In every discussion I have with benefits managers, the most common story I hear is about the cancer high-cost claimants that have blown their healthcare spend. They are seeing more of these every year in their data, and each one has a different problem and story. The biggest issue is that benefits leaders do not feel confident in strategies to prevent these from happening in the future.

Cancer now accounts for the largest driver of high-cost claims, more than the next five disease areas combined. The triple wave of major shifts impacting cancer means that employers and health plans today are seeing increasing cancer cases and cancer costs in their population, and this is expected to continue over time. However, benefits leaders still have agency on managing their cancer spend, and the opportunity is significant.

The five root causes of high-cost cancer claims

When we look at our customers' claims data, we actually find that ~2/3 of high-cost claimants are preventable. And we can trace back what went wrong to 5 major reasons:

• A screenable or preventable cancer that was diagnosed late, when costs are 3-5x higher. The cost implication of late-stage cancers is only getting worse as more expensive treatments are coming to market.

• An insufficient diagnostic workup that resulted in a suboptimal treatment being administered to the patient. This is happening more and more with all the new tumor marker testing now needed to be done for each cancer.

• An ineffective or inappropriate treatment plan that the patient was on.

• Unmanaged symptoms or absence of palliative care support that results in high-cost events and negative outcomes for patients.

• A very expensive treatment that could have been delivered at a lower cost.
  

Collectively, addressing these opportunities can save a plan 25-30% of its total cancer spend. It would also consistently drive better care for patients and better outcomes. When I ask benefits leaders what they have done about it, the most common answers I hear are:

• “I asked if there is a way we can move this member to a lower cost facility, but I don’t know if that is possible or not.”

• “I implemented site-of-care solutions but the impact so far has been very limited. I am not sure what else to do.”

• “I don’t know how to manage those costs without feeling like I am impacting the care of the members at such a hard moment in their life.”

The problem isn't network design. It's clinical decision making.

My consistent answer is that you do not need to choose today between the quality of cancer care your members receive and your ability to deliver that care at a lower cost. If anything, we continuously see that the only way to meaningfully impact your cancer costs is through making sure the right clinical care is delivered to your members. Those five root causes above are problems that require clinical decision making and oversight; they are not a plan design or network design issue. These are clinical failures that benefit managers need to address. They are also becoming more common because cancer treatment protocols are becoming more complex and nuanced and change quickly and frequently. 

However, there is no reason today, with current technology and capabilities, that patients shouldn’t always receive the best-in-class standard of care no matter what their cancer is and no matter where they live. This is why we built Color’s Virtual Cancer Clinic as the first clinic delivering cancer care virtually across all 50 states. We are the only virtual clinic certified by the American Society of Clinical Oncology (ASCO), which sets the standard of what best-in-class oncology care is. 

The Color Medical group is staffed with board-certified oncologists, oncology nurses, survivorship oncologists, and physicians who establish doctor-patient relationships and provide direct clinical and actionable care to cancer patients across the full cancer journey. They are also supported by Color’s extensive Oncology Expert Network that includes NCI specialists and others in every type of cancer, and every type of cancer intervention. These experts work with Color’s clinical team to ensure our clinical protocols and oncology care pathways are aligned with the best and latest evidence and provide expert input on the care of all the patients we serve through our multidisciplinary tumor board process.

Through this approach, we provide the clinical oversight and direct clinical intervention in collaboration with the patient’s local treating team that ensures the right clinical decisions are made for the patient throughout their journey. By doing so, we’re able to prevent high-cost claims from happening and save 25-30% of the plan’s total cancer spend. 

How we reduce cancer spend

The three ways we address these costs for our customers are:

1. A highly engaging early detection program:

We engage the full population on the importance of cancer screening and risk reduction so patients know their risk of cancer and can manage/reduce it; are getting screened for cancer and diagnosed quickly; and remain up to date over time. Our key outcomes include:

• Identifying the 25% of the population that is at high risk for some cancer and often missed in traditional care settings

• Increasing adherence to screening guidelines by 77%

• Speeding time to diagnosis and treatment initiation by 66%

Through this approach, we catch cancer early or even in the pre-cancer stage, and reduce total cancer spend.

Putting this into practice, a 4-month screening campaign for a large airline led to 15 early interventions (pre-cancer or early-stage cancer), and an estimated $1M in savings from cancer prevention and earlier detection only. Through this same approach for a large oil and gas company, Color’s program generated $1.5M in expected savings in cost avoidance by catching cancers earlier.

