MyHealthGuide Newsletter
News for the Self-Funded Community
7/25/2016

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

Job News

Market Trends, Studies, Books & Opinions

Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures


General & Company News



Goldman Sachs Invests $30 Million in Marathon Health, a National Leader in Worksite Health Centers

MyHealthGuide Source: MarketWired, 7/12/2016 

BURLINGTON, VT -- Marathon Health, one of the nation's leading providers of worksite health centers, announced that Goldman Sachs completed a $30 million equity investment and minority position in the company. Marathon Health will use proceeds from the investment to meet the ever-changing healthcare needs of its customers and expand its national presence, continuing the rapid growth it has experienced since its founding in 2005.

The investment highlights Marathon Health's leadership in developing the worksite health center market and demonstrated impact in creating healthier and more productive employees. Marathon Health's health risk management model of care has delivered a 10-15 percent reduction in net per member per month healthcare costs across its book of business, contributing to the growth and profitability of the businesses it serves. The company provides care for more than 250,000 individuals at over 140 employer locations nationwide.

"Employer organizations, including corporations, government entities, unions, health systems, and school districts alike are challenged to solve healthcare access, cost, and quality challenges. Building on the vision of our founders, Richard Tarrant and Robert Hoehl, to deliver the right care at the right place by the right provider, we have answered this challenge to change the way healthcare is experienced and delivered," said Jerry Ford, CEO of Marathon Health. "This investment bolsters Marathon Health's commitment to our people, who we call Ambassadors, and the partnerships formed with our customer base."

"It was clear in our review that Marathon Health delivers great value to its customers," said Antoine Munfa, Vice President in Goldman Sachs' Private Capital Investing group. "We are impressed with the company's integrated health coaching and clinical care methodology, healthcare cost and outcomes analytics, and total population health management approach."

Marathon Health also announced the appointment of Antoine Munfa and Marathon Health Chief Financial Officer Scott LaPlant to its Board of Directors.

About Goldman Sachs Private Capital Investing

Private Capital Investing ("PCI") is Goldman Sachs' investment platform dedicated to providing junior capital to growth and middle market companies throughout North America. PCI invests $20 million - $150 million per transaction in the form of common, preferred, and structured equity. Contact: pci@gs.com

About Marathon Health

Marathon Health offers a proven solution for helping employers reduce the total cost of healthcare. The Marathon Health approach integrates the best practices of onsite primary care, health assessment with risk identification, coaching and advocacy, and disease management for high cost chronic conditions. Marathon Health supports its unique model with an eHealth Portal delivering medical content, interactive diet and fitness tools, a personal health record, and an electronic medical record to manage care. Visit www.marathon-health.com.

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Premise Health Acquires TransformHealthRx, a Georgia-based Company Offering On-Clinics and Wellness Centers to Employer Groups

MyHealthGuide Source:  Holly Fletcher, 7/15/2016, The Tennessean

Premise Health, a company that runs on-site clinics for employers, is expanding its portfolio of clinics that serve groupings of employers.

Premise bought TransformHealthRx, a company out of Statesboro, Ga., that offers clinics and wellness centers to employer groups in addition to onsite clinics.

TransformHealthRx is similar to IMWell Health, an Arkansas-based company that runs clinics for mid-size employers, school districts and municipalities in the Southwest. Premise, based in Brentwood, bought IMWell earlier this year.

TransformHealthRx operates 17 sites in Georgia, North Carolina, Tennessee, Idaho and Indiana. Premise runs more than 500 sites in 46 states, Guam and Puerto Rico, for employers including Fortune 1000 companies.

Acquiring TransformHealthRx gives the company the chance to "improve the cost and quality of employer health care to a broader market," said Stu Clark, CEO of Premise Health in a statement.

On-site clinics are a way for employers to manage health care costs. The clinic staff can work with employees to manage chronic conditions and keep the network of providers more narrow, which helps keep costs down.

TransformHealthRx will keep its leadership team and will take advantage of clinical and technology resources as well as capital under Premise, said CEO and Founder Allison Judge, who called the deal a "natural next step" for the firm.

About Premise

Premise is a portfolio company of Water Street Healthcare partners, a Chicago-based private equity fund. It was established in 2014 via a merger of CHS Health Services and Take Care Employer Solutions. Premise employees close to 4,500 with about 500 in Middle Tennessee.  Visit www.premisehealth.com.

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selfinsurancemarket.com (SIM) Relaunches with New Features for Growing Global Self-insurance Sector

MyHealthGuide Source: selfinsurancemarket.com (SIM), 7/19/2016

selfinsurancemarket.com (SIM) plans to take advantage of the rapidly growing and prominent global self-insurance sector, As an example, in the USA between 1999 and 2015 the percentage of employers who fully or partially self-insured employee health benefits increased from 44% to 63%1 and in 2014 the number of insurance captives in the world reached a record high of 6,6782. SIM's objective is to assist participants, whether companies looking to self-insure or market professionals seeking new partners, in creating new contacts as well as helping them deliver solutions for themselves or for their clients.

To take advantage of this growth SIM has relaunched its self-insurance website with several new features which include a new business inquiry service. The new business inquiry facility allows companies and their employees to post inquiries and canvas other companies when they are seeking assistance, either for their own insurance programs or for those of their clients.

As well as the business inquiry service, the site has introduced new search facilities to allow anyone to search for companies or individuals by type of self-insurance, category and geographic area and then send an email inquiry directly to their chosen partners.

SIM Managing Director, Dominic Higham, commented:  "I like to compare the changes we've made to other internet success stories such as internet dating which has been extraordinarily successful in bringing people together and creating new relationships that might not otherwise have existed. Our new business inquiry service and search facilities have a similar approach and allow any company seeking a self-insured solution or self-insurance professional to post a business inquiry to which other companies can respond. When this service was trialled, we had numerous cases where our members established new contacts and developed trading relationships with companies that they would otherwise not have met.

As a former reinsurance broker, I understand the challenges often faced by professionals and buyers when seeking partners for insurance programs and how important business relationships and contacts can be. SIM has been relaunched to help people find new partners for self-insured solutions as well as providing information about the main types of self-insurance."

Other features of the site include guides to self-insurance, a job centre and a facility for member companies to post updates about their services. Companies and individuals can also create their own listing and description with a unique URL.

About selfinsurancemarket.com

Originally launched as specandagg.com in 2002, selfinsurancemarket.com owned by SIM Global Markets Limited. SIM Global Markets Limited is a private limited company registered in registered in England and Wales No. 04583593. The company was founded by former Lloyd's insurance broker and entrepreneur Dominic Higham and as at launch has 45 member companies. Types of self-insurance covered by the site include employee benefit trusts, self-insured workers' compensation, self-insured retentions, captive and mutual insurance.

Enquiries regarding service provider listings, advertising and general contents of the website can be made to SIM Global Markets Limited, 1st Floor, 50 Mark Lane, London, EC3R 7QR, United Kingdom or by email to info@selfinsurancemarket.com and visit selfinsurancemarket.com.

