ASG Perspectives

On-Call with Sara Winand, RN – Focus on Melanoma

Monday, August 29, 2016

Boy, have we come a long way since the ‘80s.

I had been a teenage sun worshiper, diagnosed with a Clark’s level III melanoma on my shoulder in 1982. As the panic ensued, all I could think of was a line from my nursing school textbook: “usually fatal within a few months.”

I underwent a wide excision with skin grafting and the standard CT scans as follow-up. The brain scan suggested metastasis and an experimental protocol using Peg Interferon alpha 2 injections was discussed, but their results were not impressive and I declined. I had a five-year-old old daughter and husband at home and felt I needed to prepare for the inevitable. I stocked up on shoes for my daughter’s EEE wide feet, all sorts of clothes for her next few years, and yes, a horse for Christmas. My credit cards were nearly exhausted.

Then came the waiting. Although the scans didn’t change over the next few years, I was looking at life differently. Eventually, after about five years, I realized that okay, I didn’t die, and I really didn’t have to think about this every day anymore.

So I just moved on (and continued to pay off credit cards). I am glad to say I am still doing fine, and am diligent about annual exams and body checks.

That was the early ‘80s – a time when we offered little hope for advanced diseases. Recent treatment has taken great strides, especially since around 2011, and can include surgery, radiation, targeted therapy, immunotherapy, and chemotherapy, offering hope for possible cure and extending survival.

There are some incredible survival stories with promising new therapies, but not without a cost.

2015 Melanoma — A One-Year Case Study

Paid claims: $1,240,658

A 30-year-old mother of two young children presented to the emergency room with a headache. Diagnostic imaging found a frontal mass requiring craniotomy with tumor resection and confirming pathology of stage IV metastatic melanoma, primary site unknown. She was treated with stereotactic radiation and four courses of Yervoy, and next underwent whole brain radiation and treatment with Opdivo. After a full year of treatment, the claimant was responding to treatment and reportedly the tumors had decreased in size by 50%. We did not renew this account – this claimant was at very high risk for ongoing treatment that would again be over $1 million. As of late July 2016, she was still beating the odds after nearly two years of treatment.

Then Versus Now

Today’s treatments offer new hope for a cure for even advanced stage disease, with combination therapy extending survival for almost a year without disease progression.

— Targeted therapies take aim at the genetic mutations and work to destroy the abnormal aspects of the tumor cells without harming the normal ones. These FDA targeted therapies are Vemurafenib/Zelboraf, Dabrafenib/Tafinlar, Trametinib/Mekinist and Cobimetinib/Cotellic.

— Immunotherapies trigger the immune system to fight against the cancer. FDA-approved immunotherapies are Ipilimumab/Yervoy, Pembrolizumab/Keytruda, Nivolumab/Opdivo, Talimogene laherparepvec/Imlygic/T-VEC, Interleukin-2/IL-2 and Peg Interferon alfa-2b/Sylatron.

— Chemotherapy with DTIC/Dacarbazine is FDA approved for stage IV melanoma.

All of these drugs are expensive. The average Medicare patient will pay from $60,000 to $300,000 yearly for combination treatment. For others you can predict annual costs up to $1 million or more.

About Melanoma

There are several types of melanomas but melanomas typically occur in the skin and can be due to exposure to natural and/or UV light. They can also be found in the mouth, intestine, and even the eye, where sunlight doesn’t reach. It is the deadliest form of skin cancer with incidence on the rise in the U.S. and has best outcomes when found and treated early.

… and One More Sign of Hope

Look at Jimmy Carter! Our former president was diagnosed in August of 2015, treated with surgery, radiation and immunotherapy, (Keytruda) for melanoma that had metastasized to his liver and brain. Scans in December 2015 showed he was cancer-free and he was able to stop therapy March 2016.

 

Mental Health & Substance Use Disorder – Who’s Abusing Who?

Wednesday, July 27, 2016

by Sara Winand, RN, Director of Medical Management

The Mental Health Parity and Addiction Equity Act of 2008, which went into effect January 1, 2010 has changed the way Mental Health and Substance Use Disorders are viewed and paid by employer groups.

Cumulatively, a series of changes and trends have been having a serious impact on our mutual abilities to underwrite a competitive policy that works to support our employer groups’ businesses – not cripple their budgets.

