Reducing roadblocks to employee health care through benefit design implications and unintended consequences of utilization management in cancer treatment

Abstract

PurposeHR leaders and corporate benefits managers must balance organizational costs with decisions about which new tools and treatments will be covered by their employee health insurance plans. Getting it right can mean the difference between life and death for cancer patients. Most HR leaders, however, are not experts in cancer treatment and do not know how to make sure their plan benefits do not create roadblocks to treatment.Design/methodology/approachA total of 295 people who were diagnosed with cancer from 2019 to 2022 participated in the 2023 CancerCare Biomarker Survey, which was conducted in January 2023.FindingsCancerCare’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%) avoided unnecessary chemotherapy and/or radiation and one in 10 (10%) became eligible for a clinical trial because of biomarker testing.Research limitations/implicationsBiomarker testing is a necessary tool in the advancing world of precision cancer treatment. Despite the significant and demonstrable benefits to surveyed patients, three out of 10 respondents (29%) who received biomarker testing did not have the test covered by their insurance. Some survey respondents reported that biomarker test coverage was originally denied and they had to fight to get it covered. Others had to find ways to pay out-of-pocket or seek financial assistance to cover the cost of the testing.Practical implicationsUnfortunately, health insurance plans often limit cancer patients’ access to recommended biomarker testing, impose burdensome prior authorization (PA) protocols or require unaffordable cost-sharing, which can prevent or delay cancer patients’ access to optimal treatments. PA, a significant source of roadblocks to timely testing and treatment, was required by a quarter (25%) of the cancer patients surveyed.Originality/valueBiomarker testing is increasingly a health care equity issue and there are significant gaps in the rate of biomarker testing between black and white lung and colorectal cancer patients, which can lead to disparities in clinical trial participation and hinder access to the most effective treatments. A key way to address these barriers is to broaden insurance coverage of biomarker testing, as recommended by medical experts.