Footnotes

  1. Kaiser Family Foundation--Health Research & Educational Trust (HRET) survey on employer health benefits 2015.
  2. Business Insurance April 2015

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QBE North America Named to Short List for U.S. Captive Service Awards

MyHealthGuide Source: qbena.com, 7/18/2016

Marblehead, MA -- QBE North America is pleased to announce that it has been added to the short-list for the U.S. Captive Service Awards in the Insurance Company of the Year category. 

QBE North America's Accident & Health Division is a leading writer of Medical Stop Loss and one of only a few direct-writing carriers to specialize in the development and securitization of "true" captives for medical stop loss. QBE works exclusively with Single-Parent and tightly controlled Group Captives and delivers unparalleled expertise through a dedicated captive underwriting team, skilled specifically in both medical self-funding and alternative risk transfer mechanisms.

Single-Parent Captives:

A primary focus for QBE is working with single-parent captives to expand their utility to include medical stop loss. "Unique to QBE is our ability to provide coverage either as a reinsurer (assume risk) or as an insurer (cede risk) in order to provide the most appropriate structural options to the captive. Our ability to provide stop loss as a reinsurance transaction significantly reduces the internal expenses (fronting, collateralization, premium tax, carrier retention expense, etc.) to optimize the captive's efficiency and return performance", according to Steve McFarland, Vice President -- Underwriting, Special Markets.
 
Group Captives:

As previously mentioned; QBE works only with "true captives". We do not support the large heterogeneous "open-market" structures that, due to their size, composition diversity, and structural rigidity, more closely resemble stop loss "MGU programs" rather than true group captives, according to Phillip Giles, Vice President -- Sales & Marketing.

QBE is expert in working with tightly controlled groups of like-minded employers to develop finely tailored group MSL captive solutions. "Our customized approach addresses the population-specific needs of each individual employer to more accurately respond to their independent benefit objectives", continued Giles. "These more focused groups will also capitalize on increased participation engagement of all members and improve performance in reducing the overall cost of providing healthcare benefits to employees. This approach provides levels of structural agility, market responsiveness, and management control not available through the more common "open market" group programs".
 
"It's an honor for QBE to be recognized on the short list for this award, said QBE Accident & Health President, Steve Gransbury. "We pride ourselves on having the deep alternative risk expertise and agility needed to deliver truly innovative and responsive self-funded solutions to our clients".
 
The U.S. Captive Service Awards Ceremony is presented by Captive Review Magazine and will be held on August 8, 2016 in Burlington Vermont.
 
About QBE

QBE's North American-based Accident & Health division provides exemplary coverage and services to support the specialized needs of self-insured employers as a leading direct-writing provider of medical stop loss, including single-parent and group captive programs requiring stop loss insurance.
 
QBE North America is part of QBE Insurance Group Limited, one of the largest insurers and reinsurers worldwide. Headquartered in Sydney, Australia, QBE operates out of 43 countries around the globe, with a presence in every key insurance market. The North America division, headquartered in New York, conducts business through its property and casualty insurance subsidiaries. QBE insurance companies are rated "A" (Excellent) by A.M. Best and "A+" by Standard & Poor's.  Contact Phillip C. Giles, CEBS, Vice President -- Sales & Marketing, at 910.420.8104 or visit qbena.com.

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6 Degrees Health, Inc. Expands Its OURproviders™ Network with Four Regional Transplant Leaders

MyHealthGuide Source: 6 Degrees Health, Inc., 07/22/2016, www.6degreeshealth.com

Beaverton, OR -- 6 Degrees Health is proud to announce the addition of four new transplant providers. Joining the OURproviders™ Network are:

  • MedStar Georgetown University Medical Center
  • MedStar Washington Hospital Center
  • University Health System and UT Medicine San Antonio
  • Broward Health Medical Center

"The addition of these providers is a great step for our network. Each of them give patients in those regions access to another high quality transplant center and some nationally ranked specialties." states Neal Franzer, Director of Operations for 6 Degrees Health, Inc. CEO, Scott Ray, also commented, "We are excited to see continued growth in our transplant  network, and we will be expanding on our new orthopedic network in the next few weeks."

About 6 Degrees Health, Inc. & 6 Degrees Health Dx, LLC

6 Degrees Health is a Specialty Network and Cost Management organization focusing on advanced mitigation strategies, prospective and retrospectively, with transplants, cancer, cardiac and other complex high-dollar care. 6 Degrees Health delivers a customized, transparent, and defensible counter-offense complimented by superb Provider relations. OURsolutions™ products and tools are contained entirely "In-House", boasting significant data, benchmark support, leading industry metrics, complimenting software and technology … ensuring we are an invaluable resource to our clients. Our savvy negotiations and claims analysis are produced with no upfront fees or commitments … a clear indication and testimony to our results. 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™. There is no equal in the market achieving a win-win for Patient, Payor and Provider. Contact David Vizzini, President & CSO, 6 Degrees Health, Inc., at davidvizzini@6degreeshealth.com, 503-640-9933 ext. 102 and visit www.6degreeshealth.com.

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INETICO Achieves 20% to 50% Increases in Savings for Self-funded and Captive Employer Healthplan Groups

MyHealthGuide Source: INETICO, 7/19/2016 

Tampa, FL -- INETICO, has consistently achieved 20% to 50% increases in savings for their self-funded and captive employer healthplan groups with little to no provider pushback through Reference Based Repricing (RBR). This fair payment process can only be successfully executed by a team of skilled professionals.

Healthplans enjoying the increase in these savings have not experienced the provider pushback noted in the industry specifically because of INETICO's approach to mitigate the balance billing of the employers healthplan members. First, the proactive set up and design of the RBR program is the critical component to these positive outcomes. Next, bypassing a litigious approach and focusing on provider relationship development has been the key to expansion of INETICO's RBR program.

Additionally, INETICO does not outsource any of its RBR services. All aspects are performed in house utilizing the cutting edge web-based platform INETIPASS.

Employers have had enough of year over year increases in premiums and healthplan members are fed up with increases in deductibles and co-payments that have resulted in cost-shifting directly to their wallets. The consumers (both employers and employees) are demanding accountability and transparency. RBR is one of the first steps INETICO has employed to re-establish an open conversation fair payment between the patient and provider. After all, RBR sits at the core of the value-based deliver and payment of services.

RBR is rapidly expanding beyond early-adopter status. As an employer or broker, finding yourself at the late-adopter or laggard end of the scale of diffusion of innovation means that you have already lost the opportunity to manage this critical conversation. The result will either mean the employer will look for a broker that can bring them the significant savings that are required to continue paying their employees fairly or, from the employees perspective, they will be looking for an employer who can help them achieve an income with secure healthplan benefits that don't have their salaries leaking out of their paychecks.

About INETICO, Inc.

Established in 2004, INETICO provides healthcare cost containment services to self-funded, fully insured and various health care entities across all of the United States. INETICO has developed its products and people with a mission: INETICO is committed to strengthening the fiscal health of the Plan while improving the clinical health of the Plan Members."  Call 1-877-601-2200, email Marketing@Inetico.com and visit www.INETICO.com.

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Alacura Launches Groundbreaking Healthcare Benefits Management Solution Specializing in Medical Transportation

MyHealthGuide Source: Alacura, 7/21/2016, www.alacura.com

Dallas, TX -- Alacura, the nation's first comprehensive medical transportation benefits management (MTBM) company, is pioneering a new healthcare management industry focused on medical transportation. Alacura is headquartered in Dallas, TX, with operations in Scottsdale, AZ and is a medical transportation network that reaches across the U.S. and internationally.