The impact of Health Care Reform is extensive. The act mandates:

  • – No annual dollar limits
  • – No lifetime maximums
  • – No annual limits on number of days or visits
  • – Coverage extended to dependents up to age 26

We are now seeing covered individuals seek treatment for Substance Abuse more and more frequently, with costs for treatment ranging from $150,000 to $300,000 – for a single year.

In fact, in the six years since the Act passed, the group for which we’ve seen a growing trend in high claims is 16- to 26-year-olds! This age group is the highest risk category for relapse and ongoing charges, and has become a financial liability to plans and excess carriers across the U.S.

Why? Here are a few trends that may answer that question:

  • – Mental Health (which includes Substance Use Disorder) is now a covered benefit just like any other illness.
  • – Although many facilities have been out of network in the past, we are seeing a trend for now in-network claims for Substance Use.
  • – Facilities are now outsourcing labs, so urine drug screens are billed separately and frequently (many times daily) and often cost as much as the facilities’ daily charges.
  • – Facilities are billing incrementally, meaning these charges are flying under the radar and are not readily detected as a potential LARGE claim.
  • – Many plans only require precertification for inpatient acute care and can go unmonitored when the claimant steps down to Residential, Partial Hospitalization, IOP (Intensive Outpatient) then to OP.
  • – Facilities are typically located out of state; many resemble a resort: They are lined with palm trees, feature seascape landscaping, and offer 4-star cuisine, recreation and exercise programs which oftentimes include yoga, horseback riding, spa therapy, and more.
  • – Many websites feature logos of PPO networks but are not actually affiliated with these or any network.

As partners invested in protecting our employer groups’ interests, it’s important that we do what we can to stop the bleeding. Try asking the following questions when you see claims related to Mental Health or Substance Use Disorder treatment:

  • 1.Is this person’s treatment court-ordered?
  • 2.How is this treatment being certified for medical necessity?
  • 3.Is the facility licensed for the diagnosis and services it is billing for?
  • 4.Does the facility bill for IOP more than five days a week?
  • 5.Should I have claims and the medical records sent out for review before paying the claim and submitting to stop-loss? This is highly recommended.

With the lethal cocktail of health care reform, lack of financial limits, and mandatory coverage to age 26, it is anticipated that Mental Health and Substance Use Disorder claims will only become more prevalent.

Please contact us at info@asgrmi.com and let’s work together to try to reduce the financial risk these trends can pose to our employer groups.

 

Lasers: Finding the Balance Between Risk and Reward

Wednesday, June 08, 2016

by Nathan Savage, Underwriter and April St. Cyr, Claims Manager

As we hear more and more people talking about stop-loss policies, the hot topic that keeps coming up seems to be lasers.

In its simplest form, a laser involves adjusting the stop-loss deductible for an individual who has a very high likelihood of exceeding the group’s regular individual specific deductible.

Lasers can present the group with additional liabilities – but as with any insurance, the coverage is for unknown risks, rather than known risks. There is also a cap that when hit, would start reimbursements. This allows a group to have a max cost, even on riskier members. (For example, we may have a laser of $250,000 for a cancer diagnosis but if the member’s claim goes over that amount, we still reimburse over the laser.)

Lasers can also be conditional, and are typically based on events such as transplants or chemotherapy. When this is the case, the covered member must meet the group’s specific deductible for anything that does not pertain to the condition set.

So when are lasers considered?

We start looking at members during the underwriting process. If there are obvious claimants who we predict will be over the group’s deductible, we make a note of it on our initial quotes.

Lasers are finalized when a group’s disclosure is signed and sent to us with supporting documents. The disclosure is an important tool that gives us an accurate and detailed picture of all known claimants or high-risk individuals. It’s also the last time that we look at the group to set lasers.

Click here to read more about the role disclosures play in the underwriting process.

Limiting exposure to all parties involved

When a notice is received on behalf of a high risk member, our Medical Management team reviews the notice using the following typical reporting:

– High claim reports

  • – Pended reports
  • – Pre-certification reports
  • – Case management reports

Based on the findings in these reports, we further research costs using web-based tools that provide critical information (such as clinical and financial analytics) and help with managing, reimbursing, and underwriting catastrophic claims.

