Nearly half of employers that track condition-specific data cite cancer as the No. 1 contributor to
Advancements in the precision and
While weight-loss medications like GLP-1s may be stealing headlines, cancer-related drugs remain among the most costly and complex contributors to healthcare spend. The 2024 Brown & Brown PharmaLogic reporting suite showed that oncology therapies drove a 15.4% year-over-year increase in gross cost per member per month. Oncology products alone accounted for 7.8% of total gross costs among clients.
At the same time, the rise of orally administered and self-injected oncology treatment is shifting the submission of cancer-related claims from the medical benefit to the pharmacy benefit. While this change allows more patients to receive cancer-related treatment at home, it introduces new challenges for employers.
Home-based treatments often fall under pharmacy benefits, which may have different cost-sharing structures than traditional medical benefits — potentially resulting in higher out-of-pocket costs for patients. This, in turn, places pressure on employers to re-evaluate benefit design opportunities that ensure both affordability and access.
To help mitigate the potential financial burdens of cancer therapies, employers can leverage manufacturer co-pay assistance programs that could help lower out-of-pocket expenses for patients. They also can implement utilization management strategies, such as prior authorizations or step therapy edits, to ensure medications dispensed are appropriate for a given patient's condition. In addition, they're advised to ensure that appropriate medical case management teams are in place to provide ongoing support for beneficiaries.
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Coordinated care management
When pharmacy benefit managers (PBMs) and medical case management teams operate without coordination, critical information about patient care is easily missed. But when these teams are in routine contact and share information, outcomes are improved through continuity of care, prevention of duplicative treatments and the support of personalized, effective care plans — all while reducing unnecessary costs. This alignment is especially critical in oncology whose complex treatment regimens span medical and pharmacy benefits.
Employers should seek out medical plans that offer dedicated oncology case management. The most effective programs have a multi-disciplinary team, including an oncology case manager, licensed social worker and certified oncology nurse. The best oncology management teams prioritize support and services such as early outreach to initiate care upon a new diagnosis, personalized support throughout treatment and access to pharmacogenomic testing to guide more effective, personalized medication choices.
Specialty pharmacies also play a pivotal role in bridging the gap between pharmacy and medical care. With a unique focus on dispensing high-cost medications used for complex or chronic conditions, specialty pharmacies are uniquely positioned to manage the special handling, monitoring and patient education required with these products. Because of the complexities of oncology medications and their treatment protocols, it is important that specialty pharmacies help ensure treatment plans are properly followed and continuously adjusted based on patient needs. Specialty pharmacies that actively collaborate with providers, PBMs and case management teams help reduce the likelihood of medication-related complications and adverse events.
Employers should consider partnering with a specialty pharmacy that offers comprehensive services such as integration with the PBM and case management teams, as well as education of patients and caregivers on proper self-administration techniques. Other key components include offering side-effect management resources, monitoring medication adherence and close communication with healthcare providers regarding treatment updates.
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Prevention and early detection
Because cancer treatment costs continue to drive concern, reducing the risk of developing cancer and identifying its presence very early in its progression are the most economical and impactful elements of a strong cancer strategy. The
Employers that promote healthy behaviors through environmental design, policies and intentional workplace culture can help lower the risk of employees developing cancer. When employees understand their risk of developing cancer based on lifestyle, family histories and even genomic testing, they become more empowered to make changes to help reduce their cancer risk.
Another cost-saving game-changer is early detection. Diagnosing cancer at earlier stages typically leads to better patient outcomes and lower treatment costs. Advances in screening technologies are making it possible to diagnose cancers in an early stage, but accessibility and employee engagement remain hurdles.
To enhance early detection, employers can take the following steps:
- Inform employees about the importance of age and risk-appropriate screenings and address common concerns that may hinder adherence.
- Ensure employees have access to high-quality primary care providers who can play a critical role in keeping patients up-to-date with screening recommendations.
- Adapt to shifting cancer trends, such as rising incidence in younger populations. Consider eliminating cost-sharing for key screenings like colonoscopies and mammograms for employees under 45 and 40, respectively.
- Consider offering genomic and early detection tests to groups at higher risk of cancer incidence.
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As cancer care grows more complex, so must employer strategies. Now is the time for HR and benefits leaders to re-examine health plans to ensure that they are adequately supporting employees through every stage of cancer care. It could mean the difference between rising and manageable cancer costs — not to mention better employee health outcomes. A proactive approach today can lead to healthier outcomes, greater employee trust and a more resilient workforce tomorrow and beyond.
