MyHealthGuide Newsletter
News for the Self-Funded Community
3/23/2015

Published weekly by MyHealthGuide, LLC (www.MyHealthGuide.com). This Newsletter is for personal, non-commercial use only.  This weekly newsletter is FREE OF CHARGE to subscribers.  Subscribe free. Send news, press releases and announcements to mailto:Info@MyHealthGuide.comClick here if Newsletter stops arriving.

TABLE OF CONTENTS


General & Company News

People News

Market Trends, Studies, Books & Opinions

Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures


General & Company News



Roundstone & Columbus Chamber of Commerce Launch Captive Partnership for Self-Funded Employers

MyHealthGuide Source: Roundstone Management, Ltd., 3/19/2015, www.roundstoneinsurance.com

WESTLAKE, OH -- Roundstone Management, Ltd. and the Columbus Chamber of Commerce announce an exclusive captive partnership to offer self-funded health plans to employers with 20-500 employees in Ohio. This captive arrangement offers cost-savings through best in class expense management, cost containment and wellness. This innovative healthcare delivery solution enables these employers to dramatically reduce their health benefit costs.

Gene Pompili, Roundstone's Senior Vice President of Sales, commented "We're excited to partner with a highly respected organization like the Columbus Chamber of Commerce and Wells Fargo. We've been working closely to build a unique Group Captive solution for mid-market employers. We look forward to introducing this to the Columbus area and bringing a tremendous solution to the employers."

"The partnership will help us bring more value to our members here in Central Ohio," said Michael Dalby, CEO of the Columbus Chamber of Commerce, "it's offerings like this that give small and medium-sized businesses the support they need to grow and thrive."

Jamie Zelewicz, Vice President of Wells Fargo Insurance, noted "We have assembled the A team with Medical Mutual, Nationwide, Roundstone and Wells Fargo. This fresh approach offers Chamber members a unique solution to leverage the purchasing power of the Chamber, minimize expenses and risk, and position themselves to share in underwriting profits."

The partnership reflects optimism about the continued growth of self-insurance and further expansion of the group captive's track record for delivering flexibility and transparency to better predict and control health care costs.

About Roundstone

Roundstone Management, Ltd. ("Roundstone") based in Westlake, Ohio is an insurance organization offering an expertise in the captive marketplace coupled with turnkey insurance management services. Contact Jennifer Boerio at 440-617-0333, Ext. 238, jboerio@roundstoneinsurance.com and visit www.roundstoneinsurance.com.

About Columbus Chamber of Commerce

The Columbus Chamber of Commerce is a resources-based non-profit organization serving over 1,300 businesses in Central Ohio. Providing support in areas such as research, marketing, talent advisement, networking, and government affairs, the Chamber has been in existence for 131 years.

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Competitive Health Announces New Dental Discounts with Aetna Dental Access® Network

MyHealthGuide Source: Competitive Health, Inc., 2/18/2015, www.competitivehealth.com
 
Mission Viejo, CA -- Competitive Health, Inc. is delighted to announce that discount dental services through the Aetna Dental Access® network will become the newest offering through our healthcare savings marketplace.

Members can choose from more than 158,000 available dental practice locations through the Aetna Dental Access network. In most instances, savings are 15% - 50% per visit.** Members show their discount card at the time of service and pay the discounted fee. The program offers on-the-spot savings with no referrals, no waiting periods and no claims to file. 

Competitive Health develops and delivers unique turn-key programs that provide access to national healthcare services including dental, vision, telemedicine and much more. "Eliminating monthly access fees, our model presents a unique opportunity to dramatically increase value and access to care," stated Founder and CEO, Kimberly Darling.

THIS IS NOT INSURANCE AND IS NOT INTENDED AS A SUBSTITUTE FOR INSURANCE.
The discount program does not make payments directly to the providers. The program member is obligated to pay for all healthcare services but will receive a discount from contracted healthcare providers. DMPO: AccessOne Consumer Health, Inc. 84 Villa Rd, Greenville, SC 29615; 855-588-1300; www.accessonedmpo.com. The discount dental program is not available to Vermont residents.

About Competitive Health

Competitive Health, Inc. is an award-winning, privately held company providing patented technology, consumer-driven programs and payment solutions to clients throughout the United States. To learn more call 1-888-642-6490 or email sales@competitivehealth.com and visit www.competitivehealth.com.

About the Aetna Dental Access® Network

The Aetna Dental Access network is administered by Aetna Life Insurance Company (ALIC). The list of providers may change without notice. Neither ALIC nor any of its affiliates offers or administers the discount program. Dental providers are independent contractors and not employees of agents of ALIC or its affiliates.

AccessOne Consumer Health, Inc. - Is one of the nation's oldest licensed discount medical plan organization, founded in 2005. AccessOne specializes in compliance platforms for unique and special purpose programs. Over 5 million families are served by AccessOne programs.

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Health Payer Consortium Reduces Fees on Large Dollar Claims Averaging 10.3% Savings

MyHealthGuide Source: Health Payer Consortium ("HPC"), 3/18/2015, healthpayerconsortium.com

Health Payer Consortium ("HPC") has a mission to shift profits away from third party vendors back to the Payer and their clients. HPC's numbers are in and we are proud to publish our stats. On large dollar out of network claims, HPC delivered an average discount of over 50%, with sign-off. HPC delivered these discounts at an average effective fee of only 10.3% of savings.

These results were achieved on HPC's entry-level program, Fast Start. This program does not require an investment or long-term contract and still reduces fees by half of what many vendors charge. Our membership program can eliminate cost containment the fees all together.

If you would like to learn more, HPC will be hosting a series of webinars titled "How to Eliminate 50% to 100% of Your Cost Containment Fees." 25-year industry veteran and HPC President, Patrick Crites, will host the webinars.

Besides drastically cutting fees using the consortium business model, the webinars will focus on techniques that leading healthcare payers are using today to achieve the largest discounts on each type of claim.

The webinars will be held on Tuesday, March 24 and Thursday, March 26 at various times.

Registration is available at healthpayerconsortium.com/webinars/.

About Health Payer Consortium (HPC)

Health Payer Consortium (HPC) is designed to be a payer-owned innovation company located in Saint Louis, Missouri. HPC provides innovation management services for Healthcare Payers. By marrying a cutting edge business model with talented industry veterans, the Health Payer Consortium delivers the highest quality products while eliminating waste in the current vendor based system. Contact Patrick Crites at Patrick.crites@hpcmembers.com, (314) 450-5817 and visit healthpayerconsortium.com.

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6 Degrees Health Adds University of Arkansas for Medical Sciences to its Transplant Network

MyHealthGuide Source: 6 Degrees Health, Inc., 3/20/2015, www.6degreeshealth.com

Beaverton, OR -- 6 Degrees Health is pleased to announce the addition of the University of Arkansas for Medical Sciences to its exclusive group of transplant and complex care hospitals: OURproviders™.

The University of Arkansas for Medical Sciences has contracted with 6 Degrees to provide abdominal organ and blood/marrow transplant services through the 6 Degrees' network.

"The University of Arkansas' Myeloma Institute is truly a leader in treating Multiple Myeloma. With the majority of the Myeloma Institute's patients coming from outside of the State of Arkansas, this institution is well prepared to handle the complexities of being a destination program. We are very pleased to add this fine institution to our transplant network," states Scott Ray, 6 Degrees Health's CEO.

Neal Franzer, 6 Degrees' Director of Operations, adds, "we pay particularly close attention to the needs of our clientele, and the addition of the University of Arkansas is a prime example of a network addition coming at the request of our clients."

About 6 Degrees Health, Inc.