Our team may also reach out to the TPA or case manager for any additional questions or information pertaining to the group in general, or the claim in particular.

And that’s not all.

ASG has established relationships with leading vendors who are willing to work with us, our TPA partners, and the employer group to secure deeper discounts for coverage of high-risk members.

Often, a medical bill review and audit company, or a medical cost containment and claims flow management organization, is able to negotiate with a provider and get sign-off on a rate that benefits all parties. Transplant networks for solid organ and bone marrow transplants offer excellent contracts to help mitigate the financial sting of complex care.

When Lasers Meet Claims

As we stated above, the laser is conditional and therefore specific to the covered individual. Following is a typical example.

Say Sue Smith’s policy includes a $150,000 conditional laser in the event of chemotherapy, and her employer group carries a $50,000 regular deductible.

If Sue undergoes a chemotherapy regimen and meets her laser of $150,000, our TPA partner would send in all required reporting for filing a claim as it would for anyone on the plan, regardless of a specific deductible. Our claims analyst would review and process the claim the same way as if there were no laser.

On the other hand, if Sue goes in for a knee replacement – which obviously is different than chemotherapy – and the knee replacement costs $70,000, we would simply reimburse the company the $20,000 difference over their deductible.

No matter the size of the policy or number of lasers included, what’s most important to an MGU like us is confirming that the claims:

  • – Are paid according to the plan document
  • – Meet all requirements of the stop-loss policy

At the end of the day, our goal is to write and stand by a policy that works for all parties involved.

We’re here to answer your questions about lasers. Contact us at any time! 

 

Spotlight on Bailey & Co. – All About Employee Benefits

Monday, June 06, 2016

When it comes to customer service – one of the most important metrics in our industry – we’ve benefitted from working with some of the most conscientious and caring TPAs and Brokers from all over the U.S.

Bailey & Company Benefits Group falls squarely into that category. As the Cincinnati, OH affiliate of one of the largest independent employee benefit consulting and management firms in the nation, Bailey & Company has figured out how to operate as a “boutique” firm while offering the capabilities and resources of large, multi-faceted enterprises.


The company’s goal is to help mid-sized businesses and publicly traded companies maximize the return on their employee benefits investments with an extensive list of personalized, consultative services.

Click to learn more about Bailey & Company’s areas of expertise

An Innovative Way to Work

The way they go about it is through a unique Account Management model that focuses on growth by referral.

We were curious, so we asked Bailey & Company’s Brenda Hoernschemeyer more about this refreshing approach.

She explained, “We view ourselves as an account retention organization: We are about integrating ourselves into the client. And to do that effectively you can’t have 60 clients and be involved with every client on the level we need to be.”

Instead, Bailey & Company’s Account Teams are comprised of benefit consultants, account executive and account managers. Each team maintains relationships with approximately 20 clients, rather than the typical 40-50.

Account Teams are responsible for every detail that has to do with each and every client – from marketing and customer service to negotiating the best rates and providing the customer support needed for a plan to be successful.

Exceeding Expectations Through Experience

The people managing Bailey & Co. clients know their stuff. As a company with a deep bench of tenured insurance pros, the firm prefers to hire only those with insurance or brokerage experience; very few exceptions are made, and only for motivated candidates who have demonstrated an interest and ability to learn.

Being able to stay on top of trends is equally critical, Brenda notes. For example, over the past few years, a big part of each team’s job has been to help clients navigate their way through audits – primarily related to HIPAA, but often ERISA.

Keeping up with regulations such as these and the many moving parts of the self-funded insurance world could be more of a challenge, she says, if not for the fact that “I read, read, read – everything, every day.”

Additionally, working with “honest and trustworthy” partner MGUs like ASG makes her job meeting client needs that much easier. “I call ASG because it’s a good, honest relationship,” she says. “It’s just respectful, and they always understand why I have to ask the questions I do.”

We love hearing reviews like this and appreciate our positive relationship with Bailey & Company. If you’re interested in working with an experienced MGU that offers personalized service, drop us a line!

For more information about Bailey & Company, visit www.baileyandco.com.

 

Specialty Drugs: Typical or Trend?

