Oncology practices may soon find themselves working directly with employers on benefits and treatment strategies. As evidence of that, this year was the first that employer representatives were invited to speak at the Community Oncology Alliance (COA) annual conference, held last month in Orlando, Florida; in addition, a large employer coalition recently obtained a seat on COA’s Oncology Medical Home (OMH) steering committee. Employer representatives say they have taken a back seat to benefit design and management in years past, but now it has become imperative for them to get involved. “Employers didn’t necessarily want to be in benefits.
It kind of fell on them, and now it’s a mandate,” says Cheryl Larson, vice president of the Midwest Business Group on Health (MBGH), a large employer consortium that is supporting employer efforts to effectively manage healthcare costs. MBGH is especially concerned about rising costs for oncology.
A 2014 survey of employers by the business group found that none of them were doing specialty drug carve-outs for oncology, in which a separate set of rules would apply for payment; however, Larson says she knows anecdotally that some employers have already moved in the direction of carve-outs, and she predicts that future surveys will show that the idea is taking hold. At the COA conference, Larson shared data from one employer whose employee drug claims were less than 3% of total health claims from 2010 to 2015, whereas the dollar total of the drug expense soared from 20% of healthcare spending to more than 35%. Drug costs in 2016 for that particular employer are forecast to reach 50% of total healthcare spending, Larson said.
Oncology is not a sphere in which employers have wanted to dabble. The gravity of a cancer diagnosis is something that many employees do not wish to share with their employers, and companies have erred on the side of respecting employees’ privacy, said Karen van Caulil, PhD, president and CEO of the Florida Health Care Coalition (FLHCC) of employers, which is partnering with MBGH on certain benefit reform initiatives. However, there’s a lot of confusion and frustration among employees who are now trying to obtain care through high-deductible plans as a result of the Affordable Care Act (ACA). Many of them are afraid to seek care because they don’t want to be socked with high out-of-pocket costs, van Caulil said. Many don’t realize that they are allowed covered preventive screening under the ACA or that their employers may have oncology-specific plans that can mitigate the financial burden for them. In other cases, employees are showing up in managers’ offices and expressing deep concerns about their treatment options. All of this has demonstrated to employers that they need to be properly trained and prepared to respond to these issues, van Caulil said.
Oncology practices in the community often don’t know that employers have plans available that can help with treatment costs and coordination of care, and business leaders at the COA conference strongly recommended that practices hook up with their local chambers of commerce and leading employers to make sure these knowledge gaps are filled. “Employers are willing to assist with patient management and coordination. They want to be able to help with patient education,” van Caulil said.
FLHCC works with public and private employers, including a large school district with 35,000 covered lives that found a large knowledge gap existed among its employees, who were not connecting with their available oncology management benefits until three to four months into treatment. They would receive a call from a nurse manager saying, “Hi, I’m here to help you get started with your treatment.” That was too late, because the patient was already engaged with their treatment process, van Caulil said. To solve the problem, the district hired a nurse navigator and began putting up posters around the district advertising the nurse assistance, along with a number to call. Within five days, the nurse navigator received 180 calls, van Caulil said. “So, obviously, there was a pent-up demand for that kind of assistance.”
The problem was that the claims process was the trigger for the assistance call, whereas it should have been much earlier that patients received personal contact from a professional who could steer them through the system. Initially, the addition of the nurse navigator was a success, as overall costs of cancer care dropped 5% within five months. The school district was unable to continue the pilot program because of concern from union officials that the school district should not steer the employees to a particular program or provider. FLHCC continues to work with the school district and its key stakeholders to put a similar program in place.