6 Degrees Health is a Specialty Network focusing on mitigating the risks with transplants, cancer, cardiac and other complex high-dollar care. OURsolutions™ is designed for Insurers, Third Party Administrators, Stop Loss and Reinsurance carriers, Self-Insured Employee Health Plans, Health Maintenance Organizations, and Government Health Plans. OURsolutions™ promotes improved patient outcomes, optimizes Payor savings, and delivers the incremental volume to OURproviders™. The keystone of 6 Degrees Health's solutions is its proprietary analytics platform (VeritasDx™) … there is no equal in the market executing the transparency necessary to achieve a win-win for Patient, Payor and Provider. Contact David Vizzini, President, 6 Degrees Health, Inc., at davidvizzini@6degreeshealth.com, 503-640-9933 ext. 102 and visit www.6degreeshealth.com.

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Magellan to Acquire 4D Pharmacy Management Systems, Inc. for Medicare Part D Expertise

MyHealthGuide Source: Magellan Health, Inc. (NASDAQ:MGLN), 3/18/2015, MagellanHealth.com

SCOTTSDALE, AZ -- Magellan Health, Inc. announced that it has entered into an agreement to acquire 4D Pharmacy Management Systems, Inc. (4D), a privately held, full-service pharmacy benefit manager (PBM) headquartered in Troy, Mich., serving managed care organizations (MCOs), employers and government-sponsored benefit programs, such as Medicare Part D plans. In addition to bringing scale and capabilities to Magellan Rx Management, this acquisition adds business in growing markets, such as the Medicare, dual eligible and healthcare exchange markets.

4D's commercial book of business is complementary to Magellan's, with a similar high-touch, service-oriented business model, including strong momentum with third-party administrators, consultants and brokers. 4D's management team, with a track record of execution, will supplement Magellan Rx Management's existing strong leadership team.

"4D will increase Magellan's PBM scale and provide the company with inroads in Medicare Part D, managed Medicaid, dual eligibles and exchanges," said Barry M. Smith, chairman and chief executive officer of Magellan Health. "With the capabilities that this acquisition brings, combined with our strong sales momentum, we are well positioned to exceed our long-term growth objective of $2.5 billion of pharmacy revenue by 2018."

"This acquisition is right in line with our pharmacy growth strategy, adding capabilities and expertise that will further enhance the customer experience," said Robert W. Field, chief executive officer of Magellan Rx Management. "4D's seasoned leadership team, as well as its experience as a full-service PBM, will strengthen Magellan Rx Management's offerings to provide additional competition in an area dominated by a few large players."

"4D is a great fit within Magellan's larger pharmacy organization," said Gerald Borsand, chief executive officer of 4D. "It's clear that both companies share a desire to bring their clinical expertise and innovation to the market, and together, our capabilities will be leveraged, expanded and enhanced as we seek to grow the business."

"Since its inception, 4D has been a family-owned business focused on its clients and employees," commented Jeff Polter, vice president, Business Development and Account Management of 4D. "The Magellan model is a perfect complement to the 4D culture. As a family, we are excited to be part of this larger organization, which will allow us to continue to focus on our clients and employees while bringing additional valuable products and services to market."
 
The base purchase price of 4D is $55 million, to be funded in cash at closing. Additional consideration of up to $30 million is based on future milestones, including up to $10 million for the achievement of certain growth targets in the underlying dual eligible membership served by 4D, and up to $20 million for the retention of certain business through 2018.

Closing of this transaction is expected to occur in the second quarter of 2015. For the full year of 2015, including pre- and post-acquisition periods, it is expected that 4D will produce approximately $400 million in revenue. 4D currently serves approximately 670,000 members.

About Magellan Health

Headquartered in Scottsdale, AZ, Magellan Health, Inc. is a healthcare management company that focuses on fast-growing, complex and high-cost areas of healthcare, with an emphasis on special population management. Magellan delivers innovative solutions to improve quality outcomes and optimize the cost of care for those we serve. Magellan's customers include health plans, managed care organizations, insurance companies, employers, labor unions, various military and government agencies, third-party administrators, consultants and brokers. Contact Laura Schuntermann at 860-507-1822, lgschuntermann@magellanhealth.com and visit MagellanHealth.com.

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Dell Services Positioned as Leader in Everest Group's PEAK Matrix 2015 Healthcare Payer BPO Report

MyHealthGuide Source: Dell, 3/10/2015, www.Dell.com

PLANO, TX -- Dell Services announced that Everest Group has positioned Dell's Healthcare Services in the Leader category for its inaugural Healthcare Payer Business Process Outsourcing (BPO) -- State of the Market with PEAK Matrix™ Assessment report[i]. Dell is the only vendor to receive a "High Assessment" in all categories (scale, scope, technology capability, delivery footprint, and overall market success).

With more than 27 years of experience providing services to healthcare customers, Dell's expertise combines leading automation technology, and a globally certified workforce to provide a full range of health plan BPO services in front end processing, claims administration, member management, provider management, financial performance improvement, and care management business processes.

Dell's differentiated service solutions, delivered by thousands of health plan BPO professionals around the world, infuse efficiencies into administrative processes, improve financial performance by reducing the medical loss ratio, and enable health plans to deliver care, while focusing on the consumer. Dell's BPO services are delivered on Dell's proprietary claims management platforms. These platforms deliver solutions including analytics tools for medical loss ratio and care delivery and robotic automation to improve productivity. Dell's health plan customers benefit from flexible engagement options and predictable and responsive services.

"Our customers face new and complex challenges and look to Dell to provide world-class services to help them navigate their business environment," said Sid Nair, vice president & global general manager, Healthcare & Life Sciences, Dell Services. "It is an honor to be positioned as a Leader in the first ever Everest Group PEAK Matrix report for our market success and overall service and delivery capabilities."

"We are focused on impacting the core business of our health plan customers. Not only do we help them cut costs, but actually enable them to lead the change through a renewed focus on patient care," said Tanvir Khan, vice president for Dell's BPO services. "This report reflects and validates the long-standing BPO relationships we have with our healthcare customers."

"In the rapidly evolving healthcare payer market, service providers' ability to improve operational efficiency, deliver tangible value through analytics, and enable top-line growth through seamless member enrollments are key differentiators," said Rajesh Ranjan, partner of Everest Group. "As per our assessment, Dell Services has been able to respond to some of these changes effectively and efficiently, which helped it achieve this recognition"

About Dell
 
Dell Inc. listens to customers and delivers innovative technology and services that give them the power to do more. Dell Services develops and delivers a comprehensive suite of services and solutions in applications, business process, consulting, infrastructure and cloud services to help customers succeed. Visit Dell Services on LinkedIn and follow us on Twitter.  Contact Kirsten Prucha, Business Development Consultant, at kirsten_prucha@dell.com, 571-419-9141 and visit www.Dell.com.

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People News



Healthcare Management Administrators Announces Lindsay Harris as Director of Product Management

MyHealthGuide Source: Healthcare Management Administrators (HMA), 3/19/2015, accesshma.com

BELLEVUE, WA -- Healthcare Management Administrators (HMA) is pleased to announce Lindsay Harris as their new Director of Product Management. Harris will play a critical role in determining HMA's product road map for launching new services and products to clients.

For the past seven years, Lindsay has held various leadership roles at HMA including key roles in Health Services, Client Services, and Reporting. Prior to her role as Director of Product Management, she successfully launched HMA's health and wellness suite of services.

Prior to joining HMA, Harris served as a program administrator for the disease management, nurse line and biometric screening programs at Premera Blue Cross. Prior to that, she was a program analyst for Mathematica Policy Research, a consulting firm specializing in large-scale evaluations of health and welfare programs such as the Centers for Medicare and Medicaid Services (CMS) Medicare Chronic Care Improvement Project. Lindsay has also held roles at the Agency for Healthcare Research and Quality and Georgetown University and ran a smoking cessation program in the Chicago suburb of Oak Park.

Lindsay holds a Masters of Public Policy from Georgetown University and a Bachelor of Arts in Chemistry from Knox College.

"We are thrilled that Lindsay is leading Product Management for HMA. Her experience, industry knowledge, and drive to simplify healthcare for members will help us further expand and strengthen our leadership position in third party administration," stated Steve Suter, CPCU, HMA's Chief Operating Officer.

