The Sun Life Clinical 360 program combines our extensive high-cost claim data with clinical experts that act as a second set of eyes for our clients, reviewing claims to identify cost savings and care optimization opportunities. Clinical 360 is available at no additional cost to all Sun Life Stop-Loss clients. Watch the video below to hear more about Clinical 360.
Our experienced clinicians work closely with brokers, administrators, and partners, to identify opportunities to optimize care and reduce costs. Our team draws on their clinical knowledge to find savings opportunities, such as identifying billing errors, finding duplicate charges, or moving high-cost infusions to more affordable at-home administration for a better care experience. Our relationships with care providers and preferred partnerships allow us to negotiate out-of-network fees and access condition-specific management programs.
Access to a wide variety of programs including medical Rx management, negotiation specialists, and condition-specific management.
Data-driven opportunity identification based on analysis of extensive claims and clinical data.
Introducing Clinical 360+
Clinical 360+ combines the data-driven approach of identifying opportunities for care optimization and cost savings of Clinical 360 with the coordination and deployment of targeted health capabilities for select clients who may not have access to these capabilities on their own.
Learn more about Clinical 360+
*Source: Sun Life 2023 internal data
In 2023, Sun Life's Clinical 360 program achieved over $36.2 million in savings.
Sun Life is not responsible or liable for the care, services, or advice provided by Somatus, OptiMed Health Partners, or Hinge Health, and reserves the right to discontinue this service at any time. Sun Life will collaborate with your TPA on eligibility and applicability of programs. Health Navigator is provided by PinnacleCare. PinnacleCare is a member of the Sun Life Financial Inc. (“Sun Life”) family of companies. PinnacleCare and its employees do not diagnose medical conditions, recommend treatment options or provide medical care, and any information or services provided should not be considered medical advice. Any medical decisions should be made only after consultation with and at the direction of the member’s medical provider. Any person or entity who provides health care services following a referral or other service provided does so independently and not as an agent or representative of PinnacleCare. Group stop-loss insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 07-SL REV 7-12 and 22-SL. In New York, Group stop-loss insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12 and 22-NYSL. Policy offerings may not be available in all states and may vary due to state laws and regulations. Not approved for use in New Mexico. © 2024 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. The Sun Life name and logo are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. GSLCR-10937 #1475680447 08/24 (exp. 08/26)
With Sun Life’s transformation into a health value company, we have enhanced our industry-leading Clinical 360 program by implanting new health capabilities through partnerships with OptiMed Health Partners and Somatus. These programs offer our Stop-Loss clients and their employees with access to high value, comprehensive care in the comfort of their homes for conditions that typically result in some of the highest-cost claims.
Medical Rx 360
Kidney Care 360 and Heart Care 360
In 2023 alone, Sun Life had close to 8,000 members who used a high-cost drug that contributed towards a stop-loss claim. Total spend on high-cost drugs for our clients in the same year was over $500M. This presented an opportunity for Sun Life to work towards improving the costs for members requiring ongoing treatment, saving on both stop-loss reimbursement dollars and first-dollar expenses for our clients.
Cardiovascular disease is the second highest-cost condition based on stop-loss reimbursements in 2023, with over $360M in total spend. Kidney disease, under the Urinary/Renal category, is tenth highest, with over $125M in total spend. For members with congestive heart failure (CHF) or chronic kidney disease (CKD), providing them with patient-centric, personalized care from Somatus is key to achieving both improved outcomes and reduced costs.
Learn more about Medical Rx 360
Learn more about Kidney Care 360 and Heart Care 360
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Clinical 360
Want to learn more? Contact your broker or Sun Life Stop-Loss Specialist
Powered by OptiMed
Powered by Somatus
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Optimizing care and costs
Providing expert support for preventive health and care optimization for complex or chronic conditions is important for self-funded employers to reduce costs and improve the well-being of their employees. However, finding the right partners to deliver this expertise can be challenging. Sun Life Clinical 360+ is here to help.
By enhancing Sun Life’s industry-leading Clinical 360 program, we can provide targeted, health capabilities to deliver better health outcomes and cost savings for our stop-loss clients. Giving members access to better care, preventive health support, care navigation, and clients with the member engagement strategies to enable it all.
Discover more about our Clinical 360+ program! Click below to learn about our targeted health capabilities for our clients:
To learn more, contact your broker or Sun Life Stop-Loss Specialist
Kidney Care 360 & Heart Care 360, powered by Somatus
Sun Life Health Navigator
Hinge Health
Sun Life Health 360
Click to learn more!
