MISSION TEAM RON HODGES AWARD GOVERNANCE HISTORY
Ron Hodges was an attorney who specialized in defending physicians, nurses and hospitals in medical malpractice litigation. He was a counselor, in every sense of the word, guiding the physicians and nurses who relied upon him through the personal and painful ordeal of litigation. Though Ron represented health professionals throughout the state, he had a special devotion to the University of Virginia Health System. He spent hours providing curbside consults, speaking to professional groups, and advising administrators, nurses and physicians without ever thinking about billing for his time. The legal and the medical professions lost a great friend and advocate when Ron unexpectedly passed away in 1998 at the age of 53.
Dr. Marzani, current Associate Professor in the Department of Psychiatry and Neurobehavioral Sciences, has been with UVA since arriving as a resident in 1998. She came on board as faculty in 2003. In addition to her clinical responsibilities, Dr. Marzani currently serves as the Assistant Dean of Admissions for the School of Medicine, as Quality Officer for the Department of Psychiatry, and Director of Special Projects, Office of the Chief Medical Officer.
In 2013-14 Dr. Marzani volunteered to be the primary lecturer for the PLT Lecture Series. She created and delivered a presentation, “The Legal and Medical Issues with Opioids,” to over 500 fellow faculty members in five different locations throughout Central Virginia. Opioid prescribing is a growing area of physician professional liability and discipline. Dr. Marzani’s ability to provide both medical and legal insight to her fellow clinicians on these important issues allows the Trust to serve the best interests of its covered providers. Her commitment and allocation of significant volunteer time and resources in the interests of patient safety and risk management exemplifies the best qualities of this award’s namesake, Ron Hodges.
Bruce to edit history section.
BACKGROUND
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he University of Virginia Health Services Foundation (HSF), like many health care organizations in the 1980’s, found it uneconomical to continue to purchase medical professional liability insurance through commercial means and to have this insurance provide the desired coverage at premiums that were reasonably predictable and stable. Between 1982 and 1988 insurance premiums for the clinicians at HSF rose 340%. Yet, the total indemnity and expense payments for that entire period amounted to little more than the premium paid for the single year of 1987. It was apparent that the commercial insurer gained most of its profit from the investment earnings on these premium dollars. It appeared to HSF in 1988 that writing malpractice coverage for the clinicians at HSF could be done in a less costly manner by self-insuring the risk. With all this in mind, HSF undertook a study in 1987 to determine whether there were alternative ways this malpractice coverage could be provided. The goals of the study were to find a program that, over time, would provide the best coverage while endeavoring to stabilize costs.
It is worth noting that in 2000, the commercial insurance carrier, PHICO, which had covered HSF for a seven year period in the 1980s went bankrupt.
HISTORY
On February 1, 1989, the University of Virginia Health Services Foundation Liability Trust was created. It was originally established as a grantor trust under Sections 671 and 677 of the Internal Revenue Code. The status as a grantor trust meant that the Trust was an arm of HSF and, as such, HSF appointed its Board of Directors. Initially, the Board included a representative of the Office of the Vice President for Health Sciences at the University of Virginia, two public members, four appointed insured clinicians, the Chairman of the HSF Finance Committee, the Trust Administrator and a representative of the excess carrier. Terms of these directors were one year. The grantor trust provided occurrence coverage with annual policy limits of $1 million per occurrence and $3 million in the annual aggregate for each insured. The Trust self-retained total liability of $3 million per occurrence and $5 million in the annual aggregate, and purchased excess insurance coverage on a claims-made basis from H. S. Weavers in the amount of $5 million. The decision was made by the Clinical Chairs to self-insure the tail from the previous commercial insurance policy years dating back to February 1, 1983. The self-retained limits were the same as with the annual policy. Five million dollars in excess insurance was also sought for the tail coverage. Weavers agreed to write 60% of this policy and another 20% was provided by the Illinois Insurance Exchange. The remaining 20% was never placed in the market. The total paid for both excess insurance policies, including the broker’s commission was $719,250.
Coverage was provided by the Trust to HSF clinicians, Virginia Ambulatory Surgery, Inc. (VASI), Virginia Kidney Stone Foundation (VKSF) and HSF. The total premium paid by all insured for policy period February 1, 1989 to December 31, 1989 was approximately $3.9 million ($4.3 million on an annualized basis). The tail coverage was funded at $2.5 million upon the recommendation of John Walker who headed the self-insured program at the University of Alabama (contrary to the actuarial report which recommended funding of $3.1 million).
