Industry Insights

As a pharmacist, in the past 20-plus years, I’ve owned my own pharmacy, worked for a PBM (pharmacy benefit manager), served as a consultant to health plans and more. Now, I find myself in the operations department of a Stop Loss carrier. As pharmaceutical costs continue to rise and new drugs debut with million-dollar price-tags, the market is seeing greater catastrophic claims expenses – and I’m working to share my industry knowledge and understanding of pharmaceutical costs and use across the client population.

I love solving problems. That’s the best part of my job. Lucky for me, we’re in a thought-provoking industry – one that’s become even more challenging with the growth of high-dollar claims. As a reinsurer, paying those claims is the most important thing we do. The challenge lies in creating the right solution for each client, appropriately pricing business to ensure obligations can be fulfilled and finding ways to help contain claim costs for everyone involved.

Adding a reference-based pricing component to an employer’s health plan brings an element of clarity to benefit costs by determining, from the start, what is to be paid for medical services and procedures. It’s no surprise that reference-based pricing is a hot topic in the market today, especially when claims exceeding $1 million are more and more common. Reference-based pricing is part of a greater movement toward transparency, helping to establish some type of a standard for what is paid for medical care.

Well, the Stop Loss industry seems to be a rousing one these days. Claim incidences and expenses are on the rise (with no end in sight) – and we have to figure out how to contain the costs to protect everyone’s bottom line. Our sleeves are rolled up at HM. Who else is in? This is going to take a pretty big effort from all of us if we are to minimize the risk.

When you’re facing the challenges of a market that’s experiencing continued growth in medical and pharmaceutical costs, fueling the frequency of catastrophic claims exceeding the $1 million mark, you have to take a proactive approach to managing claims. At HM, we know that excellent medical management creates the foundation for successful cost containment for self-funded employers, and we encourage its use with our partners and clients through strong communication and education.