 |
| Sep 30, 2009 |
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CDHP adoption rate rose among big employers, despite the economy |
| Sep 16, 2009 |
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Employees like their health plans, despite gaps in understanding |
| Sep 10, 2009 |
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Obama proposes controversial employer mandate, public option |
| Sep 1, 2009 |
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Hospital cracks down on ER visits |
| Aug 20, 2009 |
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COBRA enrollment soars, reports Hewitt |
| Aug 11, 2009 |
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NY law seen as harbinger of more state health reform |
| Aug 4, 2009 |
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Near-term health trends familiar, irrespective of reform |
| Jul 21, 2009 |
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Employers lukewarm on public-plan option, survey shows |
| Jul 17, 2009 |
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House committee approves health reform bill |
| Jul 15, 2009 |
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Senate committee passes health reform bill |
| Jul 7, 2009 |
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‘Pay or play’ not as painful as originally thought |
| Jul 1, 2009 |
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Five costly conditions to watch |
| Jun 30, 2009 |
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Americans go online for health information |
| Jun 23, 2009 |
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Pennsylvania passes mini-COBRA law |
| Jun 16, 2009 |
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Health benefits taxation takes center stage |
| Jun 8, 2009 |
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Obama alters stance on health reform proposals |
| May 28, 2009 |
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Mail trail shows health insurers readying for reform |
| May 19, 2009 |
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Health care costs hit women harder |
| May 7, 2009 |
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To see a doctor, get in line |
| May 1, 2009 |
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Considering the exit ramp: Employers rethink offering health benefits |
| Apr 23, 2009 |
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Hard times tighten ‘use-it-or-loss-it’ bond to health benefits |
| Apr 13, 2009 |
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COBRA subsidy expected to be costly |
| Apr 6, 2009 |
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Workplace wellness bill reintroduced with greater support |
| Mar 24, 2009 |
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New COBRA model notices released |
| Mar 10, 2009 |
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Twelve ways to slash medical bills |
| Mar 1, 2009 |
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Self-insuring is a way for employers to get 'a whole lotta cannoli' |
| Feb 23, 2009 |
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Employers turn to eligibility audits, voluntary benefits to control health care costs |
| Feb 11, 2009 |
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Senate, House debate COBRA subsidy |
| Feb 3, 2009 |
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Dems optimistic on comprehensive health reform |
| Feb 1, 2009 |
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How's this for an incentive? You get to keep your health insurance |
| Jan 27, 2009 |
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Medicare reimbursement shakes things up |
| Jan 20, 2009 |
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Health benefit costs continue to rise, survey shows |
| Jan 13, 2009 |
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N.Y. proposes policy requiring employers to extend dependent coverage |
| Jan 1, 2009 |
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Health care reform to take center stage this year |
| Dec 16, 2008 |
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Employees cut back on health costs - for better or worse |
| Dec 1, 2008 |
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Moderating health care costs could signal trouble ahead |
| Nov 25, 2008 |
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Tobacco addiction costs employers $167.5 billion a year |
| Nov 18, 2008 |
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Benefits professionals favor drastically reworked employer-based systems in new administration |
| Nov 11, 2008 |
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Employers urged to flex muscle on health care reform |
| Nov 4, 2008 |
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Obesity epidemic remains a battle |
| Nov 1, 2008 |
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Evidence shows positive outcomes from greater investment in primary care |
| Oct 21, 2008 |
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Losing sight of wellness program goals |
| Oct 14, 2008 |
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DOL seeks comments on how health plans use genetic data |
| Oct 1, 2008 |
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More patients heading to the emergency room |
| Sep 23, 2008 |
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BFE: Up your FMLA ante with these helpful tips |
