QBE North America
With rising demand for organ transplants straining the budgets of self-funded health plans, Jen Lee, vice president at QBE North America, speaks with Diana Bui about how the company’s specialised coverage and stop-loss integration offer a comprehensive solution while ensuring high-quality patient care
The number of organ transplants performed each year continues to grow in the US. How does QBE's organ transplant coverage address the financial challenges that self-funded health plans face due to rising numbers and associated costs?
The increasing frequency and cost of organ and tissue transplants, with individual claims often exceeding US$1 million, create significant financial strain for employer-funded health plans. Traditional medical stop-loss insurance has been helpful, but ‘lasering’— which applies higher deductibles to individuals expected to need a transplant — introduces additional budgeting challenges.
QBE’s organ transplant coverage provides an important solution by offering first-dollar coverage specifically for transplants, addressing transplant-related lasers. This allows self-funded health plans to carve out the financial risk of transplants while maintaining predictability through a per employee per month (PEPM) premium. As the use of transplant-related lasers increases, fully insured group organ and tissue transplant policies are becoming more relevant. These policies help stabilise budgets and manage high-cost claims, often leading to discounted stop- loss premiums, while also reducing the financial risks associated with transplants.
QBE offers first-dollar coverage for all transplant- specific physician, hospital, and drug charges. How does this coverage structure benefit both employers and transplant recipients? How does QBE ensure that patients receive the best possible care throughout their transplant journey?
QBE’s organ transplant policy provides first-dollar coverage for all transplant-related physician, hospital, and drug expenses. This means that employees face no copays or deductibles for in-network services, which ensures that they can focus entirely on their recovery without the burden of out-of-pocket expenses. The benefit period spans from the initial evaluation to up to 365 days post-transplant, offering comprehensive support throughout the entire transplant process.
For transplant recipients, QBE provides a wide range of services, including access to top-tier transplant centres, coverage for necessary drugs like immunosuppressants and antivirals, and additional support such as home healthcare, physical therapy, and durable medical equipment. The policy also covers potential complications and offers generous travel, lodging, and meal reimbursement for both the patient and a companion, ensuring that logistical concerns are minimised. Additionally, once a transplant has occurred, QBE provides an indemnity payment, offering immediate financial support to the transplant recipient. QBE also assigns a dedicated transplant nurse navigator to guide recipients through every stage of the transplant journey, providing personalised assistance from evaluation to postoperative care. This ensures that patients not only receive the best possible medical care but also have access to ongoing support for any challenges that may arise.
For employers, this comprehensive coverage structure helps to stabilise budgets by mitigating the financial risk of transplant- related claims. The inclusion of fully insured group organ and tissue transplant policies allows self-funded health plans to carve out transplant-specific risks, ensuring predictability through a PEPM premium. In addition, most stop-loss carriers offer stop- forlesing premium discounts when such a policy is in place, making this approach a highly valuable tool for managing transplant-related risks.
Transplants can cost anywhere from US$250,000 to over US$1.5 million, which can be financially devastating for self-funded employers. How does QBE’s solution help employers manage these catastrophic medical expenses while maintaining the financial health of their health plans?
Transplant costs represent a significant and often unpredictable financial burden for self-funded employers, and without the right safeguards, a single high-cost claim can severely impact the stability of their health plans. QBE's organ transplant coverage mitigates this risk by carving transplant-related expenses from the overall health plan. This approach allows employers to better predict and manage their healthcare expenditures by isolating the financial volatility associated with transplants. By transferring the financial risk to QBE, employers can protect themselves from the unpredictable nature of these large claims, ensuring that their health plans remain financially sustainable.
Moreover, QBE’s solution is more than just about managing costs — it also guarantees that employees undergoing transplants receive high-quality medical care throughout their treatment journey.
This dual focus on financial protection and patient well-being makes QBE’s organ transplant coverage a vital tool for self-funded employers facing the challenges of costly medical procedures.
You mentioned that removing transplant risk could eliminate and/or mitigate associated lasers, as well as reduce stop loss premiums. Can you explain how QBE’s organ transplant coverage integrates with stop-loss insurance to create a more cost-effective solution for self-funded employers?
