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Payers facing the need to find innovative ways to pay for increasingly costly cell and gene therapies and track efficacyWritten By Bruce Shutan
GGame-changing cell and gene therapies have emerged as new and groundbreaking ways to treat and sometimes cure diseases that previously had no treatment. Common targets include cancer, Alzheimer’s, HIV, cardiovascular disease and arthritis.
For self-insured health plans that cover these categories, the eye-popping price they pay for making them available is expected to capture more of their attention and force the need for innovative solutions.
Since many of these therapies treat rare diseases that affect a limited number of individuals and the development of such therapies can take years, it’s not surprising that the price tag is often extremely high for manufacturers to realize a return on their investment. These treatments present enormous financial challenges for payers who also are expressing concern about unknown long-term efficacy.
Other than using traditional reinsurance vehicles, there haven’t been viable ways for self-insured health plans to absorb these costs. Better understanding the financial risks posed by these costly therapies is just the start of how actuaries will help mitigate this expense.
They also believe the risk of a public-relations nightmare may be simply too great when assessing the hypersensitive nature of certain ailments relative to the rewards that can be reaped from witnessing substantial and life-changing clinical improvement.
EYEING STICKER SHOCK
These issues are top of mind for SIIA’s leadership. Shaun Peterson, VP of stop loss for Voya Financial who’s on SIIA’s board of directors, says the Drug Pricing Task Force he chaired focused on “the process of evaluating how best to support SIIA membership as we collectively face the challenges presented by new developments and approvals in this area.” This work resulted in the release earlier this year of the SIIA Drug Pricing Best Practice Guide.
That effort also kick-started efforts to educate the marketplace about this increasingly high-profile area. Since cell therapy is more “transplant adjacent,” much of it involves bone marrow and non-solid organ transplants, while gene therapy is actually a pioneering development, explains Jay Ritchie, president and CEO of Tokio Marine HCC Stop-Loss Group who moderated a SIIA crowdsourcing event on this subject.
The first cell therapies brought to market about seven years ago raised eyebrows with price tags in the $400,000 to $500,000 range, recalls Mehb Khoja, president of Medical Risk Managers, a stop-loss consultant, underwriter and actuary and wholly-owned subsidiary of BCS Financial for which he is also chief actuary. But the bar for sticker shock was raised even higher in 2018 to 2019 when he says the first gene therapies were introduced at between $850,000 and $2.1 million with a hemophilia treatment that followed with an expected price tag of $4 to $5 million.
About 50 new gene therapies are projected to reach a market that will swell to more than $25 billion over the next few years – a frenetic pace that’s not expected to cool down, observes Michael J. Baldzicki, chief brand officer for AscellaHealth.
“We’re going to see an explosion of innovation in this area with huge price tags, ” he says. Since a single event can be financially devastating to a self-insured plan sponsor overnight, he foresees smaller employer groups attempting to manage these risks, while reinsurers struggle to even forecast for that impact. These costly therapies are very focused on rare types of cancer, including myeloma, non-Hodgkin’s lymphoma, acute leukemia, B-cell lymphoma and ovarian cancer, Baldzicki says.
“Cellular therapy is taking the way we currently treat something and making it a better treatment, so it’s just that continual focus,” he says, “whereas gene therapy truly is not treating the disease anymore; it’s solving the disease. It’s advertised to be curative. We will find out if they actually are curative over time.”
As such, they’re expected to have significant price tags.
Surya Singh, M.D., SVP, medical delivery services and chief medical officer of Emerging Therapy Solutions, reports that there’s “a very rich pipeline” of cell and gene therapies in development. Of particular note based on recent events is a ex vivo treatment platform for delivering gene therapy based on lentivirus, which is the platform for the recently approved treatment of beta thalassemia, an inherited blood disorder, and efforts to treat sickle cell disease that are expected late next year
or in early 2024. “The headline that everybody’s paying closest attention to is hemophilia, both A and B,” he adds.
In addition, Singh references the importance of an announcement in the summer of 2020 about the need for more longitudinal and follow-up data for the first hemophilia
gene therapy as “a major event for the market,” which now expects these reviews could take up to seven years.
Two treatments with the most in-market, longitudinal experience among chimeric antigen receptor T-cell treatments known as CAR T therapies are Yescarta and Kymriah. Stem cell transplants for patients with lymphomas, leukemias and multiple myeloma are considered a predecessor of those therapies.
There also are additional uses for T-cell therapies on the horizon, such as post stem cell transplant for lymphoma to treat lymphoproliferative disease.
The other costly therapies, which he says are garnering more attention because of similar sticker-shock inducing price tags in the seven-figure range, are in vivo viral vector-delivered gene therapies.
One with the longest time since launch and in-market experience is Luxturna, which is an intraocular injected treatment for patients with confirmed biallelic RPE65 mutation-associated retinal dystrophy. Another is Zolgensma, which treats spinal muscular atrophy in children who are younger than two years old.
“We know oncology is tough to manage,” he observes. “You can’t strip that away from the oncologist tied to his hospital.”
Given the propensity for sticker shock, industry observers are concerned about reinsurers punting on the cell and gene therapy category, altogether, and in the process, abdicating their role.
“I think the stop-loss and the reinsurance community will by all means exclude individuals who have the identified conditions that can be treated with gene therapy,” according to Khoja. “If a stop-loss carrier or reinsurer is looking at an opportunity today, and there’s somebody who has beta thalassemia, they’re probably going to exclude them because that person is probably a likely candidate to have the gene therapy for $2.8 million. So, they will probably laser the person.”
community, also known as seconddollar payers, ends up paying for the vast majority of the dollars spent on these therapies because most of the expenditure is above the attachment point on the reinsurance that they sell,” he notes.
Most self-funded employers have historically relied on stop-loss policies to cover cell and gene therapies that on average cost anywhere from $350,000 to more than $3 million. “Once that market creeps up, and all of a sudden you have 70 gene therapies, there is no way the hospital market can meet that demand,” Baldzicki cautions.
One way to avoid some of the pricing pitfalls
to implement innovative tools that everyone agrees upon, he says, along with the way that the data is going to be monitored at the time the contract is signed. “What happens now is that the reinsurer
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Given the inherent difficulty of managing this substantial risk, he says manufacturers and payers have come under increasing pressure to enter into value-based agreements. AscellaHealth has been examining various pilots with life-science companies, brokers and reinsurers like Marsh to determine where the market is at, as well as where it’s headed, with loan-based programs to recover or recoup costs related to the impact of cell and therapies. Another area to consider for helping manage those burgeoning costs involves international sourcing from the establishment of centers of excellence abroad, he adds.
BUILDING IN WARRANTEES
Concern about the unknown long-term efficacy of these therapies also needs to be addressed. If there are treatment failures, for example, Singh says it’s important to track when they actually occur. One suggestion is the possibility of a bifurcated system whereby higher payments would be made for successful treatments and lower amounts for cases where the treatment didn’t work as well as intended.
Ultimately, he notes that these are more targeted treatments that are being implemented along the way to adoption of personalized, precision medicine.
“When you’re for the most part treating people who either were previously unaddressed or had a very high failure rate with current therapeutic options, the ability to be able to show cost effectiveness at a higher price tag is increased,” according to Singh.
At such high prices, Khoja believes payers increasingly want reassurances that cell and gene therapies work and will continue to work into the future. “Imagine you bought a TV from Costco and it doesn’t work anymore,” he surmises. “Well, you take it back to Costco and get your money back. The self-insured employer, health plan or reinsurer – whoever’s on the hook – is going to want a mechanism to see if this stuff still works down the road. You’re buying something with the idea that you’re eliminating future expense on this issue, and if that’s not the case, then we have to revert back to the old or current forms of payment.”
Drug manufacturers are building in warranties for this very purpose as they bank on these costly treatments to cure certain serious conditions, Khoja reports. But he says it will be on the payer to essentially follow through and measure whether they work and where they don’t work, as well as paving the way for recoupment of their dollars.
Mindful of the potential for enormously improved outcomes for segments of the workforce, in some cases there could be an extraordinary return on investment in terms of employee productivity.
For example, Ritchie notes that half of people who are stricken with the sickle cell red blood cell disorder they inherit from their parents aren’t able to work full time. “This is potentially a cure for sickle cell that brings a large population of what was considered unable to work into the productivity category,” he says.
There are easily 15 to 20 gene therapies in the pre-FDA approval stage, according to Ritchie. “We’re going to start seeing gene therapies kick off in a material way in the next 12 months,” he opines, hastening to add a caveat. “The one thing I see in the industry right now is it’s still a bit of a Wild West because there are a lot of different
solutions, but there’s not been a lot of experience to figure out the best solutions.”
To offer a better sense of just how rare this treatment area is, Baldzicki notes that the criteria to be on gene and cell therapy is quite rigorous. “You can’t drink and smoke. You can’t have this. You can’t do that. It’s not a free-for-all that you can just try gene and cell therapy,” he explains. “Most physicians and patients are going to wait. There’s probably about six, eight, maybe 12 options in a therapeutical area because once you try a gene and cell therapy, you’re done. You can’t go on another one. So they’re going to make sure they try the most appropriate one.”
As an intimate observer of these claims, Baldzicki can’t help but recognize the humanity associated with such expensive, life-altering treatments. “You actually get a tear in your eye when you’re seeing babies and so forth with these staggering, debilitating, rare immune deficiency diseases, and they’re cured,” he says. “But the financial risk and wraparound of that is very impactful to an employer group. It’s exciting, but I think it’s scary at the same time that we’ve got to have an evolution to really tie in technology that will lead to revolutionize how we look at containing costs in these areas.”
Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.
SIIA’S 2022 CAPTIVE SURVEY
UNVEILS INDUSTRY BENCHMARKING DATAWritten By Laura Carabello
Based upon wide receptivity to the inaugural survey among its captive insurance industry participants, SIIA has again collected key information about the state of the industry for 2022. This year’s survey reflects the ongoing and increased advocacy activities by SIIA, guidance from its Captive Insurance Committee and emphasizes its efforts to support captive professionals with information and data sharing across the industry. New this year is a survey section specifically related to issues for captive owners.
These results were released as part of SIIA’s 2022 National Conference, and discussed in detail at a special session highlighting trends and forecasts.
Ryan Work, senior vice president, Government Relations, SIIA who oversees survey activities and accompanying analyses, says, “As a growth industry where survey respondents anticipate a positive year ahead, captives remain tasked with remaining vigilant and responsive to ongoing changes and pressures to act proactively on behalf of the industry as a whole. This Survey is a pulse for the industry, level-sets the marketplace and provides a ‘GPS’ to help SIIA members plan for the future.”
The topics presented and survey results provide readers with a general understanding of the state of the captive industry as well as valuable planning opportunities.
John R. Capasso, CPA, CGMA, PFS, president & CEO, Captive Planning Associates, LLC, says
• 36% of captives report COVIDrelated claims in the past year and opportunity to assess changes from previous year’s survey.
• Average COVID-related claim amount is down which is not surprising given the changes in infection rates.
• IRS audits are slightly lower, a thankful difference from the past although still a major concern.
• Roughly 40% of respondents have had clients settle with the IRS, a sign of the times.
The survey points to the importance of engaging competent legal counsel in all stages of captive development and administration, from regulatory compliance and coverage guidance to proper tax treatment and claims administration. Captive owners’ responses reflect this need since experience shows that failure to comply with both state and regulatory guidance, as well as the inability to understand the consequences of certain decisions, may construct new and expensive risks for owners that could weaken the efficiencies and protections that captives afford.
