All posts by Denise Doyle

Specialty Drug Spending: Five Years Later, Where Are We?

Back in 2017, we wrote about a topic that vexes insurers and self-insured employers: specialty drugs. More specifically, we wondered whether specialty drugs are worth their high cost. Five years later, there aren’t any more conclusive answers about whether these drugs are effective enough to warrant sky-high prices—and in the ensuing five years, those prices have only gotten higher.  Continue Reading >

Pharmacist handing specialty drug to woman in red top and her husband.

The 5 Least Understood Benefits of Stop Loss Insurance

As self-funded health plans have steadily grown in popularity over the last decade, many business leaders have found themselves in unfamiliar territory. After switching from fully-funded insurance to self-funding, there’s a great deal of information to absorb. Stop loss insurance is one tool that self-insured employers may utilize but not fully understand. Continue Reading >

Woman working on red roses in a greenhouse. Stop Loss.

Normalizing Mental Health-The Benefits for Self-Funded Plans

Employers have to walk a fine line around employee mental health. It’s not appropriate for employers to probe their employees with personal questions about their physical or emotional health. At the same time, employers have a vested financial interest in making sure that members of their workforce have access to necessary mental health resources. Continue Reading >

Woman with red nails and a red coffee cup next to her at an outdoor cafe. Mental health.

Affordable Care Act Cost-Sharing Caps: What to Know for 2022

Out-of-pocket expenses can become overwhelming or even financially devastating for someone who’s dealing with a serious, ongoing health issue. The Affordable Care Act cost-sharing caps limit some out-of-pocket medical costs for consumers, requiring health plans to cover costs that exceed those limits. Annual ACA caps can have some impact on a self-insured employer’s healthcare spending. Continue Reading >

Affordable Care Act cost

Top 5 Ways Stop Loss Insurance Helps Self-insured Employers

Employers are clear about the fact that they need to control healthcare costs. They often aren’t as clear about the strategies they can use to do that, in a way that benefits both the organization and its employees. Self-funding a health plan is an increasingly popular choice among businesses of all sizes, but business leaders might be wary about the financial risk of taking direct responsibility for paying employees’ claims. Continue Reading >

Child smelling a red tulip in a garden. Stop loss insurance.

The Impact of Medicare’s Ability to Negotiate with Pharma

We’ve probably all experienced sticker shock at the pharmacy counter. How can employers with self-funded plans continue to provide high-quality health benefits when so many of their healthcare dollars are going to prescription drug costs? A piece of legislation that would allow Medicare to negotiate some drug prices could possibly provide some relief, for both Medicare members and self-insured employers alike. Continue Reading >

Smiling female pharmacist holding up a red medicine capsule that could be covered by medicare.

Pros and Cons of Reference Based Pricing for Self-insured

As self-insured employers look for ways to control healthcare costs, they have to evaluate every strategy that might help them accomplish that goal. Reference based pricing is a pricing strategy that eliminates rate negotiation between employers and healthcare providers, and may result in employers spending less on their employees’ medical claims. Continue Reading >

Reference based pricing allows employers to better predict medical budgets. A medical plan administrator working on billing while eating an apple.

Aggregate vs Specific Stop Loss Insurance

While stop-loss coverage has become an increasingly popular tool for self-insured employers, it’s still a topic of confusion for many people. The purpose of stop-loss coverage is to provide a layer of financial protection for employers. Two primary types of stop-loss policies exist, aggregate and specific, and employers typically use both types to give themselves maximum financial protection. Continue Reading >

A stop-loss provision as part of an employee health insurance plan helps control employer healthcare costs. Employee’s child receiving medical care during the holidays.


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    In 2011, the top 5 most expensive medical conditions treated in US hospitals were: Septicemia, Osteoarthritis, Complication of device, implant or graft, Liveborn, and Acute myocardial infarction

    From 2010 to 2013, the number of claims that were individually $1 million or above rose by 1,000%

    In 2017 approximately 18% of the American public will purchase insurance through exchanges, radically transforming the health insurance landscape.

    In 2014, 98% of large firms (= 200 Workers) offer 1+ wellness programs to their employees.

    The most costly 1% of patients account for 20% of national health expenditures – accruing average annual expenses of nearly $90,000 per person.

    6% of firms offering fully-insured plans report they intend to self-insure because of Obamacare.

    In 2014, PPO plans remained the most common plan type, enrolling 58% of covered workers.

    In 2012, 93% of businesses with 5,000+ employees and 80% of companies with 1,000-4,999 employees were self-funded

    Massachusetts has the third-highest prevalence of self-funded insurance in the small-group market (Fewer than 50 employees).

    In 2013, the average deductible was $2,906 for individuals selecting plans from marketplaces. This compares with average deductibles of $1,135 for an individual with employer coverage.

    In 2013, the average annual premiums for employer-sponsored health insurance are $5,884 for single coverage and $16,351 for family coverage, up 5% and 4% respectively from 2012.

    From 2010 – 2013, cancer followed by chronic/end stage renal disease and leukemia accounted for the top 3 costliest illnesses.