America's Benefit Specialist November 2023

NOTEWORTHY

strophic medical bills (known as specific or individual stop loss coverage) or when a higher frequency of overall claims is substantial in the aggregate (known as aggregate coverage). Individual stop-loss coverage deductibles are often tied to the underlying employee size and risk tolerance of the plan sponsor, ranging from as low as $50,000 to as high as $1 million or more per covered participant per policy year. As a result, the average premium cost per covered employee is highly variable and dependent on the size of the deductible. According to the survey, the average monthly premium per covered employee at a $100,000 deductible is $193.16; at a $500,000 deductible, it is $43.76. At a $1,000,000 deduct ible, the premium lowers to $14.08 per covered employee per month. For this survey, all contracts are equated to a mature “paid” contract. A paid contract will cover all claims that are paid during the 12-month policy period regardless of when claims are incurred. Aggregate stop-loss coverage, which is additional insur ance against overutilization of the health plan, is most prev alent alongside individual stop-loss deductibles of $250,000 or less and enrollments around or below 1,000. It becomes less common at higher deductibles and/or enrollments since those plans tend to be more stable. The most prevalent level, cited by 93% of respondents with aggregate coverage, is 125% of expected health claims. Average monthly premiums vary by size of the individual stop-loss deductible; the median premium overall is $8.55. The frequency of truly catastrophic claimants (in excess of $500,000) continues. The Medical Stop-Loss Premium Survey also collected data on the occurrence of catastroph ic claimants. Twenty-five percent of respondents reported a claimant in excess of $1 million over the last two years, with seven percent of those in excess of $2 million. These catastrophic claimants result from more aggressive hospital billing as well as specialty pharmacy and orphan drug thera pies, according to survey respondents. Forty-two percent of respondents reported that none of their catastrophic claims exceeded $500,000. When asked about lasering (which occurs when an un derwriter excludes certain individuals from coverage), 20% reported the presence of at least one known lasered claim ant, down slightly from 23% in 2022. The 2023 Aegis Risk Medical Stop Loss Premium Sur vey measured data from 799 plan sponsors covering over 845,000 employees with $727 million in annual stop-loss premium. A copy of the full survey is available on the ISCEBS website or by request at info@aegisrisk.com. SURVEY SHOWS THAT STRENGTHENING INDUSTRY TELEHEALTH HABITS WILL IMPROVE PATIENT ACCESS, CARE AND SATISFACTION Sage Growth Partners, a healthcare research, strategy and marketing firm, has released a new telehealth innovation re

port centered around what virtual care currently is, and what it can eventually come to be in the future. “Telehealth: The Innovation That’s Not Yet a Habit” offers insights from physicians and industry leaders within hospi tals, health systems and private medical practices. The report is based on results from an August survey of 155 respondents nationwide and was created in conjunction with Project Healthcare and The Disruption Lab – in support of this year’s TELEHEALTH ACADEMY III. Survey respondents stated that the current market is view ing telehealth services in many diverse ways from primary, specialty, and behavioral healthcare to condition manage ment and coordination of care in preventative, urgent and acute settings. Additionally, as telehealth continues to disrupt the healthcare marketplace, medical practices and hospitals have indicated that companies such as Amazon and CVS Health are viewed as at least a moderate business threat. Top findings and takeaways of the report include: • Patient follow-up visits make up 37% of medical practice telehealth services and 27% of hospital services. • The biggest year-over-year gains of medical practice tele health use came in the areas of behavioral health (13% to 20%) and chronic care management (eight percent to 19%). • Telehealth YOY usage declined the most for initial hospital visits (21% to 11%). • For 2025, medical practices expect telehealth use to increase the most for behavioral health and primary care. Hospitals believe that behavioral health services will grow from 20% to 31%. “Our report findings show that there is a significant missing opportunity in telehealth usage,” said Dan D’Orazio, CEO, Sage Growth Partners. “Since patients drive so many telehealth decisions, medical providers don’t yet think of it as a broader business tool. But it could be. When implemented correctly, telehealth can increase efficiency, decrease burn out, and improve costs, revenue and market share.” One additional survey finding highlighted in the report is that respondents indicate they use telehealth for follow-up care far more than for intake or any other services. Converse ly, this use has declined since 2020. Data also shows that consumerism is driving telehealth, just as it influences other aspects of the industry. “Our latest research found that patient preferences drive decisions approximately 54% of the time for medical practic es and 45% of the time for hospitals. Based on this, telehealth should not just be thought of as solely a video visit. It is very important that all stakeholders begin to connect the future success of telehealth to the future success and satisfaction of the healthcare workforce to be able to deliver the best care possible,” said D’Orazio. To download a copy of the complete report, visit sage growth.com.

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