in a geriatric revalidation center go home far earlier and doctors and physiotherapists can also provide care at home.” The trend towards more specialized care was already evident to the foundation in 2007.

Louwers explains: “Since then we already started thinking in terms of housing ladders for our clients. Renovations are often more expensive than new buildings so we began to look at properties more as investors; the properties had to keep their value, we had to build to fulfill market demands and we didn’t want to run any risk. We want to own all properties geared for specialized care, whereas for homes with their own care facilities we want to find investors or co-operate with housing corporations.” These objectives were set out in the Strategic Property Plan which was written in 2007 but which has been modified in certain areas in the meantime. All types of accommodation have to be flexible so that if one target group declines in number another group can live in the same building.

Business case

Between 2007 and 2010, St Jacob developed a multiyear management model in which all future income, property transitions and care programs were covered, from the current to the new situation. Following the real estate plan, St Jacob decided to (re)develop several locations for revalidation care, small-scale group housing and care flats. For the benefit of the financing application, the foundation also prepared a detailed business case which was completed at the beginning of 2012. In the meantime, the foundation started looking for an external expert. “A recommendation and a number of positive references led us to Zanders,” says Louwers.

We already have quite good financial know-how in-house for presenting a business case, but they (Zanders) were able to fine-tune it.

Anita Louwers, Director of the St Jacob’s board of trustees

According to Zanders consultant Hendrik Pons, St Jacob’s business case was convincing. “And above all it was explained very clearly by the foundation. Together this immediately gave the banks a positive impression,” he says. Van der Hulst adds: “Zanders reviewed the multiyear management model and sat down with us round the table during discussions with financial institutions. I am convinced this helped considerably and of course being safely in the black helped as well. We own almost all of the properties and were also able to sell one at quite a favorable moment in time. From three banks and the Guarantee Fund we finally got positive reactions.” The Care Guarantee Fund (Wfz) gave us a 100% guarantee on our new application,” added Pons “and that gave us a significant interest advantage.”

Differentiation

The financing application resulted in St Jacob obtaining a loan of €30 million. Louwers says: “This is rather unusual at the moment for a turnover of €60 million. And it is fantastic since we need property for new clients – often those with severe dementia – to be housed in a way that best suits them.”

Financing is agreed and will be used in 2014. A number of building plans are ready, including Overbos and a building with room for 100 clients with dementia and a revalidation center. Van der Hulst explains: “We are spread over three different towns and that means that we have to have different types of facilities available. With homes where people pay their own living costs they can start working on their own housing ladder earlier and can stay in their own home if their need for care increases. A good example is Nieuw Overbos, which will be opened in a year’s time. Here there are lovely flats for people aged 75 and above. There are many care facilities, such as a doctor and round-the-clock services. But we are here for all senior citizens; on the Aziëweg we are building a complex for council rental.”

By separating housing and care there is a lot more differentiation, according to Louwers. “Many people are prepared to pay for what they want. The Netherlands is a country where the AWBZ (National Act on Exceptional Medical Expenses) is too general and uniform in its coverage and this doesn’t suit everyone. I think it’s good we are a forerunner in the developments.”

More efficient

Louwers also thinks that this new approach will mean resources are used more efficiently. “We started the transition phase with a turnover of €60 million for a large category of quite easy clients. When we are finished we will have a turnover of just under €50 million for a group of difficult clients and we will have €10 million left over for care at home – which is quite a lot. Someone who lives at home is still responsible for the accommodation component and that makes long-term care more affordable.”

So the St Jacob Foundation is becoming more like a company, adapting to and playing on the market forces we are experiencing. However, St Jacob is suffering from the consequences of governmental intervention and the health insurers’ shortsighted policies. Louwers adds: “You can’t really talk about market forces because they are controlled by legislators and insurers. However, if we function well as a care provider by adapting to the needs of our client base, then our buildings will fill up of their own accord.”

How did Zanders work with the St Jacob Foundation?

• Help in preparing the business case
• Participation in talks with the banks and the Care Guarantee Fund (Wfz)
• Various memos on internal decision making
• Continuous treasury support in the form of a service subscription from early 2013; preparation of the annual treasury plan, participation in the treasury committee (strategic), participation in the monthly treasury meeting, treasury tools (loan module, liquidity forecast model).