About Healthcare Management Administrators

Healthcare Management Administrators (HMA) has been an industry leading Third Party Administrator of self-funded health plans for over 29 years. HMA is dedicated to our vision of "Creating a healthier future -- each client, every time". Through working with HMA, self-funded health plans can be a vehicle to help improve population health and take advantage of lower costs. Contact Courtney Bowman, MBA, Corporate Marketing and Project Coordinator, at 800.869.7093 ext 5266, courtney.bowman@accesstpa.com and visit accesshma.com.

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Dell Healthcare Services Adds Jennifer Lescsak and Sandy Hamilton

MyHealthGuide Source: Dell Healthcare Services, 3/17/2015, www.Dell.com

Jennifer Lescsak, Healthcare Business Senior Advisor

Jennifer Lescsak, Healthcare Business Senior Advisor, joined Dell Healthcare Services in January 2015. In her role, she is responsible for developing strategies and building new relationships that gain momentum within the Healthcare community by providing staffing and BPO service solutions to the Payer and TPA market. With over 20 years of experience in the healthcare industry including 7 years with a leading TPA, Jennifer has demonstrated success in leadership roles for business development and operations on both the Payer and Provider side of healthcare.

Sandy Hamilton, Healthcare Business Senior Advisor

Sandy Hamilton, MSW joined Dell Healthcare Staffing Solutions in January 2015 responsible for the States of Florida, Texas and Georgia as Healthcare Business Senior Advisor. As a seasoned executive in the healthcare marketplace, Sandy has achieved outstanding successes in demonstrating growth and achievements both in new and mature markets. Her broad experience in the insurance industry is reflected in managed care, reinsurance, cost containment solutions, sales and operations.

Sandy received her Master in Social Work at Florida State University and began her career serving in state government working for the Governors offices of Florida and Massachusetts prior to entering the insurance arena at BCBS of Florida. Her experience as an advocate led her to opportunities at John Alden Life, Prudential HealthCare and United Healthcare as well as cost containment companies of Health System International and Assent Medical Cost Containment.

About Dell

Dell Inc. listens to customers and delivers innovative technology and services that give them the power to do more. Dell Services develops and delivers a comprehensive suite of services and solutions in applications, business process, consulting, infrastructure and cloud services to help customers succeed. Visit Dell Services on LinkedIn and follow us on Twitter.  Contact Kirsten Prucha, Business Development Consultant, at kirsten_prucha@dell.com, 571-419-9141 and visit www.Dell.com.

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Lucent Health Hires Clay Timmons as Senior Vice President of Sales

MyHealthGuide Source: Lucent Health Solutions, LLC, 3/23/2015, www.lucenthealth.com

Nashville, TN and Dallas, TX -- Lucent Health Solutions, LLC announced that Clay Timmons has joined the company as Senior Vice President of Sales. Clay will be responsible for Sales and Marketing as well as Product Development for the Lucent Health family of companies, out of the Dallas office.

Mr. Timmons has over 23 years of both clinical and professional healthcare leadership. Prior to joining Lucent Health, Clay served as the National Vice President of Sales for HealthSmart Benefit Solutions for over 17 years. Clay has spent his entire career in the healthcare field after receiving his Bachelor of Business Administration Degree in Marketing and Management from Texas Tech University.

Lucent CEO Brett Rodewald says "We are delighted to add Clay Timmons to the Lucent Health Solutions family. His hiring demonstrates our commitment to bringing together the most talented executive leadership team possible and to the critical Texas marketplace, which Clay knows so well. He will help us expand our national footprint even more." Lucent Health's clients span from the Pacific Northwest to the Midwest to the Southeast and Southwest.

Chief Commercial Officer Alex Arnet added, "Clay brings a wealth of experience in clinical integration, data analytics, and predictive population health management as well as a strong track record of creating solutions which effectively drive down the cost of healthcare."

About Lucent Health Solutions

Lucent Health was formed with a Vision: To be the nation's most cost effective Healthcare Risk Management company and Mission: Utilize data in the most efficient and effective manner to maximize the impact of aggressive clinical, population and network risk management solutions, to deliver the most affordable health plans for all employers.

Lucent Health Solutions is a technology-driven health care risk management company, maximizing the value of data to deliver the most affordable health plans for employers. Based in Nashville, TN, the management team brings over 100+ years of experience in the healthcare and transaction processing industries. Lucent currently manages health benefits for over 120,000 members and previously acquired North America Administrators of Nashville, TN and Capitol Administrators of Rancho Cordova, CA in conjunction with its financial partner, NaviMed Capital. Call Alex Arnet at 612-940-0141, alex.arnet@lucenthealth.com and visit www.lucenthealth.com

About NaviMed Capital

NaviMed Capital is a Washington, DC-based private investment firm focused exclusively on the healthcare industry. NaviMed partners with talented management teams and entrepreneurs to create value by providing strategic counsel and operational support, while leveraging its deep healthcare expertise, broad firm network, and combined 40+ year heritage of successful investing. NaviMed invests in growth stage companies in healthcare IT, healthcare services, and specialty medical products. NaviMed's principals have extensive experience investing in businesses in the payors and payments sector of the healthcare industry, including ConnectiCare Holdings, Heritage Health Systems and Primary Health. Call Ryan Schwarz at 202-492-5470 and visit www.NaviMed.com.

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Data Dimensions Names  Mark Golino as Chief Information Officer; Promotes Amanda Kilburg and Brian Maag

MyHealthGuide Source: Data Dimensions, 3/19/2015, datadimensions.com

Data Dimensions has announced the addition of Mark Golino to its executive leadership team as Chief Information Officer, where he will direct all technology for the company.

Golino brings more than 25 years of data center management and senior-level technology experience to Data Dimensions. He has worked extensively in technology management and has designed, built and deployed high-capacity data centers, OCR solutions and natural language processing solutions. Golino has managed multiple teams of employees and several projects simultaneously, and he has extensive experience in application development, research and design.

"I'm excited to welcome Mark to our executive leadership team," says Jon Boumstein, Data Dimensions President and CEO. "He brings a wealth of knowledge and experience to Data Dimensions, and he will help us reach new levels of growth and success in the coming years."

Data Dimensions is also proud to announce the promotions of two of its team members:

Amanda Kilburg has been promoted to Vice President of Implementation. Kilburg's career with Data Dimensions began in November 1994 when she became a Data Entry Operator while attending college. Since then, she has earned several promotions, and, as VP of Implementation, will be responsible for oversight of client implementations, including the IT project management team, as well as the workflow engineers and implementation engineers.

Brian Maag has been promoted to the role of Vice President of Application Development. Maag, who started with Data Dimensions in 1995, has been instrumental in the design and development of numerous Commercial/Government high-volume workflow systems. As VP of Application Development, Maag is responsible for overseeing the Application Development team, Research and Development and QA/Testing teams.

"Both Amanda and Brian have devoted many years to making Data Dimensions the company it is today," Boumstein said. "Having them in these new positions will allow both to use their skills and experience to help Data Dimensions grow and succeed in the coming years."

About Data Dimensions

Since 1982, Data Dimensions has been helping clients better manage business processes and workflows by bridging the gap of automation, technology, and physical capabilities. As an innovative leader in the area of information management and business process automation, we provide a complete range of outsourcing and professional services including mailroom management; document conversion services; data capture with OCR/ICR technologies; physical records storage and electronic retrieval services through our state of the art Tier III data center.

Data Dimensions is a portfolio company of HealthEdge Investment Partners, LLC. HealthEdge is an operating-oriented private equity fund founded in 2005. HealthEdge's investment team has over 100 years of combined operating experience as operators and investors. For more information on HealthEdge, visit healthedgepartners.com.  Contact Will Pfeifer, Marketing Coordinator, at wpfeifer@datadimensions.com, 800-782-2907 and visit datadimensions.com,

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Brentwood Services Administrators Inc. Names Tonya Robinson as Claim Specialist, Robin Yates as Senior Claim Representative; Brentwood Services Inc. (BSI) Promotes Penny Morrow to Accounting Supervisor of Internal Accounts

MyHealthGuide Source: Brentwood Services Administrators Inc. and Brentwood Services Inc. (BSI), 3/19/2015, www.BWood.com

BRENTWOOD, TN -- Brentwood Services Administrators Inc. (BSA)., headquartered in Brentwood, Tenn., recently selected Tonya Robinson as a new claim specialist in its Champaign, Ill., claims office, according to Jeff Pettus, president and chief executive officer of BSA.