| Sep 15, 2008 |
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Companies combat high HMO premiums with aggressive strategies |
| Sep 8, 2008 |
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Steady support for wellness and disease management |
| Sep 1, 2008 |
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Chronic conditions afflict more than half of Americans |
| Aug 12, 2008 |
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HHS wants wellness program advice |
| Aug 1, 2008 |
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Attention all shoppers: How to be a smart PBM shopper |
| Jul 15, 2008 |
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Parties stand far apart on health care reform |
| Jul 10, 2008 |
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Benefits to protect— and add— during economic downturns |
| Jul 1, 2008 |
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Seven Self-Insurance Myths |
| Jun 24, 2008 |
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Growth of employer medical costs projected to accelerate |
| Jun 15, 2008 |
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Pushing the envelope: Zero tolerance on tobacco use |
| Jun 1, 2008 |
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A new direction for health care reform and HMOs |
| May 27, 2008 |
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What's next for health care reform? |
| May 20, 2008 |
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Ohio, W.Va. and Pa. say no to CDHPs, survey reports |
| May 6, 2008 |
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Health plan study shows performance varies region to region |
| May 1, 2008 |
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Benefits finance: Is a self-insured health plan right for your company? |
| Apr 29, 2008 |
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HHS Secretary Leavitt backs value-based health care |
| Apr 22, 2008 |
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Obesity costs employers $45 billion a year |
| Apr 10, 2008 |
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Want to reduce sick days by an average of 41%? The solution is easy. Just walk. |
| Apr 1, 2008 |
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Robust incentives may improve retention rates in wellness programs |
| Mar 25, 2008 |
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Mercer Report: Employers focus on generic and specialty drugs to reduce Rx costs |
| Mar 11, 2008 |
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How to make your PBM more accountable |
| Mar 6, 2008 |
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Americans alarmed by gaps in quality health care delivery |
| Feb 21, 2008 |
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PBMI launches career center for drug benefit industry |
| Feb 12, 2008 |
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Business group wants to reduce health disparities among minorities |
| Feb 5, 2008 |
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Using incentives for health risk appraisals |
| Jan 31, 2008 |
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Mid-size employer turns to "hybrid" CDHP model |
| Jan 15, 2008 |
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Employees take advantage of wellness resources - when they're available |
| Jan 8, 2008 |
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Consumers are in the dark on health insurance terminology |
| Jan 1, 2008 |
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Checking the label: Transparency, generics utilization key components to effective PBM relationship |
| Dec 18, 2007 |
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Group counters belief that benefits sky is falling |
| Dec 4, 2007 |
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Touting large-scale ideas for health reform |
| Nov 20, 2007 |
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Health benefit costs still outpace the rate of inflation |
| Nov 8, 2007 |
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Toolkit outlines best practices in health coverage for mothers, children and adolescents |
| Nov 1, 2007 |
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Communications, wellness prove challenging for HR |
| Oct 15, 2007 |
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HealthMarkets charged with misleading customers and denying required care |
| Oct 4, 2007 |
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Is your company prepared for a pandemic? |
| Sep 25, 2007 |
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Focus on health plan design paying off for employers |
| Sep 15, 2007 |
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iPhone puts consumers' health records in the palm of hand |
| Aug 23, 2007 |
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Health insurers are starting to focus on value-driven plans |
| Aug 9, 2007 |
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California to produce first PPO report card |
| Aug 1, 2007 |
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Chicago museum makes walking exhibit grounds cornerstone of successful, no-frills wellness program |
| Jul 24, 2007 |
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Health care costs top employer concerns |
| Jul 12, 2007 |
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Benefit professionals react to Moore's depiction of health care |