“One noteworthy takeaway is that a majority of respondents advise their clients to obtain an independent legal opinion signifying the increased complexity of captive structures, insurance programs, technology, laws and regulation,” says Capasso. Finally, not to be understated is the role of captive owners and operators. “This most important group is critical to the success of any captive program and the survey analyzes, among other things, motivations for setting up a captive, risk management attitude, and governance practices,” he says.
Dozens of captive managers across the industry, representing a diverse set of owners and risks, including medical stop-loss, property & casualty, and producer-owned reinsurance, responded to this year’s SIIA industry survey.
Here are some of the highlights which are more fully examined below:
• Captive formation growth significantly outpaced captive closures, with survey results showing positive signs for the industry.
• Sharp increase in the average number of captives under management and reflecting growing confidence in the captive model.
• Wide range in the total captive premium amount, raising questions as to why such disparity.
• 66.7% of respondents report having added staff in the past year–including a significant number of legal specialists – another signal that captives face an ongoing and significant legal issues.
A more in-depth summary of survey follows in several key areas:
1. Current State of the Captive Market
2. Industry trends
3. Captive Arrangement / Structures
4. COVID Impact
5. IRS Activities
1.STATE OF CAPTIVE MARKET
Prior to reviewing the results, it is helpful to understand the composition of survey respondents and some of the key characteristic differences: nearly half are Captive Managers, with the remainder split evenly between captive owners and other titles followed by a small percentage of captive attorneys.
“The role of captive owners and operators is not to be understated,” notes Capasso. “This most important group is critical to the success of any captive program and the survey analyzes, among
“SIIA’s 2022 Captive Survey & Trend Report is loaded with data and insights that benefit a variety of captive stakeholders. From a captive manager’s perspective there are topics of particular interest including new captive formations, premium volume, emerging risks, and IRS activities. Key analytics reflect trends in areas such as hiring/staffing, service providers, regulation, investments, and COVID impact.”
other things, motivations for setting up a captive, risk management attitude, and governance practices.”
While the largest number of captives managed by a single firm is 1,000, the majority of respondents manage 100 or fewer captives.
There was an incredibly wide range in reported total captive premium amounts from respondents – the lowest amount was $30,000, while the highest total was over $3,000,000,000. The ability to generate premiums may be directly tied to the captive’s track record for managing risk and success metrics related to other benchmarks, such as litigation experience, IRS audits, healthcare and claims management, marketing and overall financial performance.
She says that organizations with existing captives are using them to fund these additional risks where capacity has left the market and to create unique solutions to solve their needs and the needs of their stakeholders. “For organizations without existing captives, interest is growing as they hear more and learn about the scope of opportunities they can provide,” she explains.
What is surprising and telling is the demonstrated need for increased staffing, indicative of the workload volume, the complexity of the issues and the hardening insurance market. The need for an increased number of legal specialists is evident and may highlight the expanded number of legal issues facing the industry, as noted throughout this analysis.
One sign of the times and reflective increased business consolidation is that newly formed single-parent captives -- ones that are controlled by one parent that insures its own company along with insuring the risks of its affiliates -- were almost equal to group captives formed. The reality of this marketplace is that the majority of captive closures were in the group captives and single-parent captive space.
Leading the captive premium/unit count growth at 40.7% was medical stop-loss captives, followed closely by Property and Casualty (insurance), employee benefits and enterprise risk captives. This focus on healthcare is telling since the need for controlling medical costs is becoming a primary concern for US employers: Mercer expects medical plan costs per employee to rise 5.6 percent on average in 2023
Karin Landry, managing partner, Spring Consulting Group, says, “Captives continue to be utilized as the industry has witnessed a hard market with premiums increasing and diminishing carrier appetite. This is especially true for risks such as cyber, where premiums have seen massive increases while substantially reducing limits.”
while a Willis Towers Watson (WTW) survey of 455 U.S. employers shows that they expect healthcare costs to increase 6% next year, up from the 5% increase they are experiencing this year.
Despite the pressures of a hardening insurance market characterized by higher rates amid the continuing pandemic, increased healthcare costs and other economic factors, a decisive majority of respondents (86.7%) indicated that they are seeing opportunities that are actually driven by market conditions. In difficult markets, captives remain “bullish” as employers seek new methods for managing risk and mitigating the impacts of cyber-attacks or problematic artificial intelligence issues. This highly positive outlook transcends future opportunities for the industry with an overwhelming majority (90%) expressing optimism and confidence.
It’s no surprise that economic factors are identified as a pressing risk and likely associated with one word: inflation. Medical inflation poses a significant underlying issue, and according to CMS, US health expenditures are anticipated to grow by 5.4% annually in the upcoming years, reaching an expected USD 6.8 trillion by 2028.
Of course, this is directly related to survey respondents’ concerns about medical insurance and the significant increase in the size and frequency of catastrophic medical claims. It appears that captive owners are seriously rethinking their approach to managing employee healthcare costs, with many factors contributing to risk: removal of annual and lifetime limits in employee-sponsored group health plans through the Affordable Care Act, emergence of complicated lifesaving treatments, extended inpatient stays and skyrocketing costs for specialty drugs as well as new gene and cell therapies.
Landry maintains that insurers are in a tough spot where return on investments are less reliable, claims increase both in severity and frequency and inflation is causing public and regulatory pressure. “The P&C market in Florida is a great example of a perfect storm,” shares Landry. “Despite the lack of a significant hurricane since 2018, dozens of insurers and a few reinsurers have collapsed or left the market altogether due to a number of factors including inflation, regulatory environment, and judicial landscape, leaving the few that remain no other option but to increase premiums by double digits.”
She states that these pressures are causing insurers to increase premiums and reduce capacity, the hallmarks of a hard market. “As such, employers are turning to captives and alternative risk financing vehicles to bridge the gap and create solutions that are either unavailable or unattractive in the commercial space. Additionally, captives are increasingly being used to solve unique challenges in a more efficient manner. Whether it be introducing an innovative and alternative solution to the market or creating a program to finance a parent’s unique risk, captive interest doesn’t seem to be slowing down.”
In addition to these economic factors, it was remarkable to see the impact of cybersecurity threats and artificial intelligence (AI).
The growing prevalence of cyberattacks resonates throughout the industry as ransomware attacks against corporations were up 323% from 2019 through 2021, according to a recent Aon report. In the wake of COVID-19, more employees are working from home, rendering systems and networks more vulnerable. As a result, insurance companies are paying more claims and damages, leading to sharp increases in premium pricing and tighter underwriting.
Captives find themselves positioned as a better option for managing cyber risk, but the survey demonstrates that these risks are far more troubling in the past year as the volume of attacks has increased.
In a related area, the growth in adoption of Artificial intelligence (AI) to remain competitive, improve processes, and increase efficiency has also opened up areas of risk. Captives may encounter risks associated with trust and transparency, ethics, security, and safety, as their AI systems become more complex and cyber threats impact operations.
Evolving regulatory trends are also top of mind, with the IRS continuing to challenge captives of issues related to cryptocurrency, non-filing, syndicated conservation easement and micro-captives. It’s no wonder that captives remain vigilant in light of the June 2022 IRS News Release IR-2022-118, reiterating that it will aggressively pursue litigation to assert tax deficiencies and penalties against taxpayers who participate in what the IRS considers to be abusive microcaptive insurance arrangements.
The survey demonstrates that additional regulatory challenges remain a high priority, particularly compliance requirements related to group capital and digitization requirements heightened by the pandemic. Data security and consumer protection, climate and environmental impacts, digital assets, and the convergence of sector sales are also significant concerns.
When asked in what areas are respondents seeing an increased interest in captive use, clearly, the majority of respondents – 67.9% -- view the use of medical stop-loss as the leading interest point for increased interest. Undoubtedly, they view stop-
loss as an added layer of protection from catastrophic medical claims, enabling captive owners to enhance their flexibility, decision-making and competitive advantage while saving resources and money.
Survey results support the attitude that stop-loss reduces and stabilizes the overall cost of providing healthcare insurance to employees on a long-term basis, expanding the utility of an existing captive and bringing uncorrelated risk into the existing captive with different payout periods than the captive's existing exposures. Survey responses reflect captive confidence in the value of stop-loss to recognize and deploy surplus more efficiently, offsetting future costs and using the returns to enhance benefits or distribute as dividends.
Captives remain confident in the role of stop-loss to provide more efficient access to the reinsurance marketplace and capabilities that allow captives to better manage volatility, predictability of annual claims and experience less frequent claims.
When queried if they have noticed any trends among service providers, price inflation and staffing shortages emerged as the leading trends. Captives increasingly recognize that not all industries and jobs are impacted in the same way, with astute leaders gaining a better understanding and factoring in the impact of a recession on specific industries, customers and workforces. This includes
implications for sales, production, distribution and hiring to attract the most critical skills and jobs. Captives must balance current needs for available talent and avoid over-correcting in response to talent shortages. Many may be holding firm on salary increases and rethinking their approaches to salary negotiations.
3. CAPTIVE ARRANGEMENT / STRUCTURES
A number of respondents (89.3%) report having less than 50% of their clients insure controlled unaffiliated business, which may indicate the appetite of captives to take risk on behalf of companies that are separate and distinct (relative to ownership) from the captive's parent. Performing somewhat akin to a traditional insurer, captives can participate in third-party insurance programs that are offered to customers, vendors, or other related parties. According to IRMI, many US captive domiciles permit pure (single-parent) captives to write insurance for companies unaffiliated with the captive's parent, as long as the relationship is "controlled" as per the definitions in their captive laws.
The significant majority of respondents in the enterprise risk captive space (96.6%) report that they either always or sometimes advise their clients to obtain an independent legal opinion to support regulatory, tax, and compliance matters specific to their proposed insurance program. While the answers depended upon the types of captive structure and risk being mitigated, it is evident that outside legal opinions are highly valued and undoubtedly required in this litigious environment.
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As 831(b) captives come under increased scrutiny by the IRS, with some captives receiving warning letters from the IRS, the survey indicates that many respondents with 831(b) structures (54%) are considering converting their captive to an 831(a). This election is largely to increase the premium limit and seek a less volatile solution. Instead of exiting the captive, respondents may view converting the election from an 831(b) to an 831(a) as a simple solution that still yields the benefits of a captive model.
The survey touches upon other issues regarding captive pools, with the average percentage (60%) of captives in a pool and most reporting their loss ratio between 1125%, demonstrating solid performance. On average, only 12% of captives loan money to affiliates, although a clear majority of those report loaning 5% or less of assets. These decisions obviously require a great deal of thought and risk assessment.
Amplifying these results, Landry points to the numerous types of captives and alternative risk financing mechanisms, with no two captives alike. “One structure that has increasingly become popular is cell and group captives,” says Landry. “As the hard market applies pressure on small–midsized employers, captives offer an enticing path forward. As captives continue to grow in popularity, more and more people are discovering the potential uses and the benefits they can provide.”
For determining customer premium determinations, a significant percentage of respondents (42.5%) indicated that they rely upon actuaries compared to 22.5% of responses reporting that captive managers conduct the computations based upon formulas. The reliance upon professionals vs. simply formularies reflects the heightened complexity of these determinations accompanied by increased confidence in the expertise of actuaries.
She emphasizes that it is extremely important that employers seeking alternatives to their traditional risk management and financing practices first do their due diligence and find reliable professionals to advise and educate them on the various solutions available to them.
4. COVID IMPACT
While COVID nearly paralyzed the market with business interruptions as opposed to healthcare-related claims as reported in last year’s survey, the majority of respondents this year (51.7%) report captive utilization has increased due to the impact of COVID. While there was a wide range in responses on COVID-related claims being paid, the long tail of COVID and the persistent effects of the pandemic impacted survey results.
