A MATRIX Minute by MATRIX Group Benefits, LLC
| Medical research continues to develop and bring to market new diagnostic methods, treatments, and drugs, all of which can cure patients with unique or dread diseases. The newest advances are occurring in genomic testing for the identification of personalized drug therapies for treating cancers and in gene and cellular therapy for treatment and curing rare genetic conditions and diseases. The pipeline for new methods, treatments, and drugs to be approved by the FDA during 2021 is increasing by the week and all of these research developments come with a substantial price. It is the cost for these new advances that pose the greatest threat to an employer’s self-insured plan. New orphan drugs for the treatment of rare diseases and congenital conditions have costs beginning around $500,000 and the newest ones for gene therapy have costs ranges of $2,000,000 to $3,000,000. While it is true that plans have medical stop loss coverage that is unlimited per claim, the timing of a patient diagnosis, treatment plan and episodes of care and ongoing treatment could result in medical stop loss having very undesirable qualifications and significant cost increases. For many plans, the best solution for managing the financial risks posed by these medical advancements is to amend their plan to exclude gene and cellular therapy. Very large employers who do not want to exclude these therapies from their coverage may look toward the contracting strategy CMS has taken with the drug manufacturers to have an independent clinical review of the results of the drug/therapy several months after completion of the therapy. If successful, the plan pays a contracted amount over a couple of years, and if the therapy was not successful then the plan would not be obligated to pay the manufacturer. For employers that would like to explore other options, Matrix RMS has a relationship with Emerging Therapy Solutions (ETC) who has established contracts with the few facilities approved to provide these therapy services and the drug manufacturers. Organ transplant costs have increased significantly over the past five years and more facilities are performing transplants today than in prior years. More facilities do not necessarily equate to better outcomes or reduced cost. Transplant networks contract with centers based on the types of transplants performed, the number of procedures done, mortality and readmission rates, support services and contract value. Independent transplant networks are very transparent, easily contracted on a per patient basis, and easily included in the plan document and patient ID card. Cancer is the elephant in the room. The incidence of new cancer diagnosis across all age and ethnic groups is predicted to be greater in 2021 than in any prior year. When the frequency of misdiagnosis exceeds 20%, the need for an oversight resource, beyond the scope of the pre-cert service, becomes evident. Hospitals treating cancer patients have increased similar to transplant centers but are they clinically the best site for the patients? Like transplants, cancer centers are evaluated based on the types of cancer treated across all ages and ethnic groups, the types of therapies/modalities performed, mortality and readmission rates, and contract value. Engaging a specialty resource service to provide oversight for cancer claims from the point of initial diagnosis through the completion of treatment is easily accomplished by a plan amendment. |
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