| Jul 1, 2007 |
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Creating wellness incentives that resonate with workers |
| Jun 21, 2007 |
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Health insurance inflation is slowing down |
| Jun 15, 2007 |
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On the contrary: Employers not looking to shift costs |
| Jun 1, 2007 |
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Can't we all just get along? Achieving successful benefits integration with multiple carriers |
| May 17, 2007 |
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Employers shift focus to prevention |
| May 17, 2005 |
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Employers shift focus to prevention |
| May 8, 2007 |
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Fortune 500 firms push for health reform |
| May 2, 2007 |
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Biotech drug costs skyrocket |
| Apr 26, 2007 |
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Experts help small firms with health plans |
| Apr 18, 2007 |
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Group says health premium jumps should be justified |
| Apr 5, 2007 |
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HMOs more cost-effective in California |
| Mar 20, 2007 |
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CVS buys Caremark |
| Mar 6, 2007 |
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Americans value e-health services |
| Feb 22, 2007 |
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Top-rated hospitals have lower mortality rates |
| Feb 5, 2007 |
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Participation in wellness programs grows |
| Jan 25, 2007 |
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Country reacts to Bush health care proposal |
| Jan 16, 2007 |
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FMLA ruling protects subsidiaries |
| Jan 10, 2007 |
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Latest CDH trend may be plan attrition |
| Jan 3, 2007 |
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Tool helps employers keep up with the "Joneses" |
| Dec 20, 2006 |
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Majority unaware of medical costs |
| Dec 13, 2006 |
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Bill makes HSAs more flexible |
| Dec 5, 2006 |
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Half of CDHP users would switch plans if possible |
| Dec 1, 2006 |
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Health inflation lower, but worries grow over "fraying benefits" |
| Nov 30, 2006 |
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NBGH launches free guide to preventive care |
| Nov 16, 2006 |
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Medical costs may show double-digit increase in 2007 |
| Nov 7, 2006 |
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Most workers do not use FSAs |
| Oct 25, 2006 |
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PBMs keeping up with Wal-Mart |
| Oct 17, 2006 |
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Consumers prefer generics to brand drugs |
| Oct 11, 2006 |
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Workers worried about future of health benefits |
| Oct 1, 2006 |
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Dental providers embark on new ways to offer benefits |
| Sep 20, 2006 |
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Questions remain about provider quality programs |
| Sep 15, 2006 |
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Cheaper Zocor throws generic market a curveball |
| Sep 6, 2006 |
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HSA assets surge over past six months |
| Sep 1, 2006 |
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Consumers get more tools to gauge medical costs, quality |
| Aug 31, 2006 |
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Workers motivated by richer benefits |
| Aug 24, 2006 |
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Bush compels price and quality transparency in health care |
| Aug 17, 2006 |
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Workers uneasy about pay, health care |
| Aug 9, 2006 |
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HMOs account for one quarter of insurance market |
| Aug 1, 2006 |
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Generics influx drags prescription drug trend to seven-year low |
| Jul 25, 2006 |
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Depression costs related to health care access |
| Jul 12, 2006 |
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Research shows effects of quality ratings for surgeons |
| Jul 6, 2006 |
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Employers portend scaling back retiree medical benefits |
| Jun 20, 2006 |
|
Tips for CDHP roll-outs |
| Jun 15, 2006 |
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Ohioans recoup $6.5 million in health claims |
| Jun 8, 2006 |
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Not-so-great expectations for health costs |
| Jun 1, 2006 |
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Vermont latest state to pass health reform |
| May 30, 2006 |
|
Study gauges health data gap |
| May 17, 2006 |
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Most employers do not offer DM, wellness, but they want to |
| May 10, 2006 |