In an industry that has virtually no central core of coordination, Alacura is the first and only MTBM company with the largest air transportation network in the U.S. The company is positioned to revolutionize management of the medical transportation industry by creating end-to-end coordination between transportation providers, health plans and patients, while driving down the cost of medical transportation for both patients and healthcare payors.

"Medical transportation is extremely expensive and fragmented but does not have to be," said David Boone, Alacura's CEO. "Alacura provides expert management of transportation services to improve the medical transportation experience for patients, streamline coordination and services for health plans and create logistical efficiencies for transportation providers, while reducing costs throughout the system."

Boone explained that with Alacura, payors benefit from lower costs and reliable quality services for their members, patients have access to quality transportation, and providers can grow their business with increased access to transports. This is a win-win-win for the entire industry. One critical element is the elimination of balance billing when members work with Alacura. There have been countless news articles written about the devastating bills that consumers have received from providers that are out of network, and the member's insurance company does not pay the entire bill. As the leading MTBM, Alacura is positioned to coordinate the end-to-end logistics of the industry and create efficiencies for transportation providers. Providers that are part of the Alacura network can reduce the need to heavily invest in demand generation, minimize repositioning costs, and create certainty of collections that eliminates the need for revenue cycle management.

The aging baby boomer population, combined with Medicaid expansion and a health services trend toward care at centers of excellence, is dramatically impacting the need for quality, affordable non-emergent medical transportation services. Often, the need for this type of medical transportation comes at a very difficult time in a patient's or family's life. Alacura takes the stress and burden off of the patient by streamlining the acquisition and coordination of medical transportation. Alacura is responding to that unique opportunity by creating a new model for medical transportation and benefits management that leads to better business, better process and better care for healthcare payors, providers and patients alike.

About Alacura

Alacura is the first and only medical transportation benefits management company dedicated to simplifying bedside-to-bedside non-emergent medical transportation for patients. Alacura manages the nation's largest fixed-wing transportation provider network ready to help patients 24/7/365 with one-call-does-it-all convenient, personal service. Alacura seeks to improve financial, operational and clinical performance for healthcare payers and administrators, their member patients, and transportation providers. Visit www.alacura.com.

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People News



Re-Solutions Announces Addition of Tina Nissinen as Vice President

MyHealthGuide Source: Re-Solutions, 7/19/2016

Minneapolis, MN -- Re-Solutions, a Risk Strategies company, is pleased to announce the addition of Tina Nissinen as vice president. Nissinen's hiring is part of Re-Solutions' ongoing strategy to expand its market presence and attract the most-talented and experienced professionals.
Nissinen
Tina Nissinen, Vice President

Prior to joining Re-Solutions, Nissinen was an account executive managing HMO Reinsurance and Provider Excess client relationships and program placement at Towers Perrin/Towers Watson and, most recently, at Stratis Risk Solutions Insurance Services, LLC.

As the newest member of Re-Solutions' market-leading team of professionals in the life, accident and health markets, Nissinen will help solidify the company's position as one of the nation's premier independent accident and health (A&H) reinsurance intermediaries and consultants.

"Re-Solutions continues to add quality people with industry knowledge and experience to better serve our growing client base," said Re-Solutions Managing Director Tony Plampton. "We have a very broad involvement in the A&H marketplace, and we are delighted that Tina elected to join our team. Tina will play an active role in our continued growth serving clients particularly in the health arena."

Nissinen can be reached at:

About Re-Solutions

Re-Solutions provides analytics, consulting and creative reinsurance solutions for the health, accident, life and disability insurance industries. We are headquartered in Minneapolis, Minn., with a team of seasoned professionals working out of offices across the country. Our contacts, gleaned from the experience of more than three decades, reach even further. We are independent brokers, free to consider every one of our global contacts in the search for the risk partner that perfectly fits your needs.  Visit Re-Solutions.

About Risk Strategies Company

Risk Strategies Company is a privately held, national firm with offices across the country. As a leading U.S. insurance broker, the company offers sophisticated risk management advice and insurance/reinsurance placement for property & casualty, healthcare and employee benefits risks. Risk Strategies serves commercial companies, non-profits, public entities and individuals, and has access to all major insurance markets. Ranked in the top 25 brokers in the country, the company has offices in more than 25 locations including Boston; Chicago; Los Angeles; Minneapolis; New York City; San Francisco; Atlanta; South Florida; Portsmouth, NH; Providence, R.I.; Long Island, N.Y.; Teaneck, N.J.; Irvine, CA; and Sacramento, CA.

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Swiss Re Corporate Solutions Appoints Christine Harman and Gabriel Poppie to US Central Region Leadership Positions

MyHealthGuide Source: Swiss Re Corporate Solutions, 7/18/2016, www.swissre.com/corporatesolutions
 
NEW YORK -- Swiss Re Corporate Solutions strengthens its North American Central Region leadership team with two appointments. Christine Harman joins the company as Senior Vice President, Head Casualty, US Central Region. Gabriel Poppie is named Senior Vice President, Head of Sales Central Region. Both will be based in Chicago, Illinois.

Nissinen
Christine Harman, Senior Vice President

Ms. Harman will be responsible for leading the company's Central Region Casualty team and growing its capabilities and revenue in the umbrella and excess liability lines of business. A proven leader in the Chicago marketplace, Ms. Harman brings almost 20 years of industry experience including claims, underwriting and team leadership roles at a variety of commercial carriers.

Robley Moor, Head of Casualty North America, states: "Christine's strong casualty underwriting background provides a solid foundation from which we will continue expanding our portfolio. A great fit for Corporate Solutions, she is dedicated to maintaining long-term broker and client relationships."
Nissinen
Gabriel Poppie, Senior Vice President

Mr. Poppie, who has been a key account manager at Swiss Re Corporate Solutions since 2013, will become Head of Sales Central Region. In his new role, he is tasked with generating new business, managing relationships with key regional brokers and driving growth. With over 16 years of industry experience, he is an expert in a wide range of industries and segments and new business origination. Mr. Poppie began his career in 2000 with Marsh in St. Louis.

Sylvain Bouteillé, Head of Sales North America, says: "Swiss Re Corporate Solutions has a strong focus on internal talent development. Gabe has been a great asset to our key account management strategy in North America. I'm delighted that he will lead our regional sales activities. He is committed to strengthening our regional relationships."

About Swiss Re Corporate Solutions

Swiss Re Corporate Solutions offers innovative, high-quality insurance capacity to mid-sized and large multinational corporations across the globe. Our offerings range from standard risk transfer covers and multi-line programmes, to highly customised solutions tailored to the needs of our clients. Swiss Re Corporate Solutions serves customers from over 50 offices worldwide and is backed by the financial strength of the Swiss Re Group. For more information about Swiss Re Corporate Solutions, please visit www.swissre.com/corporatesolutions and follow us on Twitter @SwissRe_CS.