Robinson's responsibilities include reviewing, processing and handling workers' compensation claims as assigned by Luca DeVecchi, claim manager in the BSA Champaign, Ill., office. She determines the compensability of the claim and extent of liability, as well as communicates directly with clients, employers, injured workers, physicians and attorneys to manage claims in a timely and economic manner.

Prior to coming to BSA, she was employed by Selective Insurance as its workers' compensation claim specialist for six years. She holds an associate-in-claims designation and a Kentucky adjuster license. Robinson is a graduate of West High School in Salt Lake City, Utah, with a general education degree. 

Robin Yates, Senior Claim Representative in Occupational Accident Department

Brentwood Services Administrators Inc. (BSA) also employed Robin Yates as senior claim representative in the Occupational Accident Department.

In her position under Carrie Miehlich, claim supervisor in the BSA Occupational Accident Department, Yates reviews, processes and handles occupational accident claims. She determines the compensability of the claim and extent of liability, as well as communicates directly with clients, employers, injured workers, physicians and attorneys, as needed, to manage the claims in a timely and economic manner.

Before joining BSA, Yates was a claim representative for Alfa Insurance. Originally from Omaha, Neb., she now holds a Kentucky adjuster license.

Penny Morrow, Accounting Supervisor of Internal Accounts

Penny Morrow was promoted to the position of accounting supervisor of internal accounts in the Accounting Department of Brentwood Services Inc. (BSI)., headquartered in Brentwood, Tenn.,  according to Pettus, chief operating officer of BSI.

In her new position, Morrow is responsible for the accounting and preparation of the company's internal financial statements. In addition to assuming new supervisory duties over accounts receivable and accounts payable, she will be responsible for the coordination of the company's outside audit as well as continuing to handle various duties from her previous senior accountant position, according to Collette Mangold, BSI controller.

Morrow joined BSI in July 2014 as senior accountant. Previously, she was employed for eight years as a controller for Corporate Flight Management Inc., in Smyrna. Tenn. She earned her bachelor of science in accounting at Wiesbaden Air Base in Wiesbaden, Germany. In addition, she is a Certified Fraud Examiner, and is completing her study as a Certified Treasury Professional.

About Brentwood Services Inc.

Brentwood Services Inc., an independent employee-owned company headquartered in Brentwood, Tenn., specializes in structuring and managing alternative market solutions for employers and insurance providers. 

About Brentwood Services Administrators Inc.

Brentwood Services Administrators Inc. provides claims management and loss control services to employers and employer associations with self-insured and large deductible programs for workers' compensation and other casualty lines. BSA's aggressive coordinated approach to claims administration and loss control has a proven track record of reducing the cost of claims for its clients. BSA also provides underwriting, policy management and accounting services to association-sponsored pools and mutual insurance companies.

About Brentwood Reinsurance Intermediaries Inc.

Brentwood Reinsurance Intermediaries Inc. (BRII) provides insurance and reinsurance brokerage services encompassing self-insurance, guaranteed cost and deductible insurance with a focus on workers' compensation, excess liability lines, and accident and health reinsurance.  Contact John Smitherman, vice president of sales for Brentwood Services Inc., at (800) 524-0604, (615) 263-1300, bsiinfo@bwood.com and visit www.BWood.com.

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CTG Names Cliff Bleustein President and Chief Executive Officer

MyHealthGuide Source: CTG (NASDAQ: CTG), 3/13/2015, www.ctg.com

BUFFALO, NY -- CTG, an information technology (IT) solutions and services company, announced that its Board of Directors has elected Cliff Bleustein to serve as the Company's next President and Chief Executive Officer and a member of the Board of Directors with an effective date of April 6, 2015.

Concurrent with this appointment, Brendan M. Harrington, Interim CEO, will return to his position as Chief Financial Officer, Filip J.L. Gydé, Interim Executive Vice President of Operations, will return to his position as Senior Vice President and General Manager, CTG Europe, and John M. Laubacker, Interim CFO, will return to his position as Treasurer. Messrs. Harrington, Gydé and Laubacker were appointed to their respective interim positions following the death of CEO James R. Boldt in October 2014.

Bleustein, 45, joins CTG from Dell Services, where he has served as Chief Medical Officer and Global Provider Solutions Leader since October 2014. He joined Dell Services in March 2013 as Managing Director & Global Head of Healthcare Consulting and was named Chief Medical Officer and Global Head of Healthcare Consulting in July 2014.

Prior to his career at Dell Services, Bleustein was a director in the health industries advisory practice at PricewaterhouseCoopers where between 2009 and 2013 he focused on sales and delivery of PwC's consulting services to healthcare providers.

"After an extensive search, conducted with the guidance of a nationally recognized executive search firm, I am pleased to announce Cliff's appointment as CTG's next President and CEO," said Daniel J. Sullivan, Chairman of the Board of Directors of CTG. "Cliff is a renowned thought leader on health information technology with a keen interest in revolutionizing the way healthcare is managed. During his impressive career, he has provided direct patient care, served as a healthcare mentor, conducted medical research, and advised healthcare organizations on business strategies, operational improvements and resource optimization. Cliff has managed consulting services in ICD-10, revenue cycle management, and accountable care, among many other areas, and has been instrumental in growing EHR implementation and optimization practices involving a variety of software solutions, including the Epic, Cerner and Meditech systems. Cliff's passionate vision of a more efficient, results-oriented healthcare system along with his breadth of experience will serve CTG well as we continue to position the Company to take advantage of the information technology transformation occurring in healthcare and lead CTG towards profitable growth."

"I am honored and excited to lead a company with CTG's reputation for quality and innovation," said Cliff Bleustein. "I believe CTG's strategic, long-term focus on the changing healthcare landscape has created a strong framework on which we will build our future success. CTG's managed IT staffing business maintains strong relationships in the United States and Europe and I look forward to continuing to serve all of our clients' extensive IT needs. We'll continue to focus on expanding our revenue and profit contribution through managed services by targeting high volume corporate users of external IT talent where CTG is a preferred supplier. Also, in addition to building our European healthcare business, we'll continue to focus on expanding our business in the government and financial services markets in our European geographies. With a strong management team, proven offerings targeted to the healthcare and other vertical markets, and an enduring IT staffing model that has proven successful over the years, I am confident we will meet our challenges, grow our revenue and improve profitability thereby creating value for our shareholders."

Bleustein began his professional career in 1996 as a general surgery resident at New York Hospital Medical Center of Queens. He served as a urology resident at Montefiore Medical Center from 2000 to 2004, when he joined Urology Specialty Care from 2004 to 2007 and earned his board certification as a urologist. Bleustein also served as a visiting research fellow at Weill Medical College of Cornell University from 1998 to 2000 and an assistant clinical professor of urology at Albert Einstein College of Medicine of Yeshiva University from 2004 to 2007. He has been an adjunct professor of economics at New York University's Leonard N. Stern School of Business since 2008. He earned a bachelor's degree in psychology at the University of Wisconsin - Madison, a doctor of medicine degree at the Medical College of Wisconsin and a master's degree in business administration from the Stern School of Business.

About CTG

CTG develops innovative IT solutions to address the business needs and challenges of companies in several higher-growth industries including healthcare, technology services, energy, and financial services. As a leading provider of IT and business consulting services to the healthcare market, CTG offers healthcare institutions, physician practices, payers, and related organizations a full range of offerings to help them achieve clinical, operational, and financial goals. CTG has developed for the healthcare provider and payer markets unique, proprietary analytics solutions that support better and lower cost healthcare. CTG also provides managed services IT staffing for major technology companies and large corporations. Backed by nearly 50 years' experience, proprietary methodologies, and an ISO 9001-certified management system, CTG has a proven track record of delivering high-value, industry-specific solutions. CTG operates in North America and Western Europe. Visit www.ctg.com.