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Declining employer-sponsored health plans documented |
| Apr 27, 2006 |
|
Workers build muscle with incentives |
| Apr 25, 2006 |
|
Change coverage to lower pregnancy cost |
| Apr 20, 2006 |
|
Health experts face off on access vs. innovation |
| Apr 15, 2005 |
|
Target draws bead on consumer-driven health care |
| Apr 11, 2006 |
|
Female employers worry about skyrocketing health costs |
| Apr 5, 2006 |
|
Mental health benefits add value, not cost |
| Mar 27, 2006 |
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Validate your health ROI to the CFO |
| Mar 21, 2006 |
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Variety of strategies needed to curb health costs |
| Mar 9, 2006 |
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Managers doubt CDH will make workers healthier |
| Mar 1, 2006 |
|
Health care to account for 20% of GDP by 2015 |
| Feb 23, 2006 |
|
Higher co-pay differentials increase generic fill rates |
| Feb 14, 2006 |
|
Consumer advocates worry about health data privacy |
| Feb 7, 2006 |
|
Cost and talent issues challenge benefit professionals |
| Jan 25, 2006 |
|
More than half of seniors stay away from Part D |
| Jan 15, 2006 |
|
Mind the Meds: Top 10 pharmacy benefits management strategies for 2006 |
| Jan 2, 2006 |
|
Put your health care eggs in many baskets |
| Dec 14, 2005 |
|
CDH participants dissatisfied but frugal |
| Dec 8, 2005 |
|
Health care banking gets the Blues |
| Dec 1, 2005 |
|
Generic drugs offer employers untapped savings |
| Nov 29, 2005 |
|
Care management, cost-shifting reduce health costs |
| Nov 17, 2005 |
|
Pay-for-performance generates quality improvements |
| Nov 15, 2005 |
|
Employers should examine full impact of obesity |
| Nov 3, 2005 |
|
US CEOs more health care cost conscious |
| Nov 1, 2005 |
|
Health cost relief takes center stage at BMF&E |
| Oct 25, 2005 |
|
Wal-Mart extends lower-cost health insurance |
| Oct 11, 2005 |
|
Large companies find lower health care hikes since 1999 |
| Sep 21, 2005 |
|
Cost-shift trend is also costing brokers |
| Sep 15, 2005 |
|
Financial incentives touted as health care cost fix |
| Sep 8, 2005 |
|
PBM mail-order pharmacies deliver cheaper drugs |
| Aug 31, 2005 |
|
A spoonful of compliance helps health costs go down |
| Aug 18, 2005 |
|
AutoNation claims UnitedHealthcare overpaid by $10 million |
| Aug 16, 2005 |
|
Consumers elevate HMOs over PPOs |
| Aug 9, 2005 |
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Medical cost containment depends on changing habits |
| Aug 2, 2005 |
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Employers could see relief in benefit costs |
| Jul 26, 2005 |
|
PBMs scoop up specialty pharmacies |
| Jul 15, 2005 |
|
Off and running: Self-funded employers may have head start in push for wellness |
| Jul 5, 2005 |
|
Walgreens says drug costs rose 7.2% in 2004 |
| Jun 28, 2005 |
|
More than half of employers concerned about wellness |
| Jan 21, 2005 |
|
Benefit managers offer best ways to ease health costs |
| Jun 14, 2005 |
|
UnitedHealth has a million in consumer-driven plans |
| Jun 9, 2005 |
|
Uninsured worsen medical inflation for workers |
| Jun 1, 2005 |
|
New study puts medical costs into focus |
| May 24, 2005 |
|
Disease management has become the norm |
| May 10, 2005 |
|
Unions found to have better access to health insurance |
| May 4, 2005 |
|
Employers don't lie down for higher premiums |
| Apr 28, 2005 |
|
Mandatory health insurance rejected in California |
| Apr 21, 2005 |
|
GM says health costs partly to blame for first-quarter losses |
| Apr 12, 2005 |
|
Group launches program to buy health insurance in bulk |
| Apr 7, 2005 |
|
Maryland considers bill that mandates benefits spending |
| Mar 25, 2005 |
|
Many would sacrifice choice for lower health costs |
| Mar 15, 2005 |
|
State health mandates scrutinized |
| Feb 9, 2005 |
|
Scandals may prompt more online insurance bidding |
| Jan 19, 2005 |
|
Employers should investigate disease management math crimes |
| Jan 12, 2005 |
|
Clients tackle medical inflation roots |
| Jan 8, 2005 |
|
Employees prefer work-based insurance |
| Dec 21, 2004 |
|
Automated Systems For Drugs Examined |
| Dec 14, 2004 |
|
Companies Rapidly Cutting Health Benefits |
| Dec 2, 2004 |
|
40 Percent in U.S. Use Prescription Drugs |
| Nov 1, 2004 |
|
Your New Health Plan |
| Sep 27, 2004 |
|
Health costs rising faster than incomes, study says |
| Sep 13, 2004 |
|
Employers slow shift of health care cost burden to workers |
| Aug 10, 2004 |
|
Health care costs employers more than paid leave |
| Jul 15, 2004 |
|
Health insurers lost $85 billion to fraud last year |
| Jul 22, 2004 |
|
Health and productivity management intrigues firms |
| Jun 4, 2004 |
|
Rising benefit costs hurt small businesses' financial health |
| Feb 28, 2004 |
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Strike-weary grocery workers eye new offer |
| Feb 28, 2004 |
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Experts ponder limitations of cost-sharing |
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Five costly conditions to watch
Many employers choose to self-fund their medical plan because of the significant flexibility, enhanced control over benefit design and potential cost savings they afford over conventional fully-insured health plans. The tradeoff, of course, is that under a self-funded plan, the employer takes on the direct financial risk of providing the benefits and is ultimately responsible for paying claims.