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Munich Health North America Announces the Hiring of Ellen Hyser

MyHealthGuide Source: Munich Health North America, 07/13/2016 www.munichhealthna.com

MINNEAPOLIS, MN -- the Managed Care and Reinsurance Solutions Division of Munich Health North America, a leading provider of healthcare reinsurance solutions, is pleased to announce an addition to its Minneapolis, Minnesota office.

Ellen Hyser will assume the role of Client Manager dedicated to the Program Business, initially focusing on Managed Care quota share opportunities. Ellen has over 25 years of experience in the healthcare industry with roles in Operations, Claims, and Sales, most recently with UMR, a Third party Administrator of United Healthcare, where she was the Director of Account Management for the North Texas and Oklahoma markets. Ellen and her family will be relocating to the Minneapolis area from Frisco, Texas.

Dave Sipprell, President of Managed Care and Reinsurance Solutions, comments: "We are very pleased to have Ellen join our team here in Minneapolis. Ellen has been in may management and leadership positions throughout her career, and we look forward to bringing her expertise to Munich Health North America!"

About Munich Health

Munich Health is one of three business segments of Munich Re, where all international health care business in insurance and reinsurance operations, as well as related services, are pooled under the Munich Health brand.  Contact Stephen Fedele, Marketing Manager, at SFedele@munichhealth.com, +1 (609) 243-4238, and visit www.munichhealthnare.com

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AIG Announces Bill Edrington as Vice President of Stop Loss and Voluntary Distribution Development

MyHealthGuide Source: AIG, 7/19/2016, www.aig.com

Bill Edrington has joined AIG as Vice President of Stop Loss and Voluntary Distribution Development.

Bill will be responsible for driving top-line growth and retention of AIG's Stop Loss, Organ Transplant and Voluntary Benefits coverages nationally. He will manage key national strategic relationships and stop loss panel partnerships, and provide subject matter expertise to support regional field leadership and regional distribution teams.

Bill comes to AIG with a successful track record in stop loss sales and sales leadership with key carriers in the market. Most recently, he served as Managing Director of Marketing and Business Development at Symetra.

Dan Palermino, Vice President and Head of Core and Voluntary Benefit Sales, Group Benefits, AIG Consumer Insurance, said, "I am confident that Bill's experience and collaborative approach to our business aligns perfectly with our strategic focus on growing AIG's Group Benefits business in the mid- and large-market segments with key strategic distribution partners."

Bill is based in AIG's Atlanta office and can be reached at william.edrington@aig.com.

About AIG

AIG is the marketing name for the worldwide property-casualty, life and retirement, and general insurance operations of American International Group, Inc. All products and services are written or provided by subsidiaries or affiliates of American International Group, Inc. Visit www.aig.com.

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MCM Announces Changes in Leadership

MyHealthGuide Source: MCM Solutions for Better Health, 7/18/2016, www.medicalcost.com

CHICAGO, IL -- MCM Solutions for Better Health, an independent, national leader in providing population health management services, is excited to announce the following changes to their leadership team:

  • Mike O'Connor, Founder and President will now serve MCM as the Chief Executive Officer (CEO).
  • Amy Gasbarro, formerly the Chief Operations Officer (COO) will now be serving MCM as the President.
  • Tom O'Connor formerly the VP, Finance and Accounting will now be serving MCM as the Chief Operating Officer (COO).
  • Connie Wolf, formerly the VP of Sales will be serving as SVP Sales & Marketing, following the retirement of Brian Vervynck on July 1st.

We are also excited to announce the addition of a new sales person to the MCM team, Matt Rose. Matt has significant experience in the population health management space having been a key sales person with Interlink.

All other management and supervisory roles at MCM and MedCare will remain the same.

Mike O'Connor, CEO, stated, "We welcome Matt to our sales team and wish Amy Gasbarro, Tom O'Connor and Matt Rose much success in growing MCM and MedCare."

Amy Gasbarro, MCM President, stated "I am excited to be serving MCM in the role of President and to have the opportunity to grow MCM with the team we have in place."

About MCM

Medical Cost Management Corporation, dba MCM Solutions for Better Health, was founded by Michael O'Connor in 1986. They are a leading provider of population health management programs that cover the entire continuum of care. MCM is a physician directed company that is URAC accredited and licensed in all states with requirements. MCM and its subsidiary Med-Care provide services to over 550 plans representing over 600,000 members on a nationwide basis. Visit www.medicalcost.com.

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Job News


Auxiant Seeks Sales Consultant for Wisconsin and Nebraska Territories

MyHealthGuide Source: Auxiant, 7/18/2016

Auxiant announces it has opening for sales consultant for Wisconsin and Nebraska territories.

Summary

  • Responsible for business development, networking, conducting needs analysis, and consultative selling to existing and prospective brokers/consultants and clients

Essential duties and responsibilities

  • Developl prospective brokers and consultants
  • Maintain a superior relationship with existing agents/consultants
  • Maintain regular communication with brokers/consultants and clients
  • Conduct needs analysis and future needs forecasting
  • Have superior knowledge of how self funding works and knowledge of all self funding terminology
  • Educate clients and brokers/consultants on difficult to understand services
  • Using a consultative approach, sell services to brokers/consultants and their clients
  • Up-sell existing clients Auxiant services through the broker/consultant
  • Excellent knowledge of our competition and our vendors
  • Other duties as assigned or appropriate

Minimum qualifications

  • Proven outside sales experience in self funding is preferred
  • Excellent interpersonal, written/verbal communication and presentation skills
  • Proficient PC skills including e-mail, record keeping, routine database activity, word processing, spreadsheet, PowerPoint, etc.
  • Excellent time management and organizational skills with the ability to handle multiple projects, meet established deadlines and change as the business needs require
  • Previous sales experience is preferred

Education and/or experience

  • Bachelors Degree and 2-4 years related experience; or equivalent combination of education and experience.

Send resumes to Brienne Wilson, PHR, SHRM-CP, HR Manager, at BWilson@auxiant.com.

About Auxiant

Auxiant is the largest privately owned Third Party Administrator in Wisconsin and the oldest TPA in Iowa doing business since 1982.  Our features and strengths include reporting and data Analysis, strong financials, on staff ERISA attorney, disaster recovery plan in place and tested, flexibility, access to a number of stop loss carriers A- or better, flexibility to work with a number of PBMs, commitment to the highest level of service, integrated population health and disease management programs, employee health management tools & resources.  Visit www.auxiant.com.

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International Medical Group - Stop-loss Seeks Experienced Senior Claims Auditor

MyHealthGuide Source: International Medical Group, 7/13/2016, www.imglobal.com

Indianapolis, IN -- International Medical Group - Stop Loss, headquartered in Indianapolis, is seeking an experienced Senior Claims Auditor to join a unit that has been at the forefront of stop loss insurance for the past 25 years.

The Senior Claims Auditor will audit Specific & Aggregate (Accommodation and Transitional) stop loss claims filed by TPAs, adjudicate and determine appropriate reimbursements, correspond with TPAS regarding claim issues and any related issues, and work with stop loss underwriting & administration departments. There will be occasional travel for on-site aggregate audits.