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Market Trends, Studies, Books & Opinions



Response to 'Go Slow On Reference Pricing: Not Ready For Prime Time'

MyHealthGuide Source: Mike Dendy, CEO/President Advanced Medical Pricing Solutions Inc. and Claims Delegate Services, Inc. 3/21/2015, www.advancedpricing.com

Editor's Note:  Last week, this Newsletter published, "Go Slow On Reference Pricing: Not Ready For Prime Time" by David Frankford and Sara Rosenbaum, originally published in Health Affairs Blog.  This week, Mike Dendy, CEO/President, AMPS responds.

Reference based pricing (RBP) certainly has its share of critics nationally and those critics are typically led by those in the hospital or PPO industry who are benefiting significantly through the grossly broken healthcare financing system currently in place.

Just this week, I was apprised of a $25 million hospital claim presented to an employer and their stop loss carrier by United Health Care's ASO and their accompanying PPO. PPOs attempt to guarantee, through their collaboration with hospitals (to the detriment of employers), that a hospital be paid whatever the hospital decides to bill for a service less some discount that is typically off of an egregiously overcharged amount and never detailed. Regardless of whatever type of discount the PPO noted above might have touted overtly relative to the hospital service in question it is highly likely that the very covert outlier clause was triggered greatly exacerbating the allowable payment amount. These types of outlandish payments to hospitals would almost never happen if a quality reference base reimbursement program were in place.

The mistaken concepts of authors Frankford and Rosenbaum are numerous and start off with the fact that they quote the outcomes of the CalPERS program which they suggest represents Reference Based Pricing (RBR) but in actuality is defined contribution.

  • First, they say "The purpose of reference pricing is to enable patients to shop for care and to spur provider competition by creating a group of "designated" in network providers that agree to abide by the reference price while others do not ("non-designated providers").

This description relates only to a very specific type of reference pricing that involves a Network with carve outs establishing fixed prices for specific procedures (e.g., Calpers), not true on "pure" reference based pricing.

It is important to understand that there are three general types of reference-based benefit designs:

  1. A Network plan design with carve outs establishing fixed prices for specific procedures (e.g., Calpers) and an in-Network/OON differential [THIS IS WHAT THE recently released FAQs were meant to address]
  2. Hybrid -- RBP with underlying Network and an in-Network/OON differential
  3. Pure RBP, which has (a) no Network, (c) no Fixed Prices, and (b) no in-network vs out-of-network differential, and uses direct contracts to provide safe harbors but has no differential or punitive element).

It is also critical to recognize that the FAQs speak specifically to health plans that:

  • a. Have a network ("…if a plan has a network of providers…"). There is a difference between a "Network" and providing safe harbors via direct contracting!
  • b. Have a "reference based pricing structure, under which the plan pays a fixed amount for a particular procedure…" -- As an example our Claims Delegate Services RBR Plan does not pay at fixed amounts for any procedures
  • c. Treat only providers that accept the RBP as in-network

The authors' negativity of RBR brought into question the lack of quality of outcomes data as well as possible access limitations relative to the CalPERS "experiment". Again, the CalPERS program is not a true reference based reimbursement program but rather a specified services defined contribution program. Pure RBR does not have designated vs non-designated providers thus allowing for an open panel of providers for member usage. Further, any quality RBR program will include the same extensive outreach noted in CalPERS efforts and employers should seriously question using an RBR vendor that doesn't employ such mechanisms.

  • The authors use second hand rumor mongering in suggesting that "For example, news coverage suggests that plans are excluding specialized cancer centers from their networks to discourage enrollment by people with cancer. To achieve the same result, a health plan might set its reference price for cancer treatment (or other services) at a price point that excludes specialized centers or it could limit its designated providers in ways that make them geographically inaccessible".

In reality, quality providers of RBR services know that this type of deterrence and Discrimination is illegal. The possibility that someone will break the law is not unique to an RBR plan design and using this argument against RBR plans is disingenuous.

The authors also mistakenly suggest that RBR plans pose a risk of higher administrative costs. This is not true with a quality managed RBR program and ignores all of the costs that are eliminated with a pure RBR plan such as network access fees and often significantly higher ASO admin fees. For decades now, BUCA payers have extracted double and triple the admin fees charged by independent TPAs by tying access to their networks with the overpayment of administrative service fees. It will be interesting to see if the BUCAs begin to reduce their admin fees now that their PPO networks are proven time and time again to be anti-value from a cost management perspective.

All professionals involved in our industry know clearly that employee/members are almost completely disenfranchised from decisions related to healthcare pricing and refuse to educate themselves on such because the broken system of PPOs does not require participation on their behalf.

  • The authors sophomorically use that point as a negative against reference based pricing programs and further suggest that CalPERS was only successful because "its members are likely more sophisticated than most".

If our system of privately funded and managed healthcare is to stay in place member involvement (consumerism) must be part of the solution. In a quality managed RBR program there is significant and ongoing employee education program along with a proactive member advocacy service.

  • The authors' biggest mistake is probably in their ridiculous statement that "reference pricing likely will have a small impact on expenditures".

This statement clearly shows the authors did absolutely no research on the yield of the PPO discounting mechanism currently in place with most employers. Our very voluminous research shows that on average employers are paying over 250% of Medicare when using BUCA network discounts and over 300% of Medicare when using other networks. This of course does not factor in those hospital facilities that still extract 500% or more of Medicare for carved out services or purely due to the fact that they are located in an isolated region with little or no immediate competition. The average RBR plan benchmarked against Medicare will typically yield reimbursements in the 140% to 170% range with no outlier provisions to allow payment manipulation.

  • The authors, again using very limited research completely relative to CalPERS suggest that RBR does not control utilization and "is limited to only certain categories of care, such as outpatient colonoscopies, arthroscopies, cataract removal, and imaging and laboratory services".

This statement is completely wrong and simply does not apply to Pure RBR, which does not fix prices for specific procedures or limit procedures covered and re-priced under the plan.

The authors final "recommendations" are also very consistently flawed.. to wit:

  • "First, at least until much more is known about the impacts of reference pricing, the agencies should limit its use to a few, simple services. The risk of error and consequent harm are large" The authors clearly do not understand that it is exactly the limitation to "a few, simple services" that creates all of the problems and risks cited in this article and limits the value of reference pricing.
  • "Second, reference pricing should be allowed only when it consists of a composite payment. Patients are surprised when, for example, they have surgery at an in-network hospital but are stuck with charges from anesthesiologists who are out-of-network".

This is overly simplistic, applies to PPO plans just as much as reference pricing plans, and can be addressed with robust employee education and support.

About the Author and AMPS

Mike Dendy is CEO/President of Advanced Medical Pricing Solutions (AMPS) is a healthcare cost management company serving the self-funded payer community. AMPS specializes in physician led, technology driven, facility claim review. AMPS primary goal is to ensure medical facility claims are accurate and reasonably paid and to provide alternatives to the non-effective PPO market. Based in Atlanta, GA with offices in Phoenix and Houston, the company provides proprietary solutions that help large and mid-size businesses address rapidly expanding hospital costs. Visit www.advancedpricing.com.

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Express Scripts Lab 2014 Drug Trend Report Shows Unprecedented 30.9% Spending Increase on Specialty Medications

MyHealthGuide Source: The Express Scripts Lab, 3/17/2015, Express Scripts Report Page

The Express Scripts Drug Trend Report provides detailed analysis of U.S. prescription drug costs and utilization, as well as the marketplace factors that affect future changes.

In 2014, the pharmacy landscape underwent a seismic change, and the budgetary impact to healthcare payers was significant. U.S. prescription drug spend increased 13.1% in 2014 -- the largest annual increase since 2003 -- and this was largely driven by an unprecedented 30.9% increase in spending on specialty medications.