While companies that opt for a one-size-fits-all, fully insured plan may not focus as much on particular medical conditions, companies that self-fund need to be keenly aware of the unique health characteristics of their employee base. Yet, when it comes to which medical conditions pose significant financial risk for self-funded plans, many employers remain in the dark.
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As a registered nurse and medical risk consultant for a leading stop-loss insurance provider, I regularly work with employers, third-party administrators, hospitals and health care providers on a variety of complex medical conditions affecting self-funded medical plans. The job of our entire team of medical risk consultants is to utilize our health care expertise to reduce the claims experience on behalf of employer group clients.
Based on the team's experience, I have assembled a list of five common conditions that represent some of the more costly and complicated treatments particular to self-funded health plans.
1. Kidney disease
According to the Centers for Disease Control and Prevention, nearly one in six adults has chronic kidney disease. The two main causes of chronic kidney disease are diabetes and high blood pressure. Rather than exhibiting a rapid onset, kidney disease tends to follow a progression through five stages: slight damage, mild decrease in function, moderate decrease in function, severe decrease in function and end-stage kidney failure.
High costs usually take hold in stage five when dialysis is imminent. Dialysis costs on average are approximately $25,000 per month. Annually, costs can vary from $200,000 to $400,000 depending on network arrangements, availability of care centers and the dosages of the high-cost supportive drugs typically administered.
As in the broader population, the proportion of employees with high blood pressure or diabetes is growing. This increases the probability of kidney-related problems and other health issues arising among plan participants. Yet, many self-funded plans are not set up to address all phases of the disease. For example, plans may not be able to handle proactive kidney disease case management aggressively enough at an early phase, which can lead to more claims exposure at more severe stages later on.
The process for lowering charges should begin before the first bills arrive. Within the plan, establish advance screening, notification processes and assessments for kidney conditions. Plan language that requires precertification and delineates working with effective cost-containment partners seems to get the best results for preserving patients' lifetime benefit maximums and conserving fund dollars.
Early identification of the condition also can greatly reduce costs over time. Chronic kidney problems often can be delayed or even avoided through preventive procedures, early intervention, and patient education and counseling. Aggressive disease and case management can in some cases slow the progression to kidney failure.
2. Hemophilia
Hemophilia is a rare genetic disorder that prevents the blood from clotting normally. Research shows 60% of the hemophilia population falls into a severe category requiring advanced therapies several days a week. Currently, there is no cure for hemophilia. The main treatment currently available is a lifelong infusion of replacement "blood clotting factors."
Hemophilia consistently comes in near the top of claims among the employer groups we work with. We have found that, on average, treatment costs have an annual run rate of over $300,000 per individual.
Treating hemophilia is not just expensive, but it is a condition where insureds tend to burn through the lifetime benefit maximum at a rapid rate. Because of the repetitive and intense treatments, including infusions, it is not uncommon for hemophiliacs to reach their lifetime benefit maximum while still in early childhood. Without adequate stop-loss coverage, this can put significant pressure on reserves and potentially affect the company's overall capital position.
Hemophilia treatment is expensive in large part due to the drug component. As a result, make your pharmacy providers compete on price. If your plan does not include more than one preferred pharmacy provider, look to build in at least one or two additional options.
As soon as a hemophilia case is identified and before paying claims, reach out to your pharmacy benefit manager to see about negotiating deeper discounts beyond standard PPO levels. If you are not sure how, your medical stop-loss carrier should be able to go to work on the discount for you. We recently did this on behalf of an employer and found it would result in an average savings of $147,840 per year.
3. Transplants
Transplant procedures continue to improve with dramatic, often life-saving, results for patients. While stem cell/bone marrow, liver and kidney transplants are among the most common, physicians are now able more than ever before to effectively treat more medical conditions using transplants. According to Milliman, the usage of virtually every type of transplant surgery increased from 2004 to 2008. Improved transplant availability, however, comes at a hefty price.
Transplants remain one of the most complicated and expensive of all medical procedures. Reports show that common liver-kidney transplants rack up average billed charges of $760,000 and, in our experience, stem cell transplants and the accompanying care cost on average between $350,000 and $600,000.