Medical Rx 360, powered by OptiMed
Highly recommended
Clinical 360+ is available to select small-to-mid-sized self-insured employers who use a third-party administrator. All services provided within Clinical 360+ are managed by your Sun Life team, and implementation is completed through a seamless adoption process, including coordination of the Memorandum of Understanding (MOU) and monthly eligibility files. Clinical 360+ is available to select small-to-mid-sized self-insured employers that use a TPA. [SH1] All services provided within Clinical 360+ are managed by your Sun Life team, and implementation is completed through a seamless adoption process, including coordination of the Memorandum of Understanding (MOU) and monthly eligibility files. [SH1]Need Krysten to confirm.
How it works
Delivering results for our members
About OptiMed
For over 30 years, OptiMed Health Partners has been a nationally licensed, multi-accredited provider of specialty injectable drugs and infusion services. With their national operational capabilities and clinical expertise, OptiMed supports patients in their treatment journey with safe, convenient, and cost-effective services within a variety of healthcare settings.
Source: OptiMed Health Plan internal data from 2018-2023. Estimated savings are case specific and will vary with each patient and situation.
Sun Life and OptiMed are focused on providing:
High-cost injectable specialty drugs
Our expansive list of specialty drugs managed by Medical Rx 360 includes high-cost drugs we see often in Sun Life stop-loss claims, including: Tepezza, Soliris, Ocrevus, Hemlibra, Neulasta, and Remicade.
A change to at home treatments from a dedicated care team, gave a pediatric member and their family peace of mind that the life-changing infusions their child needs will continue to be covered and delivered with limited interruption to their daily lives, while reducing costs to by an estimated $396K per year.
By redirecting infusions from the hospital to the members’ homes, we lower the risk of infection and complications while reducing costs to an estimated $100K per year.
Applying Medical Rx 360 strategies to even just a small percentage of claims can reduce spend on certain high-cost drugs 15-55%, while also providing members with better access to care. In addition, this solution does not conflict with PBMs.
Access to the best treatments and infusion care at home
Member support from a dedicated care team
Reassurance knowing their approved medications are clinically appropriate at the lowest possible costs
To learn more, contact your broker or Sun Life Stop-Loss Specialist.
Flexibility in treatment schedules to fit into a member’s daily life with limited disruption
Medical Rx 360 is provided with no business administration fees or program costs. It can be delivered as comprehensive carve out program or single case agreement.
Sun Life’s partnership with Somatus makes it easier to connect health plan members to care management services. Somatus believes in whole person care with multidisciplinary in-home teams that work as an extension of existing providers to improve outcomes. Through better managed care, Somatus has helped reduce unnecessary hospitalizations by 31% and achieved 17% average per person annual cost savings and a 26% reduction in dialysis crashes.* Sun Life’s partnership with Somatus makes it easier to connect health plan members to care management services. Somatus believes in whole person care with multidisciplinary in-home teams that work as an extension of existing providers to improve outcomes. Through better managed care, Somatus has helped reduce unnecessary hospitalizations by 31% and achieved 17% average per person annual cost savings and a 26% reduction in dialysis crashes.[SH1] [SH1]Need to include source
Click here to hear how this approach to care has impacted OptiMed patients.
Sun Life is your second set of eyes. To learn more, contact your broker or Sun Life Stop-Loss Specialist.
Delivering better outcomes to our members
Care and cost optimization with Somatus
About Somatus
Sun Life works closely with Somatus to engage eligible members and get them enrolled in Somatus services and care.
A 50-year-old male with a history of high blood pressure, congestive heart failure (CHF), stage 3 chronic kidney disease, and diabetes had multiple hospital admissions related to his CHF before working with Somatus.
He connected with Somatus for help controlling his blood pressure and managing his symptoms and medications. Through working with a Somatus coach, he was able to better manage his condition by taking his medications and diuretics regularly. In addition, he was provided assistance with medication costs, education on managing his CHF and dietary counseling to reduce fluid and sodium intake.
After implementing these health changes to his daily life, his blood pressure improved to normal levels, his weight decreased, and his risk level was reduced from high to low. Additionally, he had a 98% reduction in healthcare claim costs after working with Somatus.
How care and cost for care are dramatically improved with Somatus
Somatus improves quality of life for members with kidney disease, cardiovascular disease, and comorbidities through personalized, in-home care that reduces hospitalizations, resulting in healthier members and lower costs for plan partners. With a proven track record managing over 50,000 patients, Somatus uses physician-designed, predictive technology to deliver immediate value.
