Managing a Cancer Diagnosis as a Self-funded Health Plan

Key Takeaways

• Oncology consistently ranks as the leading driver of large claims.
• Without structured oncology management, self-funded plans are susceptible to higher costs.
• Proactive management improves clinical outcomes and manages costs by offering personalized support.
• Healthgram’s Oncology Management program is an integrated approach that supports the patient’s well-being but also enhances stop loss reimbursement efforts.

Self-funded employers bear the financial responsibility of providing healthcare to their employees. This model offers greater control over benefits and potential cost savings. However, the unpredictability and high costs associated with cancer treatments can pose substantial financial risks. Effective cost management and positive health outcomes are key considerations, making it essential to consider how your self-funded plan will manage cancer cases.

To benefit both the employee battling illness and the self-funded employer, oncology management programs need to take a comprehensive approach to care.

The Impact of Cancer on Self-Funded Plans

Cancer remains one of the most common and costly health conditions affecting employer-sponsored health plans. According to the American Cancer Society, more than 2 million new cancer cases are expected to be diagnosed in the United States each year, while advancements in treatment continue to improve survival rates and extend the duration of care required.

For self-funded employers, cancer often represents one of the largest contributors to catastrophic claims. Recent stop loss industry data shows that oncology consistently ranks as the leading driver of large claims, accounting for a significant portion of claimants exceeding $250,000, $500,000, and even $1 million in annual spend.

The financial burden continues to grow. The National Cancer Institute estimates that annual U.S. cancer care costs could exceed $240 billion by 2030. Perhaps the most significant cost driver today is specialty medication. Global spending on cancer medicines reached approximately $223 billion in 2023 and is projected to exceed $400 billion by 2028. Many emerging oncology drugs now carry annual treatment costs well into six figures, with certain therapies exceeding $500,000 per patient per year.

Beyond treatment expenses, employers also experience indirect costs through absenteeism, disability, reduced productivity, and the emotional toll cancer places on employees and their families.

The Employer’s Role

Self-funded employers must balance cost control with providing comprehensive, high-quality care for their employees. Without a structured oncology management program, plan costs can escalate due to expensive treatments, emergency room visits, and inpatient stays.

Why Oncology Management Matters

The cancer treatment landscape is more complex than ever before. Patients may receive care from multiple specialists, treatment facilities, pharmacies, and support providers throughout their cancer journey.

Without active clinical oversight, health plans often experience:

• Delayed treatment coordination
• Unnecessary emergency room utilization
• Avoidable inpatient admissions
• Inefficient site-of-care selection
• Missed opportunities for financial assistance programs
• Higher specialty drug costs
• Increased stop loss exposure

As stop loss carriers report growing frequency and severity of oncology-related claims, employers are increasingly looking for solutions that improve outcomes while controlling costs.

Taking a Personalized Approach to Cancer Care

In order to best support employees while keeping an eye on their bottom line, self-funded employers need to find a TPA partner who takes a whole-person approach.

Healthgram’s Oncology Management program functions as both an employee and plan advocate, offering the following benefits:

• Personalized clinical support. After diagnosis, the patient is assigned a designated and specialized case manager from Healthgram’s clinical department. The case manager will work closely with the patient, the patient’s family, and physicians throughout treatment.
• Early intervention. One of the biggest predictors of successful outcomes is early engagement. Healthgram’s clinical team has direct access to claims and medical information, allowing nurses to identify oncology cases early and begin coordinating care before costs escalate.
• Complete integration. As a service provided by Healthgram’s clinical department, no outside vendor is necessary. Patients have a single point of contact within the Healthgram ecosystem.
• Cost and quality optimization. Our clinical team evaluates treatment plans, sites of care, and available support programs to ensure members receive high-quality treatment in the most appropriate setting. This approach can reduce unnecessary utilization while improving the patient experience.
• Stop loss coordination. Healthgram’s integrated clinical and claims teams provide timely documentation and detailed clinical notes to support stop loss reimbursement efforts, helping employers maximize recoveries and improve cash flow.
• Financial assistance identification. Many members may qualify for manufacturer assistance, foundation support, or government-sponsored programs that significantly reduce treatment costs. For example, one Healthgram member undergoing chemotherapy and a stem cell transplant was connected to a federal assistance program through their case manager’s intervention. Redirecting treatment expenses through the program resulted in more than $215,000 in plan savings while ensuring the member received the care they needed.

As oncology diagnoses become more prevalent and treatment costs continue to rise, cancer management has evolved from a clinical support service into a critical component of financial risk management for self-funded employers.

An effective oncology management strategy can improve member outcomes, reduce unnecessary costs, enhance the patient experience, and help protect both the health plan and stop loss performance over the long term.

Cancer care is personal. Managing it effectively should be, too.

To learn more, reach out to a member of our team.