A six month premium was charged from January 1, 1990 to June 30, 1990, in order to place the Trust on July 1, 1991 fiscal year, consistent with the HSF budget process. A 10% increase in premiums was charged to each insured in order to make up for the under funding of the tail. This came as a result of Price Waterhouse’s 1989 Audit Report recommendation. (The annualized premium was $4.7 million.)
The Trust experienced turmoil when it attempted to purchase excess insurance at the end of its first policy year with Weavers. At that time there was considerable media attention to the financial problems of Lloyd’s of London, of which Weavers was not a part. Upon the advice of its broker, Johnson & Higgins of Richmond, the Trust agreed to renew its policy with Weavers for a fifteen-month policy period at a cost of $869,805, including broker fees. However, by March of 1990 there were news articles questioning the solvency of several of the insurance houses writing for Weavers, one of which underwrote part of the Trust’s policy. During the month of March, the Trust was informed by Johnson & Higgins that its insurance premium had not yet been transferred to Weavers. Upon the resolution of the Trust’s Board of Directors, Johnson & Higgins was requested to return the money to the Trust and to inform Weavers that the Trust did not wish to execute its policy renewal. The Trust’s brokers were requested to seek alternative bids for excess insurance coverage. An actuarial projection for total self-insurance without the incorporation of a commercial excess policy was also sought from Tillinghast, the Trust’s actuarial firm. After the Board considered its limited options, it voted to totally self-insure without purchasing any excess insurance. The Trust was able to accomplish this without raising its premiums for the policy year July 1, 1990 to June 30, 1991. The total premium for this period was $4.7 million.
The law firm of McGuire, Woods, Battle and Boothe had requested a Private Letter Ruling from the Internal Revenue Service formally recognizing the Trust as a grantor trust, and thus, clearly establishing its tax-exempt status. In August of 1990, the Internal Revenue Service informally advised McGuire, Woods that it would not recognize the Trust as a grantor trust. In October of the same year, the Trust filed on its own behalf a Group Exemption Letter requesting that the Trust be recognized as a 501(C)(3) entity based on its being related to the tax exempt “group” of HSF. The IRS refused to recognize this “group.” As a result of not being recognized by the IRS as a tax-exempt grantor trust or a part of a group headed by HSF, the Trust restructured itself as a 501(C)(3) entity in its own right. This meant amending its Trust Agreement and reappointing a Board of Directors. The Trust took the opportunity to change the designation of its Board in an effort to separate from HSF so as to protect Trust financial statements from being viewed as part of HSF’s consolidated financial statements, and thus, reported in the University’s statements. The primary goal was to maintain the confidentiality of Trust financial and claims information in recognition of particular sensitivities of the Trust’s business. The new Board consisted of five insured clinicians elected by the Clinical Chairs of HSF, the Trust Administrator and the Executive Director of HSF, as ex-officio directors. These individuals’ terms began January 1, 1991 with terms lasting for three years. The University of Virginia’s name was also deleted from the Trust name so that it was now the Health Services Foundation Liability Trust. The Board elected its first Chair of the newly reorganized Board, Stanton P. Nolan, M.D., and Vice Chair, Munsey S. Wheby, M.D. These two physicians continued to serve the Board in these capacities through December of 2004.
In the Spring of 1991, the Trust undertook a review of the excess market to determine whether it should continue to totally self-insure its liability. With the assistance of a consultant, EMCOL, Ltd., the Trust selected a new broker, Willis & Corroon. Upon reviewing options presented by the new broker, the Board voted to purchase excess insurance for the policy period July 1, 1991 to June 30, 1992 from State Volunteer Mutual Insurance Company of Tennessee. The self-retained coverage was $1 million per occurrence and $3 million in the annual aggregate. The excess coverage was a claims-made policy providing $10 million for any one medical incident with no more than $10 million being afforded any one clinician or other insured and with an unlimited annual aggregate. The excess premium was $642,588.00, including broker fees. The total premium charged to Trust Covered Persons for fiscal year 1991/92 was down 30% to $3.4 million. This excess policy was renewed July 1, 1992 for another 12 month period with no increase in premium. Premiums for the fiscal year 1992/93 were $2.6 million, providing a 28% reduction in individual insured premiums from the prior year, down from $4.2 million at the inception of the Trust.
