Roadblocks and rising costs in cancer treatment: What employers can do

Despite major advances in the diagnosis and treatment of cancer over the past two decades, it continues to pose significant health challenges, affecting millions of individuals and their families each year. 

The American Cancer Society estimates that nearly two million individuals were diagnosed with cancer in 2022. Beyond the health toll on employees, the escalating costs associated with cancer treatment also impact employers. As new discoveries in medical technology and innovative therapies continue to emerge, the price of cancer treatment has skyrocketed, placing a considerable financial burden on employers.

Employee benefits managers are responsible for evaluating and choosing benefits packages that balance sufficient coverage with cost. However, insurance companies and benefits consultants often propose cost-saving strategies, called utilization management (UM) practices, that control patients' access to healthcare services.

Unfortunately, UM can have a negative — though unintended — impact on outcomes for employees diagnosed with serious illnesses like cancer.

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For example, consider biomarker testing, which can identify how specific biomarkers within a person's tumor can respond to precisely targeted treatments. In a recent CancerCare survey of patients who had biomarker testing, only three of out of 10 had it covered by insurance. This important test, which can improve outcomes, helped 20% of cancer patients surveyed avoid unnecessary chemotherapy and/or radiation and 10% became eligible for a clinical trial based on the biomarker testing results.

Roadblocks to care
One roadblock to care is pre-authorization (PA), (also referred to as "prior authorization," "prior approval," and "pre-certification"), which requires that certain services and treatments be submitted to the insurer for review and approval as medically necessary before the care is provided. Unfortunately, PA can delay treatment, restrict access to medications or specialists and increase out-of-pocket costs for patients.

Another hindrance can be a result of the design of formulary, which is a list of drugs approved for coverage by a health plan, often arranged into tiers. Health benefits plans may control or change access to medications with limited notice to members or clinicians, which can cause significant unintended consequences for patients who are in serious need of their prescribed treatments.

Step therapy is a protocol that forces patients to try one or a series of drugs before being allowed access to the medication prescribed by their clinician. Patients may suffer weeks or months of delay while taking less effective, or even harmful treatments, which can be devastating for people with cancer or other serious conditions.

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In addition, some health plans require that patients use specific specialty pharmacies, which restricts where patients can access their medications. Although some specialty pharmacies increase access to treatment, others may be too restrictive, and offer very limited in-network choices of pharmacies that carry the prescribed treatment.

Employees with serious medical conditions are also challenged by copay accumulator programs, which have changed the way patients pay for their medications. This program is a strategy used by insurance companies and Pharmacy Benefit Managers (PBMs) to prevent manufacturer copay assistance coupons from counting towards the patient's deductible and the maximum out-of-pocket spending. For patients, the unexpectedly high costs can make their medications unaffordable altogether.

What Employers Can Do
It's clear that common utilization management practices can negatively impact patients — especially those with cancer and other serious conditions — by delaying, disrupting or denying care, increasing out-of-pocket prescription costs, and creating barriers to receiving personalized care. Many of these cost-saving measures can actually cause harm because insurance plan restrictions prevent patients from accessing the medications they need, thereby compromising employee wellbeing and productivity.

Employers would be well-served to work closely with health insurance providers to design benefit plans that balance comprehensive coverage and cost containment. Negotiating with insurers to include more cost-effective treatment options and pharmacy benefit management strategies can help control expenses. Additionally, exploring alternative coverage models, such as high-deductible health plans combined with health savings accounts, can provide employees with options without increasing the financial burden on tight budgets.

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To reduce roadblocks to care, employers should consider eliminating cost-sharing for medications or supplies related to chronic illnesses, making coverage available for these services and treatments before employees reach their deductibles, and streamlining burdensome pre-authorization processes.

Quality health plans not only benefit patients, but employers, too. They can enhance productivity, help control long-term medical spending, attract and retain talented employees, and build satisfaction and loyalty by demonstrating that the company values its people and their wellbeing.