Based on current survey responses, the average size of the COVID-related claims is $354,667, with the largest being $1,500,000. These results can be favorably compared to last year’s survey where the average amount paid on COVID-related claims was $650,000, with the highest claim being $2 million.
Offering even broader perspectives, Landry says COVID-19 has had an immense impact on the healthcare and employee benefits spheres, adding, “A range of factors has led to both higher costs in the provision of health and benefit plans as well as an increase in claims costs.”
These factors include:
• Direct costs related to COVID-19, such as testing, vaccinations, and treatment
• Deferral of care for elective treatments which has dominoed into higher costs and difficulty in securing appointments now
• Missed preventative care and lower test numbers in areas such as labs, CT scans, and MRIs, which will make it harder to detect conditions early and could lead to increased severity and a corresponding higher cost of care down the road
• Behavioral health issues which rose to crisis levels as a result of the pandemic, impacting productivity, pharmacy costs, and increasing the likelihood of chronic disease.
She says that as a result of this difficult climate, captives have never been a more strategic or more timely risk management tool: “A captive arrangement is a strategic way for employers to benefit from selfinsurance while creating a sustainable solution to partner with commercial markets. Captives provide substantial competitive advantages over traditional self-insurance, such as reduced total cost of insurance, insulation from market fluctuations, and protection from cashflow volatility.”
5. IRS ACTIVITIES
On a very positive note, a majority (57.1%) of respondents reported that they did not have any captives undergoing IRS captive campaign audits in the enterprise risk captive space. Perhaps the increase in outside legal or other counsel has helped captives to defend or thwart IRS audits, with some respondents reporting no new captive audits in 2021. Captive managers that are under audit are primarily helping their clients fund their defense or assisting clients or advisors coordinate defense strategies. This may further support the need for additional legal counsel as reported elsewhere in this analysis, and account for the
large number (40.9%) that reported clients had settled with the IRS or the 70% that indicated that no notice of deficiency had resulted from the audit. Another positive sign is that most respondents (60.0%) report that they have not had any clients receiving no change letters from the IRS.
The average estimated cost of defending a captive came in at $284,938, with the median being $38,750. The largest reported estimated defense cost per captive was $2,000,000, however, most respondents report having less than $100,000 in average defense cost per captive. While captives reported expanded legal support, it appears that the costs may have been commensurate with time invested and positive outcomes.
Going forward, the good news is that a significant majority (81%) of respondents report that they do not have any upcoming tax trials scheduled in 2022. Although this is a promising response, the need for defense and counsel is likely to continue.
“As with most things in life, there tend to be a few bad apples, trying to take advantage of the system,” comments Landry. “As the IRS continues to crack down on those bad apples, it is important to understand that most captives and those involved with captives are there trying to legitimate business problems.”
Further, recent case laws are providing a roadmap of best practices as viewed by the courts.
Landry suggests asking these questions:
• Is there no circularity to the flow of funds?
• Did the captive charge actuariallydetermined premiums?
“These are helping the industry move forward and mature,” she continues. “For example, in the realm of compliance, it is important to focus on ensuring clients’ captives are true insurance arrangements, which means they must: involve insurable risks, shift the risk of loss to the insurer, distribute the risk among its policyholders, and qualify as insurance in the commonly accepted sense.”
Was comparable coverage in the marketplace more expensive, or even available?
“With IRS scrutiny still front and center, captive owners and risk managers need to prioritize compliance by leaning on their consultants, actuaries, and attorneys,” she concludes.
2022 SIIA CAPTIVE OWNER SURVEY RESULTS
As expected, the benefits and opportunities of forming a captive usually emanate from financial advisors such as CPAs, tax professionals and accounting firms. Respondents typically set up a single captive for their business, with the impetus tied to better risk management and structured as a shared captive, micro captive or single captives. The primary area of concern is medical/healthcare risk, which is likely related to increased concerns about the anticipated rise in healthcare costs as covered earlier.
What is surprising is that the majority of respondents (57.9%) reported that they were not able to find appropriate coverage in the commercial market, while 42.1% reported that they were able to do so but could only find coverage for some of their captive-related risk. This points to the need for more coverage options, especially with most respondents reporting that they self-insure employees’ health and other benefits. On a positive note, most captive owners say they understand their captive insurance coverage very well which means that they can better address their risk, and the majority do not struggle with risk mitigation. This also accounts for the vast majority responding that their company mas a moderate risk tolerance level, although a volatile market could test their mettle.
In an era of accountability, a significant number of respondents (47.4%) report meeting with their captive’s board of directors periodically (monthly, quarterly, semi-
annually) whether in person or via phone/web. The results of this survey may be helpful for captives to gauge their performance and report to their BODs. During these meetings, it is likely that there will be many decisions regarding the proposed changes in tax laws and how this has influenced decision-making regarding dividends.
Nearly 80% indicate that such changes have, in fact, influenced their decisions which is not startling since the stakes remain very high. Companies are continuously called upon to adjust to a new world order of technology disruption such as cybersecurity attacks, volatile political climates both domestic and abroad, supply chain issues and the enduring impacts of COVID.
Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel, and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com
EASING THE COST IMPACT OF CANCER CAREWritten By Laura Carabello
LLook around any workplace and it is likely that every employee knows someone who has been touched by cancer. Cancer rates are soaring, taking a toll on patients, survivors and their families, and impacting workforces in measurable ways such as productivity, absenteeism and presenteeism as well as the cost of health benefits.
This year, an estimated 1.9 million Americans will be diagnosed with cancer — up from 1.8 million in 2021, and the highest levels seen since 2007. The cost and financial impact to patients can be significant — as much as $21 billion a year, in both outof-pocket costs and time spent traveling to, waiting for, and receiving treatments. The lofty goals of the supercharged “Cancer Moonshot” announced recently calls for cutting the cancer death rate by at least 50% over the next 25 years, with many pinning their hopes on achieving these goals.
Looking back, however, oncology hasn’t been a top priority for benefits managers due to the complexity of care and related issues. But today, it has become a top concern. Results of a national survey of large employers reported in August 2022 show that oncology is now the biggest cost driver of employer healthcare benefits, nudging into first place ahead of musculoskeletal conditions which had previously held the lead position. Notably, 13% of those surveyed said they have seen more late-stage cancers and another 44% percent anticipate seeing an increase in the future, likely due to delays in screenings, and diagnoses because of health care closures related to the COVID-19 pandemic.
National Cancer Institute reports cancers that are diagnosed with the greatest frequency in the United States, excluding nonmelanoma skin cancers are:
• Bladder Cancer
• Breast Cancer
• Colon and Rectal Cancer
• Endometrial Cancer
• Kidney Cancer
• Lung Cancer
• Non-Hodgkin Lymphoma
• Pancreatic Cancer
• Prostate Cancer
• Thyroid Cancer
Most common type of cancer is breast cancer followed by prostate cancer and lung cancer. Because colon and rectal cancers are often referred to as "colorectal cancers," these two cancer types are combined for the list.
There appears to be consensus that over the past several decades of medical progress, few advances can match the achievements made in cancer prevention, early detection and therapeutics in the United States. Luke Burchard, MD, MMM, DABFM, FAAFP, Medical Director, Avande, LLC, points out that the cancer death rate for men and women combined fell 32% from its peak in 1991 to 2019, the most recent year for which data were available.
SOME CANCERS MAY MORE PROBLEMATIC
Andy Szczotka, PharmD, chief pharmacy officer, AscellaHealth, shares this perspective, “All cancers are medical conditions that should be taken seriously. Cancers with the lowest five-year survival rates such as pancreatic, mesothelioma, gallbladder, liver and lung, are some examples of cancers that cause some of the greatest concerns. Additionally, cancers with the highest number of deaths, such as lung, colorectal and liver, are also of concern.”
“For the three most common cancers in men (prostate, lung and colorectal) and women (breast, lung and colorectal) most, if not all, cases can be either prevented, especially lung cancer by smoking cessation or detected early, especially breast, colon, and prostate cancer,” says Dr. Burchard. “It is strongly recommended that health plans include reimbursement for proven screening strategies such as mammography (breast cancer screening), colonoscopy, fecal occult blood, and fecal molecular/DNA testing (colo-rectal cancer), Prostate Specific Antigen (PSA) testing (prostate cancer), and chest CT scanning (lung cancer), as the bare minimum coverage for their members. Unfortunately, many of these screening tests were not performed during the Covid pandemic.”
He hails the emergence of advanced therapeutics combined with molecular and genetic testing that likely will continue the trend of decreasing cancer morbidity and mortality.
“Genetic testing has moved well beyond basic testing such as the BRCA mutation,” emphasizes Dr. Burchard. After maintenance chemotherapy, breast cancer and prostate cancer are top “types” cancer by cost, according to Karin Landry, managing partner, Spring Consulting Group. She says, “Neoplasms make up approximately 13-15% of total costs and have been the top “condition” by cost for the past 3 years. But we have seen a steady increase, about 7-8%, for the past few years in the total cost of cancer.”
Some industry thought leaders advise that there are certain cancers that are more troublesome than others. Amy Tennis, vice president of Medical Management, MedWatch, advises, “Breast, lymphomas and ovarian cancers can be problematic because of their aggressive nature and progression to specialty drugs, costly medications/ therapies, and in the case of lymphomas, high-cost transplants. All metastatic disease is particularly troublesome, and we are seeing a surge in these advanced disease states.”
She says that regardless of industry, the pandemic has thrown a bright spotlight on the need for early detection of cancers. While prior to 2019, early detection was key to reduce morbidity
and the costs associated with treating cancers across the board, the delay of treatment associated with managing the pandemic has seen the incidence of cancers detected in later stages increase exponentially.
She cites these examples, according to Roundstone: Melanoma is 43x more expensive to treat at Stage IV ($42,303) than Stage 0 ($984). Breast Cancer Treatment per patient in the 12 months after diagnosis ranges from $60,637 at Stage 0 to $134,682 at Stage IV.
Dave McLean, PhD, CEO, Emerging Therapy Solutions, points to three cancers that are the most troublesome: pancreatic, glioblastoma and multiple myeloma. “This is because they are hard to treat and there are not many therapies available,” notes Dave. “Costs for these as well as other cancers have increased over the last two years as result of inflation and staffing expenditures related to COVID and new high-cost therapies.”
Concurring that cost of care is directly related to a cancer diagnosis and treatment, Tatia Sheppard, chief clinical officer, Nova Healthcare Administrators, advises, “Effective communication and patient understanding are key to improved outcomes and avoidance of unnecessary services. Patients need constant reminders and reinforcement of expected side effects of treatment vs. when they should be concerned and contact their doctor. All this is overwhelming and complex.”
“As members delayed care and treatment during the onset of the pandemic, providers are seeing a surge of patients presenting for initial treatment of cancers in later stages,” says Tennis. “Patients diagnosed prior to the pandemic are also presenting with advanced disease due to treatment delays over the last two years, which may have been avoided had treatment not been delayed or avoided due to pandemic concerns.”
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She reports that patients who are wellinformed and have a good understanding of expected side effects will also know when an unexpected complication warrants a timely call to their provider, which will help avoid exacerbation of symptoms that may lead to higher cost services.
She advises that leaders consider certain options, including the advantages of Centers of Excellence for cancer care, or direct contracts with local oncologists or providers within the plan network. “Patient Navigators can help the patient navigate the plan offerings and steer them to appropriate providers,” says Johnson.
In the years ahead, annual costs for cancer-related medical services and drugs in the U.S. are projected to reach $246B by 2030 — a 34% increase since 2015. For employers, oncology is among the top three spend categories for high-cost claimants, and while oncology accounts for only 1% of claims volumes, it comprises 15% of overall employer health care expenditures.