Transplants are truly uncharted waters for health insurance. All types of plans, self-funded included, struggle with how to accommodate this rapidly growing treatment. Employers can pay a high price if they fail to take into account the potential future claims exposure from expanding transplant therapies when drawing up their plan design.
Make sure your plan provides access to at least one transplant network. With demand outstripping supply, this can save both time and money in securing a transplant for participants. Also, require external peer review. We typically contract with at least three different transplant facilities for clients in order to improve responsiveness and choice, while also reducing risks and establishing greater discount leverage.
4. Specialty drug treatments
Pharmacological and biologic innovation is spurring a myriad of specialty drugs designed to treat serious health conditions such as cancer, immune deficiency disorders and metabolic syndromes. Some of these wonder drugs hold the promise of unprecedented improvements in patient health and survival rates. Cutting-edge drugs for advanced cancer treatments are likely to be among the key cost drivers for this area going forward.
However, specialty drugs have also begun to find broader application as it relates to less life-threatening conditions, such as rheumatoid arthritis.
Specialty drugs already account for roughly a quarter of outpatient pharmacy expenditures, according to CuraScript's Specialty Pharmacy Management Guide and Trend Report, and that proportion is expected to continue growing. On the patient side, prices can range from $5,000 to more than $300,000 a year, according to a recent AARP report.
Most plans have benchmarked and forecast benefits using historical utilization data. Yet, these new specialty drugs look to have very different administration and cost characteristics than more conventional prescriptions. In addition, unlike other drug categories, these treatments are less likely to have available a generic equivalent or substitute treatment option.
Find vendors with expertise in this area and get them involved early on to collaborate with the physicians handling the treatment plan. Verify that you have access to specialty drug consultants through your TPA or medical stop-loss insurer. They should be able to make available a team of cost-containment experts to help whittle down direct charges for these drugs and other treatments as well. They can also ensure specialty drugs are being administered appropriately and in fact going to those patients who really require them.
Drugs approved by the FDA are for specific conditions with specific dosages. If dosages and frequencies do not concur with FDA guidelines for a particular drug, questions about experimental or investigational uses may come into play.
As for plan design, prescription drug plans do not usually cover specialty drugs and infusion therapies, so include plan wording that prevents constant exceptions. Clearly define how each coverage area will accommodate these treatments so as to avoid specialty drug claims spilling over.
5. Extreme premature births
Every year, millions of babies are born smaller and sooner than expected. One in eight babies born in the U.S. fall into the preterm classification of being born before 37 weeks, and the number of extreme premature births is growing. Since the United States began keeping records of premature infants in 1981, the trend has been on a steep upward path, increasing 30% by 2005.
A baby born at 24-to-25 weeks gestation, who is small enough to fit into the palm of your hand, is likely to cost more than $1 million dollars. Even after plan discounts, actual claims can easily run between $700,000 and $900,000.
Physicians have difficulty both in predicting preterm births and preventing the event, as it occurs in women who get prenatal care as well as those who do not. This limited ability to foresee the condition, coupled with frequent failures by hospitals to provide timely notification to plans, complicates expense management under a self-funded plan.
The newborns often require extended stays in neonatal intensive-care units with highly-specialized medical care, but there are few such qualified facilities available, and they operate at a high cost. These early births often result in later complications, including congenital heart disease, mental retardation, cognitive defects and cerebral palsy. Overriding all of this is the fact that, when the survival of a precious newborn is at stake, it is obviously an emotionally charged situation for the family and all parties involved.
Find a specialty vendor with a record of successfully working in partnership with hospitals that have a record in effectively managing preterm infant care. Such a vendor will often partner with the neonatologist, have expertise in medical management for these fragile babies and provide dedicated hospital discharge planning. This interaction even involves direct physician-to-physician consulting.
It also is a good idea to have a case manager at your disposal with experience in neonatal intensive nursing, again either through the TPA or medical stop-loss carrier. Should further health complications emerge down the road, this case management can be quite helpful in ensuring proper diagnosis and treatment for premature birth-related conditions and in reducing the likelihood of unnecessary or duplicate tests and procedures.
By Patricia Edwards, RN |
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