Friday, April 08, 2016

We’ve been noticing an increase in the costs of specialty drugs for various diseases, and how the phenomenon is beginning to make a real impact on the cost of health insurance programs among businesses of all sizes.

It’s been reported that specialty pharmaceuticals today represent one of the fastest growing areas in health care, with these medications accounting for approximately 25% of total drug spending in the U.S.

Yet the situation is becoming a lot like a train that’s moving too fast – the costs of some of these drugs have begun barreling down the health care track and are about to get completely out of control.

No indication of slowing down

Last year, 17 of the 25 drugs approved by the FDA were specialty medications; already this year, the FDA has approved nine specialty drugs.

The agency is expected to continue approving specialty prescriptions in higher volumes, with some estimates predicting 70% of top-selling drugs to be specialty medications within the next four years.

With some experts predicting these drug expenditures to quadruple in the next six years, companies are more and more frequently looking to the flexibility of self-funded options as a way to lower and/or limit rising medication costs while still providing health care benefits to their employees.

Because our mutual goal is to ensure your employer clients have maximum liability in place, be assured we are watching the situation closely form the carrier side.

We hope you'll e-mail us at mguperspectives@asgrmi.com with any concerns or thoughts you have about this topic.

Visit Sara’s Corner for info on Hepatitis C and standard treatments.

Interested in more? Check out this report

We recently came across a PBS Newshour post on “How the growing cost of drugs might affect your employer’s health plan.”

The post says: More than half of large U.S. employers will more tightly manage their employees’ use of prescription drugs next year, according to a new survey. The increased expenses from costly drugs threaten to push some employer health care plans over a threshold that will make them subject to a high tax.

Click here to view the report.

 

Welcome to our new training program: Stop-Loss 101

Wednesday, March 23, 2016

In February, we kicked off a new training program to help incoming TPA and Broker vendors learn about the industry and get a better understanding of how things work from the MGU perspective.

Our goal in offering this free program is to help businesses become strong producers and work as seamlessly as possible with industry carriers and MGUs like us.

Inaugural Class

Our first attendees were Austin Urkiel and Wendy Tirrell from Consolidated Health Plans (CHP) in Springfield, Mass.

– Austin comes to his role as a CHP sales coordinator as a recent college graduate who had yet to see the underwriting process in action. He said his goal was to “better understand what information and data I should target from the groups we’re quoting to give us the best opportunity to win a case and how that information is used.”

– Wendy, an account manager who’s worked on the Underwriting side for over 12 years, mostly on fully insured rating, was curious about the differences in her new role, which involves pricing self-funded business.


ASG Vice President Mike Holland led Stop Loss 101 training in our Portland, Maine headquarters in February.

We covered a ton of info over the course of two days! Following an overview of self-funding, our Underwriting team walked Austin and Wendy through the basics of Stop-Loss (including how Specific Stop-Loss differs from Aggregate, and how they work together). We also covered the purpose and requirements of disclosures, how our in-house RN offers TPAs a great resource, and the ins and outs of the application process.

This was followed by information about the interaction between plan documents and policies. We wrapped up with a presentation about how reporting and submissions work on the Claims side.

Click here to see ASG’s distinctive Client Service Model.

For our part, we loved talking shop and comparing notes on what we’re each seeing in the business. Both of our attendees came ready with questions about industry trends (such as Level Funding and ELAP/Reference-Based Pricing) and were fantastic first-time “students” of Stop Loss 101!

If your organization is interested in participating in our free training program, please drop us an e-mail at info@asgrmi.com for more details.

 

On-Call with Sara Winand, RN – Focus on Hepatitis C

Monday, March 21, 2016

Hepatitis C is an infection caused by a virus that attacks the liver and leads to inflammation. The virus is spread by coming into contact with contaminated blood or body fluids – for example, when needles are shared or tattoo equipment is unsterile.

Those who contract Hep C typically show no symptoms, but may have fatigue, nausea, loss of appetite, and yellowing of the eyes and skin.

While standard treatment also includes the drugs pegatron and/or ribaviran, guidelines for treatment in adults are changing constantly with an array of new antiviral medications available. These newer drugs have significantly higher effectiveness – and some can actually eradicate the virus – but they also come with a higher cost for treatment.