Cancer is a complex disease and challenge individuals and families to identify highquality providers, manage care coordination and make multiple decisions regarding care and treatment. Employees often rely upon employers and their benefits professionals to assist at all levels.
Additionally, Allison R. Johnson, president, Benefit Dynamics Company, cautions that health plans need to make sure they have a strong case management vendor in place that understands cancer protocols and standards of care. “We increasingly are seeing oncology treatment using chemotherapy drugs offlabel,” says Johnson. “This can be prescribing drugs not approved for the specific diagnosis, or in dosages which are not proven effective.”
Source: Cancer Workplace https://nebgh.org/wp-content/uploads/2015/10/CancerWorkplace_FINAL.pdf
Anthony Masotto, executive vice president of Drexi, says, “All cancers are troublesome and some have a much lower survival rate. I think early detection is critical not only in increasing survival rate but also decreasing the cost. We have seen a huge uptick in late-stage cancer for a variety of reasons. but I think most could be attributed to the lack of screenings over the past few years due to COVID.”
Dr. Burchard raises a red flag about the costs of these ‘medical marvels,’ adding, “While it’s not possible to quantify the value of prolonged human life, the financial costs can be calculated and mitigated. New cancer therapeutics are costing over $100,000 per year per patient, and unfortunately, some institutions
are maximizing their profits at the expense of health plans and our patients.”
In his experience, the Company has identified two major health care systems in Indiana and Ohio that are charging up to 17 times their acquisition cost for certain chemo-therapeutic drugs, even though the nationwide average for price mark-up of such drugs ranges from 120% to 630%.
“Moreover, many hospitals can participate in the Federal 304b Drug Pricing Program that can save them an additional 20% of their usual acquisition cost for these medications,” he observes.
STRATEGIES TO LOWER THE COST OF CARE
Adhering to evidence-based guidelines in cancer care can lead to notable cost reductions, concluded researchers who studied the relationship between total cost of care and the use of National Comprehensive Cancer Network (NCCN) guidelines to direct care. They found savings among both breast cancer and colon cancer patients and found that using NCCN Guidelines® drove significant declines in total cost of care. NCCN Guidelines® are comprised of recommendations for the prevention, diagnosis, and management of malignancies across the continuum of care. The NCCN Guidelines® currently apply to more than 97% of cancers affecting patients in the United States.
Looking ahead, Szczotka stresses that patient-centered care should be the focus for comprehensive cancer care and will lead to opportunities for coordinated programs that enhance patient outcomes and reduce overall health care expenditures. He points to some specific strategies for lowering the cost of care, including: “Application of Utilization Management programs such prior authorization, step care therapy, quantity limits and partial fill programs will have meaningful results,” says Szczotka. “We also foresee greater use of Benefit Maximum and Deductible programs and application of Rebate Management programs.”
He points to the growing importance of Specialty Pharmacy Networks which have specialty drugs dispensed and coordinated through identified specialty pharmacies to assist with enhanced pricing, minimizing waste by preventing excess drug accumulation, potential inappropriate dose escalation and ensuring appropriate dosing based on patient and drug specific parameters.
Szczotka also explains the increased utilization of copay assistance programs which improve the ability of the payer to make high-cost specialty and rare disease agents more affordable through their health benefits. He continues, “Alternative Funding Programs also provide means of access to philanthropic organizations, grants or other foundational programs that support access to high-cost therapies and shift the cost away from the patient and payer.”
Landry cites Rx management as fundamental to controlling costs and recommends these strategies:
• Formulary Evaluation, Valued- based Limits, Clinical Outcome Payment
• Medical Necessity and Prior Authorization
• Co-Pay Accumulators
• Discount Application Providers
• Investing in Preventive Care and Wellness
• Demand Price Transparency
• Retail and Medical Pharmacy Strategy
• Factor in Indirect Costs
• Consider New Entrants
Looking ahead, next generation strategies are likely to include specialty carve outs that move specialty drugs away from traditional prescription drug management to a PBA or specialty administrator. These arrangements provide cost savings, remove any incentives to dispense product and present opportunities for management and control of the utilization management programs that align with payer expectations.
tracking, pointing to the need to modify or discontinue therapy.”
One area that is drawing significant concern is the identification of alternative Site of Care (SOC) Programs since lower cost sites of care can provide cost savings to the patient and payer. “Alternative sites may also be more convenient for patient and caregivers/ support team members,” says Szczotka.
Landry concurs, stressing that drugs that are dispensed in a hospital setting could potentially be moved to an office visit or even home-based treatment.
“Often changing the site of care can be more convenient to the patient as well,” she explains. “Carving out medical prescriptions is possible but can be disruptive for patients and therefore, is not typically desirable. The focus should be on net average cost vs. other medical alternatives for the clinical requirement of the individual. Savings projections also need to consider rebates and other fees or performance guarantees.
Masotto expands on this point emphasizing, “Cost will continue to rise if we don’t change how and where we get treatment. The number one money maker for hospitals is drugs to treat cancer patients and we see it every day and we need to carve out drugs from the hospital setting. If the diagnose is correct, then how and where they get their treatment should have the same outcome.”
“Such programs also improve patient care coordination activities, with expanded opportunities to identify high-cost patients, predictively model potential high-cost patients and identify drivers of cost,” says Szczotka. “This approach serves to educate patients and provide opportunity to enhance patient adherence to therapy, identify non-adherence and proactively monitor patient adverse events. Programs can identify and mitigate barriers for continued patient compliance and symptom
He offers these examples: Patient #1: Diagnosis is Stage IV lung cancer and patient is put on six infusions of Optivo. The hospital charged the plan $53,614.56 per infusion, bringing the total to $321,687.36 which is 400% of the Medicare allowable rate. By carving out this drug to be filled through the PBM
would bring the cost down to $87,448.02.
Patient #2: Patient was prescribed Soliris (Eculizumab; generic name) a prescription medicine used to treat the symptoms of Paroxysmal Nocturnal Hemoglobinuria, Hemolytic Uremic Syndrome, Myasthenia Gravis, and Neuromyelitis Optica Spectrum Disorder. Approximate cost of a 20ml vial $8,000 which would give the patient four treatments. Another hospital practice is to break up the vial into four separate 5ml vials, repackage it and charge $10,000 per treatment. The group would be billed over $450K for the 12 month treatment. Again, using the PBM to the group’s advantage, this treatment would cost less than 100K sourcing the drugs through the PBM.
Masotto underscores the importance of getting a second opinion since too often, the diagnosis is incorrect, adding, “Make sure the plan is set up to not allow for the egregious practice by the hospital systems to take advantage of not only sick patients but also everyone within the plan. These behaviors have adverse effects on the medical cost, the stop loss cost and
Tennis asserts that early detection through screening programs and aggressive Case Management with member participation is key. “Treatment in early stages provides better outcomes for the member and allows cost containment measures to be deployed early in the treatment regimen. Working with a Case Manager early in treatment allows network steerage, referrals to Centers of Excellence, and monitoring of the treatment program to ensure adherence to guidelines and standards of care, while also supporting the member and identification of costly gaps in care.”
She also stresses the role of stop-loss or reinsurance which looks for tight management of plan dollars in ensuring treatment guidelines and standards of care are followed to ensure seamless reimbursement of paid claims.
“MedWatch is instrumental in managing care to meet these requirements, and documenting adherence so that there are no questions regarding reinsurance coverage reimbursement or renewal issues,” she notes. “Reinsurance also wants to be informed of the case and on-going activity on an on-going basis on a case as soon as it is identified and throughout the case.”
the Rx cost, with all costs eventually passed on to plan members at no fault of their own.”
Dr. Burchard expands upon these perspectives, citing the No Surprises Act (NSA) which was designed to force hospitals to publish their prices for chemo-therapy drugs, adding, “Unfortunately few have complied thus far. It is apparent that many factors will continue to provide cost containment challenges for self-insured employer groups and stop loss carriers. However, with aggressive prior-authorization protocols and relentless early detection and prevention strategies, it is still possible to provide the highest quality of cancer care and still contain the costs.
McLean echoes these perspectives, stressing the critical importance of early identification as a key driver of cost mitigation. He also recommends the use of genetic testing to better stage and treat cancers as a pathway to ensure that patients are getting to the right center for care with the right clinical protocols – NCCN or NCI as cited earlier. He also notes the importance of stop loss insurance for risk protection and expertise around cost containment and quality programs.
Underscoring the role of stop-loss insurance, Landry asserts that many of self-insured programs are looking at putting medical stop-loss into a captive, with a Spring survey reporting that although less than 50% of self-insured programs have stop-loss coverage, 42% of those that do have it within a captive.
“The largest concern when considering a self-funded program relates to the risk of the program being impacted by unexpectedly high claims – be it due to the volume of claims or due to the exposure to a handful of large loss claims,” says Landry. “One very sick individual or a series of unanticipated smaller claims could lead to a higher-
than-expected claims level in a self-insured plan. Stop-loss insurance minimizes or eliminates this risk as well as dramatic fluctuations in claim costs over time, creating a level of predictability.”
Increases in late-stage cancer diagnoses since COVID have driven a higher priority on reducing the costs of cancer care, advises Rob Gelb, CEO of Valenz® Health.
FOCUS ON GENE AND CELL THERAPIES
Gene therapies are not simply another new class of specialty drugs to treat symptoms of a given disease -- they aim to cure by correcting the underlying genetic abnormalities causing the disease. With more than 900 investigational new drug (IND) applications for ongoing clinical studies of gene therapy products underway, and the FDA predicting they will be approving 10-20 gene therapies per year, the availability of these groundbreaking drugs is becoming an emerging driver of change in specialty pharmacy benefit management. But the significant benefits of gene therapies will not be realized unless patients have access to them, and the accompanying high price tags may be a significant deterrent for both employers and patients.
From Amy Tennis’ viewpoint, “Gene therapies are emerging treatments that show promise, and each will be more expensive than the one prior as they are proven effective. Funding these therapies will be a challenge for employers and stop-loss carriers going forward.”
While some therapies have shown positive results, she says more studies are needed. A cost vs. benefit analysis should be considered, as many are prohibitively priced with negligible benefit in outcomes.
“In 2022, we released enhanced care navigation with our Care Value Optimizer, matching members to solutions that offer greater predictability and control over these escalating costs,” says Gelb. “Our 501(r) network matches members living at or below 400% of the Federal Poverty Level with nonprofit hospitals that provide low- to no-cost cancer care; and we work with specialized Centers of Excellence to offer high-quality, pre-negotiated care at significant savings. These solutions benefit both the member and employer.”
WHAT IS GENE THERAPY?
Gene therapy is a type of highly targeted treatment that uses genetic material with the goal of changing the course of a disease. Most often, gene therapy works by introducing a healthy copy of a defective gene into the patient's cells. The idea is to modify the genetic information of the cell responsible for a disease, and then return that cell to normal conditions.
Source: The National Human Genome Research Institute, https://www.genome.gov/genetics-glossary/Gene-Therapy
Masotto would like to believe that technology will be able to cure a disease, "…but at what cost? Cancer treatment, mainly drug therapy, is big business for not only pharma but also for hospitals and health systems and unfortunately even things like gene therapies only work on certain people with specific DNA markers. Gene therapies are extremely expensive and have a low success rate because of all the things that have to be taken into account.”
The market entry of genetic therapies that represent new and potentially life-altering options for the people who use them represents steep costs as multi-million-dollar drugs have arrived. In fact, a new record was set recently when the FDA approved Zynteglo, a gene therapy for beta-thalassemia, a rare disorder requiring regular blood transfusions that carries a record $2.8 million price tag and making it the most expensive drug on a single-use basis in the U.S. and among the highest globally. Others such as Zolgensma which treats spinal muscular atrophy (SMA) cost $2.1 million for a one-dose treatment and Luxturna for genetic blindness runs $850,000. Szczotka points to the promising early data on the currently available gene therapies but says they have not yet fully demonstrated clinical cure for these patients.