Duties and Responsibilities

  • Auditing specific & aggregate stop loss claims.
  • Communicating with TPAS and underwriting/administration departments regarding claim issues
  • Organize work load to maintain claim department reimbursement turnaround goal
  • Adherence to company guidelines and policies
  • Occasional on-site audits for large aggregate claims

Knowledge Skills and Abilities

  • A minimum of 2 years stop loss claim auditing or related experience
  • Strong attention to detail and plan document interpretations
  • High level of accuracy when performing specific and aggregate claim audits
  • Ability to work effectively with others when needed
  • Effectively communicate with TPAS/brokers
  • Enhanced knowledge of medical conditions and costs

Perks

  • On site fitness center
  • Casual dress
  • 401k with a 2 year vesting period
  • Short and Long term Disability after one year of employment

Qualified candidates can send their resumes directly to HR@imglobal.com

About International Medical Group

For more than 25 years, International Medical Group -- headquartered in Indianapolis, Indiana, U.S.A. -- has provided global benefits and assistance services to millions of members in almost every country. We're committed to being there with our members wherever they may be in the world, providing them Global Peace of Mind®. With 24/7 worldwide assistance and medical management services, multilingual claims administrators and highly trained customer service professionals, IMG delivers the insurance products international members need, backed by the services they want. IMG's global family of companies includes Akeso Care Management®, IMG Europe Ltd., Global Response Ltd., IMG-Stop LossSM and International Medical Administrators, Inc.  Visit www.imglobal.com.

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Blue Cross Blue Shield of Massachusetts and Indigo Insurance Services Seeks Stop Loss Sales Executive

MyHealthGuide Source: Blue Cross Blue Shield of Massachusetts,  7/14/2016, www.bcbsma.com

As an Indigo Stop Loss Sales Executive you'll have the support of one of the nation's leading insurance companies and the flexibility and growth potential of running your own business. You'll solve clients' needs through consultative and solution based selling, by building relationships with contacts in your territory to identify, develop and close sales opportunities.

  • Sell Indigo Insurance Services Medical Stop Loss product through insurance brokers, third party administrators and consultants.
  • Build and establish relationships with key sources to market our product to some of the nation's leading employers.
  • Construct and maintain a business plan for your designated territory based on sales and strategic initiatives.
  • Call on existing and potential customers to not only prospect new customers but also to develop a book of business.
  • Meet annual targets and individual sales goals.

For more details and to apply go to https://bcbsma.wd5.myworkdayjobs.com/en-US/BCBSMA/job/Boston/Indigo-National-Stop-Loss-Sales-Executive_R00070-3

About Indigo

Indigo Insurance Services is a full-service insurance agency that offers a comprehensive array of specialty insurance including; life, disability, critical illness, cancer care, stop loss, and more. Employers can buy financial accounts, COBRA, FMLA, and ERISA administrative services, as well as Employee Assistance Plans. For clients with employees traveling and working around the globe, our GeoBlue ExpatSM and GeoBlue TravelerSM group plans provide easy access to quality health care and medical assistance services worldwide. We also offer customized stop-loss coverage options for employer groups headquartered outside of Massachusetts. Visit www.indigo-insurance.com.

About Blue Cross Blue Shield of Massachusetts

Voted as one of the Most Admired Health Care Companies in 2014 by Boston Business Journal, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.  Visit www.bluecrossma.com.

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Market Trends, Studies, Books & Opinions


A Dose of Reality: PBM's Job is Rarely To Save Costs

MyHealthGuide Source: Ron E. Peck, Esq., Sr. VP & General Counsel, The Phia Group, LLC, The Self-Insurer July 2016 - pages 10-15 Full Text

Utilization review. Precertification. Medical case management. It seems as if health plans have been, for lack of a better word, micromanaging how medical care is sought and obtained by plan participants, for decades upon decades. It makes sense. Whether I'm a fully insured carrier or a self-insured plan sponsor, I know that a complicated pregnancy, chronic illness, cancer diagnosis, or any other number of conditions will seriously hurt -- if not sink -- my plan.

As specialty drugs, implants and other devices usher in an age of skyrocketing costs, not enough attention is being paid to this area in dire need of improvement.

Drug costs already make up 25% of all healthcare expenses. Indeed, a recent study revealed that large employers spent -- on average -- almost a thousand dollars per covered life, on pharmacy costs in 2014.

  • Specialty and Compound drugs accounts for between 25% and 35% of total drug spending.
  • Further, the costs associated with specialty drugs is increasing at nearly double the 10% rate attributed to other drugs; meaning a 20% jump per year.
  • Even more startling, more than 50% of drugs in the later stages of FDA approval are specialty drugs.
  • Some existing medication have increased substantially, with some increases exceeding 47%.
  • All of this adds up to a total pharmacy spend projected to double by 2020.

The Role of the PBM

A report says that eighty percent (80%) of employers agree or somewhat agree that their Pharmacy Benefit Manager (PBM) is sufficiently managing drug costs. I'm sure -- if asked about medical expenses in general -- the same respondents would be full of complaints. Yet, when we focus on drug costs which -- as described above -- are one of the (if not the) fastest growing drivers of plan expense, 80%+ of plan sponsors are satisfied. Someone isn't getting the memo!

  • PBMs are not necessarily the problem. The issue is that we -- as an industry -- don't recognize their role, limits and mission. People assume PBMs exist to contain drug costs. This is simply not the case (with a few exceptions).

Plan sponsors contract with PBMs directly or through their third party claims administrator, to decide what drugs are covered, what the costs shall be and, as it relates to payment to pharmacies, the where, when and how much. Further, plans rely upon their PBM to set the participant cost-share and establish pharmacy networks. PBMs therefore serve many important roles; none of which are -- first and foremost -- dedicated to identifying cost containment opportunities.

  • Understanding the role of a traditional PBM, what they do to create revenue for themselves and recognizing the pros and cons of said arrangement, is the key to devising independent cost controls.

Some plan sponsors think that they simply pay the PBM for the cost of any drugs actually dispensed and usually an administrative fee for managing the prescription drug program. Little do they know, but many other costs -- and conflicts -- impact the bottom line when it comes to prescription drug purchasing and distribution, above and beyond the problem of rising drug costs.

The costs of the drugs purchased are exploding. Plans, however, are not only contending with the rising cost of the drugs themselves. They must also worry about lost refunds, PBMs pocketing spreads (the difference between what the plan pays and the pharmacy receives) and other revenue bolstering tactics, such as up-charging and therapeutic shifting.

PBM's Job Rarely Includes Reducing Drug Cost

PBMs are contractually tasked to complete a particular set of jobs. Rarely does that include reducing costs for the plan, no matter what. PBMs enter into contractual arrangements with other entities, to achieve their duties, even when those other entities may not share the same goals as the plan. For instance, PBMs may enter into contracts with retailers, where -- in exchange for steerage -- said retailers provide discounts to PBMs. Is that retailer the best option for the plan? Who knows?!?! Can we confidently say that said steerage is being driven with plan cost savings as the chief impetus? Not with any confidence; no.

A significant source of revenue for PBMs comes from drug manufacturers in the form of rebates. Brand-name drug manufacturers have the ability to financially incentivize PBMs to stimulate demand for their drugs; using discounts and rebates as a form of compensation to PBMs. Meanwhile, few people know that there are at least two types of rebates: performance and access. Generally speaking, PBMs are only obligated to share performance rebates with the plan, meaning that drug purchasing, usage and other plan spending may not be producing the most cost-effective path for the plan, despite putting the greatest number of rebate dollars into the pocket of the PBM.