Here are a few common brand names:

  • – Olysio (simeprevir)
  • – Sovaldi (sofosbuvir)
  • – Harvoni (ledipasvir/sofosbuvir)
  • – Viekira Pak (ombitasvir, paritaprevir, ritonavir with dasabuvir)
  • – Technivie (ombitasvir, paritaprevir, ritonavir combination tablets)
  • – Daklinza (daclatasvir)
  • – Zepatier (elbasvir/grazoprevir)

Cost-wise, just a few years ago the standard treatment with antivirals/immunosuppressants such as Pegasys (peginterferon) or Rebetol, Copegus, Virazole, or Ribasphere (ribavirin) was running around $45,000 to complete treatment; today’s new drugs can range from $90,000 to $185,000 per year.

For example, Solvadia, a new specialty pharmacy drug for treating Hep C, costs approximately $28,000 per month and $84,000 for the full 12-week treatment.

Click here for more about how the cost of today’s medications impact self-funded health plan claims. 

Spotlight on LBG Advisors: Why Relationships Matter

Friday, March 04, 2016

We recently chatted with Ron Kirkpatrick of LBG Advisors, an employee benefits firm based in Lynnwood, Wash., who we’ve been doing business with for the past few years. Ron made an interesting point about the relationship between a consultant (like LBG Advisors) and a risk bearer (like us) that we thought might resonate with our readers.


Ron pointed out that ours “is always a unique relationship because obviously, working directly with the client, we’re tasked to negotiate with that vendor. Our objectives can be the same, but a lot of times they’re not – the influences of the stop-loss carrier may conflict with ours, because the stop-loss carrier needs to make money off the premium – and that can become a risk to our client, the employer.”

The key to overcoming this obstacle, we agree, is establishing long-term relationships based on transparency and built on fairness. Ron’s correct in that the structure has to be profitable for the carrier and the advisor, but in the end, favorable to the client employer.

As he noted, risk certainly can be difficult to quantify long-term.

Today, with new variables like the high cost of specialty prescriptions muddying the picture and forcing both parties to hold a harder line, the tension can become even tighter.

So we at ASG agree wholeheartedly with Ron: With an increasingly greater regulatory environment, there is more and more of a risk structure around being able to run an insurance program effectively. However, if our mutual goal is to help employers keep their costs down, then we also have the option of looking at why we are doing certain things and how we can control them – perhaps even to change the system a little, including the way health insurance is delivered.

It’s a big topic, but at the core, we at ASG feel it’s our responsibility as a stop-loss vendor to work as closely as possible with you to remove conflict, maintain transparency and ultimately, do what we can to help our mutual clients keep their costs down.

Ron commented, “by using stable MGU or MGA partners like ASG, who are willing to work with us to offer fair quotes and renewals that are going to be open to transparency, we’re typically able to control the trends that our employers see. Bending that trend from between 6% and 8% down to 3% or 4%, which is more in line with the cost of living, combined with other techniques to control costs and increase transparency on their plan, typically allows us to save clients $1,000 to $2,500 per participant in the first year with matching or highly similar plan designs.”

Interesting, right? Drop us an e-mail at mguperspectives@asgrmi.com and let us know what you think.

If you’re a plan sponsor interested in this topic and other emerging issues affecting our industry, LBG is hosting its sixth annual LBG Advisors Benefits Symposium May 15-17 in Las Vegas. It’s the pre-eminent educational conference for group-based benefits and features the latest in cutting edge concepts for more effectively managing benefit programs. Click here to check it out, and maybe we’ll see you there!

ASG Welcomes New Team Member

Tuesday, January 19, 2016

We’ve added a medical specialist!

Sara Winand, RN, has been named Director of Medical Management, responsible for medical underwriting support and proactive claims management for ASG clients.

 

 “I have always enjoyed the continuing challenge of assessing each case individually,” she said. “It requires daily research of new trends, new procedures and treatments and their costs, covering all health conditions.”

Sara brings more than 35 years of healthcare experience to our team, with 16 of those specific to the stop-loss insurance field.

“Our firm is recognized nationwide for our focus on high-touch customer service, which allows us to administer claims proactively while protecting employer interests,” said Peter Parent, President of ASG. “Sara provides our TPA and Broker clients with an experienced, knowledgeable resource for helping to control employer costs and achieve the best possible outcomes for everyone.”