In December 1991, the IRS formally granted the Trust tax-exempt status as a 501(C)(3) organization. In light of the growth of the Trust and the important issues faced during this time period, the Trust felt broader representation by clinicians was needed on the Trust Board of Directors. On November 5, 1991, the Clinical Chairs of HSF voted to add four additional clinician directors to the Board, bringing the number of physician directors to nine and the total number of directors to eleven. The Board also voted to change the name of the Trust to Piedmont Liability Trust.
In October 1992, after a great deal of discussion surrounding the need to ensure that Trust information remained confidential, the Board voted to create a for-profit captive insurance company based in Bermuda and to make Trust staff employees of the Trust rather than HSF, as in the past. The expectation was that these changes would take place January 1, 1993. Upon further study with the assistance of Willis Corroon and the Chicago law firm of McDermot, Will & Emery, it was determined that a captive insurance company was not necessary. With the movement of employment of staff to the Trust, sufficient independence was found to exist under the current structure without jeopardizing the Trust’s tax-exempt status. Therefore, in December 1992, the Board voted to table its resolution to create a captive insurance company until further evidence warranted its creation. To-date, the Trust has found its current structure as a revocable 501(C)(3) trust to be adequate and most reasonable to serve its mission.
At the December 1993 Board meeting, the Board requested a review of the Trust Bylaws. It was unanimously agreed that an outside attorney should be added as an additional director. A Committee was appointed to name an individual to fill this position and to review the Bylaws. Since that time, R. Carter Scott has served as the only outside director on the Board of the Piedmont Liability Trust. Mr. Scott is paid on an hourly basis for his time serving the Board.
It was not until policy year 2002/2003 that the Trust found it necessary to implement changes to its rate classification system and to the associated premium assessments. A two-year study of industry rate classifications indicated that the relativities between surgical and non-surgical specialties should decrease. Similarly, the rate classification for anesthesiologists, emergency medicine physicians, neurologists and clinical psychologists required upward adjustments, which were approved by the Board with implementation in the 2002/2003 policy year. At the same time, based on significant increases in the coverage limits offered as a result of Virginia’s statutory cap increasing from $1 million per occurrence to $1.65 per occurrence in the 2002/2003 policy year, a 15% increase in the cost of premium assessments was approved by the Board, with some specialties deferring 5% of this increase until the 2003/2004 policy year. Likewise, some portions of the increases in rate classifications were slated to be implemented over two policy years. These changes were fully implemented in 2004. In light of more adverse claims experience appearing in the Trust’s 2004 actuarial study, a 7% increase in premium assessments was recommended and approved by the Board, then implemented with the new fiscal year beginning July 1, 2004.
PRESENT
In 2006 and 2007, HSF’s CEO and Chair of its Board of Directors questioned the Trust’s legitimacy, stating that there was no HSF Board of Directors resolution approving the changes in the Trust’s structure in 1990. They also questioned the Trust’s tax exempt status. After a year and a half, on August 17, 2007, formal mediation took place with the Honorable Jean Cunningham from McCammon Mediation Group as the mediator. HSF and the Trust agreed as follows:
- The Trust’s tax exempt status as a 501(c)(3) entity has at all times since 1990 been valid.
- The Trust supports HSF’s 509(a)(2) purposes, which have existed since the inception of the Trust and this is adequate for the Trust to legitimately be a supporting organization of HSF since 1990.
- Going forward it is in both The Trust’s and HSF’s interest for HSF to formally file with the IRS as a 509(a)(2) organization, which purposes the Trust will continue to support.
- Last year’s Trust IRS form 990 should have checked that it was either a Type II or III supporting organization for this added description to a question that had been solely fill in the blank question historically. Going forward the Trust will correctly identify itself as either a Type II or III supporting organization on these returns. There is no tax implication to the previous erroneous designation. The remainder of the question correctly described the Trust’s relationship and had since 1990.
- The Trust had agreed as of July 23, 2007 that its financial information would be consolidated in HSF audited financial statements. That agreement shall continue unless there are changes in organizational structures or changes in applicable accounting standards. This change came based on current HSF auditor opinion from Ernst and Young that were the opposite of those given by Price Waterhouse in 1990 when changes were made to segregate HSF and Trust financial statements. There were no new accounting regulations cited; rather a different opinion of the same regulations.
- The consolidation of financial statements does not expose the Trust assets to the claims of HSF creditors.
- HSF will continue to be represented on the Trust Board through its ex officio Directors, HSF CEO and President, and all physician Directors, who are HSF employees and elected with the concurrence by HSF’s Clinical Chairs.
