What Employers Need to Know About Insurance Plan Restrictions in Cancer Care

The health insurance industry is very complicated and getting more so every year. There are many different players, as well as numerous policies and practices insurance companies and their partners use that can delay or deny the care your employees need.

According to a Business Group on Health survey¹, cancer is the top driver of employer healthcare costs, with 13% of employers seeing more late-stage cancers impacting their workforce and 44% predicting they will see an increase in cancer diagnoses in the future.

More than one in three Americans will be diagnosed with cancer in their lifetime, but with new advancements in medicine, cancer is highly treatable. The availability of precision medicine, including innovations in biomarker testing, has contributed to the 27% decline in cancer deaths since 2001. However, even though cancer treatment has improved, many patients still struggle to access the care they need at the time they need it.

One of the biggest obstacles employees with cancer face is utilization management (UM), a process that evaluates the efficiency, appropriateness, and medical necessity of treatments, procedures, and services on a case-by-case basis. Another impediment to care is pharmacy benefit managers (PBMs), who control patients’ access to medications.

While UM may help control costs in the short term, it can also create unintended consequences that may end up being more expensive in the long term. For example, delaying or denying access to necessary tests or treatments can result in disease progression, which may require more extensive and expensive treatment down the line. Additionally, UM can create administrative burdens and delays that can be frustrating and stressful for patients and their families.

Common UM Practices and Their Unintended Consequences

Employers should be aware of the most common utilization practices and the unintended consequences they present to employees diagnosed with cancer. These practices include:

Coverage Gaps For Biomarker Testing

Despite the potential for improved outcomes with the use of biomarker-directed treatments, many cancer patients still aren’t receiving biomarker testing, which identifies the specific genetic mutations that drive a person’s disease.

Recent cancer treatment advances have led to precision medicine, which uses biomarker testing (also called genomic testing) to identify the specific genetic mutations in an individual’s cancer. Biomarker testing enables clinicians to determine if there’s a targeted therapy that’s likely to control their disease and allows patients to avoid generic chemotherapy and radiation that might not be effective for their form of cancer.

A 2023 CancerCare survey² of cancer patients found that biomarker testing helped doctors tailor therapy for nearly all the patients (93%) whose cancers were tested over the past 3 years. One in 10 cancer patients became eligible for a clinical trial because of biomarker testing, and 20% avoided unnecessary chemotherapy and/or radiation.

Restrictive Formularies

A formulary, which is a list of drugs approved by a health plan, often limits or changes access to drugs for financial reasons, which can cause serious unintended consequences for patients. Restrictive formularies have become a common UM tool, and patients are increasingly likely to discover “gaps” in their drug benefits and face significant out-of-pocket costs if they need to access a medication that isn’t on the list.

Prior Authorization

Prior authorization⁴ (PA) requires that certain medical services, treatments, or prescriptions be approved by insurers before a patient can access them. This process is supposed to control healthcare costs but can lead to long delays and cause serious unintended consequences while not really saving money.

An American Medical Association study found that nearly all (93%) doctors reported that PA was linked to delays in patient care, and 9 in 10 (91%) said PA had negative impacts on clinical outcomes. For cancer patients, a delay in getting needed medication can be risky because these medications are necessary to control their cancer. 

Out-of-Pocket Costs

Insurance companies have long been shifting the financial burden to patients, but high-deductible health plans, coinsurance, and copay accumulators have exacerbated the problem. A 2022 study revealed that a staggering 100 million U.S. adults are currently in debt due to healthcare expenses, with 12% owing more than $10,000. This epidemic of healthcare debt is having a devastating impact on the lives of individuals and families, with nearly half of all cancer patients experiencing financial distress that can lead to a decrease in health-related quality of life.

Plans That Prioritize Patients

Health insurance should be designed to provide employees with access to the care they need without unnecessary roadblocks. However, cost-control measures can sometimes interfere with this goal, leaving cancer patients struggling to get the treatment they require. Employers have an important role to play in prioritizing the needs of patients and advocating for benefit plans that balance cost while ensuring cancer patients have timely access to the care they need.

Patricia J. Goldsmith is CEO of CancerCare. A frequent speaker at national meetings and symposia, she was named in 2021 to Forbes Magazine’s 50 Over 50 Vision List, honoring women making an impact on society and culture. In 2022, CancerCare published a free toolkit that helps inform the benefits package design and decision-making process and offers key considerations when plans include UM.

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