Drive Health Plan Engagement and Savings With Cost-Effective Disease Management Programs

JULY 2, 2024

Promoting preventive care helps improve overall population health, significantly reducing long-term costs and the impact of catastrophic claims on employer health plans. Serious conditions like diabetes and cancer can require complex and often expensive care — yet these conditions can be managed, and even prevented, if detected early.

Cancer is now the leading condition driving health plan costs. According to USI’s client database, medical claims paid for cancer have increased 12% to $731 million over the past 3 years while cancer drugs have increased 30% to $263 million and costs for chemotherapy and radiation treatments have increased 24% to $390 million.

Early detection, while the costs to intervene are low, can significantly improve health outcomes for plan members — which can help reduce health plan spending for employers:

Despite the benefits of early intervention, employers face the continuous challenge of ensuring plan members are benefiting from timely detection — and receiving the most cost-effective treatments:

• Half of catastrophic claims over $50,000 have been tied to individuals who have not had any preventive care in the past year. Only 20% to 30% of the adult population engages with a primary care physician (PCP) annually.¹
• Plan members who do not engage with a PCP also miss recommended screenings. The recommended screening age for certain cancers, like colon cancer and breast cancer, has been lowered due to increasing diagnoses for people under the age of 50.
• Medical diagnoses may not always be correct or complete. Cleveland Clinic found a second medical opinion led to a diagnosis change in 28% of its cases.
• The majority (77%) of cancer care is delivered in community-based hospitals, which have a lower survival rate than specialized care centers due to a lack of resources and expertise.⁴

The prevalence of diabetes is also increasing, creating another cost challenge for employer-sponsored health plans. Adults are being diagnosed with Type 2 diabetes at earlier ages. Type 2 diabetes is also increasing dramatically in children, spiking 77.3% in 2021 compared to 2019 and 2020.⁵ Consequently, medical claims paid for diabetes increased 49% to $824,000, while the cost of medication and supplies increased 150% to over $8 million, driven in large part by increasing demand for high-cost diabetes drugs.¹

Without medical intervention, individuals with diabetes may experience complications like blindness, amputation, advanced kidney disease, heart disease, and stroke. For complex conditions like diabetes, effective disease management is key to reducing the risk of catastrophic claims.

Most health insurance carriers offer disease management programs to help coordinate care and control costs, but these programs often struggle to effectively reach targeted members. USI takes a more comprehensive approach, starting with PCP engagement.

Comprehensive Disease Management

USI takes a multi-step approach to disease management for cancer and diabetes:

Incentivized physician engagement

We work with employers to develop meaningful incentives that encourage plan members to actively engage with a PCP annually, and receive age- and gender-appropriate screenings for early cancer detection.

Using this strategy, employers have successfully increased engagement between 50% and 80%, resulting in a 3% to 5% reduction in the total cost of care.

Specialized care

For individuals with an advanced cancer diagnosis, we work with vendors that connect plan members to specialized care facilities and resources for more accurate diagnosing and treatment. These vendors also collaborate with local providers and specialized facilities to ensure the best treatment practices, regardless of where the plan member receives medical care.

As the disease management market evolves, we will continue to evaluate service providers and make recommendations based on our clients’ specific needs.

Plan design

For members with Type 1 diabetes, we promote access to modern treatment options for all plan members, reducing the risk of high-cost complications. Referred to as a “closed loop” system, this approach combines the use of a continuous glucose monitor (CGM) and insulin pump to deliver accurate dosing of insulin automatically as needed.

For individuals with type 2 diabetes, we work with plan design options to promote compliance with recommended hemoglobin A1c and cholesterol testing, and help manage access to high-cost medications such as glucagon-like peptide-1 (GLP-1) receptor agonists.

Sources:
¹ Screening costs based on USI 3D 2021 data
² https://www.cancercenter.com/community/blog/2023/07/managing-cancer-treatment-cost
³ https://www.cancer.org/cancer.html
⁴ Risk Adjusting Survival Outcomes in Hospitals That Treat Patients With Cancer Without Information on Cancer Stage. JAMA Oncol. 2015 Dec;1(9):1303-10.
⁵ Magge SN, Wolf RM, Pyle L, Brown EA, Benavides VC, Bianco ME, et al. COVID-19 and type 2 diabetes consortium. The coronavirus disease 2019 pandemic is associated with a substantial rise in frequency and severity of presentation of youth-onset type 2 diabetes. J Pediatr. 2022;251:51–59.e2