Help for the Opiod Crisis–But at What Cost

The implications of H.R. 6 for ESRD Patients and their Plans

Just read this eye-opening article about House Resolution 6, the “SUPPORT for Patients and Communities Act,” which addresses the rising cost of the opioid epidemic in America—but at the expense of health plans managing ESRD claims. Could this affect the affordability of care in the future?

Read the article

Benefits Consultant Spotlight: Shay Cowan

Specialty Care Management (SCM) is fortunate to work with many innovative benefits consultants, one of which we’d like to highlight today. Shay Cowan, Principal, Katz/Pierz, worked alongside SCM President and CEO Rick Garrison during our recent Pareto case study panel and has been a stellar addition to our circle of trusted benefits consultants.


Experienced in multiple facets of the health insurance industry including liability, property and casualty insurance, employee benefits design and term life insurance, Shay works tirelessly to solve healthcare problems one client at a time. Always putting his groups first to ensure they’re in the best possible position year after year, Shay is wholly dedicated to those he serves within the insurance industry and has proven to be a valuable partner to us at SCM.


We look forward to many more years of working with Shay and will continue to strive together with him to provide all our clients with service that always goes above and beyond.

SCM Leads the Way in Self-Funding’s New Frontier

Specialty Care Management (SCM) is helping lead the charge of a new initiative for the Self-Insurance Institute of America (SIIA). On May 9-10, 2018, the newly formed Health Care/Captive subcommittee, of which SCM’s own Chief Operating Officer Craig Clemente is a founding member, met together in Chicago to pave the way for a new era of collaboration between the memberships of two fundamental self-funding groups—health plans and captive insurance companies.

With the goal of facilitating increased collaboration, business referrals and information sharing between these two association membership constituencies, the Health Care/Captive subcommittee took the first steps toward combining the health plan and captive arena to form a new coalition that is beneficial to all involved. The subcommittee plans on reconvening in Washington, D.C. to continue the progress achieved in their inaugural meeting.

SCM is proud to be at the forefront of this pivotal point in self-funding. By working toward these changes in association with the SIIA subcommittee, we are doing our part to help move the self-funded space forward and keeping our sights firmly focused on the future.

Specialty CM CEO Opens SIIA Executive Forum

Specialty Care Management (SCM) is pleased to have our CEO Robert Clemente as the Chairman of the Board of the Self-Insurance Institute of America, Inc. (SIIA). In this role, Mr. Clemente helps provide leadership to the self-funded community, working to advance the growth and success of self-insurance within the healthcare space.

During SIIA’s recent Self-Insured Health Plan Executive Forum held on March 5-7, 2018, in Charleston, SC, Mr. Clemente addressed the conference attendees consisting of senior executives of self-insured employers, third party administrators, stop-loss insurance carriers/MGUs and a variety of industry service providers.

Drawing on his over 25 years of SIIA involvement, Mr. Clemente kicked off this fast-paced and highly interactive conference where attendees were able to connect with other industry leaders while attending educational sessions that provided key insights into the self-funding marketplace.

After this successful SIIA forum, Mr. Clemente once again turns his attention and expertise toward providing innovative products and services to manage high-cost, high-risk claims as he leads SCM to be the marketplace’s only total risk solution.

How the Future of Dialysis Technology is Changing

Out of the approximately 100,000 people on the waiting list, there are only enough kidneys for 20% of patients. That leaves 80% of patients with kidney failure on the line (and on your bottom line).

The only hope for the 80% that don’t get a kidney is dialysis, which isn’t pleasant. It’s expensive for both clients, insurances, and facilities alike. It’s also disruptive to the patient’s everyday lives. Needless to say, dialysis could be better.

Will it get better? People are working on it, but only time will tell. Learn about the medical professionals, entrepreneurs, and scientists trying to improve dialysis technology below.

Portable Kidneys

The startup Qidini Labs is working on a nano-filter artificial kidney. The filter works as a tiny dialysis machine, almost like a small portable kidney.

The unit connects to dialysis ports on the neck and the patient (a sheep at this point) can go on with their day.

In October, Qidini labs won $550,000 in funding for this project, but the founder says they need at least two million to make it ready for human testing.

With this constantly working nano dialysis machine, renal failure patients wouldn’t need clinical dialysis at all. With increased functioning and an open schedule, they may even be able to go back to work!

Scientific Kidney Tissue

What if we could put an end to needing any sort of dialysis technology altogether? Scientists have made the first steps towards making that happen as of Friday, February 9, 2018.

Scientists at Manchester University successfully grew human kidney tissue that is able to produce urine. They used embryonic stem cells to grow Kidney Glomeruli, which make up parts of the organ.

They then combined this kidney stem cell mixture with a “gel-like substance” and inserted it into mice. Within three months, human kidney structures formed inside the mice.

The only thing missing? A large artery to power the kidney. This means these constructed-organs will only function at a fraction of a normal kidneys power.

We’re too far off to tell if this will mean occasional dialysis for renal failure patients or if the discovery cancels out the need for dialysis technology at all. Whatever happens, it’s an exciting development we’ll be sure to keep on our radar.

New Stem Cell Shunts

A company in California is in the late stages of testing a “lifelong shunt” in patients with renal failure. It’s made of human stem cells, unlike the man-made material of current dialysis shunts.

The idea behind it? The body won’t reject organic material and will be able to fight it’s own shunt infections. The shunt becomes a piece of the patient’s body, like any other.

Humacyte’s new shunt development is in stage two and three of FDA clinical trials. More research needs to be done on the long-term health of the patients before it’s released to the public.

Future Dialysis Technology and Cost Analysis

While there is still much work needed on these developments, we at Specialty CM are excited about the possibilities. Were they to come to fruition, these advancements would cut down on daily dialysis needs for both patients and clinics.