“For example, the initial remission rate among patients treated with Kymriah ® was about 85 percent with more than half the patients did not show relapses after a year,” notes Szczotka who explains that Kymriah® is used to treat adults with certain types of B-cell non-Hodgkin lymphoma and people up to 25 years old with certain types of B-cell acute lymphoblastic leukemia. “Studies are planned to track outcomes of patients who received the therapy for 15 years to better understand and quantify the long-term effectiveness. Provenge®, used for prostate cancer in a 2020 retrospective study of 6,000 men, extended survival by nearly 15 months over traditional oral hormone therapy. While not providing a cure, these examples show improvements in the patient’s disease progression and may be an important addition to the treatment arsenal for appropriate patients.”
He further explains that while demonstrating improvements in their respective limited clinical studies, the gene therapy products come with unprecedented costs.
“True value demonstration will be needed to help provide a value determination for these products,” he continues. “Independent evaluations of gene therapy products from organizations such as ISPOR, the leading professional society for health economics and outcomes research globally and the
Nobody delivers like we do.
National Institute for Health and Care Excellence (NICE) will be needed to assist with value determination and reimbursement from various governmental sponsored programs and payers.”
He suggests that one mechanism for paying for these therapies is a Loan Based Assistance Program which converts the high upfront cost into a pay-over-time loan in small, predictable payments.
“These programs are also beneficial in that the sponsoring companies help protect the plan sponsor from therapeutic failures by use of drug product warranty and/or value-based agreements to have objective metrics in place to assist with the quantification of gene therapy success with the respective pharmaceutical manufacturer,” explains Szczotka. “This helps minimize the risk and cost to the payer for a treatment failure.”
McLean asserts that although the upfront cost of cell therapies is significant, as therapies become available earlier in the clinical pathway, this will become a more cost-effective option with better outcomes.
“For instance, a very hard cancer to treat is multiple myeloma,” he explains. “At this time, they are a fifth line of treatment, so risk-takers have paid hundreds of thousands of dollars to treat the member by the time they qualify for CAR-T. Once they receive the CAR-T they have much higher chance of having a positive outcome, so moving this up in line will save the cost of other chemotherapies as well as potentially bone marrow transplant.”
Landry predicts that gene therapies will grow exponentially over the coming five years and will become a major spend item for insurers and self-insured employers.
She also says that while gene therapies are already expensive, “The Food and Drug Administration (FDA) is expected to approve 50 to 100 gene and cell therapies by 2025, by which costs could exceed $13 billion. In addition, as gene therapies migrate from treating rare to common conditions, demand, usage and expected coverage will grow considerably. Gene therapies are an example of when an additional discount negotiation or pooling may make sense.”
A FINAL WORD: GENOMIC TESTING
The scope of advanced genomic testing, which is designed to help identify the DNA alterations that may be attributing to the growth of a certain tumors, is expanding. Sheppard believes that precision cancer care is evolving rapidly, and advanced genomic testing is not necessary for every patient, explaining, “However, in certain situations, having more specific information about genomic mutations that are unique to an individual’s cancer can be beneficial in helping providers develop a more targeted treatment to address the identified mutations.”
By looking at the tumor’s profile with genomic testing, physicians may be able to recommend a drug or protocol not previously considered, allowing them to offer more precise therapy, which improves patient outcomes and eliminates waste.
Sheppard continues, “There is more evidence of the benefits to identify better ways to detect, treat, and prevent cancer in people who carry genetic variants that increase the risk of certain cancers. Ongoing research and advances continue at a rapid rate
“At a basic level, gene therapy uses sections of DNA to introduce genetic material into cells to treat or prevent disease,” she explains. “The genetic material contains a functioning gene which corrects the effect of the diseasecausing mutation. Due to the targeted nature, gene therapy offers great promise for treatment of diseases from Alzheimer’s to Parkinson’s, but the cost to the healthcare system may not be sustainable.”
and there are improvements in accuracy and consistency of classifying the genetics that can help inform a more targeted approach to treatment.”
In some situations, Sheppard says this can attribute to cost savings and improved outcomes avoiding the “trial and error” approach, as a more refined treatment regimen can be administered. She points out that the testing cost does vary, and they can be costly. However, the cost associated with testing that can refine treatment approach is worth the investment.
“Additionally, there are misconceptions about genetic testing, lack of knowledge and understanding regarding the benefits of some testing – some of which include that results are not useful in making healthcare decisions and will not provide useful information about complex diseases,” concludes Sheppard. “Some believe testing is for understanding of ancestry only.”
Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel, and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com
https://www.google.com/search?q=National+Comprehensive+Cancer+Network+(NCCN)+guidelines+to+direct+care.&rlz=1C1CHBF_en US850US850&oq=National+Comprehensive+Cancer+Network+(NCCN)+guidelines+to+direct+care.&aqs=chrome..69i57.5674j0j4&sou rceid=chrome&ie=UTF-8#:~:text=The%20NCCN%20Clinical,of%20Guidelines%20%2D%20NCCN
2022 Cancer Facts and Figures, American Cancer Society
JAMA Oncology 2022;8(6):835-844 Published Online April 21, 2022.
JAMA Oncology 2022;8(6):871-878 Published Online April 14, 2022.
JAMA Internal Medicine 2022;182(6):603-611 Published Online April 18, 2022.
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2022 NOVEMBER MEMBER NEWS
SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/ captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to firstname.lastname@example.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org.
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TOKIO MARINE HCC - STOP LOSS GROUP IS PLEASED TO ANNOUNCE BEATA MADEY AND THE CREATION OF CHIEF EXPERIENCE OFFICER (CXO)
Beata Madey has been appointed to the newly created role of Chief Experience Officer for TMHCC. In this new role, Beata will be responsible for strategic and operational direction across key outward facing operating areas within the company.
The goal of this role is to examine and review how and when we communicate with Producers, Policyholders, TPAs and other organizations to create business processing speed and excellence.
At TMHCC, our goal is to create a platform, process and consumer centric approach to being the industryleading stop loss provider. Our ability to connect and communicate with multiple interested parties in a fast and efficient manner will drive our future.
Jay Ritchie, President and CEO, states, “I am excited about this position and how we will drive our Company into the future by creating more efficient methods to exchange data and to promote Client & Producer interaction on a scale not previously seen. This role is critical to enhance our ability to deliver stop loss products more cost effectively and with improved accuracy, in order to create an environment where assets can be used to mitigate and manage catastrophic claims rather than pumping resources into dated process management approaches.”
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VĀLENZ® ACQUIRES FOURTH COMPANY: HEALTH COST CONTROL ENHANCES MEDICAL COST SAVINGS SOLUTIONS FOR EMPLOYERS
PHOENIX, AZ —Vālenz® announced it has acquired Health Cost Control Inc., a national provider of medical cost containment solutions with more than 25 years’ experience.
With specialization in claim and cost review services for high-dollar claims, including dialysis, air ambulance and behavioral health billing, Health Cost Control offers custom-designed programs for health plans, third-party administrators, insurance companies and employers.
The fourth company acquired by Valenz since May 2022, Health Cost Control ensures provider adherence to the national guidelines that govern inpatient and outpatient
Protecting plans and patients across the U.S.
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billing, identifying significant savings from inaccurate billing and incomplete documentation.
Health Cost Control registered nurses conduct thorough claim reviews for duplication, unbundling, data entry errors and other discrepancies that often go unnoticed and result in higher costs for employer groups.
With deep experience covering most clinical settings and understanding related operational costs, Health Cost Control also has expertise in repricing claims to usual, customary and reasonable levels, often garnering 70%+ savings off billed charges.
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“We are very excited to welcome Health Cost Control, their clients and their members to the Valenz family,” said Rob Gelb, Chief Executive Officer of Valenz. “In exploring new opportunities to deliver on our core promise to drive smarter, better, faster healthcare, it was clear that the company is an outstanding fit for Valenz. We have partnered with Health Cost Control
since 2021 and know we can seamlessly integrate their offerings into our claim management solutions, providing the transparency necessary to lower total health plan spend, improve claim outcomes, and enhance the member experience.”
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The Health Cost Control acquisition further fortifies the Valenz Healthcare Ecosystem Optimization Platform, a fully integrated suite of solutions that simplifies the complexities of selfinsurance.
To balance the relationship between healthcare quality, advocacy and cost, Valenz aligns the member, provider, health plan and payer, supported by a steadfast commitment to data transparency and decision enablement.
Ultimately, Valenz drives value across clinical and member advocacy, network development, and the validation, integrity and accuracy of claims.
“Our two companies are truly aligned in our cost containment approach and our dedication to innovation, advocacy and quality,” said Carl Papp, CLU, Principal and President of Health Cost Control. “As we continue to serve our clients with customized, flexible programs for reducing healthcare costs, we look forward to becoming an integral part of the Valenz ecosystem.”
About Valenz Valenz® simplifies the complexities of self-insurance by offering an end-to-end Healthcare Ecosystem Optimization Platform that manages the cost and quality of care for employers and their members. To balance the relationship between healthcare quality, advocacy and cost, the Valenz enterprise-level solution suite aligns the member, provider, health plan and payer.
Supported by a dynamic, innovationfirst culture and a steadfast commitment to data transparency and decision enablement, Valenz leverages its technology infrastructure and enterprise data warehouse to drive value across
clinical and member advocacy, network development, and the validation, integrity and accuracy (VIA) of claims. Learn more about how Valenz engages early and often for smarter, better, faster healthcare. Valenz is backed by Great Point Partners.
About Health Cost Control
Health Cost Control, based in Texas City, TX, is a leading national provider of cost containment solutions with over 25 years’ experience. The company was founded with the mission that still holds true today: to reduce healthcare costs for clients and ensure that the national billing guidelines that govern inpatient and outpatient billing are adhered to by providers. With specialization in group health claim review, and drawing from a large range of services, Health Cost Control creates a program tailored to fit your needs and deliver optimum results for lower healthcare costs. Visit www.healthcostcontrol.com
STRATEGIC LEADER, CORTE IAROSSI, NAMED DIRECTOR OF STRATEGY AND VENDOR INITIATIVES AT HPI
Westborough, MA – HPI has tapped Corte Iarossi as their new director of strategy and vendor initiatives. Corte will join the business development team to fortify vendor relationships and point solutions in support of our clients and members.
He brings over 20 years of success building and leading account management and sales teams, vendor management, product development, and strategic planning.
“We’re thrilled to welcome Corte to the HPI team,” said Paul Forte, senior vice president of strategic development at HPI. “His approach and experience with vendor management solutions will help us elevate our client support and develop new partnerships that will bring our point solutions to the next level.”
Iarossi most recently served as director of PPO & vendor relations at Maestro Health, Inc., for which his responsibilities included contracting, implementation, and management of client facing PPOs and vendors. Previously, he worked as EVP, client relations for S & S Healthcare.