2. Clinical cancer management for cancer patients that keeps them on the right treatment plan:

We ensure every patient is receiving the right treatment and the right support at every key decision point in their treatment journey. This includes:

• An Expert Medical Opinion review for 100% of patients in treatment that looks comprehensively at all aspects of care, including the initial diagnosis, full diagnostic workup, the treatment plan, and the quality of care being received.

• Palliative care and symptom management support that increases treatment adherence and success, while reducing emergency visits, hospital admissions, and negative patient outcomes.

• Survivorship planning and care after treatment for the ongoing and long-term impact and complications of cancer. 

• Comprehensive supportive care for the patient that includes cancer nutrition, financial hardship, return-to-work support, caregiver support, and mental health support through a program specifically tailored to cancer patients, survivors, and their caregivers.
  

The impact of these clinical interventions is significant: 95% of patients we have supported have had a recommended change in their care plan for better outcomes, saving hundreds of thousands of dollars per patient and improving patient care in the process. 

As one example, a Color patient was locally diagnosed with pancreatic cancer and had already been prepped for treatment. The Color Expert Medical Opinion team conducted a tumor board review, evaluating the patient’s records and tumor-mutation data, and determined that the cancer was actually cholangiocarcinoma, a different disease requiring a different treatment plan. Color worked with the treating team to stop the inappropriate treatment and redirect care. That single intervention avoided an estimated $174,000 in unnecessary treatment costs, and put the patient on a much more effective treatment pathway.

Color also supports patients in cancer treatment through ongoing reviews to head off high-cost claims before they happen. In one case, Color recommended an adjustment to the treatment plan of a patient whose neuropathy was contributing to recurring falls. Addressing the issue before it resulted in emergency or inpatient care generated an estimated savings of $54,000.

In yet another situation, the Color clinical team addressed a patient’s cardiac condition during CAR-T treatment, helping prevent a potentially serious event and generating an estimated $368,000 in savings in avoidable costs.

3. Therapeutics management so your members get the right care at the lowest cost possible:

In addition to ensuring patients are on the right treatment, we make sure the treatment is delivered at the right cost. Most benefits managers have already designed their benefits ecosystem with low-cost options, they are just not being used. You already have lower-cost infusion centers, and lower-cost providers. You also have lower-cost drug options through your specialty pharmacy, they are just not being utilized today. 

The driver of those decisions is clinical and patient choice. This is even more complicated in cancer because the treatments are complex: no two patients are alike, and the treatment decisions are very clinically nuanced. If you want to move a patient’s infusion to a local center or their home, for example, you need to make sure that it is clinically appropriate (e.g. they are not on other medications), the monitoring labs are still being done, the patient’s symptoms and tolerance are effectively monitored, and the providers are of the highest quality. It’s hard to really determine what is a real opportunity for saving and what is not without:

• A consistent process of comprehensive case and medication review 

• A clinical determination of when it is possible to do it

• The work that needs to happen to make the change

• And strong trust with the patient to make it happen in a way that works for them

Having a 50-state virtual cancer clinic ensures you have the tools to do that when clinically appropriate, with the right clinical oversight and quality. Often we find opportunities that are win-win for the patient and the plan because they reduce out-of-pocket costs, or provide more convenience for the patient by staying home or close to home. In our experience, there is a savings opportunity there, but it does not come from adding more or carving out of your plan. It comes from finding clinically appropriate opportunities to switch site of care, administration modality (e.g. infusion vs. injection), formulary options (brand vs. biosimilar), and other therapeutics optimization within your current benefits.

The bottom line

To recap, if there is one major takeaway for benefits managers, it’s that they can significantly reduce their full cancer spend, not a subset, not just one use case, not just a few drugs or a few cancer types or a few locations, and they can reduce it by 25-30%, while delivering better care and better support for their members. Your claims data, our outcomes data, and the patient’s experience and outcomes back it up. And the path to get there is not through a patchwork of discrete point solutions or in-network carveouts or narrowings that increase the burden on the patients for a problem that was not theirs to start with. It is in:

• The ability to deliver to all your members the highest quality clinical cancer care that you would want for yourself and your family, no matter where they live or what cancer diagnosis they have.

• The clinical layer that can get the low cost network options you already have in your plan to be utilized when clinically appropriate.
  

This is the promise behind Color’s Virtual Cancer Clinic, both for you and for your members, and it is a promise of better outcomes and better experience that can impact more than a quarter of your full cancer spend.