Justifying a major investment in employee healthcare benefits isn’t getting any easier. While many healthcare point solutions and specialty care programs improve health outcomes, proving a clear return on investment (ROI) feels like nailing Jell-O to a wall. That’s because every benefits solution has its own way of calculating ROI—there’s no apples-to-apples comparison; claims data can be confusing or even inaccurate; and, let’s just face it, the healthcare system is complex.

Benefits leaders continue to feel the pressure to demonstrate value to their executive team, however, with healthcare costs expected to be around $16,000 per employee this year. The cost of healthcare benefits has continued to increase over the past several years, with latest estimates at 9% for 2025.

While calculating ROI for healthcare solutions is tough, it’s not impossible. It starts by challenging the status quo and pushing for standardized, clear reporting from your benefits solution partners.

The Difficulty in Measuring ROI of Healthcare Benefits

In the past, ROI was more inferred than calculated for solutions such as wellness or targeted diabetes management programs. Program outcomes were measured by tracking participation and quantifiable biometric outcomes, such as cholesterol, blood pressure and weight loss.

“Solutions that are preventive in nature or address chronic conditions can take years to show measurable results. It’s just hard to show short-term ROI impact,” says Brian Marcotte, past president of Business Group on Health and a current advisor for health tech and health solution companies.

The longer it takes to demonstrate ROI, he adds, the harder it is to draw a line between outcomes and the impact of your solutions. “Employers have to take a hard look at how solutions calculate ROI and push for objective, externally validated studies. Without external ROI validation, it’s kind of like the fox guarding the chicken coop,” Marcotte says.

Today, it’s even more difficult to measure ROI because employers can have 20 point solutions or more. And many of these are integrated within an employer’s benefits ecosystem. For example, an advanced primary care provider or navigator might recommend a member to virtual physical therapy within their employer’s benefits offerings. “When considering a positive outcome, who gets credit along the way and how?” Marcotte says.

Calculating ROI for Specialty Care Solutions is Just as Hard

Many healthcare solutions promise value through soft-dollar savings, such as avoided procedures and complications, rather than direct, hard-dollar savings. “It’s inherently difficult to measure something that’s avoided – or not going to happen,” says Ben Sanders, SVP of Strategy and Emerging Products at Lantern.

Before evaluating any solution, leaders need to know what they’re currently spending on specific areas to identify priorities and compare potential solutions. “Should you focus on a mental health solution, cancer care, a surgery program? You can’t answer that until you know how much you’re spending today,” Sanders says.

The pure reality: it’s difficult for benefits leaders to get to that number due to any number of external factors, from economic uncertainties that could impact healthcare costs to carriers not willing to share proprietary rates. “Lack of access prevents you from understanding your actual costs,” Sanders says.

Defining what constitutes a surgery or an episode of care varies widely, too. Some definitions are broad (including pre-op, post-op, and readmissions from complications), while others are narrow and focus only on the procedure during the hospital stay.

There’s also a significant lag time before claims data is complete, especially for surgical claims. Using only recent data can lead to incomplete and inaccurate analysis. Claims data also contains errors like transposed columns or missing information. “For example, anesthesia codes are mistakenly deleted during processing,” says Sanders, who adds implant costs are often omitted and site of care codes tend to be wrong. “The data is a mess. You’re left with wrong information to make decisions.”

What Benefits Leaders Can Do to Ensure Success

Calculating ROI for complex healthcare solutions is tough, but not impossible. It requires a shift in mindset and methodology. Follow these tips for success:

Create a Strategy

Before signing the contract for any solution, benefits leaders need to define their strategy, expected outcomes and how ROI will be measured. “Establish your baseline data and what data you should be capturing along the way,” Marcotte says. “It can be difficult to retrospectively capture the data you need to prove ROI if you do not define it up front.”

Understand How Vendors Calculate ROI

Don’t accept opaque calculations. Ask vendors tough questions about their methodologies. How do they define an episode? What’s their process for handling claims lag? How are outliers and site-of-care differences handled? Push for standardized, clear reporting. Determine how they quantify savings, what assumptions they are making and the reason behind every step they take in their calculation.

“If a solution can’t articulate the methodology by which they’re calculating ROI, you shouldn’t believe it,” says Sanders, who notes that transparency is key. “If a benefits leader sends Lantern a list of CPT codes, we can define their spend on surgery. We’ve made our savings calculation methodology publicly available to make it easier to understand how we deliver hard-dollar savings with our specialty care platform.”

Align on Goals

Setting clear expectations with your leadership is key. Every company has a focus on financial performance, so the ROI of your point solutions will be critical. “Will you see short-term gains in year one or two or will savings materialize down the road?” Marcotte says.

With cancer, for example, you only have two levers you can influence, Marcotte adds. One is active cancer management—how do I manage the population dealing with cancer today to ensure the right diagnosis and the right course of treatment with a provider in the most efficient setting? The other lever is a longer-term play and requires investing in early detection through preventive screenings.

“Both levers are important, but they impact your bottom line at different times,” Marcotte says. “While requiring an investment, detecting cancer early is more treatable and significantly less expensive than a late-stage diagnosis.”

Investments in employee health are integral to a company’s workforce strategy and should be no different than business investments in safety, training, or learning and development. “The goal is to deploy the most productive, engaged, competitive workforce possible,” Marcotte says.

Share Member Success for Buy-In

Getting buy-in from your C-suite is crucial. “Make your value proposition relevant on a personal level,” Marcotte says. “Use cases can demonstrate an employee’s journey using the solution, how they ended up with a better outcome and how it ties back to the overall financial impact. Everyone can relate to a personal health care journey.”

Those same stories should be shared with your employees to increase engagement in your program. “Can you engage people in these programs and sustain engagement? And if you can’t, it doesn’t matter how good your program is, you’re not going to get the ROI,” Marcotte says.