- The Trust’s Board of Directors as currently comprised, which includes those positions listed in #6 above, plus the Dean of the School of Medicine or his/her designee, the President of UVA’s Clinical Staff, two public directors – one attorney and one insurance expert – and the CEO of the Trust who is the only non-voting director, meets current standards for good corporate governance in the present day.
- At the next Board of Directors meeting of the Trust, the Trust shall adopt an amendment to its current Amended Trust Agreement to provide that HSF must approve future amendments to the Trust Agreement.
- At the next Board of Directors meeting of HSF, they shall adopt a resolution that ratifies the Trust’s Amended Trust Agreement dated October 8, 1990 and all subsequent amendments to this Trust Agreement to present.
The parties agreed that the proposals from HSF that a public member of HSF’s Board be added to The Trust’s Board and that HSF’s CEO be added to The Trust’s Executive Committee would both be tabled for the present time.
In 1989/90 the total premium assessment for coverage of 397 clinicians (not tracked in terms of FTEs) and HSF were $4.29 million. Despite a third medical malpractice crisis in the history of the Trust, in 2007/08 the total premium assessment for 956 clinicians (783.07 FTEs) was $5.3 million. Coverage continues to be provided on an occurrence basis. Actual premium assessments by rate classification as compared to 1989 are as follows:
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Inflation |
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Adjusted |
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Rate Class |
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1989/90 |
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2007/08 |
% Change |
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1989/90 |
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2007/08 |
% Change |
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0 |
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4,961 |
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3,017 |
-39.2% |
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8,153 |
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3,017 |
-63.0% |
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0A |
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3,917 |
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1,886 |
-51.9% |
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6,497 |
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1,886 |
-71.0% |
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0B |
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944 |
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944 |
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1 |
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6,372 |
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3,772 |
-40.8% |
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10,471 |
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3,772 |
-64.0% |
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1A |
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4,969 |
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3,395 |
-31.7% |
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8,166 |
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3,395 |
-58.4% |
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1AX |
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2,298 |
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2,298 |
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2 |
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9,735 |
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5,657 |
-41.9% |
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15,999 |
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5,657 |
-64.6% |
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3 |
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17,578 |
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8,297 |
-52.8% |
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28,888 |
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8,297 |
-71.3% |
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4 |
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20,376 |
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12,069 |
-40.8% |
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33,486 |
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12,069 |
-64.0% |
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5 |
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30,609 |
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15,840 |
-48.3% |
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50,303 |
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15,840 |
-68.5% |
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6 |
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36,358 |
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19,989 |
-45.0% |
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59,751 |
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19,989 |
-66.5% |
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7 |
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48,571 |
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24,515 |
-49.5% |
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79,822 |
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24,515 |
-69.3% |
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8 |
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60,338 |
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29,418 |
-51.2% |
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99,160 |
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29,418 |
-70.3% |
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Total Premiums |
$4.29 M |
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$5.3 M |
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Covered Persons |
397 |
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956 |
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Once again, the latest national malpractice crisis again has shown the wisdom of the decision to self-insure. In the wake of the bankruptcies amongst medical malpractice commercial insurers during this crisis, the need for vigilance in assuring that the Trust is appropriately funded is reinforced.
INVESTMENTS
The long tail nature of medical malpractice insurance (the length of time between paying the premium for a policy and payment of indemnity losses on the same policy) meant that commercial insurers often made their profit from the investment earnings on the premium. By self-insuring, the Trust expected to be able to use investment earnings to reduce future premiums, ultimately causing Trust premiums to be lower than those in the commercial market.
Initially, the Trust Board of Directors simply adopted HSF’s Investment Policy, which limited investments primarily to short and medium term Treasury Bills and placed its entire fund with Jefferson National Bank. In June of 1991, recognizing that the Trust fund had grown substantially, the Trust Board adopted a revised Investment Policy, which liberalized the duration of the Treasury Bills and added some variety with corporate bonds and agencies. A second money manager, Sanford C. Bernstein, Inc. of New York, was approved by the Board. In September 1991, the Board heard proposals from its two money managers to add equities to the fund’s portfolio. A revised Investment Policy was adopted which provided that up to 30% of the fund balance be invested in equities. It was expected that this change in policy would enhance the financial growth of the fund, while maintaining its long-term stability. The Investment Policy is reevaluated annually by the Board.