QBE’s organ transplant coverage works seamlessly with stop- loss insurance to create a more cost-effective solution for self- funded employers by carving out the financial risk associated with high-cost transplant claims. When employers choose to integrate QBE’s transplant coverage, they transfer the specific risk of transplant-related claims to QBE. This process is known as risk transfer, which helps employers manage their overall claims spend more efficiently.
By removing transplant risk from the general stop-loss policy, employers benefit in several key ways:
Reduction or elimination of transplant-related lasers. The practice of setting higher deductibles for individuals who anticipate high-cost medical events, such as transplants, is known as ‘lasering’. By carving out the transplant risk with QBE’s specialised coverage, employers eliminate transplant- related lasers, meaning the stop-loss carrier no longer needs to apply these elevated deductibles. This helps employers avoid unpredictable, case-specific costs and provides greater financial clarity.
Lower stop-loss premiums. With the transplant risk transferred to QBE, stop-loss carriers often reduce premiums. This is because the stop-loss insurer now faces a lower overall risk exposure without the potential for costly transplant claims. The result is a more cost-effective solution for employers, who benefit from both reduced stop-loss premiums and comprehensive transplant coverage.
Stop-loss captive and excess layer protection.QBE's organ transplant coverage can be applied across various layers, including the stop-loss captive and excess layers. This provides employers with an additional shield against catastrophic transplant costs at both the captive risk level and higher excess levels, further ensuring the financial stability of self-funded health plans.
Budget stability. QBE’s transplant coverage operates with a PEPM premium, which offers employers a predictable and stable cost for managing transplant risks. This budget stabilisation is critical for self-funded health plans because it protects them from the volatility of potentially massive transplant claims, allowing for more precise financial planning.
Comprehensive coverage and risk mitigation. QBE’s coverage includes first-dollar payment for transplant-related services, such as organ procurement, hospital and physician services, drugs (like immunosuppressants and antivirals), and other necessary medical and logistical expenses. This level of coverage ensures that transplant recipients receive the necessary care and shields employers from the financial burden of transplant claims.
Integrating QBE’s organ transplant policy with stop-loss insurance allows employers to manage their health plan costs more effectively. This comprehensive approach provides a holistic risk management solution, helping to reduce stop-loss premiums, eliminate transplant- related lasers, and ensure employees receive top-tier care, all while preserving the financial health of their self-funded plans.
As the landscape of employee benefits continues to evolve, how does QBE plan to innovate and adapt its organ transplant coverage and captive insurance offerings to meet the changing needs of employers and employees alike?
QBE remains committed to innovating its organ transplant coverage and captive insurance offerings to meet the changing needs of both employers and employees. Any self-funded group, regardless of whether their stop-loss carrier is QBE or another provider, can adopt QBE's organ transplant coverage as a standalone policy. This flexibility enables employers to seamlessly integrate transplant coverage into their existing benefits structure, offering enhanced protection without disrupting their broader insurance strategy.
QBE recognises the growing importance of captive insurance in the self-funded market. In the captive space, organ transplant coverage serves a dual purpose: it enhances the employee benefit plan by providing first-dollar coverage for all transplant- related expenses, while also protecting the employer and the captive layers from the financial risks associated with high-cost transplants. Transplant claims pose a significant risk to captives. By carving out this risk through a dedicated organ transplant policy, QBE helps captives preserve their financial integrity, ensuring that the layers of risk in the captive structure remain intact and manageable.
Looking ahead, QBE is focused on adapting its offerings to meet the evolving needs of the modern workforce in the future. This includes exploring ways to offer more personalised solutions that can help employers anticipate and manage the rising costs of transplants and other catastrophic health events. As healthcare trends change and the demand for specialised, comprehensive coverage grows, QBE is committed to maintaining a high standard of care by continually expanding access to top-tier transplant centres and improving patient support through services.
In the captive insurance space, QBE is exploring new ways to collaborate with partners to deliver even more tailored solutions for self-funded employers. By leveraging data analytics, risk assessment tools, and innovative financing models, QBE aims to further integrate its organ transplant policy into captive structures, allowing employers to proactively manage complex healthcare risks while offering employees robust and comprehensive benefits.
In addition to protecting employers and captives from expensive medical events, QBE's organ transplant coverage adapts to the changing landscape of employee benefits. This guarantees the necessary protection for both employers and employees in a constantly evolving healthcare landscape.
