ASG Perspectives

On-Call with Sara Winand, RN – Pediatric Neuroblastoma: Wow!

Friday, January 27, 2017

Neuroblastoma is a tumor that develops from nerve tissue, most commonly in the adrenal glands, and affects mostly infants and young children. It is staged I-IV and categorized as low-risk, intermediate-risk and high risk.

– Children with low-risk disease can be treated with surgery, and a complete resection is usually achieved.

– Intermediate-risk disease treatment includes combined chemotherapy and surgical resection.

– For children with high-risk neuroblastoma, there have been substantial improvements with aggressive combination modalities. These generally include chemotherapy, surgical resection, high-dose chemotherapy with stem cell rescue, radiation therapy and biologic/immunologic therapy (e.g., Unituxin® (dinutuximab*)). These approaches have improved event-free survival, but unfortunately, many are at high risk for relapse of their disease.

Let me share a brief summary of two high-claim cases we have followed recently. In cases like these, it’s difficult to anticipate ongoing costs.

CLAIMANT # 1:

2015

Imagine having a newborn just four months old diagnosed with stage IV neuroblastoma per exploratory laparotomy, liver biopsy and bone marrow biopsy. The chemo regimen required inpatient confinement, then another confinement for low blood counts. Two months later, after chemo was completed, they began stem cell harvesting in preparation for the planned autologous stem cell transplant. Scans showed residual tumor with incomplete response and the baby was admitted for excision of the residual tumor. High dose chemo and autologous stem cell transplant followed surgical recovery.

2016

This young child unfortunately had suffered post stem cell transplant complications and required home TPN, but was eventually weaned off and able to undergo radiation to the liver and primary site. With reevaluation and family conference, the decision was made to proceed with immunotherapy treatment regime with Unituxin® (dinutuximab*). This required inpatient care for the infusion therapy and paid claims varied from $65,000 to $175,000 per admit. Post treatment complications required acute care, but by August, the medical team was able to report no recurrence or progression!

The outcome was the good news, thanks to the fact there was a global transplant policy that covered the autologous stem cell transplant.

The bad news was the claims incurred.

– In 2015, the seven months of treatment (excluding the stem cell transplant, which was covered by the global contract) billed charges were $763,196. The TPA paid $341,644 from ground up.

– In 2016, with six months of treatment, billed charges were $1.6 million and the TPA paid $750,000.

CLAIMANT #2:

2015

This seven-year-old was diagnosed with high-risk neuroblastoma in mid-summer 2015 and began treatment with induction chemo, requiring multiple hospital admits followed by surgical resection/adrenalectomy with lymph node dissection in late November. A tandem autologous stem cell transplant after recovery was also planned, with an Optum transplant contract placed with Boston Children’s Hospital.

2016

The child was admitted in March 2016 for the first stem cell transplant (paid $280,000) and readmitted the next month for the second stem cell transplant (paid $203,000). Post-transplant chemo of five cycles began in July, requiring four to five days of inpatient care. She was hospitalized for 18 days in August (paid $140,000) with hypertension and thrombotic microangiopathy (clots in small blood vessels) and has been treated with the monoclonal antibody Soliris® (eculizumab). Other complications required inpatient care and intensive outpatient care, and the eculizumab treatments remain ongoing every two weeks ($35,000 to $40,000 per treatment).

– Claims in 2015 billed $825,000 and the TPA paid $425,000.

– Claims in 2016 billed $2,176,303 and the TPA paid $1.8 million. Claims will be ongoing in 2017.

Although treatment outcomes are dependent on tumor characteristics, age and extents of metastasis, it is interesting to note that infants less than one year of age have a better survival rate than older children.

 

*On March 10, 2015 the U.S. Food and Drug Administration (FDA) approved dinutuximab, which is a monoclonal antibody against GD2, for use in the treatment of high-risk neuroblastoma. It was approved as part of a multimodality regimen, including surgery, chemotherapy, and radiation therapy, for patients who have achieved at least a partial response to prior first-line multiagent. It is indicated in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2) and 13-cis-retinoic acid (RA) for pediatric patients with high-risk neuroblastoma.

 

Spotlight on the Demoray Group: Passing values down through the generations

Friday, January 20, 2017

Like fine china (and Patriots season passes), there are some things that are naturally passed from generation to generation.

In a successful carrier-TPA relationship, the thread that never breaks is good old-fashioned personal service. If you ask anyone in the industry, they’ll agree this particular value has served the Demoray Group, an employee benefits consulting group in Centerville, OH, very well.

Now, as founder Bill Demoray considers how he’ll step away from the business some day in the future, his son Brent will be poised to carry the mantle of trust and service – core values that have defined our working relationship since a time when industry knowledge and personal service ruled the business day.

 

 

“This is my 48th year in the business and you can’t put a price on a company that knows the background and history of our work together,” recalls Bill. “Even though I’m sales and ASG is underwriting, we have known each other for years, and that has made a big difference: You know, ‘Remember when we did X?’”

It is that “X factor” that Bill points to as the quality that will ultimately continue the Demoray Group’s legacy. “If there’s one key thing between ASG and my firm, I think it’s that we’ve developed a sense of trust. This industry – which is a very small industry when you look at it – is that all of us know each other, and the ASG leaders were in that group that goes back to those days. It’s that trust that’s a number one thing.”

For example, he says, “I know that when I go to ASG, they give me what I ask for; they read what I ask them to do. So many carriers, when you write a cover sheet or describe what a case is, they come back with a dozen other options. ASG doesn’t do that – I don’t have to throw anything away. That one quality saves 50% of my time – and that just comes from plain experience and being able to work with what we need.”

While Bill is considered a pioneer in the business, his eye is very much on what’s next on the horizon. “Now,” he says, “my son Brent, a CPA, is looking at these things like customer service and trust from his perspective as someone who has held many high-level finance executive positions in corporate America and saying, ‘Those are good – but if we were also to incorporate some newer, more flexible options, we could really make a policy work for this client or that one.’ And ASG is at that stage where they can do the same thing.”

A Great Partnership

We love working with businesses like the Demoray Group for all the same reasons. We are delighted to know that our core values align so well with many of our TPA partners. While our commitment to high-touch customer service, valued business partnerships, and streamlined underwriting, administrative and claims management services has served us well, each of us personally appreciates hearing what direct relationships mean to TPAs and brokers throughout the country.

As Bill says, “A good business relationship is just simple, concise and to the point. ASG is fair and when duplicate cases come in, they don’t try to get involved and make it a free-for-all – because it’s a partnership. They know what we can do and we do it.”

We agree with Bill that a challenge in building on this long-standing relationship model is assessing and evaluating the many new options that seem to emerge on a frequent basis. “It’s not like in the past, when we were all simply selling self-insurance,” explains Bill. “Now it’s: ‘Yes, we do that, but we’ve also got these nine different options.’ So you’re going to have to be able to adjust to change.”

As he considers the future of our industry, Bill remains both practical and optimistic. “I think self-funding here in the Dayton area is the same as it in St. Louis, in Scottsdale, or in New York – it’s not that much different. The difference is that today, you’ve got brokers on every corner. You’ve got promises not being kept and everybody’s got a new flavor. It’s become less technical and more salesmanship. But if you work consistently, with trust, and you take the time to learn the business and build those relationships, it will work really, really well.”

We couldn’t agree more!

Click to find out more about the Demoray Group.

 

 

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