Learn more about Kidney Care 360 and Heart 360
Cost of care based on 33-year-old female with CKD 4 and unmanaged blood pressure over a 12-month comparison period. 1. https://business.caremark.com/insights/2021/early-identification-chronic-kidney-disease-key-lowering-costs.html
Information anonymized to protect patient confidentiality
Unlikely to have kidney transplant or home dialysis
Shifts to in-center dialysis, 3x / week, 4 hours / day
Unplanned dialysis crash in ER
No nephrology care, limited primary care
Frequent avoidable hospitalizations
Plan for home modality start, swift transplant
Goal to avoid in-center start
Blood pressure controlled with diet and medications
Regular nephrology care and primary care
Zero hospitalizations
Traditional path
Path with Somatus
Annual Total Cost of Care
See Ms. Jones success story for details. Information anonymized to protect patient confidentiality.
~ $180,000
$10,464
*National, client-designed, propensity-matched study of kidney patients participating in the Somatus Care Management program vs patients not in the Somatus program
The Sun Life Clinical 360 team continuously identifies members with specific diagnoses related to kidney disease and heart disease.
For clients who have adopted Clinical 360+, their eligible members can access Kidney Care 360 & Heart Care 360 in the Sun Life Health 360 app.
Kidney Care 360 & Heart Care 360 are provided at Sun Life’s expense.
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Learn more about Hinge Health
About Hinge Health
Hinge Health is a digital health company that provides virtual physical therapy for MSK conditions like back and joint pain. Hinge Health aims to help employers and health plans reduce MSK-related medical spend while improving outcomes. Their virtual care model allows patients to conveniently access care from home while still receiving high-quality personalized treatment.
Supporting members no matter where they are in their MSK journey with easy access to Hinge Health support through the Sun Life Health 360 app.
The impact of Hinge Health, the nation’s leading MSK health solution
• 68% pain reduction on average • 52% of MSK surgeries avoided • 58% average reduction in depression and anxiety • 42% reduction in new opioid prescriptions
Pre/post surgery rehab
Surgery decision support
Chronic pain and pelvic health
Prevention
Recent Injury
Click here to see how Hinge Health helps members with their pain.
1. In a 12-week study of chronic knee and back program participants. Bailey JF, et al. Digital Care for Chronic Musculoskeletal Pain: 10,000 Participant Longitudinal Cohort Study. J Med Internet Res 2020. 2. In a 2022 study comparing 4,207 Hinge Health members with 4,207 matched comparison group members in the year after starting the Hinge Health chronic MSK program, 136 Employer Medical Claims ROI Study, 2022. The study defined surgery as any MSK- related surgical procedure that would have been rendered to a study participant in a 12-month period. 3. In a study comparing Hinge Health members with traditional PT patient s. Wang G, et al. Opioid initiation one year after starting a digital musculoskeletal (MSK) program: an observational, longitudinal study with comparison group. J Pain Res. 2023.
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As a part of Clinical 360+, Sun Life and Hinge Health, Sun Life and Hinge Health provide members with a team of experts and leading technology to access the MSK care needed to achieve better health and cost outcomes.
Orthopedic physicians help members make informed surgery decisions, if needed
Physical therapists lead and monitor care
Board-certified health coaches help members build healthy habits
Provided at Sun Life’s expense for the first policy year.
Expert support and guidance
Learn more about Health Navigator
Why Health Navigator
Value Story
FAQs
Knowledgeable and skilled team to help members
75 Medical Advisory Board members
Health Navigator is comprised of a muti-disciplinary team of health experts who collaborate to support our members. Our team includes:
54% of expert opinions identified a more appropriate treatment plan or variation to the original diagnosis $13K average savings per treatment outcome. Outcomes may be avoided treatments, less invasive testing or surgery or a change in treatment. Does not include productivity savings. One third of appointments for members diagnosed with cancer were expedited and scheduled with more qualified cancer specialists than the members' current providers.
Watch how Health Navigator helped one member after her daughter suffered a traumatic eye injury. Then, read more of our member success stories to discover how Health Navigator can benefit your organization and employees.
Source: 2023 Sun Life Health Navigator book of business data.
20 MD, PhD, and specialized medical researchers, including dedicated Behavioral Health researchers
130+ relationships at top regional and national hospital systems
8 Medical Directors
100 Care Advisors (MDs, NDs, RNs, BSNs, MSWs)
Health Navigator is available at a competitive PEPM.
By providing Health Navigator at a competitive PEPM alongside your Stop-Loss coverage, you will receive two new cost-saving benefits: a 10% step down deductible ($25k max) and 3% ADF credit.