About HPI Health Plans, Inc. (HPI) redefines what is possible with self-funded health plans. As a leading national third-party administrator, they partner with health plan brokers and employers to provide innovative self-funding strategies and customized plans tailored to each client’s needs and population. HPI’s solutions give employers greater cost transparency and control, while elevating the member experience. It is their flexible approach, entrepreneurial spirit and commitment to quality, technology, and service that enable them to deliver premium value to their customers. Contact Su Doyle, VP of Strategic Marketing, at sdoyle@ healthplansinc.com and visit www.hpiTPA.com
dollar protection to the employer. The Gene Therapy Solution provides coverage for three Food and Drug Administration (FDA) approved treatments:
• Luxturna treatment for hereditary blindness up to $850,000
• Zolgensma treatment for spinal muscular atrophy (SMA) $2,200,000
• Spinraza treatment for spinal muscular atrophy (SMA) up to $2,200,000
Luxturna is a curative treatment for a rare form of inherited vision loss. Zolgensma is a curative treatment for children under two years of age for SMA conditions that were previously fatal. Spinraza is proven to significantly slow the progression of spinal muscular atrophy in pre-symptomatic infants.
CHARLOTTE, NC – Amwins Group Benefits released its new Gene Therapy Solutions program exclusively available through Stealth Partner Group, an Amwins company.
This new solution when coupled with stop-loss coverage, provides a sustainable, revolutionary strategy that prepares employers to face unexpected, high-dollar gene therapy claims with confidence.
“Our goal is to help employer groups navigate the future of gene therapy while providing unrivaled knowledge and expertise to help mitigate their financial risk,” said Harley Barnes, Jr., co-chief executive officer at Stealth Partner Group. “We’re launching the Gene Therapy Solutions program to empower employers as they implement smart, practical and complete risk management programs and strategies for their employees.”
Amwins Gene Therapy Solution offers unique program advantages like easy billing, seamless contract management, portability between carriers, and meaningful first-
“Developments in gene and cell therapies have the potential to provide life-changing treatments, but also present significant financial risk to selffunded plan sponsors,” said Josh McGee, vice president Amwins Accident & Health Underwriters, who is responsible for proprietary program development for Stealth Partner Group. “Our mission is to support our retail partners by providing meaningful solutions that protect employers as they face the ever-evolving and complex gene therapy landscape.”
According to the FDA, there are 22 cellular and gene therapies in the market today of which include 18 cellular treatments and four gene therapy treatments ranging in price from $500,000 to $3,000,000 and seven
“I am very excited to join the HPI team,” said Iarossi. “In my time in the industry, I knew of HPI and their reputation as an innovator and customer-focused organization. I’m looking forward to contributing to HPI’s continued success and the success of their clients.”
AMWINS GROUP BENEFITS LAUNCHES GENE THERAPY SOLUTIONS PROGRAM EXCLUSIVELY AVAILABLE THROUGH STEALTH PARTNER GROUP
expected to rise beyond $3,000,000 within the next 12-18 months. Amwins anticipates adding
Costs for these
for additional treatments as they are approved and available in the market.
About Amwins Group, Inc.
Amwins is the largest independent wholesale distributor of specialty insurance
to negotiate, implement, and assist in managing medical stop-loss and ancillary benefits with the nation's toptier carriers. With 15 offices across the U.S., Stealth offers its clients more than 150 years of collective experience in the stop-loss and ancillary insurance marketplace. Visit www.stealthpartnergroup.com
by providing property and casualty products, specialty group
in the U.S., dedicated to serving retail
products, and administrative services. Based in Charlotte, NC, the company operates more than 155 offices globally and handles premium placements in excess of $26.4 billion annually. Visit www.amwins.com
About Stealth Partner Group
Stealth Partner Group, an Amwins Company, was founded in 2009 and has grown to be one of the largest specialized general agencies in the country. The firm partners with brokers, consultants, and third-party administrators (TPAs)
BERKLEY ACCIDENT AND HEALTH RELEASES 2022 HEALTH CARE PRESSURES FACING U.S. EMPLOYEES
Hamilton Square, NJ – U.S. employees are feeling the pressure of health care costs, with 8 in 10 concerned about the cost of care and more than half reporting that they have skipped medical tests, office visits, or prescriptions.
- CFO, Commercial Construction Company
“Our clients have grown accustomed to Berkley’s high level of customer service.”
“The most significant advancement regarding true cost containment we’ve seen in years.”
- President, Group Captive Member Company
“EmCap has allowed us to take far more control of our health insurance costs than can be done in the fully insured market.”
- President, Group Captive Member Company
“With EmCap, our company has been able to control pricing volatility that we would have faced with traditional Stop Loss.”
- HR Executive, Group Captive Member Company
“You have become a key partner in our company’s attempt to fix what’s broken in our healthcare system.”
These findings come from the 2022 Health Care Pressures Facing U.S. Employees report, released by Berkley Accident and Health, a Berkley Company.
“Cost-sharing is a major problem for U.S. employees, who are struggling with increased out-of-pocket costs due to high deductibles and coinsurance,” said Brad N. Nieland, President and CEO of Berkley Accident and Health. “These costs can place the largest burden on those who are least able to pay, forcing patients to skip care, self-pay, and take on medical debt.”
Key findings of the survey:
• Despite having health insurance, respondents worry about their ability to pay for care, with 84 percent concerned about affordability.
• 61 percent admit to skipping a medical test, visit, or prescription due to cost. 56 percent have paid cash because it was cheaper than using their insurance.
• 38 percent report having medical debt, with the majority owing between $1,000 and $10,000. The top reason cited for medical debt was an unmet deductible or coinsurance.
• Most respondents find health costs and billing hard to decipher. 69 percent have received a medical bill they did not expect – typically between $500 and $3,000. Others found it hard to get a price estimate before scheduling a medical service or filling a prescription.
• Review cost-sharing arrangements, in light of average employee income levels and other factors
• Consider a self-funded health plan or a group captive program (for small to midsize employers), which both offer significant economic and strategic advantages
• Help address the complexity of care by offering price transparency tools and patient navigation services
“The goal of this report is to spark dialogue between employers and their benefit brokers. We hope it encourages employers to consider innovative solutions that can move the needle on costs and ease of use,” concluded Nieland.
“With these findings in mind, employers and benefit professionals should consider how they can make health care more affordable, easier, and more transparent for employees and their families,” explained Nieland.
Employee insights such as these can be key tools for shaping a company’s approach to health care. Health benefits, which provide a competitive advantage when hiring, should be an integral part of any long-term recruiting and retention strategy.
In addition to insurance protection, Berkley Accident and Health also provides insights and advice for companies wanting to better support their workers. The report offered several strategies for addressing employees’ costs and concerns:
The findings come from a survey commissioned in March 2022 of 1,000 U.S. adults age 18 and older with employer-based health coverage, balanced across age, gender, U.S. region, and employer size. Respondents received medical coverage either as an employee or a covered dependent.
About Berkley Accident and Health
Berkley Accident and Health is a member of W.R. Berkley Corporation, a Fortune 500 company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captive, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty
Accident. The company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. For more information, please visit www.BerkleyAH.com
TRUESCRIPTS MANAGEMENT SERVICES ANNOUNCES REX WILCOX AS NATIONAL DIRECTOR OF BUSINESS DEVELOPMENT
TrueScripts Management Services is pleased to announce and welcome Rex Wilcox as National Director of Business Development.
Rex has spent over 16 years in the employer benefits space, focused on corporate wellness, employee benefits strategy, and, most recently, Pharmacy Benefits Management. Prior to this stint of his professional career, Rex studied at California State University, Fresno, where he received a MA in Kinesiology, Exercise Science and a BS in Sports Medicine.
His education and training in Sports Medicine and Exercise Science have provided him with opportunities to work in professional baseball and football as a Certified Athletic Trainer, Strength & Conditioning Coach, and Medical Coordinator.
As a former catcher in baseball, Rex has a continued passion for the sport and now uses his education and training to coach others. In 2018, he formed the Colorado Catchers, a training program that is focused on providing coaching in the fundamentals of catching for youth baseball players.
In his most recent professional endeavors, Rex has supported health benefits providers in delivering value to employees and plan sponsors. Rex's broad range of experience and talents – inside and outside the health benefits realm - will provide practical advantages to his new position at TrueScripts.
The benefits landscape is broad and complex.
Skyrocketing prices. Administrative challenges. Shock claims. Aging workforces. At Amwins Group Benefits, we’re here to answer the call. We provide solutions to help your clients manage costs and take care of their people. So whether you need a partner for the day-to-day or a problem solver for the complex, our goal is simple: whenever you think of group benefits, you think of us.
Bring on the future – we’ll cover it.
"In looking to expand our Business Development team, Rex's industry acumen and personal character were a great fit for TrueScripts. He is known and respected by many colleagues in our space, so the decision to bring him on board was an easy one," said VP of Sales & Marketing, Dave Parker. “We look forward to the seamless progression of adding Rex to our team.”
SERVICES ANNOUNCES CURT SCHAEFER AS DIRECTOR OF BUSINESS DEVELOPMENT
TrueScripts Management Services is pleased to announce and welcome Curt Schaefer as Director of Business Development, serving Texas, Oklahoma, and Louisiana.
Curt’s professional background provides more than 25 years of customer facing experience, with ventures ranging from Sales Associate to Business Manager to Business Owner.
The past eight years of his work have supported brokers and consultants in serving their clients through various means. Above all, though, Curt has remained focused on team building and maximizing each team member’s potential in each of his professional roles.
With an educational background in Business Marketing, Curt has supported sales and marketing teams in many capacities, including his time with Harley Davidson and, most recently, as Regional Sales Director, Strategic Partnerships for ReviveRx.
A Harley owner himself, Curt enjoys riding his motorcycle and sharing in other outdoor activities, such as biking and
golfing. He is a lifelong advocate for animal rights and volunteers as much time as possible to local charities.
“Curt’s sales and marketing ingenuity, people-first mentality, and servant heart will be valuable assets to the TrueScripts team,” says VP of Sales & Marketing, Dave Parker. “We are excited to expand our Business Development efforts into the Texas region and know that Curt will provide a great deal of support to our existing and prospective partners.”
About TrueScripts Management Services
TrueScripts Management Services is a pharmacist-founded, fully transparent PBM that has been revolutionizing the pharmacy benefit management industry since 2014. Our mission is to build lasting relationships by providing prescription benefit management expertise at a personal and customized level to ensure optimum value at the lowest possible cost. The people we serve can rest assured in our commitment to lowering prescription drug spend, achieving clinically effective solutions, and always delivering Amazing Care. Visit www.truescripts.com
JEFFREY GILCREAST JOINS PARTNERRE’S EMPLOYER STOP LOSS TEAM AS AVP, REGIONAL SALES MANAGER
PartnerRe is pleased to announce that Jeffrey Gilcreast joins the Employer Stop Loss team as AVP, Regional Sales Manager, Employer Programs.
An experienced consultant and client manager in the employee benefits industry, Jeffrey will be responsible for growing PartnerRe’s US Health book and building and managing ESL producer relationships across the East territory, further enhancing PartnerRe’s profile and footprint. Prior to joining PartnerRe, Jeffrey held a consulting role with Brown & Brown Insurance.
At PartnerRe, we are a community of curious, intelligent industry experts, united by a drive to outperform. As an international reinsurer with over $8 billion in total capital, we are a market leader with a reputation of financial stability and strength, and a commitment to rebuilding businesses and communities after risk events around the world. Contact Natalia Vayner-Heyraud, Head of Content & Channel Marketing, at firstname.lastname@example.org and visit www.partnerre.com
SPECIALTY CARE MANAGEMENT ANNOUNCES NEW SENIOR VICE PRESIDENT OF SALES IN WILL RUMSEY
Will Rumsey has been hired as the new Senior Vice President of Sales at Specialty Care Management. In this role, Will will build and develop the national sales organization.
Will is an experienced and successful sales management professional with 5+ years of sales leadership experience. In his previous role as SVP of Sales for First Stop
The right solution
Self-funded health plan administration
The speed of change in the health care industry is expanding the definition of health care and redefining roles for traditional players. New and emerging technologies led by single point solution vendors, rising health care costs, regulation, and non-traditional market entrants have many payers and health systems evaluating their options.
