Employers’ Perspective

In today’s fast-paced healthcare environment, managing health benefits requires dexterity, foresight, and collaboration. At the inaugural multistakeholder Employer-Provider Interface Council (EPIC) of the Hospital Quality Foundation interactive Leadership Conference that took place on June 11, 2019, the relationships among employer plan sponsors, employee healthcare consumers, and healthcare providers were explored. To understand how health benefits are managed to deliver value to stakeholders, several speakers discussed the importance of how to define and derive value in the rapidly changing healthcare industry. Each presentation was followed by reactions from a stakeholders panel from various segments of the healthcare industry, including consumer advocacy, employer, payer, government, and provider.

It is no surprise that healthcare costs are at an all-time high and continue to take center stage in political, social, and economic debates. Employers, as health plan sponsors and as purchasers of care, are looking to take matters into their own hands and tackle the problem through innovative reimbursement strategies. Not all employers, however, are built the same. Experiences in controlling healthcare costs vary between small and large employers. The most affected employers are in the middle and are known as midsize employers.

Unlike other countries around the world, the United States does not regulate or negotiate drug prices. In general, the European Union members (eg, United Kingdom, France, Germany), Australia, and other countries incorporate pricing at the time of new drug approval, and allow the use of a new drug when it provides a significant clinical benefit over existing drugs, relative to the drug price.

Washington, DC—Employers recognize that oncology care is expensive, and they are shifting their focus on cost management. As such, employers are seeking approaches to determine which drugs and health plan designs will help them manage pharmacy and medical costs to improve patient outcomes, said F. Randy Vogenberg, PhD, RPh, Partner, Access Market Intelligence, and National Institute of Collaborative Healthcare, Greenville, SC, at the Sixth Annual Conference of the Association for Value-Based Cancer Care.

In today’s changing oncology landscape, the quality and value of cancer care have become increasingly integrated. With the rising costs of cancer treatment, payers and policymakers aim to better define value, as well as to educate patients about their therapeutic options. Insurers and payers have implemented a variety of strategies to control costs at the behest of employer plan sponsors, including utilizing oncology clinical pathways.

“Value” in healthcare has been defined as outcomes relative to cost. Determining the value of a healthcare benefit remains difficult and complex for many stakeholders. With the increasing cost of cancer therapies, value has become an important topic of conversation for patients, healthcare providers, self-funded plan sponsors (employers), and payers.

The term telehealth is used interchangeably with telemedicine by some organizations. However, telemedicine is typically associated with the delivery of traditional clinical diagnosis and monitoring by using some form of medical technology, whereas telehealth has a much broader definition that comprises education, disease awareness, and wellness, in addition to the use of technology to connect physicians to patients.

The United States has the largest biologic drugs market and high prices for biologics, such as monoclonal antibodies, therapeutic proteins, immunomodulators, and growth factors. Cancer treatments utilize traditional chemical-based drugs and, increasingly, biologic-based drugs.

As one part of an ongoing macrotheme regarding big data, understanding the benefits and limitations of using drug claims in employer-based population health is an important topic for employers in their health plan coverage strategies. Pharmacy claims are a common source of data used to describe the uses of cancer medications by employees and by their covered family members. Despite the availability of these data and a plethora of analyses, however, several limitations must be considered when interpreting drug use data.