PBM Conflicts

These and other contractual relationships may represent a conflict of interest for the PBM, because the PBM stands to gain additional revenue from parties with interests competing with  those of the plan.

One last concern I have, whereby the status quo runs headfirst into (and against) efforts to contain the rising drug costs, relates to PBMs that own their own specialty pharmacy -- and more importantly -- handle the prior authorizations. Indeed, these particular organizations authorize themselves to buy drugs from their own pharmacy. Huh? Could you imagine if a hospital were in charge of pre-certifying procedures they will be performing?

Yet, most agree that PBMs still offer valuable services. If that is the case and we all agree that the cost of prescription drugs is skyrocketing, plans are obligated to: (1) implement programs either themselves, with third parties, or with their PBMs to make cost containment priority #1 and (2) recognize the limits and needs PBMs deal with -- noting that if the plan wants to use a PBM, they may need to be flexible in their demands and expectations.

Actions to Avoid Conflicts

So, with these potential issues in mind, we next need to consider some actions we can take to avoid such conflicts, while still benefitting from many of the valuable services PBMs provide. If PBMs cannot be relied upon (and, in many instances, ought not to be relied upon) to reduce costs to the plan and manage drug utilization, the duty falls upon the plan fiduciary to do it themselves, or find someone who can do it for them.

  • First and foremost, the PBM (or someone else, providing oversight) should constantly evaluate medical necessity as it relates to the drugs being purchased. In other words, eliminate the "set it and forget it" attitude that tends to apply to medication purchasing. This is especially true with some of the most common conditions we see today. An industry expert and friend explained to me the outrageous waste he sees related to back injuries and conditions. According to him, 67% of all back surgeries are not medically necessary and too often the TPA just approves them. Worst of all? Most of them don't solve the problem!
  • Another ally in the battle against rising drug costs assured me that, to deal with this problem and ones like it, a savvy benefit plan must implement a program that involves evidence-based clinical care management -- meaning they perform detailed analysis and identification of opportunities based on historical data, perform clinical review for appropriateness and cost effectiveness and continuously monitor diagnoses, treatment options and new therapy options, to ensure that the option that was best for both the patient and plan yesterday, is still the most impactful for the client as well as most likely to produce the best clinical outcomes today.

An exasperated professional said it best when he remarked that people are not even remotely up to speed on the cost of new drugs and therapies. There is, he said, a new therapy on its way that will cost benefit plans more than $1 million per year; (insert Dr. Evil laughter here). One of the hottest topics in our industry today is "price transparency for hospitals." How about transparency here? If a benefit plan's current arrangement would allow them to get slapped with a $1 million claim for the purchase of a drug or medical supply and they didn't have measures in place to provide early warning, stop payment pre-purchase and analyze the situation to identify any and all alternatives, they deserve what they get! With price inflation on current medication and a storm of high cost drugs brewing on the horizon, pipeline monitoring that allows for real-time actionable recommendations is a must.

Whether these measures are implemented by PBMs seeking to self-police themselves and counterbalance incentives to ignore cost containment, or, are provided by third party cost containment partners, the time to take drug costs seriously hasn't come... it's already been here for years. Act now or no amount of sugar will help this medicine go down.

About the Author

Ron E. Peck, Esq. is The Phia Group's Senior Vice President and General Counsel. Ron has been a member of The Phia Group's team since 2006. In that time he has been an innovative force in the drafting of improved benefit plan provisions, handled complex subrogation and third party recovery disputes and spearheaded efforts to combat the steadily increasing costs of healthcare. Ron's theories and innovative ideas regarding all industry issues are well regarded and he is routinely asked to speak at industry events on these and other topics . Ron obtained his Juris Doctorate from Rutgers University School of Law and earned his Bachelor of Sciences Degree from Cornell University. Ron is also a dedicated member of SIIA's Government Relations Committee.

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Legislative & Regulatory News


DOL Holds Modest Sway With Courts on Benefits Issues

MyHealthGuide Source: Jacklyn Wille, 7/20/2016, BNA Pension & Benefits Daily

The Obama administration's Labor Department has filed more than 100 amicus briefs attempting to influence how courts interpret the Employee Retirement Income Security Act.

How has the department fared in these cases?

Perhaps not as well as one might expect.

  • Of the 77 cases that led to clear decisions on the questions raised by the DOL, the department has scored 44 victories and suffered 33 losses. That's a win rate of about 57 percent--only modestly better odds than a coin flip.

Although the department has filed ERISA-related briefs in all the federal circuit courts and several district and state courts, its win-loss record doesn't vary significantly by court. In most courts, the department has won about as many cases as it's lost.

Briefs by Court

  • The DOL's best record--7 wins and 5 losses--is in the Second Circuit, which is also where it has filed the most briefs.
  • The department has been completely shut out in two circuits--the First Circuit and the D.C. Circuit--after filing a single brief in each court.

Despite this mixed record in the circuit courts, the department has had significantly more luck in the federal district courts. There, the department's 11 amicus briefs have resulted in seven victories.

Bloomberg BNA analyzed the DOL's ERISA-related amicus briefs filed in federal circuit courts, federal district courts and state courts throughout the Obama administration to get a sense of which issues the department has championed and how successful those efforts have been.

Help(?) From SCOTUS on ERISA Cases

Throughout the Obama administration, the DOL's biggest preoccupation by far has been holding companies liable under ERISA for drops in company stock price that erode workers' retirement savings.

  • The department has filed 20 amicus briefs on this topic during the Obama administration, 18 of which came during the president's first term.

Most of these briefs argued against the judge-made presumption of prudence that a number of courts once used to dismiss lawsuits against fiduciaries of employer stock plans. With the exception of the Sixth Circuit--which crafted a slightly more worker-friendly presumption--most courts were unpersuaded by the DOL's arguments.

The department's efforts appeared to be vindicated in 2014, when the U.S. Supreme Court struck down the judge-made presumption of prudence as unsupported by the text of ERISA.

Despite this apparent victory, workers have continued to face significant roadblocks when bringing ERISA lawsuits challenging drops in company stock price. Two recent briefs in cases against BP Plc. and Greatbanc Trust Co.--the department's first employer stock-focused briefs in nearly four years--suggest that the battle isn't over.

Help From SCOTUS, Part II

The DOL has seen a lot of success in cases involving ERISA's equitable remedies provision. In more than a dozen amicus briefs, the department argued that ERISA plan participants can win monetary awards in cases involving allegations of misconduct by plan fiduciaries.

The department had little success with this strategy at first, as many courts found ERISA's statutory text to foreclose monetary awards in these cases. The tide shifted dramatically in 2011, when the Supreme Court held in CIGNA Corp. v. Amara that monetary awards might be available to ERISA plan participants under certain equitable theories.

  • Since Amara, the DOL has filed 10 amicus briefs on the question of equitable relief and hasn't lost a single case.

Switching Strategies on Plan Fiduciaries

The DOL has made no secret of its desire to impose fiduciary status on those involved in managing workers' retirement savings. Before the Department finalized its controversial fiduciary rule in April, it used its amicus brief program to urge fiduciary status on 401(k) service providers like American United Life Insurance Co., John Hancock Life Insurance Co. and Principal Life Insurance Co.

