As seen in Managed Care...e2">As seen in Managed Care...
Million-Dollar Claim Club
By Maureen Glabman

Charles Crispin tells the sad tale of a commercial health plan that opened for business in January 2006. A month later, a hemophiliac member started bleeding, requiring large doses of a blood factor, an expensive clotting drug.

By April, the patient had received so much that he reached his lifetime policy limit of $5 million. Over $3 million was for factor product administered in an outpatient setting. The plan paid for it all out of reserves: It began operations with $6 million in statutory reserves, $1 million greater than required by the state. But as a result of inadequate reinsurance, the plan had to absorb almost 100 percent of the claim itself. Five million dollars of surplus was wiped out, and the plan now sat far below state requirements. It might have gone under were it not for a wealthy and willing parent able to infuse cash to boost reserves.

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As seen in AHIP Coverage...
Managing Catastrophic Claims
By Charles Crispin

Catastrophic claims, defined here as medical claims of $1 million or more, were rare a decade ago. While still not a typical occurrence, they are surfacing with greater frequency. In fact, it is no longer unusual to see claims of $2 million or more incurred by a single member.

A recent study by one reinsurance organization found that the number of $1 million-plus claims in its pool of reinsured members has tripled in the past three years. In a 1999 study by another reinsurance company, 2 million covered lives generated only two claims greater than $1 million. In 2006, however, the company projects that 1 million covered lives will generate 10 such claims.

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As seen in National Underwriter Life & Health...
Medicare Advantage: As Enrollment Grows, So Do Risks For Plans

The new, revamped Medicare Advantage program has proven surprisingly popular with the public—and with plan sponsors. As of July 1, 2006, nearly 7 million Americans had signed up for an MA plan and 20 million had enrolled in the separate Part D drug benefit. The number of individual health plans participating in the MA program has also increased this year. Acc ording to a recent Kaiser Family Foundation report, as of July 1, there are 512 separate MA plans, up from 292 in July 2005.

As the number of beneficiaries and the number of plans grow, the potential rewards and risks for each plan also grow. Many new contractors are smaller, regional health plans, competing in a market that is dominated by large, publicly traded plans.

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As seen in Business Insurance...
Managed care companies seek help, advice from reinsurers

A rapidly changing market for managed care companies is altering the relationship between medical reinsurers, reinsurance brokers and their clients.

As managed care companies deal with opportunities such as a reinvigorated Medicare market, they will need more help and advice from their reinsurance partners about how to make the best of those opportunities, reinsurers and brokers say.

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As seen in Senior Care Management...
Medicare capitation poised for major comeback in 2005

By all estimates, Medicare Advantage is poised for an enrollment explosion in 2005, and capitated physician and hospital organizations should immediately start reassessing their risk contracting management systems, two experts tell Senior Care Management.

“We are in a very strong managed care cycle now. It is significant, especially with Medicare,” says
Charles Crispin, president of Evergreen Re, a Stuart, FL-based reinsurance brokerage and consulting company. “With all the new benefits brought into Medicare, we will see payers like Humana and others put the metal down, and there will be a large migration into managed care.”

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As seen on AAHP.org...
Strategies for Managing Risk in an Era of Rapid Change
By Charles Crispin

The nation's changing health care landscape is forcing health plans and health insurers to newly confront the old business adage of "no risk, no reward." With the recent passage of the Medicare reform bill and the growing popularity of consumer-choice products, many companies are considering entering new markets and launching new products.

Plans embarking on these new marketing opportunities naturally want to maximize the possibility of reward while minimizing the risk. The calculation of risk has long been a core business activity for health plans and health insurance companies. Now executives must go beyond simply computing risk or accounting for it in underwriting tables, they must actively manage its component factors.

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As seen in Drug Cost Management Report...
Evergreen Re Says Its PBM Audit Service Cuts Drug Spending

Health care reinsurance and medical risk brokerage firm Evergreen Re is offering an auditing service to evaluate health plans' and employers' PBMs that it says can generate between 3% and 5% savings on pharmacy spend off the cuff. The service was developed as a "best in class" approach to utilizing various types of pharmacy cost analysis products, according to the company.

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As seen in National Underwriter...
New Risks, Tighter Reinsurance Terms Pose Risk for Self-Funded Plans

For many employers, the era of self-insuring health care benefits has quickly turned into the era of managed risk.

Rising health care expenses, fueled by new technologies, treatments and increasing utilization, have created new, potentially damaging risks. The continued risk in health care costs and ongoing changes in reinsurance underwriting capacity and pricing are making future benefits cost projections all the more difficult for employers.

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As seen in Capitation Rates & Data...
Give your reinsurance policy a thorough check up

The nature of risk management has changed dramatically over the past few years, with the reinsurance trend rate leapfrogging the overall medical trend, according to Charles Crispin, president in the Stuart, FL, office of Evergreen Re, a managed care consulting firm and reinsurance brokerage. An overall loosening of referral and management controls by health plans has led to increased utilization, which is likely to continue. Providers, especially hospitals, have leveraged their negotiating strength to seek -- and, in many cases, receive -- higher contractual reimbursements. The aging of the U.S. population has heightened the incidence of certain diseases that most frequently occur in older adults, such as Alzheimer's, Parkinson's, and many cancers.

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Health Plan Advisor - February 2003
By Reden & Anders, Ltd.

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As seen in The Wall Street Journal...
Sorry, Only Half of That Surgery Is Covered
By Amy Dockser Marcus

Undercoverage has become more pervasive as sophisticated new medical procedures become more commonplace. Charles Crispin, chief executive officer of Evergreen Re Inc., a health-care consultant in Stuart, Fla., says he has noticed more restrictive policies recently as companies struggle to protect themselves from catastrophic claims. He points to one client that provided coverage for a hemophiliac teenager whose drug bill was over $16,000 a month. "It all comes back to the company's ability to finance it," says Mr. Crispin.

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As seen in HealthLeaders...
Payback Time
By Bonar Menninger

Practical lessons in managed-care contracting usually don't come cheap. Terry Hargadon, CEO of Long Island Health Network in Melville, N.Y., recalls one of his former employers that developed a new heart program but overlooked on important detail: The hospital neglected to renegotiate payor contracts to insure adequate coverage of the service.

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Branching Out with Self-Funded Health Care
By Chuck Newton, Evergreen Re

HR executives preparing to deal with the costs of health care benefits may feel like they're being led to the chopping block as analysts estimate annual increases ranging from 16 percent to 20 percent this year. With no relief in sight and pharmacy costs tailing right behind health care costs, HR executives are turning - or returning - to self-funded benefits programs.

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