Health advocacy and care navigation
Medical intelligence
A better member experience and improved outcomes
High-touch, highly personalized engagement model delivered by experienced Care advisors.
Successful healthcare navigation
In-depth medical knowledge on a wide range of health conditions combined with deep expertise in nuances of the healthcare system.
Confidence in healthcare decisions
Improved health outcomes, often leading to reduced costs
We help members with any health need including finding in-network primary care providers and specialists, facilitating and preparing for appointments, collecting medical records, obtaining expert second opinions from qualified providers, and more.
Learn more about Sun Life Health 360
About Sun Life Health 360
View a demo of Sun Life Health 360
Access to Sun Life Health 360 is provided at Sun Life’s expense.
Sun Life Health 360 is powered by Dialogue, a leader in virtual healthcare and wellness platforms currently serving 2.5 million members. Health and wellness resources available all in one app focusing on:
Wellness
Physician-reviewed library
Sun Life Clinical 360+
Movement
Mental Health
Preventive health support to promote healthier living through daily habits
An expansive library of content to provide members with data-backed information about their health and wellness
Members gain access to patient-centric support for those with musculoskeletal challenges, kidney disease, and congestive heart failure as well as care navigation support for all health needs
Fitness content, workouts, and tracking capabilities to support a healthy lifestyle
Self-led mental health support and educational content available 24/7, to address the needs and preferences of members
IV infusion alternative
Having a second set of eyes
Out-of-network bill negotiation
Verifying medication costs
Validating high cost cancer drug charges
Investigating anti-rheumatic drug charges
Repricing for multiple dosages
Lowers injectable drug prices
Correcting duplicate charges
Site of care change
Recognizing incorrect charges
Making site of care more convenient
Transitioning to infusions at home
From hospital to home infusions
Treatment delays lead to change in care
Savings from transplant network agreement
Making specialty drugs more convenient
Moving to home infusions
Negotiating a high-cost hospitalization
Transplant network contract placement
Evaluating high-cost specialty drug charges
Member's choice of at home provider
Saving time moving to home infusions
Using the Clinical 360 data-driven approach to identify individual opportunities, our clinical experts will work closely with Somatus, broker partners, and administrators to deliver Kidney Care 360 and Heart Care 360 services at the case level. Engaging with the client and member, Somatus will:
• Provide the member with a team of experts as an extension to their existing care team and providers to coordinate and improve outcomes for the member. • Focus on proven care models to slow the progression of chronic kidney disease, congestive heart failure, and related conditions that impact member's overall health and productivity.
Applying Medical Rx Management strategies to even just a small percentage of claims can reduce spend on certain high-cost drugs
As part of Clinical 360+, Kidney Care 360 and Heart Care 360 come as a value-added solution included with every Sun Life Stop-Loss policy. With our approach, we can help to reduce the financial pressure on self-funded employers and provide access to the best care to their members.
Clinical 360, our broker partners, and clients
Clinical 360 + Somatus + broker + health plan administrator
Clinical 360 + Somatus
Somatus + client + member
Identify members with specific diagnoses related to kidney and heart disease.
Assess individual member for appropriateness and potential for Somatus support.
Review opportunity with a solutions overview asking for premission to offer care management services to the member.
Somatus will work to engage the member directly and get them enrolled in their care management services.
Click each step of the process to learn more
The Sun Life Clinical 360 team identified a pediatric claimant receiving Remicade infusions in a facilitaty two hours away, every four weeks, to manage their Crohn's disease. The employer group was being charged 4.6 times the average wholesale price for Remicade.
Optimed reviewed the case and proposed the best available pricing, and also recommended a change to at-home infusions from a dedicated pediatric care team.
With Optimed's support, we were able ot provide a better experience for the claimant and their family, including: • The security of knowing the infusions their child will receive for years to come will be covered and provided at no out-of-pocket cost to the member, or subject to a health plan deductible • The best possible care provided at home, allowing for flexibility in treatment to fit in to their lives—no long drives for treatments, a regular school and activity schedule, reduced time off from work to provide care
Remicade is on the list of top 20 high-cost injectable drugs within Sun Life’s 2022 book of business
Click here to learn more about Medical Rx Management, powered by Optimed!
15-55%
$396k
anticipated savings per year
33-year-old female with diagnosis of CKD 4 and high blood pressure
• Poorly controlled blood pressure, in need of symptom management plan and daily log • Very limited CKD diet education, needs help with meal planning and recipes • Requesting weight management support • Interested in kidney transplant