Utilization of traditional medications stayed flat (-0.1%), while the use of specialty drugs increased 5.8%. The largest factors contributing to the increased spending, however, were the price increases for these medication categories -- 6.5% for traditional and 25.2% for specialty. While specialty medications represent only 1% of all U.S. prescriptions, these medications represented 31.8% of all 2014 drug spend -- an increase from 27.7% in 2013.

  • Increased inflation and utilization of hepatitis C and compounded medications were the most significant accelerators of U.S. drug spend in 2014. Excluding those two therapy classes, overall drug spend would have increased only 6.4%.
  • More than 15% of Express Scripts’ clients spent less, per capita, on prescription drugs in 2014 than in 2013. Closely managed pharmacy plans spent nearly 30% less per member on traditional medications, when compared to unmanaged plans.
  • Express Scripts’ hepatitis C solution, announced in December 2014, will save its clients more than $1 billion in 2015 on hepatitis C medications, while expanding treatment to all patients who need it.
  • Express Scripts’ compound management solution, implemented in waves through the last half of 2014, will save its clients more than $1.9 billion in 2015 that would have otherwise been wasted on compounded medications that do not provide a proven clinical benefit.

Commercially Insured Trend

Overall drug spend increased 13.1% in 2014, following several years of increases below 6%. Market forces and changes in patient behavior impacted drug expenditures in 2014, but brand drug pricing was one of the most important factors driving trend, especially for specialty medications.

Overall Trend Insights

For the commercially insured, compounded drugs and hepatitis C therapies were the key drivers of 2014 spend and trend. Without them, total overall trend would have been just 6.4%.

Trend Forecast (2015 - 2017) for Key Therapy Classes

The utilization of traditional medications is likely to increase, but the continuing decline in overall costs related to an abundance of generics and a relative lack of brand innovators in the pipeline for the most commonly used therapy classes (aside from diabetes) will keep traditional drug spend from increasing substantially.

Top Traditional Therapy Classes
Therapy Class 2015 2016 2017
Diabetes 18.3% 18.3% 18.3%
High Blood Cholesterol* -8.5% -14.3% -24.7%
Compounded Medications -45.0% 8.0% 8.0%
Pain/Inflammation 13.1% 9.4% 99.5%
High Blood Pressure/Heart Disease -3.5% -6.7% -10.6%
Heartburn/Ulcer Disease -31.4% -34.0% -30.7%
Asthma 12.7% 9.8% 9.9%
Attention Disorders 11.8% 11.0% 10.2%
Depression -26.3% -10.8% -0.8%
Mental/Neurological Disorders 0.7% -6.0% -5.5%
Contraceptives 15.0% 11.0% 9.0%
Anticoagulants 25.1% 15.5% 12.3%
Other Traditional Classes 1.7% 3.1% 2.4%
TOTALTRADITIONAL -0.5% 3.9% 4.3%

Although the specialty trend will slow to more sustainable levels in the next three years, it still is expected to experience fairly stable double-digit growth in 2015, 2016 and 2017. The major contributors to rising PMPY spend for specialty medications are brand inflation and the accelerating development of expensive, highly targeted therapies.

Top Specialty Therapy Classes
Therapy Class 2015 2016 2017
Inflammatory Conditions 21.6% 21.6% 21.1%
Multiple Sclerosis 11.3% 6.5% 3.0%
Oncology 21.6% 20.4% 19.8%
Hepatitis C 66.5% 55.4% 44.3%
HIV 17.3% 16.6% 16.2%
Miscellaneous Specialty Conditions 31.1% 29.7% 28.2%
Growth Deficiency 12.5% 10.4% 10.5%
Hemophilia 3.9% 3.3% 3.4%
Pulmonary Arterial Hypertension 12.5% 12.0% 12.1%
Transplant -5.8% -1.3% 0.0%
Hereditary Angioedema 22.5% 24.2% 20.7%
Other Specialty Classes 6.7% 6.7% 6.4%
TOTAL SPECIALTY 22.6% 22.3% 21.3%

Key Highlights

  • Compared to the prices of generic drugs and brand drugs a year earlier, in December 2014 generic drug prices were 20.0% lower whereas brand prices were 15.4% higher.
  • Price increases for several commonly used generics have contributed to a slowing of the decline in prices for generic drugs as a whole. Even so, generic medications overall continue to deliver significant savings over brand-name alternatives.
  • From January 2008 through December 2014, a market basket of the most commonly used generic medications decreased in price by 62.9%. During that same period, a market basket of the most commonly used brand medications increased in price by 127.4%.
  • In contrast, a market basket of commonly used household goods, as measured by the Bureau of Labor Statistics Consumer Price Index, grew only 11.2% during this same time period.

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Legislative & Regulatory News



SIIA Supports Federal Legislation To Define Stop Loss

MyHealthGuide Source: The Self-Insurance Institute of America, Inc. (SIIA), 3/18/2015, www.SIIA.org 

The Self-Insurance Institute of America, Inc. (SIIA) applauds the Self-Insurance Protection Act (SIPA), introduced on 3/18/2015 in the United States Senate by Senators Bill Cassidy (R-LA) and Lamar Alexander (R-TN), and in the House by Rep. Phil Roe, (R-TN). S. 775/H.R. 1423 clarifies existing law to ensure that federal regulators cannot re-define stop-loss insurance as traditional health insurance. The legislation was originally introduced during the last Congress at the suggestion of SIIA.

"Given the continued uncertainty we see in the broader health insurance marketplace, the timing of this legislation is particularly important in order to ensure stability in the self-insured market segment," said SIIA President & CEO Mike Ferguson. "Self-insured health plans often work particularly well for both plan sponsors and plan participants, so it should be in everyone's interest that Congress take action to prevent any possible market disruption due to unwarranted regulatory action."

Stop-loss insurance is utilized by most private and public employers with self-insured plans, along with self-insured Taft-Hartley Plans, to provide a financial backstop to reimburse the employer or the plan for catastrophic claims.

Self-insurance is an alternative to traditional group health insurance, where organizations custom design their own health plans consistent with federal law and pay claims as they are incurred instead of paying fixed premiums to an insurance carrier. It is estimated that nearly 100 million Americans receive health benefits through various forms self-insured plans.

For more information about SIPA, please contact Ryan Work, SIIA senior director of government relations, at rwork@siia.org.

About SIIA

SIIA is national trade association that represents companies involved in the self-insurance marketplace. Call 800-851-7789 and visit www.SIIA.org.

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Federal Court Clarifies and Approves ERISA Rights for Out-of-Network Providers regardless of Non-PPO Discount

MyHealthGuide Source: AVYM Healthcare Revenue Consultants, 3/19/2015, AVYM Article

Case: North Cypress Medical Center Operating Company, Limited; North Cypress Medical Center Operating Company GP, LLC, v. CIGNA Healthcare; Connecticut General Life Insurance Company; CIGNA Healthcare of Texas, Incorporated, Case No. 12-20695, in the United States Court of Appeals for the 5th Circuit, filed on March 10, 2015.  Court's Ruling

Related case: Spinedex Physical Therapy USA, et al v. United Healthcare of Arizona, et al, Case No. 12-17604, in the United States Court of Appeals for the Ninth Circuit, filed on Nov. 5, 2014.  Court's Ruling

More fallout from the recent Fifth Circuit Court of Appeals decision against Cigna: wide ranging implications for out of network provider reimbursement paradigm on a nationwide scale; 3rd party "re-pricing negotiation" agreements and (Non PPO) discounts would be preempted by ERISA if: "[t]he contracts by their terms are subject to the underlying ERISA plans"

In a recent federal appeals court decision, the court ruled against CIGNA and in favor of Out-Of-Network (OON) providers. All Out of network providers should be aware of the practical implications of this appellate court opinion; namely, that it allows out-of-network providers the right to sue, under ERISA, for all eligible payments under the plan terms, regardless of any third party cost containment or negotiation agreements (Non-PPO Discount Agreements) which are usually negotiated by intermediary companies on behalf of Cigna.

