Final Assessment 2: Case Studies

Case Study: Rural Manufacturer

You were just named the advisor for a 160 life company in a rural community. The average employee income is $35K/year. The plan is self-funded and administered by a BUCAH carrier, and has what is considered to be one of the strongest BUCAH networks in terms of PPO discounts. The current plan has a $1000/3000 deductible, $3000 OOP max for single / $6000 for family. The specific deductible is $75K and while four claimants have exceeded 50%, none are thought to be ongoing. Through claim analysis, you have identified 50 members with chronic conditions. The CEO, CFO, and HR are highly motivated to find ways to improve member health and provide a better benefit plan. However, they have had to continue to cost shift to employees by increasing out-of-pocket (OOP) costs over the years due to the escalating cost of providing healthcare to the membership. If they cannot decrease costs, OOP will need to increase this year also. It pains the CEO to continue the cost shift given that the workforce is like family. The plan sponsor is not ready to change TPA/PBM at this time. The PEPY for the plan is $15,838.

Question #1: What changes do you recommend and what savings do you project in Year One?

Case Study: Rural Manufacturer (see above)

Question #2: What information would you request to allow for a more thorough recommendation? Explain how this information will allow you to design a plan that is mindful of employer budget constraints while avoiding more cost shift to employers.

Case Study: Cancer Case

You are the advisor for a 250 life self-funded employer with a $150K deductible. The current plan administration is with a BUCAH TPA and PPO network.

There is only one specific stop loss claimant – 61 year old male diagnosis of malignant melanoma. The patient is prescribed Opdivo and is approved for 14 cycles initially and the protocol is 26 treatments if patient tolerates. Opdivo is used to treat people with a type of advanced stage cancer that has spread or grown and is used for people who have tried chemotherapy and it did not work or is no longer working. The average cost through a PBM is $6500/cycle. The administration of Opdivo is being done in a hospital outpatient setting and the billed charges by the hospital through the medical benefit are $27K per treatment with an amount paid after a 35% discount of $17K per treatment. The stop loss provider is concerned about projected costs and is considering a laser for the cancer patient.

Question #1: What is your plan to mitigate the laser?

Case Study: Cancer Case (see above)

Question #2: What other information would you request and what options would you consider to better support the sponsor and the member?