The Executive Committee of the Board reviewed the performance of its money managers in August, September and October of 1992. After careful consideration, the Executive Committee recommended that a money manager with particular expertise in investments for insurance companies be sought. In October 1992, after presentations from three potential managers, the Executive Committee voted to replace Sanford Bernstein with Scudder, Stevens & Clark’s insurance investment division SIAM, as a Trust money manager. The Committee agreed that Scudder would be used as the Trust’s primary investment advisor and the majority of the fixed income securities were moved to its management. The equity portion of the portfolio was left with Jefferson National Bank while Sanford Bernstein was eliminated as an investment manager.
In the Spring of 1996, the Trust’s investment advisor at Jefferson National Bank departed. Funds under management there were moved to Merrill Lynch for management by the staff at the Trust. Scudder, Stevens & Clark, meanwhile, continued to provide fixed asset management until April 1997, at which time their performance was determined to be inadequate. From that time until the present, with the exception of a small quantity of convertible bonds managed by Calamos Investment Management for four years beginning in January 2000, all investment management and strategy has been determined by the Trust Executive Committee and executed by the Director of Finance and Administration and Executive Director with advice from a financial consultant at Merrill Lynch. History has proven that the Trust can perform as well as the money managers we have used in the past without the added fees involved with such outside management.
FINANCIAL STATUS
It has always been the goal of the Trust to fund claims reserves at greater than a 75% confidence level; and, the Trust funding has not fallen below this requirement. During most of the Trust’s history, the funding has remained closer to 90% and currently slightly exceeds the 90% confidence level. As seen in the chart above, adjusted for inflation, premium reductions ranged from 58% to 71%. Trust premium assessments have remained less than comparable commercial insurance coverage. As of September 30, 2007, the Trust’s claims reserves were $35.1 million. Trust assets as of the same date totaled $52.3 million. The amount reserved for claims includes a self-funded excess liability reserve fund in the amount of $10 million created by the Board of Directors in 2005. From the inception of the Trust in 1989 through September 30, 2007, the Trust has paid out $ 23.1 million in indemnity payments and $ 10.5 million in claims expense payments.
CLAIMS STATUS
As the Trust matured during the 1990’s, its claims and litigation experience mirrored trends in Virginia and the nation. Claims frequency and severity steadily increased. More money was paid as Virginia’s cap on medical malpractice damages, fixed at $1 million during the first decade of the Trust, was increased to $1.5 million in 1999 and incrementally increased in $50,000 to $75,000 increments each year thereafter. The number of open claims peaked in 2002 with 75 cases actively managed by the Trust and 41 cases in litigation. Indemnity payments reached a corresponding high in 2005, when over $3.1 million was paid in medical malpractice damages.
In early 2006, the Virginia Supreme Court issued its opinion in Ola v. YMCA. This decision confirmed the continued viability of the doctrine of Charitable Immunity in the Commonwealth. After carefully researching and considering the issue, the Trust was convinced that HSF and its covered clinicians qualified for the immunity under the rationale published by the Court in Ola. Accordingly, the plea of Charitable Immunity was made on behalf of Trust-covered defendants in all pending and new litigation. After a series of inconsistent Circuit Court decisions, the Supreme Court agreed to hear the specific circumstances pled by the Trust. Except is a few, special circumstances, no indemnity payments were made in 2006 and 2007. Unexpectedly, however, the number of claims also dropped. By May 2007 the total number of open claims was 49 and the number of cases in litigation had dropped to 26.
As of September 30, 2007, the Trust was managing 50 open claims. Twenty-three were in litigation. All Trust claims are managed by Beth Sanderford, Claims Manager for the Trust. Bill Archambault, General Counsel for the Trust, continues to represent Trust Covered Persons in the majority of open claims. Five outside law firms approved by the Board of Directors are assigned to defend Trust Covered Persons in the remainder of the open claims.