At AmeriHealth Administrators, we have a proven history of working with employer and payer clients to address their challenges and have the vision, technology, and people to meet the needs of our customers and partners.
us build the right solution for
and his team
well-rounded, motivated leader
growth of outside and inside teams.
About Specialty Care Management
100 to 20,000 employees.
Taking a new approach to managing catastrophic claims,
provides the marketplace a unique opportunity to take control of their plan’s risk by normalizing costs
making them predictable. With exclusive dialysis programs featuring flat case rates, no set-up fees, and a full administrative carve-out, SCM doubles your savings compared to typical network discounts without any of the hidden fees, delivering a solution that completely pays for itself. Contact Rick Garrison at email@example.com and visit www.specialtycm.com
Insurance technology startup, Verikai, launches Med/Rx to build on their existing product base and further optimize the underwriting process for their carrier clients.
Verikai uses machine learning models to give insurers a deeper view of risk, using extensive clinical and behavioral data to create risk scores. Now, with the addition of Med/Rx, carriers will be able to run group reports through Verikai’s platform
LAUNCHES MED/RX TO GIVE UNDERWRITERS AND INSURERS ROBUST INSIGHTS ON MEDICAL CLAIMS & PRESCRIPTION DATA
to establish a baseline of high-cost conditions and prescriptions that appear in each group.
The Med/Rx report includes 10,000 of the most expensive medical diagnoses, including cancers, chronic illnesses, mental disorders, injuries, and drug abuse – to name a few.
The Rx half of the report provides all known prescription data on a group, broken down by pricing category (generic, brand, and specialty drugs).
As Med/Rx takes shape, Verikai will continue to update the product with additional medical conditions and deeper insights into price.
Verikai’s President and CEO, Jeff Chen, said, “Our mission is to utilize our unique dataset and machine learning technology to provide the insurance industry with the best insight, so underwriters can make the most accurate decisions possible around evaluating risk. Med/Rx will offer our health insurance customers historical claims, medical, and Rx data – ondemand, within minutes.”
“We have been working on this product for over a year and coupled with our risk scores from our flagship Capture product, underwriters will have the most powerful set of predictive risk tools at their fingertips, all within a single platform. There is no other predictive risk vendor on the market that offers carriers a complete and holistic view of risk like Verikai does. We look forward to the positive impact Med/Rx will have on the industry for years to come.”
Within the predictive risk space, Verikai is known as “The Future of Underwriting”, based on their use of behavioral data to predict future risk. Now, with Med/
Rx providing historical risk indicators, the competitive edge for Verikai customers is unparalleled.
Founded in 2018, Verikai is an insurance technology company leveraging alternative data and machine learning to change the way the industry views risk. Our well-established database of more than 1.3 trillion data points includes over 5,000 behavior attributes for 250+ million people in the United States and provides deep insight to these individuals’ true health risks. With this data, Verikai generates risk reports in real-time with only a census. With Med/Rx, those risk reports are coupled with historical claims and prescription data, giving our customers every underwriting tool available. This greater insight helps insurance companies increase new business, reduce losses, and improve efficiency in the underwriting process – and ultimately, provides consumers and businesses with greater access to a broader range of insurance products. Contact Ellie Newby, Head of Marketing, at firstname.lastname@example.org and visit www.verikai.com
NOVA HEALTHCARE ADMINISTRATORS CELEBRATES 40 YEARS OF INNOVATION IN SELF-FUNDING
Nova Healthcare Administrators marks its 40th anniversary of providing selffunded solutions in 2022. The Buffalo, NY-based health care solutions company has been celebrating the milestone throughout the year with associate events and communications.
While much has changed in the past 40 years, Nova’s philosophy on valuing and empowering our associates remains steadfast. Sustaining a positive workplace culture has long been a priority for Nova, as happy associates deliver the best results for clients and members.
Nova was founded in 1982 and acquired by Independent Health (a community-based, non-profit health plan headquartered in Western New York) in 2003.
Originally a traditional third-party administrator (TPA), Nova has evolved into not only one of the largest TPAs in the country, but more of a trend management organization with the ability to work with various entities to help them manage risk.
This includes offering a spectrum of customizable benefit solutions, including medical, dental, vision, COBRA, reimbursement account administration, and in-house medical management.
In addition to supporting self-funded employers, Nova has seen growth in recent years partnering with health plan start-ups and other TPAs, private labeling all or part of their operations or medical management services. Nova is URAC-accredited for case management and utilization management.
What sets Nova apart is not our services, but how they are delivered. Nova takes pride in building solutions to meet each client’s unique needs. Additionally, by using a connected company model, each client has a dedicated team of cross-functional experts to support their plan and members.
“Today’s market requires an organization to be innovative, flexible, and nimble enough to quickly design and develop strategies and plans for clients; finding the right balance between an entrepreneurial organization and a process-centric one is essential,” says James Walleshauser, Nova’s president. “Nova associates approach each day with a sense of passion and purpose for providing our clients and their members with the highest level of service and innovative, customized benefit plans that meet their specific health care needs; we are an extension of our clients and members.”
“We believe that Nova’s commitment to associate engagement and empowerment, and an overall positive, healthy culture, translates to the high level of service we provide,” notes Walleshauser. “Happy associates make for happy clients. If the past 40 years have shown us anything, it seems we’re on the right track.”
For more information on Nova and its products, services or employment opportunities, contact email@example.com or visit www.novahealthcare.com.
NOVA HEALTHCARE ADMINISTRATORS RANKED AMONG 2022 BEST PLACES TO WORK IN HEALTHCARE
Nova Healthcare Administrators was recently named one of Modern Healthcare’s 2022 Best Places to Work in Healthcare. Recognized for the fourth year in a row, Nova ranked 52 out of 75 organizations in the supplier category.
The annual nationwide recognition program honors organizations that empower employees to provide patients and customers with the best possible care, products and service. This year’s list includes 150 honorees in total, across two categories. Rankings were revealed at an awards gala on Sept. 29 in Nashville, Tenn.
“It is an honor to be recognized by Modern Healthcare as a Best Place to Work for the fourth consecutive year,” said Nova’s President James Walleshauser. “Culture is at the heart of everything we do at Nova and is top-of-mind every day. The best way to know if we are making Nova a great place to work is to ask associates. Their active engagement and feedback help to guide events, activities, and communications.
“We continue to be faced with constant change in our working environments and industry,” Walleshauser added. “The resilience of our associates, combined with their talent and passion for what they do shows in our ability to maintain our place on this distinguished list of companies, as well as in the top-notch service provided to our broker partners, clients and health plan members day in and day out.”
Whether meeting a client deadline or meeting for a hike a local park, Nova associates work hard and have fun. A variety of associate-led groups, including a Diversity
Council, Renovations wellness committee and Nova in the Neighborhood volunteer committee offer the opportunity to connect with one another, grow and make an impact on the company and community.
The Best Places awards program includes a two-part survey. The first part consisted of evaluating each nominated company’s workplace policies, practices, philosophy, systems and demographics. The second part consisted of an employee survey to measure the employee experience. The combined scores determined the top companies and the final rankings.
Founded in 1982 and headquartered in Buffalo, NY, Nova is one of the largest third-party administrators of self-funded employee benefit programs in the nation, providing the health care solutions our clients need in the way they need them. And we go far beyond the basics. We are creative problem solvers who build custom solutions. Nova provides a unique, comprehensive array of services, including medical, dental, vision, COBRA, reimbursement account administration, and privatelabeled solutions. Nova also offers award-winning, in-house, integrated medical management programs. We are the stewards of our clients’ benefit plans, offering best-in-class partnerships, customized solutions, and personalized service. To learn more, visit www.novahealthcare.com
DALLAS, TX – hi-tech health is excited to welcome Tom O’Connor to their team as Executive Vice President of Sales and Business Development. Tom brings over thirty years of experience in sales for Fortune 500 companies, mid-market organizations, and larger government agencies. He will be a crucial part of hi-tech health’s future growth, leveraging his knowledge of health plans’ needs and cost containment.
“It’s great to have Tom as part of our team as he will bring some valuable insight into how we can expand our reach within the market to service payers of all types and provide an additional presence at future conferences like SIIA and HCAA,” said Mike Carrara, Founder and Chief Revenue Officer. “Our philosophy of relationship-driven business is one that Tom shares and he’s already proved an excellent fit into our culture.”
hi-tech health’s claims administration cloud-based platform is highly customizable and offered at a fraction of the cost compared to other platforms.
Their core product, Series 3000, is comprised of a portal suite and mobile app offering, with incredible speed in implementation and high-touch customization to support all clients’ individual needs.
About hi-tech health
Founded in 1990, hi-tech health offers claims administration to Third Party Administrators, carriers, insurtech entities, provider sponsored plans and Medicare Advantage. Series 3000 is a highly customizable system that serves customers of all sizes and needs. hi-tech health supports clients through implementation and beyond, with highly customizable solutions, and back-office support for enrollment services, consolidated billing, ID card printing, and more. Visit www.hi-techhealth.com
JMS provides data capture, claims adjudication and plan building services, all supported by a strong client-centric service delivery model. Chuck Agrusa, CEO, Daniel Feng, President, and the rest of the JMS team will join SDS postacquisition.
“We are thrilled to be joining forces with SDS. We have known the organization and its team for a number of years and see great cultural alignment and a shared focus on client success,” said Agrusa. “We look forward to maintaining the same level of focus and dedication to our clients while also working with the broader organization to provide even greater value to SDS’ base of payer clients.”
“SDS is focused on driving sustainable digital transformation for our clients, bringing tangible value through our tech-driven set of solutions,” said Shashi Yadiki, CEO of SDS. “The addition of JMS brings a complementary set of high-impact services that can be leveraged to improve a payer’s operational agility and thrive in today’s dynamic health benefits market. We are excited to have Chuck, Dan and the whole JMS team join the SDS family.”
HEALTHCARE AUTOMATION LEADER SMART DATA SOLUTIONS ANNOUNCES ACQUISITION OF JMS AND ASSOCIATES
Eagan, MN – Smart Data Solutions (SDS), a leading provider of data management, claim routing and workflow solutions to payers, announced the acquisition of Farmington Hills, MI-based JMS and Associates (JMS), a provider of tech-enabled outsourced solutions to TPAs and other healthcare organizations. The acquisition brings new clients and capabilities that will broaden the set of solutions SDS is able to provide to existing and future clients.
Founded in 1975, JMS provides leading healthcare companies across the country with value-added outsourcing solutions that leverage automation and technology-based business processes.
SDS is supported by Parthenon Capital, a leading growth oriented private equity firm focused on building franchise companies in healthcare.
Kirkland & Ellis served as legal counsel to SDS. Kerr Russell served as legal counsel to JMS.
About Smart Data Solutions
As a leader in healthcare automation, Smart Data Solutions’ mission is to make the healthcare market more efficient by leveraging technology
HI-TECH HEALTH ANNOUNCES TOM O’CONNOR AS EXECUTIVE VICE PRESIDENT, SALES & BUSINESS DEVELOPMENT
to provide effective, high-quality claims processing solutions. SDS brings a comprehensive set of tools and processes to every opportunity, carefully configured to the individual needs of each client. Smart Data Solutions has focused on creating innovative solutions specifically to meet the needs of the healthcare market. Today, more than 400 TPAs, PPOs, HMOs, hospitals, and insurance companies depend on SDS for automation of intake, data capture, and front-end workflows for health insurance and claims administration. Contact Susan Berndt at firstname.lastname@example.org and visit www.sdata.us
RINGMASTER® TECHNOLOGIES AND SUBSIDIARY RINGMASTER® RX LAUNCH A PHARMACY CONSULTING PLATFORM FOR SELFFUNDED COMMUNITY
Boca Raton, FL - Ringmaster Technologies®, Inc. (RMT) a leading healthcare software provider in the U.S., and its wholly owned subsidiary, Ringmaster® Rx announced the launch of the first pharmacy consulting, platform to provide cloudbased tools and services for pharmacy experts who serve the self-funded community.