Each of these efforts led to thorough defeats, with three appellate courts declining to impose fiduciary status on the service provider defendants.

These losses may have inspired the department to focus more attention on the regulatory process as a way to expand ERISA's fiduciary definition. In the two years prior to the fiduciary rule's release, the department sharply decreased the number of ERISA-related amicus briefs it filed. The DOL filed only five ERISA briefs in each of 2014 and 2015, compared to an average of 17 briefs in each of the preceding five years.

Arguing Against Preemption

The interaction between the federal ERISA statute and various state laws has caught the department's interest on several occasions.

  • Over the course of the Obama administration, the department filed 10 separate briefs on questions of ERISA preemption.

Surprisingly, none of the DOL's Obama-era amicus briefs have argued that a particular state law is preempted by the federal law.

Rather, the department has sought to save a number of laws from ERISA preemption, including state laws regulating health insurance and pharmaceutical benefit managers, laws governing sick and family leave for workers and laws facilitating government data collection efforts. In some cases, the challenged state law provided individuals with greater benefits or protections than those provided by ERISA.

  • The department has a modest winning record in these preemption cases, notching five wins and four losses with one appeal dropped.
  • Notably, the department suffered a high-profile loss earlier this year, when the Supreme Court used ERISA's preemptive powers to throw a wrench into Vermont's efforts to create a database of medical claims data.

Mixed Results on Standing

Over the course of eight amicus briefs, the DOL has championed an expansive view of which individuals have standing to bring claims under ERISA.

Briefs by Subject Matter

The department has had no success convincing courts that pension plan participants have standing to sue over mismanagement regardless of how well their plan is funded. Both the Fourth and Eighth Circuits have denied standing to participants in well-funded pension plans over the department's objections, and other courts have come to similar conclusions.

Despite these losses, the DOL is continuing the fight. In June, the department filed a brief in the Second Circuit arguing that a recent Supreme Court decision under the Fair Credit Reporting Act strengthened the pension plan participants' claims to standing.

The department's standing arguments have been more successful in cases involving health insurance benefits.

  • Both the Fifth and Ninth Circuits have followed the DOL's advice and allowed medical providers to bring ERISA claims against insurers even if the providers haven't sought payment from the insured patients in question.

Winning the Claims Procedure Battle

Some of the department's biggest successes have come in disputes over the proper handling of an individual's claim for benefits from an ERISA plan.

  • The DOL has filed seven briefs seeking to hold plan administrators to high standards, and the department's only loss came when the Eighth Circuit declined to rehear a case in front of a full panel of judges.
  • One of the DOL's major victories came in the Ninth Circuit, which ruled in 2011 that an ERISA plan that doesn't have and follow reasonable claims procedures can't defeat a participant's lawsuit by alleging that the participant never exhausted the plan's internal remedies.
  • In another claims procedure case, the Fourth Circuit agreed with the DOL that a claims administrator abuses its discretion if it fails to obtain and consider readily-available information in the course of denying a claim for benefits.
  • Most recently, the department scored a partial win in a Second Circuit case involving Yale University's health plan.

Forum Selection Clauses

  • On four occasions, the DOL has taken up the issue of forum selection clauses, which are terms in an employee benefits plan that force participants to litigate their claims against the plan in the plan's preferred court. According to the DOL, these clauses are incompatible with ERISA's policy of allowing participants broad access to the federal courts.
  • Only one of those cases has led to a final judicial decision. In that case, the Sixth Circuit upheld an ERISA plan's forum selection clause over the department's objections. The Supreme Court declined to review that decision in January after the solicitor general pointed out that no other circuit court had ruled on forum selection clauses in ERISA plans.
  • Recently, the DOL urged the Eighth Circuit to part ways with the Sixth Circuit when it considers forum selection clauses in an upcoming case.

Whistleblower Protections

The department has had mixed results convincing courts that ERISA's whistleblower provision protects workers who make unsolicited complaints about benefits issues to management.

  • After notching losses in the Third and Sixth Circuits and a win in the Seventh Circuit, the DOL recently asked the Fourth Circuit to join its side of this debate in a pending case.

What Comes Next?

With six months left until Obama leaves office, the department's amicus brief program appears to be ramping up, rather than slowing down.

Briefs Over Time

  • In the first half of 2016, the DOL filed eight amicus briefs in ERISA cases--more than it filed in all of 2014 (5) and all of 2015 (5).
  • In these briefs, the department is revisiting a number of arguments that garnered little success in the past, like the unenforceability of forum selection clauses, the ability of participants in well-funded pensions to sue over mismanagement and the scope of ERISA's whistleblower protections.

Links to many of the department's benefits-related amicus briefs are available at the DOL website: https://www.dol.gov/sol/media/briefs/main.htm.

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Medical News


Higher Risk of Death via Transfusion when Blood Donor is Young or Female

MyHealthGuide Source: Michaël Chassé, MD, PhD, et al., 7/11/2016, JAMA Internal Medicine Abstract

Red blood cell transfusions from younger donors and from female donors were statistically significantly associated with increased mortality according to a study published in JAMA's Internal Medicine.

While red blood cells (RBCs) are administered to improve oxygen delivery and patient outcomes, they also have been associated with potential harm.

The study analyzed the association of RBC donor age and gender with the survival of transfusion recipients.  Researchers established a longitudinal cohort by linking data from a blood collection agency with clinical and administrative data at 4 academic hospitals. 

Between October 25, 2006, and December 31, 2013, a total of 30,503 RBC transfusion recipients received 187,960 RBC transfusions from 80,755 unique blood donors.

Study findings

  • For recipients receiving an RBC unit from younger donors, the risk of death was 8% higher for donor age range 17-19.9 years compared with recipients receiving an RBC unit from a donor 40 to 49.9 years old.
  • Receiving an RBC transfusion from a female donor was associated also with an 8% statistically significant increased risk of death compared with receiving an RBC transfusion from a male donor.

Recurring Resources



Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 4/16/2016)

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 update 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)
1 CIGNA     $2,701
2015
 
  Source - CIGNA Financial Supplement 2015, P.5 12/31/2015
2 Sun Life Financial     $1,034
2014
 
  Source - 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 Tokio Marine HCC
>35 Years Tokio Marine HCC Life
(A.M. Best Rated: A+)
$907
2015
$29,700 as part of Tokio Marine Group
  Source - Ketrice Williams, 5/6/2016
4 Voya Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
$807
2015
$396
12/31/2015
  Source - Joe Keller, Lead Financial Analyst, Voya Employee Benefits, 3/28/2016
5 HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
$751.4
2015
$588
12/31/2015
  Source - Matt Rhenish, President & COO, 2/19/2016
6 Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $495M
MRM - $233M)
$728
2014
$3,360.6
12/31/2014
  Source - Symetra 4Q 2014 Financial Supplement;
Tom Doran, President, Medical Risk Managers, Inc., 2/9/2015
7 Companion Life > 20 Years   $440
10/8/2014
 
  Source - Philip Gardham, Vice President, Specialty Markets, 10/8/2014
8 Swiss Re Corporate Solutions >40 Years Standard Security life Insurance Company of New York, Westport Insurance Corporation and Independence American Insurance Company $324
3/31/2016
 