The Trust is committed to diligently defending all non-meritorious claims and contesting unreasonable settlement demands. At the same time, we acknowledge our responsibility to identify and make all reasonable efforts to resolve well-founded claims quickly and fairly. The closed claims statistics of the Trust prove the success of those efforts. Between February 1, 1989 and September 30, 2007, the Trust closed 436 claims. Relevant statistics of our closed claims are as follows:
321 (74%) were closed without indemnity payment
196 (44%) involved a filed lawsuit
66 (28%) of claims in which a lawsuit was NOT filed closed with indemnity paid
49 (25%) of all lawsuits were closed with an indemnity payment
43 (22%) settled
6 ( 3%) were plaintiff verdicts
28 ( 6%) of all claims went to trial
28 (14%) of all lawsuits went to trial
22 (79%) of all trials resulted in a defense verdict
Indemnity payment averages also tell an interesting story. The average settlement prior to a filed lawsuit was $117,000. The average settlement of a lawsuit was $313,000, while the average plaintiff verdict was $565,000. We should bear in mind that while these results evidence the effectiveness of the Trust’s philosophy of early identification of marginally defensible cases, we recognize that some cases that were settled early might have resulted in a defense verdict if forced to trial.
STAFFING
The Trust currently has 10 employees. Rebecca West continues to serve as the Chief Executive Officer and as one of two Trustees. Ray Morgan serves as the other Trustee and has done so since 1993. Ms. West is responsible for oversight of all aspects of the Trust. Bill Archambault has been the Trust’s General Counsel since 1990 and has shepherded Trust claims in superb performance. He continues to be assigned to defend Covered Persons, together with a list of five law firms that may also be assigned to defense of Trust cases. The Claims Manager has been Lizabeth Sanderford since 2000.
Since the fall of 2003, the Trust has reorganized functions several times partly in response to a Charlottesville Circuit Court decision affecting the confidentiality of Trust documents and communications. The reorganization involved policies, procedures and personnel review and modification to help assure protection of Trust confidential information. As a result the Trust has separated the risk management and clinician support side of its operation from the claims side. The Risk Manager for the Trust has been Judy Fortineux since 1990. In August 2007, recognizing the growth in services in this area and a need to expand further how inquiries are handled, new legal counsel was added to the staff. Bruce Gehle, an attorney, who has significant experience representing physicians at academic institutions, was recruited to fill the position of Legal Services Counsel for the Trust. He reports to Ms. West and Ms. Fortineux reports to him.
A business manager was added in the summer of 1992 in recognition of the growing responsibilities of the Trust and the increased funds to manage. Bill Smith has held this position as Director of Finance and Administration from August 1992 to present. He is responsible for the accounting, audit, budget, investments, human resources management (including benefit plans) and supervision of office support staff. Office support staff includes Lance Frasier, who ably supports our information technology needs on a part-time basis. It also has included Judy Damron since October 1995, who has served as Administrative Assistant supporting Covered Person services as well as providing accounting support to Bill Smith. Linda Yowell’s position has recently been reorganized, and she currently serves as our Office Manager (half-time position), supervising our receptionist, Tammy Tuthill, who also provides support to claims activities, and a new half-time position of Office Assistant, to be filled by Dawn Sorrell, who will provide support to the clinical services/risk management side of our operation as well as to the office manager. Linda handles matters associated with the Trust Board and its committees, along with being responsible for assuring administrative support for Trust activities.
The Trust has been fortunate to retain long-term, exceptionally qualified and committed people to provide the services necessary for the Trust to operate efficiently and effectively. We continue to believe in our mission at the Trust and are privileged to serve in each of our important capacities.
CONCLUSION
The Trust has weathered a number of transitions since its inception. Throughout this time, it has never failed to further the mission and goals of its founders and those who have since joined the Trust Boards. The long term service of many UVA clinicians has been central to the stability and success of the Trust. In particular, the leadership of the Trust Board has been remarkable. Two of the founding Board members, Drs. Stanton P. Nolan and Munsey S. Wheby served respectively as Chair and Vice Chair of the Trust Board of Directors from 1991 until 2005. They continue to serve the Board as ex officio directors. Their leadership and service has been immeasurable and invaluable. In 2005, Drs. Jonathon Truwit and Randy Canterbury took over as Chair and Vice Chair of the Board respectively. They have continued to shepherd the Trust in a manner that fulfills the mission set out in 1989. We have survived yet another national medical malpractice crisis and a challenge from HSF leadership as to our organizational structure. We expect the Trust will continue to change and adapt so as to address the needs of those it serves. There are many decisions that must continually be re-examined, such as reinsurance, investment policies and the organization structure of the Trust. To-date, the Trust has proven itself to be a stable force that produces positive financial results and works to promote quality of care in the University of Virginia Health System, through service to our Covered Persons. Our daily responsiveness to the needs of the Medical Staff is central to all our efforts. It is imperative that we continue to look forward and envision where the program needs to be on so that current decisions anticipate future needs.
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