Below are some 2022 stats and observations from several independent providers of medical stop-loss insurance in the USA.

STATS AND OBSERVATIONS:

• 71% of all stop-loss claims came from 10 procedures; over the last four years, 37% of claims came from the top three procedures: malignant tumor; leukemia, lymphoma, multiple myeloma; and cardiovascular.
• 62% of all organizations have seen at least one stop-loss claim related to cancer in the last year.
• 11 of the top 20 high-cost injectable drugs are for cancer treatment; Rylaze, a new drug averages $808,000 per year.
• Million-dollar claims on a per-million covered members basis rose 45% over the last four years.
• Mental health conditions have risen in the past four years from outside of the top 20 to #16; alcohol-related disorders are the major contributor to the rise, and alcohol disorders are a major contributor to other chronic conditions.
• A number of gene therapies are in the pipeline for approval in 2023/2024 for conditions including hemophilia and sickle cell anemia with price tags in the millions.
• 87% of the clients from a national stop-loss provider had at least one stop-loss claim in 2022, with injectable drug claims rising 70% over the last four-year period.
• Obesity management drugs, although not likely to exceed a plan’s stop-loss deductible, will add significant cost if not properly managed.
• Institutional billing practices continue to be a source of pressure on self-funded plan finances. Large claims are particularly vulnerable to unbundling, upcoding, duplicates, product mark-up, and other questionable administrative charges, along with accidental and simple human error.

IDEAS TO CONSIDER:

• A focus on cancer-specific support programs and access to cancer Centers of Excellence for optimal outcomes.
• Treatments, like dialysis infusion, done at home versus a medical facility; review your plan language to make sure it supports care delivery in the settings that will result in the best outcomes.
• Ensuring access to detailed claims data to support areas of focus such as identifying emerging trends, assessing new strategies and identifying institutional billing issues; the 2021 Consolidated Appropriations Act section 201 mandates access to your data from all carriers.
• If considering support of weight-loss drugs, work with an independent obesity management or care management solution to ensure patient compliance on obesity medications.
• A focus on primary care and mental health access to build a culture of prevention.
• A specialty drug co-pay assistance program through your pharmacy benefit manager to save money for both the Fund and its members.

Questions? Contact your Bolton representative, or email us at solutions@boltonusa.com.