According to the appellate court's ruling, Third Party "re-pricing negotiation" agreements and discounts will be preempted by ERISA if: "[t]he contracts by their terms are subject to the underlying ERISA plans".

Even after re-pricing discounts have been negotiated, OON providers, with valid and complete assignments, have the right to seek all eligible payments according to the plan terms. The profound impact of this appellate court ruling may fundamentally change the nation's healthcare landscape and existing managed-care model.

Federal Court Decision

In its decision, the Fifth Circuit identifies Third Party "re-pricing negotiation" agreements and (Non-PPO) discounts relation to ERISA plans, as "[t]he contracts by their terms are subject to the underlying ERISA plans".

The Court sheds some light on the issue:

  • "We turn next to the grant of summary judgment against North Cypress's state contract law claims. According to the hospital, Cigna breached the terms of the "Discount Agreements"--contracts between North Cypress and Cigna requiring Cigna to pay a negotiated amount for specific insurance claims. The contracts by their terms are subject to the underlying ERISA plans."

OON providers typically receive "re-pricing" and discount requests every day, with little or no options-Until now. The fifth circuit decision has clarified OON provider's ERISA legal standing to sue; and managed care contracting or re-pricing discount agreements cannot substitute or replace ERISA claim regulations.

The Fifth Circuit first addressed the district court's ruling that ERISA did not preempt:

  • "The district court first addressed whether the Discount Agreement claims were preempted by ERISA, which "supersede[s] any and all State laws insofar as they may now or hereafter relate to any employee benefit plan." This provision is "intended to ensure that employee benefit plan regulation would be ‘exclusively a federal concern,'" and as such, the Supreme Court has commented that the preemption provision is "conspicuous for its breadth" and is "deliberately expansive." Nonetheless, the district court found that the contract law claims were not preempted because North Cypress could not bring the claims under ERISA….The court went on to rule on the merits, finding no breach because Cigna was entitled to reduce payment under the terms of the "Discount Agreement" contracts."

The Fifth Circuit vacated the district court's non ERISA preemption decision and found for North Cypress' ERISA legal standing to sue, and remanded for ERISA preemption consideration for (Non-PPO) Discount Agreement contracts:

  • "In holding that North Cypress has standing to bring ERISA claims, we removed the foundation of the district court's preemption ruling. The parties have not briefed the issue of whether the Discount Agreement claims nonetheless survive un-preempted. Accordingly, we vacate the grant of summary judgment and remand so that the district court may consider the question of preemption in light of our ruling on standing."

About Avym

Avym is headquartered in in Los Angeles, CA and is the leading provider of ERISA/PPACA health claim appeal services, reimbursement compliance, overpayment recoupments and offsets appeals, dead claims recovery services and ERISA/PPACA healthcare claim litigation support services. Visit www.Avym.com.

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Medical News


Folic Acid Reduces Risk of Stroke

MyHealthGuide Source: Yong Huo, MD, 3/15/2015, Journal of the American Medical Association

Among adults with hypertension without a history of stroke or heart attack, the combined use of enalapril and folic acid, compared with enalapril alone, significantly reduced the risk of first stroke according to a study published in the Journal of the American Medical Association.

The study called, The China Stroke Primary Prevention Trial, was a randomized, double-blind clinical trial conducted from May 19, 2008, to August 24, 2013, in 32 communities in Jiangsu and Anhui provinces in China. A total of 20,702 adults with hypertension without history of stroke or myocardial infarction (MI) participated in the study.

Patients were randomly assigned to receive double-blind daily treatment with a single-pill combination containing enalapril, 10 mg, and folic acid, 0.8 mg (n = 10,348) or a tablet containing enalapril, 10 mg, alone (n = 10,354).

The primary outcome was first stroke. Secondary outcomes included first ischemic stroke; first hemorrhagic stroke; MI; a composite of cardiovascular events consisting of cardiovascular death, MI, and stroke; and all-cause death.

Study findings

During a median treatment duration of 4.5 years, compared with the enalapril alone group, the enalapril–folic acid group had a...

  • 21% risk reduction of  first stroke (2.7% of participants in the enalapril–folic acid group vs 3.4% in the enalapril alone group),
  • 12% risk reduction of first ischemic stroke (2.2% with enalapril–folic acid vs 2.8% with enalapril alone), and
  • 21% risk reduction in composite cardiovascular events consisting of cardiovascular death, MI, and stroke (3.1% with enalapril–folic acid vs 3.9% with enalapril alone).
  • The risks of hemorrhagic stroke and all-cause deaths did not differ significantly between the 2 treatment groups.
  • There were no significant differences between the 2 treatment groups in the frequencies of adverse events.

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Recurring Resources


Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 3/9/2015)

Source: MyHealthGuide

Editor's Note: The following is a recurring article. This Newsletter is often asked by readers for a list of medical stop-loss providers and their respective premiums. Below the first of a recurring article that attempts to lists stop-loss providers and annual premiums. Sources includes press releases, AM Best reports, conference presentations and more.

Stop-loss Premium Ranking
Compiled by MyHealthGuide Newsletter

Reader response and correction is encouraged.
Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com

  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
(Millions)
Capital /Equity
(Millions)
Source
1. CIGNA     $2,318
2014
  CIGNA Financial Supplement 2014, P.5 12/31/2014
2. Sun Life Financial     $1,034.2
2014
  Sun Life 2/12/2015 Management Discussion of "13% stop loss growth over 2013" of 2013 premium of $915.2M provided by Scott Beliveau, Sun Financial 4/28/2014
3. HCC Life Insurance Company >35 Years HCC Life
(A.M. Best Rated: A+)
Perico Life
(A.M. Best Rated: A+)
$862
2014 10Q (2x $431 for 6 mons)
$3,900 HCC Insurance Holdings, Inc. Release,
6/30/2014
4. HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
$792.9
2014
$550.7
12/31/2014
Matt Rhenish, President & COO, 2/16/2015
5. Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $495M
MRM - $233M)
$728
2014
$3,360.6
12/31/2014
Symetra 4Q 2014 Financial Supplement;
Tom Doran, President, Medical Risk Managers, Inc.
2/9/2015
6. Voya Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
$681
2014
$1,945
12/31/2014
Joe Keller, Lead Financial Analyst, Voya Employee Benefits,
3/9/2015
7. Companion Life > 20 Years   $440
10/8/2014
  Philip Gardham, Vice President, Specialty Markets,
10/8/2014
8. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
5/2014
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
6/20/2014
9. Independence Holding Company   Standard Security Life Insurance Company of New York,
Madison National Life, Independence American Insurance Company
$200   Roy T.K. Thung, CEO, Letter to Stockholders
3/31/2014
10. Zurich North America     $130   Tracey Brennan, Zurich North America.
7/22/2011
11. Munich Re Stop Loss, Inc.   AIC, TransAmerica $110
2012
  Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
4/25/2013
12. The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
$104
12/2014
  Victor Moran, Second Vice President, Actuarial Operations.  3/6/2015
13.
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $3,388
12/31/2011
Mark Nichols, Managing Director.
7/20/2012

Other stop-loss leaders include the following list. However, we await reader response providing stop-loss premium volume (and additional carriers) so that each could be added to the table above. 

  • ACE America
  • Aetna
  • Amalgamated Life
  • American Fidelity Assurance Company 
  • American National Life Insurance Company of Texas
  • Berkley Accident and Health
  • BEST Re 
  • Blue CrossBlue Cross Blue Shield (various regions)
  • Gerber Life Insurance Company
  • International Insurance Agency Services, LLC
    (IIS)
  • Lloyd's of London
  • Nationwide Life Insurance Company
  • Pan American Life
  • QBE Insurance Company
  • Trustmark Insurance Company
  • UnitedHealthcare

Stop-loss Premium Volume is not the Whole Story

Industry executives question the purpose of a chart reporting only stop-loss premium without additional information such as:

  • Ratings from Best, S&P, Moodys and others (data collection began 6/2012)
  • Capital size of the insurance company (data collection began 6/2012)
  • Reinsurance purchased and from whom
  • Length in the business (data collection began 6/2012)
  • Number of open litigation claims
  • Is stop-loss a core business or ancillary business?
  • % age of risk retained vs. ceded
  • Average stop-loss claim processing turn-around time
  • % age of claims denied
Should reader interest indicate such measures are important, this Newsletter will attempt to collect and report.  

