Scenario 1 of 3: Employer-driven navigation

In this future scenario, employers, supported by health plans, pursue steerage to value-based cancer providers.

How could nationwide  value-based payment for cancer care become a reality in the next 5 to 10 years? Looking to today’s market for clues, our team has envisioned three scenarios of how stakeholders could make this happen.

In each scenario, we describe what the future would look like, how it would unfold, and what it would mean for major stakeholders in healthcare — and what to do if this future doesn’t look rosy for your organization.

Read the full background


Scenario 1: employer-driven-navigation

Continued growth in cancer spending would push employers to steer employees to high-value cancer providers. Self-funded employers would work with third party vendors to identify and contract with low-cost, high-quality cancer providers in their markets, especially those already engaged in value-based care initiatives. Fully insured employers would then follow suit, urging health plans to use incentives to navigate members to high-value cancer providers.

Self-funded employers have the flexibility to drive this strategy as part of their benefit design. Rising price transparency, a growing awareness of site-of-care cost differentials, and increasing employee openness to lower-cost cancer care options are already providing the motivation to do so.

As a result, competition between cancer providers would grow and the total cost of cancer care would decrease. This would play out at the market level


IMPACT ON THE INDUSTRY
  1. Site-of-care shift will accelerate.
    When seeking to navigate employees to high-value cancer care providers, employers will set their sights on the physician office setting, where costs are significantly lower than the hospital outpatient department (HOPD). This will accelerate the already-occurring shift of cancer treatment away from the hospital setting.

  2. Cancer care will become (even more) competitive, hastening the adoption of value-based payment.
    As employers narrow their cancer provider networks, employee choice will be limited to specific providers, with exceptions for rare or complex cases. This will force cancer providers to compete to attract employers, who will factor cost more heavily in their provider selection than individual patients do. To set themselves apart from other provider options, more cancer practices will enter value-based payment arrangements, enabling them to demonstrate their commitment to providing high-value cancer care. Doing so will also help pay for value-based care transformations, such as patient navigation and 24/7 urgent care, that could attract employer attention.

WHY THIS SCENARIO IS POSSIBLE

Managing cancer costs is becoming top-of-mind for employers, as cancer is now the top driver of employer healthcare costs, surpassing musculoskeletal conditions. Though employers have traditionally been hesitant to put restrictions around cancer coverage, a lack of meaningful cost control levers and the pressure of skyrocketing prices is making them more open to steering employees to specific facilities or centers of excellence that will provide efficient and high-quality care.

Employer steerage to high-value cancer providers is becoming more feasible, as several companies have launched products in the last few years to help employers with this type of navigation. Each of these organizations has grown rapidly since launching, demonstrating employer appetite for these types of solutions.

This trend coincides with rising employer interest in “soft steerage,” in which employees are incentivized to visit preferred providers or settings, while other options remain in-network. Soft steerage presents a more palatable solution to cost reduction than mandatory steerage or narrow provider networks, which limit employee choice. Employers that have already been exploring soft steerage have found that employees with cancer, instead of feeling limited, are eager to be presented with provider options that are less financially burdensome.

At the same time, the rise of remote second opinions and expert review services means patients can have access to subspecialist knowledge even while being treated in lower-cost community settings. Hundreds of employers, covering millions of employees, are already offering these types of services, making it possible to narrow cancer provider networks without limiting employee access to the latest innovations and expertise.


THE REALITY IS…
  • Some employees will want greater choice to see experts at expensive, highly-ranked cancer centers and will not be open to navigation.
  • In a tight labor environment, employers may not be willing to limit their cancer provider networks.
  • Most self-insured employers delegate network contracting to brokers or third-party administrators (TPAs) and likely aren’t thinking proactively about site-of-care management for cancer care.
  • Not all cancer providers offer the same services or expertise, making it necessary for employers to keep multiple options in-network to ensure appropriate access.
  • Employers will need to contract with third parties to help them assess the value of different cancer providers, adding an additional layer of complexity.
  • Self-insured employers operating in multiple regions would need to expend significant resources to curate a high-value cancer provider network in each market.
  • Many provider organizations are still not engaging meaningfully in price transparency, making it difficult to assess and understand their value.

IMPLICATIONS
Not every stakeholder would be a winner in this future scenario. Here’s how key stakeholders would be affected and how they should respond. 

SPONSORED BY

INTENDED AUDIENCE
  • Digital health
  • Employers
  • Finance and investors
  • Health plans
  • Hospitals and health systems
  • Pharma
  • Physicians and medical groups

AFTER YOU READ THIS
  • You'll understand how nationwide value-based cancer care could become a reality.
  • You'll learn the impact of three scenarios on major industry stakeholders.
  • You'll identify strategies for success if a scenario isn't favorable for your organization.

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