 

 

On-Call with Sara Winand, RN

Friday, January 15, 2016
  • Welcome to ASG Risk Management’s On-Call Corner!

Because our goal is to minimize your policy risk, we think it’s important to provide as much information as possible about different conditions our employer groups encounter.

Feel free to share this page with your clients, or use it as a helpful resource for any condition you’re looking into.

 

What you should know about: Shingles

By Sara Winand, RN | Director of Medical Management

Shingles is a reactivation of the varicella-zoster virus, a type of herpes that causes chickenpox. After you have had chickenpox, the virus lies dormant in your nerve roots and remains inactive until it flares up. If the virus becomes active again, you may develop a rash that occurs only in the area of the affected nerve. This rash is called shingles.

Who is at risk for getting shingles?

– Anyone who has had chickenpox

  • – Those who have a weakened immune system, such as people with cancer or HIV

– People over 50 years old

– People who have been ill, suffered physical trauma or are under significant stress

– Those taking medication that affects the immune system, such as steroids

– Pregnant women who get chickenpox (A baby will have a high risk for shingles during the first two years of life.)

– Babies who get chickenpox in the first year of life

It is not clear why the virus reactivates in about 20% of those who have had chickenpox, but there is evidence to suggest a weakened immune system may cause the virus to reactivate, multiply and move along nerve fibers to the skin.

What are the symptoms?

– Itching, stabbing or shooting pain with tingling under the skin

– Flu-like symptom such as fever, chills, headache or upset stomach

– Helplessness and depression

– Rash that develops into blisters on one side of the body, often around the waistline or face. (These fluid-filled blisters usually dry and crust within seven to 10 days.)

How is it diagnosed?

– By associated symptoms such as presence of rash, blisters on one side of the body, pain, itching, or fever

– Lab analysis from scraping or swabbing of the fluid-filled blisters

Is there a treatment?

There is no cure for shingles, although it is important to seek medical evaluation early as treatments can help with associated pain and discomfort.

  • Antiviral medications such as Zovirax, Valtrex & Famvir may shorten the duration of the symptoms.
  • Pain medications, antidepressants and topical creams are also options to ask about.

Is it contagious?

Yes.

– People who have never had chickenpox and have not been vaccinated against the disease can develop chickenpox if exposed to shingles.

– Someone who has shingles can expose you to the virus if you have come into contact with the fluid in the shingles blisters.

  • – If you are have an outbreak of shingles, you can prevent the spread of the virus to others by covering any fluid-filled blisters that are not covered by clothes with a dressing that absorbs fluid and protects the sores.

Complications

– Delaying or not getting medical treatment may increase your risk for complications.

– Postherpetic neuralgia, or a pain that does not go away within 30 days after the shingles rash heals

– Disseminated zoster, where the blistery rash spreads over a large area of the body and can affect heart, lungs, liver, pancreas, joints and GI tract

– Scarring and/or skin discoloration

– Bacterial infection of the blisters

– Cranial nerve complications (if shingles affects these nerves), which cause impaired vision, intense ear pain, loss of movement of facial nerves and inflammation of blood vessels that may lead to stroke

– Muscle weakness in the area of the infected skin before, during or after the episode of shingles

Who should take the shingles vaccine?

The vaccine, Zostavax, decreases your chances of getting shingles by 51% and lasts about five years.

– People age 60 and older (The vaccine is FDA-approved for those age 50 and over.)

– If you already have had shingles (The vaccine may lower your risk of getting it again.)

– If you have never had chickenpox (You should talk to your doctor as there is a good chance that you don’t remember having chickenpox. Studies show that 99% of Americans over 40 had chickenpox at some point.)

You should not take the vaccine if you are allergic to gelatin or neomycin (an antibiotic) or have a weakened immune system.

Women who are or might be pregnant should not take the vaccine.

Got a topic you’d like more info on? Let Sara Winand, our Director of Medical Management (and registered nurse!) know what hot topics people are talking about. E-mail Sara directly at sara@asgrmi.com.

Sources:

WebMD

Medscape News & Perspective

Centers for Disease Control and Prevention


 

 

 

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