Posted on in General

WATCH.VIDEO- Making Insurance Customer Friendly


A 31 year old female living in Northern Ontario had Hodgkins Lymphoma. Her stem cell transplant had failed. Her chemo drugs no longer worked.

A new drug (brentuximab) had recently been approved for use in Canada. Her oncologist wanted to use this highly effective drug. The drug is a new class called an antibody drug conjugate (ADC). The sticky antibody in the drug targets a bad boy protein on the cancer cell- CD30. The ADC zaps the cancer cell. This can lead to remissions in 30% of patients and improvement in another 40%.

Unfortunately, the application to the private insurer for funding for the drug  was declined.

RCM was retained by the client’s employer to solve this complex problem.

After a detailed review of the case, RCM assembled a local team to solve the problem.

RCM worked with the local oncologist, a local pharmacist with specialty drug experience, a local infusion center and with a local doctor who would supervise the infusions.

RCM resubmitted the application for funding to the private insurer. Approval was granted.


Healthcare is a COMPLEX ADAPTIVE SYSTEM. If you allow solutions to emerge by following the rules of the road, then they do.  VISA started by Dee Hoek began with a simple set of rules and a clear objective. A powerful transaction infrastructure emerged.

We began the case with a clear understanding of the objective- to seek funding for the new drug.

By being curious, we discovered a number of solution providers in the community.

Each solution provider delivered a part of the total solution. Then we contracted with each of the local solution providers to deliver the total solution.

In this case, Seattle Genetics had discovered a highly effective new class of drugs- ADC for Hodgkins Lymphoma.

The oncologist had been informed about this drug by publications from researchers working with brentuximab in clinical trials.

An enterprising specialist in the patient’s community had started an infusion center.  His staff were trained in safely infusing these complex medications.

A local licensed pharmacy had developed expertise in preparing these medications for the infusion center.

The manufacturer, Seattle Genetics, had an outreach program to teach local teams about how to infuse brentuximab.

The private insurer (Sun Life) had sold pooled stop loss insurance to the employer. This is an innovative new insurance solution that pools large numbers of employers and employees. The cost of this drug was $250,000. Pooling by Sun Life allowed for funding without penalizing any specific employer in the pool who experienced a high cost drug claim.

Our job at Rupert Case Management Inc. (RCM) acting as advocates and case managers was to put the solution together.

The solution emerged quickly when we recognized that all the pieces of the solution were available. We contracted with each solution provider. Then all we had to do was the start the engine and steer to the finish line.

It was a pleasure calling the patient at home to tell her that the brentuximab was to be funded and that the infusion center would call her in a few days to start the treatment.

This is an example of complex problem solving at Rupert Case Management.

The case shows how highly effective solutions can emerge in healthcare if there is a deep understanding of the issues and how the system works.