Reader response and correction is encouraged. Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com.  

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The Value of Self-Funding

MyHealthGuide Source: The Self-Insurance Educational Foundation, Inc. (SIEF), 2014, www.SIEFOnline.org. Click The Value of Self-Funding for overview, reasons, tools and examples of self-funding.

Self-funding is an important contributor to the financial and physical health of America's wellness future. Self-funding is more than processing claims and receiving premiums, it provides quality coverage and proactive healthcare management for employers of all sizes and industries.

About the SIEF

The Self-Insurance Educational Foundation, Inc. (SIEF) is a 501(c)(3) non-profit organization affiliated with the Self-Insurance Institute of America, Inc. (SIIA). The foundation's mission is to raise the awareness and understanding of self-insurance among the business community, policy-makers, consumers, the media and other interested parties. Visit www.SIEFOnline.org.

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Upcoming Conferences


March 24 and 26, 2015 - webinar
How to Eliminate 50% to 100% of Your Cost Containment Fees presented by Health Payer Consortium (HPC).  President Patrick Crites hosts a series of webinars focused on techniques to eliminate between fifty and one hundred percent of their cost containment fees, particularly around the area of large dollar claims negotiations. HPC uses an evolved business model- known as the "Consortium" model- to shift profits previously captured by third party vendors back to healthcare payers and their clients. This business model, combined with strategies and tactics gained through decades of experience, are being used by leading Third Party Administrators, Health Plans, and Reinsurance Groups today to drastically improve their overall bottom line. Registration: healthpayerconsortium.com/webinars/

March 25, 2015 - webinar 1:00 PM EST to 2:00 PM EST
'To Be, Or Not To Be'... A Fiduciary - Do You Even Have a Choice? presented by The Phia Group. Being a fiduciary is serious business. Determining whether you are one can also be very complicated. Case law increasingly establishes that being a fiduciary has more to do with the action one takes, than the contract one signs. Entities working on behalf of self-funded benefit plans may be unknowingly taking on fiduciary status. Are you a fiduciary? What are the advantages and disadvantages of taking on that burden? What can you do to protect yourself? 
Registration (If you do not receive a confirmation email shortly after registration with webinar log-in details, check your spam filter for emails from customercare@gotowebinar.com.)

April 1, 2015
Healthcare Benefits Broker Symposium presented by Advanced Medical Pricing Solutions (AMPS). Mike Dendy, CEO of AMPS will lead insurance professionals in a discussion about payment integrity strategies and the future of the cost containment industry. Key Takeaways:

• Integrating Reference Based Reimbursement and Medical Bill Review into your client offerings
• Payment Integrity strategies that will increase broker prospecting opportunities
• Savings statistics from employer groups currently utilizing these strategies in Texas and surrounding markets
• The future of the cost containment industry

Houston, TX. To register for the symposium visit: www.brokersymposium.com

April 13-15, 2015
International Conference presented by Self-Insurance Institute of America. Latin America is a promising new frontier for self-insurance/captive insurance. Based on this perspective, SIIA is taking its International Conference to one of the leading economic hubs in Latin America to explore and discuss emerging self-insurance business opportunities in this important region of the world. Consistent with this outlook, the educational program will cover the following topics:

• Evolving regulatory environment for self-insured health plans in Latin America
• Captive insurance opportunities in Latin America
• Multi-national pooling for group benefits programs in Latin America
• Evolving roles for TPAs, brokers and carriers in Latin America
• Insurance carrier panel discussion
• The Panama Canal - a self-insurance case study
• Self-insurance opportunities in the Caribbean
• Medical travel in Latin America

Hilton Panama, Panama City, Panama.  Call 800/851-7789 and visit www.SIIA.org

April 29-30, 2015
Self-Insured Taft-Hartley Plan Executive Forum (NEW EVENT!) presented by Self-Insurance Institute of America. This one-day forum features a focused educational program designed to showcase self-insurance strategies and information that is sure help unions provide even more robust benefits while more effectively controlling costs. Register before February 27, 2015 and take advantage of discounted early bird fees. SIIA room block at the Marriott Metro Center will be released on April 7, 2015, so if you would like to stay at the host hotel, please register and make your room reservations at your earliest opportunity as we expect the hotel to be sold out. Marriott Metro Center, Washington, DC.  Information and registration: www.siia.org/i4a/pages/index.cfm?pageid=6794 

May 6-8, 2015
Northshore's 26th Annual Claims Conference.  Salem, Massachusetts. This is an invitation only event. If you are interested in attending or presenting at next year's conference, you may contact Steve Murphy at smurphy@niis.com


May 12-14, 2015
Self-Insured Workers' Compensation Executive Forum presented by Self-Insurance Institute of America. Windsor Court Hotel, New Orleans, LA www.SIIA.org

June 3-5, 2015
Institute 2015 presented by America's Health Insurance Plans.  Be part of the nearly 4,000 health care professionals focused on making health care work as consumers are more in control of health care decisions, and data and technology are transforming our industry. You'll enjoy lively discussions about what's working and what's ahead, learn from leaders from other industries, see firsthand the newest products and services, and have plenty of time to network and forge new business relationships. Register: www.ahip.org/Conferences/Institute2015/Registration/ Contact: registrations@ahip.org or 877.291.2247

July 15-17, 2015
TPA University 2015 presented by Health Care Administrators Association (HCAA). Swissotel Chicago.  Information and registration: www.hcaa.org/?2015TPAU 

June 15-17, 2015
Second annual Claims Symposium presented by Advanced Medical Strategies (AMS). Sheraton Colonial in Wakefield, Massachusetts.  Contact Adria L. Garneau, CEBS at agarneau@mdstrat.com, 781-224-9711, ext. 106, and visit www.mdstrat.com.

July 21-23, 2015
MCIA Annual Conference presented by The Montana Captive Insurance Association, Inc. (MCIA). Features key captive regulators, captive owners and leading service providers addressing a variety of timely educational topics. The conference also serves as the premier networking event for those doing captive insurance business (or would like to) in the growing Montana captive domicile. Lodge at Whitefish Lake in Whitefish, MT. Sponsors: Shane Byars at 866/388-6242, or via e-mail at sbyars@mtcaptives.org. Contact mcia@mtcaptives.org and visit www.mtcaptives.org

September 28-30, 2015
SPBA Fall Meeting (members only). Scottsdale, AZ. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

October 18-20, 2015
National Educational Conference & Expo presented by Self-Insurance Institute of America. Marriott Marquis, Washington, DC  www.SIIA.org 

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February 9-11, 2016
Executive Forum 2016 presented by Health Care Administrators Association (HCAA). Caesars Palace, Las Vegas, NV. www.HCAA.org

March 30-April 1, 2016
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

July 13-15, 2016
TPA University 2016 presented by  Health Care Administrators Association (HCAA). Renaissance Dallas, Dallas, TX. www.HCAA.org

October 17-19, 2016
SPBA Fall Meeting (members only). Minneapolis, MN. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

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February 8-10, 2017
Executive Forum 2017
presented by Health Care Administrators Association (HCAA). Bellagio, Las Vegas, NC. www.HCAA.org  

March 15-17, 2017
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

September 13-15, 2017
SPBA Fall Meeting (members only). Cincinnati, OH. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

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Editorial Notes, Disclaimers & Disclosures


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Clevenger Ernie Clevenger
President & Publisher
MyHealthGuide, LLC
Clevenger@MyHealthGuide.com