In working with TPAs and Brokers representing self-funded employer groups, Ringmaster learned that clients often had difficulty interpreting and/or comparing PBM responses. Accessing AWP data and evaluating nuance contract terms such as: exclusion language, generic definitions, specialty definitions and limited distribution definitions proved to be outside the scope of what most TPAs and Brokerage firm could handle. This created an opportunity for a technology platform to help align clients and PBMs.
The unique attributes of the Ringmaster Rx platform provide clients a cloud-based data warehouse integrated with a RFP workflow process that solicits, compares and awards pharmacy benefit management (PBM) contracts and programs.
“This combination of automated workflows and data warehouse capabilities gives clients the ability to customize their own panel of preferred PBM’s, generate reports, create sophisticated analytics for their employer groups and perform contract reconciliations and audits on performance. All of which is virtually impossible with today’s manual processes and the lack of access to key data,” stated Jason Wenzke, President of Ringmaster Rx. "We believe that this new platform is a huge win for pharmacy benefit consultants, Brokers and Third-Party Administrators (TPA’s) who will use the platform to take advantage of meaningful PBM sourcing solutions, analyze the performance of those contracts and ultimately manage cost for their employer groups by stepping into the ring and utilizing the system.”
“We created Ringmaster Technologies and its subsidiary, Ringmaster Rx, because I believed we could deliver technology to self-funded experts that would improve their operations significantly and those improvements would lead to smarter investments and better health outcomes. Our great success in creating the world's only stop-loss
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marketplace and automation technology has shown us that the challenges in self-funded pharmacy offerings were also solvable on our technology platform and we are excited to deliver this stateof-the-art capability to our partners,” said Todd Roberti, Founder and CEO of Ringmaster Technologies.
About Ringmaster Technologies, Inc.
Ringmaster is a cloud-based healthcare software provider created to simplify and enhance administrative processes by utilizing cutting edge technologies. Ringmaster offers the first fully automated workflow optimization solution that drastically reduces processing time and complexity while minimizing the turnaround time for Stop-Loss quoting, contracting, and policy administration. Additionally, Ringmaster Rx offers a pharmacy consulting platform which provides cloud-based tools and services for SelfFunded Pharmacy Experts. Contact Leo J. Garneau III, Chief Marketing Officer, at email@example.com and visit www.ringmastertech.com
CEO of Allied. "They will be pivotal in Allied's success in the coming years."
As CSO, Valerious will be responsible for executing a multi-year business strategy to accelerate growth. While continuing to be Allied's voice to the market, he will be focused on strategic partnerships, product development, and medical management services.
"Over the last 33 years, Rob has been the voice and face of Allied to our clients and business partners," said Sternklar, "Under his leadership, our business has – and will continue to - grow and prosper."
With over 22 years of business development and sales management experience, Rozmiarek will lead Allied's sales, client management, and underwriting teams, with end-to-end responsibility for new and existing client growth. "I have long admired Allied for their stellar reputation for quality service and innovative medical management products," said Rozmiarek, "I am thrilled to join the Allied Team and contribute to the company's continued success." Rozmiarek most recently served as Senior Vice President of National Sales for Health Plans Inc. (HPI).
"Drew's success as a growth leader is impressive, but he will bring more than that to the organization," said Sternklar. "He has a passion for customers, admirable leadership skills, and inexhaustible drive. I have complete confidence that he will be enormously impactful."
About Allied Benefit Systems, LLC
Allied is a national healthcare solutions company providing professional administrative, medical management, and compliance services to over 10,000 selfinsured employers. Founded in 1980, Allied has grown to be one of the largest, independent third-party administrators in the United States. Visit www.alliedbenefit.com
SMART DATA SOLUTIONS ANNOUNCES SHASHI YADIKI AS CHIEF EXECUTIVE OFFICER
Eagan, MN – Smart Data Solutions (SDS), a leading provider of data management, claim routing and workflow solutions to health plans and TPAs, announced that Shashi Yadiki has joined the company as its new Chief Executive Officer.
CHICAGO -- Allied Benefit Systems, LLC, the nation's leading health solutions company, announced that Rob Valerious will assume the role of Chief Strategy Officer (CSO), and the appointment of Andrew (Drew) Rozmiarek as Chief Revenue Officer, effective October 10, 2022.
"The executive firepower and leadership that Rob and Drew bring are unparalleled in the industry," said Michael Sternklar,
A proven leader in healthcare services and technology, Yadiki brings over 20 years of experience scaling tech-enabled and data-driven healthcare businesses.
Most recently, Yadiki served as President of the Health Plan and Life Sciences business for NTT DATA, helping healthcare organizations execute against their digital transformation objectives.
Prior to NTT DATA, Yadiki held leadership roles at Dell Services and Wipro Technologies. Yadiki is a graduate of the Indian Institute of Management, Bangalore and the University of Mysore. Yadiki joins SDS as the CEO and a member of the Board of Directors.
ALLIED BENEFIT SYSTEMS ANNOUNCES ROB VALERIOUS AS CHIEF STRATEGY OFFICER AND DREW ROZMIAREK AS CHIEF REVENUE OFFICER
“John Prange and I started SDS more than 20 years ago to help health plan and TPA clients improve the efficiency of their claims management process,” said Pat Bollom, SDS’s co-founder. “We are thrilled to have Shashi join SDS to build on this mission and lead the company in its next chapter. Shashi’s track record of delivering exceptional growth, deep understanding of the operational challenges faced by healthcare organizations, and an appreciation for the role automation and advanced technologies can play in driving tangible client impacts make him uniquely qualified to lead the business.”
“I’m very excited to be joining SDS, a trusted partner to a number of the nation’s leading health plans and TPAs. SDS is uniquely positioned to be a transformative partner for clients to simplify and automate healthcare processes built on an impressive track record of delivering results. I look forward to driving more innovation and value for our clients,” said Yadiki. “On behalf of SDS, I’d also like to recognize Pat and John’s many contributions leading the company from its early days to an industry leader in claims workflow automation. I look forward to their continued involvement in SDS going forward as members of the Board of Directors and shareholders.”
SDS is supported by Parthenon Capital, a leading growth oriented private equity firm focused on building franchise companies in healthcare.
About Smart Data Solutions
As a leader in healthcare automation, Smart Data Solutions’ mission is to make the healthcare market more efficient by leveraging technology to provide effective, high-quality claims processing solutions. SDS brings a comprehensive set of tools and processes to every opportunity, carefully configured to the individual needs of each client. Smart Data Solutions has focused on creating innovative solutions specifically to meet the needs of the healthcare market. Today, more than 400 TPAs, PPOs, HMOs, hospitals, and insurance companies depend on SDS for automation of intake, data capture, and front-end workflows for health insurance and claims administration. Contact Susan Berndt at firstname.lastname@example.org and visit www.sdata.us
BLACKWELL CAPTIVE SOLUTIONS WELCOMES ARLEIGH KENNEDY AS NEW NATIONAL VICE PRESIDENT, SALES
CHICAGO- - Blackwell Captive Solutions, an innovative medical stop-loss captive domiciled in South Carolina and sponsored by Carrick Capital Partners, announces Arleigh Kennedy as the new National Vice President, Sales.
“We are delighted to welcome Arleigh to the Blackwell Captive Solutions team,” said Kari L. Niblack, President of Blackwell Captive Solutions. “As Blackwell continues to differentiate and deliver flexible options and solutions that are unique from other captives, Arleigh’s excellent reputation, vast knowledge of the industry, and creativity elevate Blackwell to a higher level of service in providing groundbreaking solutions to our clients.”
Kennedy comes to Blackwell Captive Solutions with over 25 years of experience in the insurance and selffunded industry. Her knowledge and expertise expand from her past work for carriers, BUCA, and an MGU, as well as her work in underwriting, sales, product development, and vendor relationships.
“I’m excited to join Blackwell Captive Solutions to help deliver unique, impactful solutions for clients with an emphasis on choice and flexibility,” said Kennedy. “In the years that I have been in this industry, I have seen a lot of change. Employers are looking for partners who are going to help them manage the rising costs of health insurance. It’s also the recognition that one size does not fit all. It’s a flexible approach balanced with access to best-in-class partners that sets Blackwell apart.”
Blackwell Captive Solutions delivers essential stability with desired flexibility with cutting-edge solutions that combine buying power with tailoring freedom. Domiciled in South Carolina, Blackwell Captive Solutions forms partnerships with industry leaders to provide the best-in-class cost containment and clinical services platform. Blackwell’s services and solutions are uniquely available on an opt-in basis, so captive members need only partake in solutions that work for them and their members.
SELF INSURANCE INSTITUTE OF AMERICA, INC. 2022
BOARD OF DIRECTORS
CHAIRWOMAN OF THE BOARD*
Kari L. Niblack, JD, SPHR
ACS Benefit Services Winston Salem, NC
Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN
TREASURER AND CORPORATE SECRETARY*
President & CEO
Captive Planning Associates, LLC Marlton, NJ
Thomas R. Belding
President Professional Reinsurance Mktg. Svcs. Edmond, OK
Chief Operating Officer
Vālenz Phoenix, AZ
Laura Hirsch Co-CEO
Aither Health Carrollton, TX
Deborah Hodges President & CEO Health Plans, Inc. Westborough, MA
Lisa Moody Board of Directors Chair Renalogic Phoenix, AZ
Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN
SIEF BOARD OF DIRECTORS
Nigel Wallbank Preisdent Leadenhall, LLC Ocala, FL
PRESIDENT Daniél C. Kimlinger, Ph.D. CEO MINES and Associates Littleton, CO
Freda Bacon Administrator
AL Self-Insured Workers' Comp Fund Birmingham, AL
Advantage Insurance Management (USA) LLC Charleston, SC
Chief Executive Officer Hudson Atlantic Benefits Bellmore, NY
Virginia Johnson Strategic Account Director Verisk/ISO Claims Partners Charlotte, NC
SIIA NEW MEMBERS
Peter Rowe President Arcwood Phoenix , AZ Katherine Duckworth Senior Vice President Citi Chicago, IL Doug Sherman Chairman Clearwater Benefits Administrators Austin, TX Susheel Jain CEO Exouza Falls Church, VA Trey Marinello Director Houlihan Lokey Chicago, IL
David Spinale VP, North America
MediGuide International Wilmington, DE Christopher Heman CEO MedVed, Inc Springfield, MO Andrew Barth Executive Vice President MGB Re Burlington, ON Joanne Romasko Health Care Trust Administrator Montana Association of Counties Helena, MT
Tommy Maher Senior Vice President RMTS
Jersey City, NJ Craig Stephan President/CEO SecureOne Benefit Administrators Grand Rapids, MI Julia Peebles Events Manager
SentryHealth Louisville, KY Leo Sugg SVP
Starr Insurance Companies New York, NY Charles Hildebrand Executive Vice President Welvie, LLC Saint Louis, MO
Dominick Diomede VP, Payer Solutions Netmark Business Services Cincinnati, OH Tayebe Shah-Mirany Vice President of Business Development PsycHealth Care Management, LLC Skokie, IL
Kari Niblack JD, SPHR
Blackwell Captive Solutions Chicago , IL