Health Plan News Q4 2022

Key statistics

What plan sponsors are doing to manage the rising cost of cancer care and improve outcomes

For most plan sponsors, oncology is now the number one disease category in terms of health cost spending. As the U.S. population ages, 77 percent of cancers are diagnosed in people over age 55. Nearly 40 percent of American adults are obese, which increases the risk of cancer. High-risk behaviors, including excessive alcohol consumption, tobacco use, excessive sun exposure and use of tanning devices contribute to increased cancer prevalence rates. Additionally, during the pandemic, many people missed preventive cancer screenings, which could lead to diagnoses of more advanced stage cancers.

Prevention

While some risk factors (e.g., age and genetics) can’t be changed, actions reduce or eliminate exposure to cancer-causing factors. Plan sponsors may want to consider cancer prevention education that focuses on:

• Smoking-cessation programs addressing all tobacco products, including marijuana and vape products
• Protecting skin from the sun and avoiding intentional tanning
• Limiting alcohol consumption
• Maintaining a healthy weight through regular physical activity and a nutritious diet
• Ensuring proper sleep (8–10 hours)
• Drinking plenty of water and avoiding sugary drinks

Screening

The earlier cancer is caught, the easier it will be to treat. Screening increases the chances of detecting certain cancers early. The ACA requires preventive screenings to be covered without cost sharing. Communicate screening recommendations annually and educate participants on the benefits of early detection.

Diagnoses

Providing support at diagnosis and during treatment has the highest impact on quality and cost. Treatment decisions should be made after discussing all cancer treatment options. Pathology has high variability in accuracy and will impact diagnosis and treatment. Consider these strategies that aid accurate diagnosis and treatment:

• Build second opinions into your prior authorization so the patient doesn’t have to trigger them.
• Centers of excellence (COE) provide high-value healthcare, often at lower prices than other medical centers. Oncology care is emerging as an area where COEs excel. New, cutting-edge cancer care infusion treatments are very expensive, so precision matters. Experienced oncology teams avoid giving expensive treatments by trial and error, so the right care is delivered the first time.
• Offer coverage for approved genetic testing and counseling.
• Offer preference-sensitive decision-making support for cancer treatment when active treatment is not desired by the patient.
• Ensure the network is based on high-quality publicly available data with a strategic benefit design. Consider asking vendors if they are tracking five-year survival rates, infection rates and surgical complications.
• Consider caregiver benefit strategies to support both the person diagnosed with cancer as well as the caregiver.

Management of cost and quality of care

Proper medical management can improve cost, quality and patient experience. Focusing care management on the highest-stage malignancies reduces the impact to the overall population. Provide support for uncomplicated, lower-stage cases with a focus on the social and behavioral health needs of this population.

Ensure accurate diagnosis and treatment through:

• Utilization management guidelines based on National Comprehensive Cancer Network criteria, ensuring alternative pathways that may offer the same clinical efficacy with variations in cost
• Clinical care management that includes support for social determinants of health and integrated behavioral health management to prevent interruption in treatment
• A proactive pharmacy site of care steerage program at first dose for cancer treatment as well as adjunct therapy, which should also move from outpatient to alternative infusion site, physician office or home, when clinically appropriate
• Increased patient access to lower-cost generic or biosimilar drugs where clinical alternatives are available
• A registered dietitian consulting with patients to reduce negative side effects, mitigate nutritional losses and maximize treatment
• A low-touch and/or virtual model for lower-stage uncomplicated cases, with a focus on social and behavioral health needs of the population
• Survivorship support that includes financial recovery and fertility support

Compliance reminders

Prescription drug reporting deadline approaching

Plan sponsors are preparing to comply with the prescription drug reporting requirements of the Consolidated Appropriations Act of 2021. By December 27, 2022, they must report to the federal government certain information concerning their plans’ Rx costs. Learn more in our August 30 insight.

The Inflation Reduction Act’s health provisions

The Inflation Reduction Act extends premium subsidies in the ACA marketplace and lowers prescription drug prices and out-of-pocket costs for Medicare participants. The law has the potential to significantly affect plan costs for both prescription drugs and retiree Medicare supplemental programs, particularly Employer Group Waiver Plans. Read more in our August 10 insight.