Designing Pharmacy and Medical Benefits for Cancer Care

Designing Pharmacy and Medical Benefits for Cancer Care: An Employer Perspective – published in Value-Based Cancer Care

F. Randy Vogenberg, PhD, RPh, FASHP; Catherine E. Cooke, PharmD, BCPS

October 2016, Vol 7, No 9Employers’ Perspective

With the increasing complexity of cancer care after the passing of the 2010 Affordable Care Act, employers as purchasers of healthcare need guidance in designing effective medical and pharmacy benefits. Approximately 50% of people diagnosed with cancer in the United States are of working age at the time of diagnosis.1 In addition, as a result of improved treatments, more patients are surviving cancer and are continuing to work.

A growing number of traditional and biologic prescription cancer medications are used in pharmacy and medical benefits that carry increasingly high costs. This evolving landscape of chronic cancer care presents new short- and long-term challenges for employers, especially if they are self-funded as the health insurance plan sponsor.

What guidance is available to purchasers of cancer care? Early research describes the economic impact of cancer on the employer and the employee, but fails to provide solutions to address these concerns.2 And although recent publications describe the importance of aligning incentives with care delivery, a recent study on this topic provides few real-world examples in use.3 A search using PubMed revealed several articles that address a value-based insurance design, but only a handful include the perspective of the employer.4-8

During its 2012 and 2013 annual meetings, the Association for Value-Based Cancer Care (AVBCC) held open forums encouraging stakeholders, including employers, to come to a consensus about coverage of cancer care by balancing cost, quality, and access to care.9,10 A key message that arose from these forums was that employers are vested in uncovering the value proposition, with a key focus on the specific services or products from a vendor used to deliver clinical or economic outcomes for plan performance. How is the healthcare system poised to deliver positive clinical, economic, and patient-reported outcomes?

In collaboration with the Institute for Integrated Healthcare, the Midwest Business Group on Health began its National Employer Initiative on Biologics & Specialty Drugs in 2009, with its first annual survey released in 2012.11,12 The results of this survey, and subsequent annual surveys, continue to substantiate employer concern about the increasing cost of specialty medications.11,12

The cancer care–related findings were presented at the 2014 and 2015 AVBCC annual meetings, highlighting a focus on cost-shifting options for specialty drugs, which does not work in cancer care.11,12 The reason is that the impact of benefit design (ie, copay, deductible, coinsurance) on specialty drugs, including cancer drugs—unlike traditional drugs—typically adversely affect desired workplace outcomes, increase discontinuation of therapy and out-of-pocket expense of plan members, while not saving plan sponsors much cost.

In late 2013, the National Business Group on Health, together with the National Comprehensive Cancer Network, released “An Employer’s Guide to Cancer Treatment and Prevention.” This was the first guidance focused on providing “technical assistance to help employers design, implement and monitor the performance of their cancer–related strategies.”13 An additional resource resulting from the collaboration was the “Employer’s Companion Guide to the Cancer Benefits and Resource Guide,” which aimed to educate employees about important decisions related to cancer care and coverage.14

In general, there is a paucity of employer-focused benefit design information in the peer-reviewed or gray literature that addresses effective pharmaceutical care related to cancer. Despite a high demand that has recently intensified, few resources are available to assist employer decision makers with designing group health benefit plans that effectively address cancer care to improve employee health and productivity.

Employee benefit plans offered by employers continue to be a major segment in the US healthcare market. Therein lies an opportunity to develop employer-focused resources, as well as to publish innovative benefit strategies, designs, or case studies and research related to employer-sponsored pharmaceutical care coverage in oncology.


  1. de Boer AG. The European Cancer and Work Network: CANWON. J Occup Rehabil. 2014;24:393-398.
  2. Lawless GD. The working patient with cancer: implications for payers and employers. Am Health Drug Benefits. 2009;2:168-173.
  3. de Souza JA, Ratain MJ, Fendrick AM. Value-based insurance design: aligning incentives, benefits, and evidence in oncology. J Natl Compr Canc Netw. 2012;10:18-23.
  4. Misra-Hebert AD, Hu B, Taksler G, et al. Financial incentives and diabetes disease control in employees: a retrospective cohort analysis. J Gen Intern Med. 2016;31:871-877.
  5. Maeng DD, Pitcavage JM, Snyder SR, et al. The value of value-based insurance design: savings from eliminating drug co-payments. Am J Manag Care. 2016;22:116-121.
  6. Musich S, Wang S, Hawkins K. The impact of a value-based insurance design plus health coaching on medication adherence and medical spending. Popul Health Manag. 2015;18:151-158.
  7. Clark B, DuChane J, Hou J, et al. Evaluation of increased adherence and cost savings of an employer value-based benefits program targeting generic antihyperlipidemic and antidiabetic medications. J Manag Care Pharm. 2014;20:141-150.
  8. Kim YA, Loucks A, Yokoyama G, et al. Evaluation of value-based insurance design with a large retail employer. Am J Manag Care. 2011;17:682-690.
  9. Beed G, Owens GM, Benson AB III, et al; for the AVBCC 2012 Steering Committee. Defining value in cancer care: AVBCC 2012 Steering Committee report. Am Health Drug Benefits. 2012;5:202-217.
  10. Zweigenhaft B, Bosserman L, Kenney JT Jr, et al; for the AVBCC 2013 Steering Committee. Defining value in cancer care: AVBCC 2013 Steering Committee report. Am Health Drug Benefits. 2013;6:236-246.
  11. Vogenberg FR, Larson C, Rehayem M, Boress L. Benefit design trends and value-based oncology coverage related findings from the 2013 National Employer Survey. Value-Based Cancer Care. 2014;5:16.
  12. Vogenberg FR, Larson C, Rehayem M, Boress L. 4-year employer trends and value-based oncology coverage–related findings from a national employer survey. Value-Based Cancer Care. 2015;6:28.
  13. The National Business Group on Health; National Comprehensive Cancer Network. An employer’s guide to cancer treatment & prevention: executive summary. 2013. Accessed September 6, 2016.
  14. The National Business Group on Health; National Comprehensive Cancer Network. Employer’s companion guide to the cancer benefits and resource guide. 2013. Accessed September 19, 2016.