  Source - Swiss Re Corporate Solutions Accounting Department
9 National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $253
2/1/2016
 
  Source - Jeff Gavlick, FSA, FCA, VP, Stop Loss Products, AIG Benefit Solutions, 2/1/2016
10 Zurich North America     $150  
  Source - Joseph Byers, Zurich North America, 4/6/2015
11 Munich Re Stop Loss, Inc.   American Alternative Insurance Company (AAIC),
TransAmerica
$147
2015
 
  Source - Travis Micucci, the Chief Executive Officer of Munich Re Stop Loss, Inc., 11/09/2015
12 United States Fire Insurance Company 15   $120
2015
$1,200
  Source - Lauren Woods, VP Marketing Fairmont Specialty, 1/4/2016
13 The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
$104
12/2014
 
  Source - Victor Moran, Second Vice President, Actuarial Operations.  3/6/2015
14 Gerber Life Insurance Company   Gerber Life Insurance Company $35
2016
$6,800
  Source - Gerber Life Insurance Company Stop Loss Director Job Description.  4/11/2016
15
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $3,388
12/31/2011
  Source - 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 Cross Blue Shield (various regions)
  • 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 The Self-Insurance Educational Foundation, Inc. (SIEF has published The Value 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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Video Highlighting Captive Solutions for Mid-market Companies

MyHealthGuide Source: The Self-Insurance Educational Foundation (SIEF), 5/11/2016, www.siefonline.org

The Self-Insurance Educational Foundation (SIEF) announced that it has released a new video highlighting captive insurance solutions for mid-market companies, including stop-loss captive programs, enterprise risk captives, and property & casualty group captives. Please click here to access the video.

The video can be accessed through the Foundation's web site at www.siefonline.org or by clicking here.  The video includes a separate video focused on self-insured group health plans. Both videos can be private labeled by individual companies interested in using them for their own purposes. Contact Justin Miller at jmiller@siia.org or 800-851-7789 for more information about private labeling.

About 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). Its 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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ICD-10 Readiness Tools

MyHealthGuide Source:  Industry Study Group (ISG), 9/19/2015

In the early 2000s a group of industry professionals collectively known as the Industry Study Group ("ISG") created a Standard Disclosure Notification form and a standardized list of ICD-9 diagnosis codes, known as the Trigger list. On October 1, 2015, our industry transitions to the new ICD-10 coding system. The ISG has once again undertaken the development of a new Trigger list based on the ICD-10 diagnosis codes. The new ICD-10-CM Trigger list is endorsed by SIIA and HCAA and supported by SPBA.  

Below are useful links for members of the self-funded community including TPAs, stop-loss carriers, MGUs, and others.

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Upcoming Conferences


August 15-16, 2016
Advanced Reinsurance Seminar.  In-depth view of the important topics and fundamentals of reinsurance, from the perspective of a U.S. life insurance company. Reinsurance industry experts will cover various types of reinsurance, contract issues, financial implications and other considerations and more. Sessions will include presentations on reinsurance conflicts and mock arbitration, reinsurance structures, market updates and more. Hyatt Rosemont Hotel. 
Registration: https://www.soa.org/Professional-Development/Event-Calendar/2016-advanced-reinsurance-seminar.aspx 

September 19-21, 2016
MCRA's 2016 Conference presented by Managed Care Risk Association.   Don't miss out on what this year's conference has to offer. We will hear speakers address the potential impacts on the ACA from this year's election; join in a discussion with industry underwriters to share lessons learned with underwriting Exchange business; receive information on today's concerns with specialty pharmacy, and much more. Agenda:

  • Monday
    • Cocktail Welcome Reception in Stratus Rooftop Lounge
  • Tuesday
    • Election Impact / ACO / Market Update: David Smith, Leavitt Partners
      Bringing New Talent to Your Door: Abbe Sodikoff, The Jacobson Group
      The State of ACA and Where We Are Headed: Robert Field, Drexel University
      Specialty Pharmacy: Susan Faust, Diplomat
  • Wednesday
    • Panel Discussion: Lessons Learned 2014 to 2016
      Making Sense of Clinical Trials: Melinda Baxter, ROSE® Program
      Transparency in Healthcare: Dir. Marty Makary, Johns Hopkins

The MCRA hotel room rate at Hotel Monaco is $249 which allows use of many hotel amenities without an additional resort fee. Reserve your room now by visiting our website for a link to the Hotel Monaco reservation site: www.mcraweb.org. Registration and Information: www.mcraweb.org

September 25-27, 2016
36th Annual National Educational Conference & Expo presented by Self-Insurance Institute of America. Austin, TX. www.SIIA.org  

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

December 1-2, 2016 - A Hybrid Conference and Internet Event
Population Health Colloquium Special Edition: Pop Health Policy & Strategy Under the New Administration.  Speakers: Sheila Burke, MPA, RN, FAAN, Chair, Government Relations & Public Policy, Baker, Donelson, Bearman, Caldwell & Berkowitz, Faculty Research Fellow, Stephen K. Klasko, MD, MBA, President and Chief Executive Officer, Thomas Jefferson University and Jefferson Health, Donato J. Tramuto, President and Chief Executive Officer, Healthways, Founder, Health eVillages, Nashville, TN.  Hyatt Regency on Capitol Hill, Washington, DC.  Information and registration: www.populationhealthcolloquiumspecialedition.com/index.html 

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January 30-February 1, 2017
26th Annual National Health Benefits Conference & Expo.   Real-world education with numerous sessions focusing on case study evaluations and addressing many of today's hottest topics and issues from the latest ACA regulations to wellness program trends. To assist you in continuing your education, we are also pleased to provide CE credit for numerous designations including PHR/SPHR/GPHR, CIMA, CPA, CHES/MCHES, CEBS CPE and more! And because we understand that education goes beyond the classroom, this three-day program is designed to give attendees numerous opportunities to network with peers, speakers and exhibitors. ​Clearwater, FL.  Registration and information: https://www.hbce.com/Pages/Default.aspx  

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

March 27-29, 2017 -  A Hybrid Conference and Internet Event
17th Population Health Colloquium.  The Leading Forum on Innovations in Population Health & Care Coordination Academic Partner: Jefferson College of Population Health. Loews Philadelphia Hotel, Philadelphia, PA. Information and registration: www.populationhealthcolloquiumspecialedition.com/index.html

March 28-30, 2017
Self-Insured Health Plan Executive Forum presented by The Self-Insurance Institute of America. www.SIIA.org

May 16-18, 2017
Self-Insured Workers' Compensation Executive Forum presented by The Self-Insurance Institute of America. www.SIIA.org

October 8-10, 2017
37th Annual National Educational Conference & Expo presented by The Self-Insurance Institute of America. www.SIIA.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


  • Articles are edited for length and clarity.
  • Articles are selected based on relevance and diversity.
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  • Articles do not necessarily reflect views held by the Publisher.
  • Disclosure: Owner of MyHealthGuide also has ownership interest in CareHere, LLC® and LabInsight®
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Clevenger Ernie Clevenger
President & Publisher
MyHealthGuide, LLC
Clevenger@MyHealthGuide.com