With less time and effort in a dialysis center, financial and human resources could be re-assigned to lacking places in a clinic. More financial efficiency, less staff tied up in dialysis, and more patient freedom? That’s what we want to see!

Until then, see how we can help you cut your costs in other ways. Give us a call today!

Caring for Stage 4 Kidney Disease Patients Through Renal Case Management

Stage 2 to stage 4 kidney disease costs Medicare more than $49 billion each year. This doesn’t even compare to the costs incurred as the patient’s condition deteriorated.

30-40% of patients with type 1 and type 2 diabetes will progress to stages of kidney failure. The total estimated cost of diabetes in the United States is over $245 billion annually.

These costs account for the largest portion of healthcare expenses in the US. Medical plans struggle to find the best care and minimize financial burden.

The proper renal case management can ease stress and reduces the financial toll.

Keep reading to see how the right renal case management can benefit everyone.

Fewer Mistakes and Better Care

Medical errors are now the third leading cause of death in the US. This doesn’t count millions of deaths not classified as medical errors but caused by them.

Renal Case Management streamlines and consolidates a patient’s care. Case management monitors treatments, medications, and care plans. They ensure the right course is being taken. This leads to fewer medication interaction errors.

Errors in treatment plans get corrected before implemented. Patients are safer and healthier. Billions of dollars saved because of fewer errors. Expenses reduced because unnecessary and redundant services get eliminated. The best course of action is identified and developed earlier.

Proactive Education with Stage 4 Kidney Disease

Many patients don’t feel in control of their health but with the right education, they can be. Stage 4 kidney disease is a difficult diagnosis emotionally and financially.

Educational resources for patient care providers help ensure they make the healthiest choices. Outcomes improve and complications reduce when compliance with best practices is enforced.

Healthcare plans can experience millions in savings with proper renal case management.

The dialysis costs for one patient can range between $45 000 and $90 000 monthly. Transplant programs, co-existing conditions, and other complications can add up to millions.

Legal Benefits of Renal Case Management

Renal case management services that include a defense fund relieves the client’s responsibility. A CDF can completely end financial liability for anything above actual medical costs.

Dealing with the medical, financial and legal burdens of stage 4 kidney disease can be confusing and overwhelming. It takes knowledge and expertise.

Renal case management is the most efficient way to accomplish this. Experts in their field manage each case. RCM allows collaboration to make the best decision for each individual situation.

The Expertise of Renal Case Management

It’s a complicated diagnosis and treatment process to manage and requires expertise. Renal case management provides a team approach to minimizing costs. It ensures the best course of action.

Collaboration occurs between:

  • A Registered Nurse who becomes the case manager assigned to the individual case,
  • A Medical Director who has specialized training and expertise in the areas of endocrinology and nephrology
  • A specialist in nutrition
  • Expert in pharmacology expenses and concerns
  • Financial specialists focusing on renal billing and coding

Providing the right care while minimizing the financial burden is not easy. It can be easier and more efficient with the proper renal case management.

Check out some testimonials on the benefits of renal case management.

5 Reasons Medical Stop Loss Insurance is a Must

Did you choose to fund your employees’ medical plans?

If so, you’re providing your employees one of the best benefits of all: great health. However, you still need to protect yourself. You and your company don’t deserve any downfalls regarding liability.

What’s the best form of health insurance protection?

Medical stop-loss insurance prevents you from assuming liabilities from an unexpected amount of claims. You can choose between individual protection and protection from the whole workplace.

Do you have a self-funded health insurance employee plan or plan on self-funding an employee health insurance plan? Here are 5 reasons why you should get stop-loss insurance.

1. Your Employees May Have Serious Health Issues

You want to provide the best health insurance for your employees, but you know there are expenses out of your budget. This is true for your employees with severe health issues.

Can you afford to pay for an employee’s weekly doctor visits or their serious surgical procedure?

These procedures and doctor visits can cost between hundreds and thousands.

Don’t put your company at financial stake — get medical stop-loss insurance.

2. Protect Against Lawsuits

Self-funded health plans have many benefits, but they also put companies at more risk.

If a company doesn’t monitor their health plans and spending, they could be sued. This includes fees that were never paid or forced the employer to pay extremely high fees.

When you have stop-loss insurance, you’re only responsible for paying certain aspects of the health plan. Therefore, you can be blamed for any other expenses.

3. Prevent Bankruptcy

If you have several employees, imagine how much healthcare costs add up?

This will result in catastrophic financial losses and could result in bankruptcy. Since you choose what you cover, stop-loss insurance helps maintain an affordable insurance policy.

You don’t want to go out of business because an employee is suffering a major health issue. Stop loss insurance helps you provide health benefits while handling the costs you can afford.

4. Medical Stop-Loss Insurance Helps Cover Additional Costs

As an employer, you choose what you cover and you cap your annual amount.

But what happens if your spending goes over budget? The stop-loss insurance company settles these costs. However, stop-loss insurance companies may have spending limits.

5. You Have Flexibility

Would you rather protect your company from a large and catastrophic claim or from multiple smaller claims that add up? With stop loss insurance, you have flexibility.

You can choose between individual or total claims. You can also choose to use both types of insurance.

Protect Yourself and Your Company

A self-funded medical plan is an affordable option to ensure your employees have health insurance.

But medical costs can become unpredictable. Specialty Care Management offers services to help make those catastrophic events more predictable and normalize the financial impact when they do happen.

It’s important you protect your company’s finances. The easiest way to do this is by purchasing stop-loss insurance and having the right cost-containment strategies in place before those events happen – and they will.

If you are currently experiencing a catastrophic claim, or are looking be more proactive with your cost-containment strategy, take a look at our services and contact us today!