3 ways employers can remove barriers to employee health care

Providing access to quality health care for employees is a top priority for employers who understand the value of healthy, productive workers. That’s why HR and leadership want to remove barriers to employee health care.

Cancer, which affects millions of people and is the second leading cause of death in the United States, accounts for 12 percent of employers’ total medical costs in the U.S. Cancer treatment costs four times more than other major health conditions, including stroke or diabetes. However, despite the importance of cancer care, many barriers still exist that can prevent employees from accessing the care they need when they need it.

Remove barriers early

To reduce costs, many insurance policies include utilization management (UM), which can make it difficult to get timely testing, access the right treatments, and provide patients with the advanced therapies that are most effective in curing or controlling cancer. Although UM may effectively manage short-term costs for the payer, it can also have unintended consequences that create roadblocks to timely diagnosis and access to optimal treatments.

It’s essential that employers take steps to be aware of and remove these barriers in order to ensure that their employees have access to the best quality cancer care. First and foremost, employers should provide comprehensive health insurance plans that cover all aspects of cancer care, making testing, diagnosis, treatment, and follow-up care easily accessible to their employees.

Precision medicine in cancer treatment

Biomarker testing is one of the most significant advances in cancer treatment. It identifies the specific genetic mutations within a person’s disease and often enables clinicians to tailor treatment to each patient’s unique cancer.

With biomarker testing, clinicians can determine targeted therapies that are most likely to control lung, breast, colorectal and melanoma cancers, as well as some rare cancers. Biomarker testing also helps identify clinical trial opportunities and avoids the use of generic approaches that might not be effective.

CancerCare’s 2023 survey of cancer patients found that biomarker testing helped doctors tailor therapy for nearly all the patients (93%) whose cancers were tested over the past three years. Two in 10 cancer patients (20%) surveyed were able to avoid unnecessary chemotherapy and/or radiation and 10% became eligible for a clinical trial after biomarker testing.

Despite its significant benefits, three out of 10 cancer patients who received biomarker testing did not have insurance coverage for it. In some cases, patients and physicians were required to jump through hoops to have the test authorized but even when it is, the cost sharing can be prohibitive.

Unintended consequences of UM

Although biomarker testing has proven to improve patient outcomes and help reduce healthcare costs, many employee health insurance policies do not adequately cover guideline-recommended care that the testing identifies as the best option. 

Barriers to optimal care, which have a disproportionate impact on racial and ethnic minorities and socioeconomically disadvantaged patients, typically include:

• Formularies dictate which medications will be covered and at what cost to patients, or
• Insurance companies and Pharmacy Benefit Managers (PBM) claim that the formulary designs they recommend are based on clinical effectiveness and affordability.

However, in reality, drug manufacturer rebates often play a significant role in determining which medications make it onto the formulary and at which pricing tier. This can impact individuals with cancer, as certain drugs may be excluded from the formulary, resulting in they’re having little choice but to take treatments that are not optimal for their specific needs or cause adverse side effects. With the rise of personalized cancer treatments, policies that restrict drug coverage solely to those selected by PBMs could mean that cancer patients are unable to access lifesaving treatments.

Prior authorization (PA) can be a double-edged sword. While it is intended to ensure the appropriate use of medical services and prescription drugs, it often results in delayed access, which can have serious consequences for patients. Since most prescription drugs with PA requirements are ultimately approved by insurers, this process seems unnecessary, a burden to physicians and a risk for patients.  Research has shown that over one-third of prescriptions subject to prior authorization are ultimately rejected by the patient, indicating that the process does not always lead to the best clinical outcomes.

Cost-shifting strategies

The burden of rising healthcare costs in the United States has disproportionately fallen on patients. Insurance companies and PBMs have been leading the charge in shifting these costs. Unfortunately, the trend towards high deductible health plans has only served to exacerbate the problem, resulting in an alarming rise in healthcare debt.

Several examples of cost-shifting strategies employed by insurers include co-insurance, which requires patients to pay a percentage of the list price of a drug, rather than the lower price that PBMs actually pay for the medication. Additionally, copay accumulator and maximizer programs have gained in popularity, but they do not allow financial assistance paid on behalf of a patient to count towards their deductible or out-of-pocket maximum, leaving patients with a larger financial burden.

Employers are under pressure to both alleviate the increasing costs of healthcare benefits and ensure that employees have access to high-quality healthcare. It’s important to realize, however, that what may look like ways to reduce costs may not provide adequate, patient-centric coverage for employees.

Removing barriers to treatment for cancer and other serious illnesses helps employees get optimal care, at the right time, often speeding recovery and preventing expensive medical costs down the road.   Many organizations offer a wealth of free resources to employers to help them better understand the potential barriers to care and balance the needs of cancer patients with the rising costs of healthcare.