Hemophilia was Symetra’s fourth largest excess loss claim diagnosis in 2006. Although that represented only 9 percent of the top four categories of excess loss claims, individually the claims were substantial — totaling more than $1.4 million and averaging $326,000 per individual.

Treating hemophilia is expensive. It is not uncommon for hemophiliacs to reach their lifetime benefit maximum while still in early childhood. In 2006, two Symetra claimants exceeded their lifetime benefit within 30 days during inpatient hospitalizations due to complications. For that reason, it is imperative that all measures be taken to assist claimants in conserving their benefits.

What is hemophilia?

Hemophilia is a rare genetic disorder that prevents the blood from clotting normally. While most hemophilia is inherited, approximately 30 percent of cases are due to spontaneous genetic mutation. About 18,000 people, mostly males, are afflicted in the United States. Worldwide, about 400,000 people are affected, 70 percent of whom do not have access to treatment.

Sixty percent of the hemophilia population falls into the severe category requiring prophylactic therapy several days a week. Affected populations bleed after injury and have spontaneous bleeding in the joints and muscles.

Presently, there is no cure for hemophilia. The only treatment currently available is a lifelong infusion of replacement “blood clotting factors” — the deficient protein — with either human plasma derived (least cost per unit) or manufactured recombinant product.

Costs and Solutions: A Case Study

Arthur (fictitious name) is a 12 year old with severe-level Hemophilia A on maintenance Recombinant Factor VIII, Advate. He was effective on his father’s health plan on January 1, 2005. In early 2006, Arthur was averaging $34,000 per month in charges. The costs of the infusions alone were $28,000 after the PPO discount.

After reviewing the case, a Symetra Medical Risk Consultant (MRC) determined that at the current monthly costs, the child would exceed his $2 million lifetime benefit before he was 18 years old. The MRC recommended two options to the employer’s benefit consultant to consider:

1. Approach the family to discuss changing to another reliable pharmacy provider, such as Symetra’s preferred provider, or
2. Negotiate an additional discount above the PPO discount with the current provider.

Symetra’s preferred specialty pharmacy provider charged $1.18 per unit, or a 43 percent discount below the PPO payable. That would have resulted in a savings of $12,320 per month or $147,840 per year.

However, moving to another provider was not an option for the family, so the employer’s consultant, the primary case manager and the family opted to negotiate with the current provider. The negotiation resulted in a savings of $52,000 per year.

Symetra is here to help

Symetra has three specialty pharmacy providers that are able to provide hemophilia products across the country at pre-negotiated rates. Please contact one of our Medical Risk Consultants to assist you in discussing the best possible outcome to manage this and other high cost infusions. Call
1-800-426-7784 or visit our web site for contact information.

Greta Pressler, RN CCM, is a Medical Risk Consultant for Symetra Life Insurance Co. She has 18 years hospital based nursing experience & 22 years of experience health insurance industry. As an MRC at Symetra Life Insurance Company, Greta oversees ongoing catastrophic medical concerns and consults with our TPA partners and regional sales staff to provide support for their employer groups regarding access to Symetra’s managed care providers and other support services.