A small percentage of your health plan members end up needing specialty care, yet the category still accounts for around half of healthcare costs.

“Surgery tends to be somewhere between 20% to 25% of total health spend. Cancer tends to be between 15% and 20% and infusions are another 5% to 10%,” says Lantern CEO John Zutter. “They’re also generally growing twice as fast as healthcare at large.”

To help curb these costs, more employers and funds are starting to look for a specialty care benefits solution that tackles several categories at once. But it’s a new approach—and not all solutions are created equal. Benefits buyers should look for solutions that offer:

• Cost containment
• Quality care
• A strong partnership you and your employees or members can rely on

Here’s what our leaders and clients recommend looking for.

Find a Specialty Care Partner that Provides Cost Containment

Surgeries, specialty infusions and cancer care are all top cost-drivers on your health plan. When conducting an evaluation of benefits solutions, ask the vendors to explain their strategy for delivering savings. Specific questions to ask include:

• How do your negotiated rates compare to Medicare benchmarks?
• Are savings measured on a per employee per month (PEPM) basis or total claims reduction?
• Are you delivering hard-dollar savings (contracted rates, site-of-care shifts), soft-dollar savings (utilization, avoided procedures), or both?

“If you’re not going to see a reduction in what you’re actually reimbursing surgeons, and primarily facilities, then you’re not going to get that aggregate cost impact on the plan that most plan sponsors are typically looking for when they’re evaluating a program,” says Erin Tatar, SVP of Consultant Relations at Lantern. “You really need to find a solution that’s leveraging prospective bundles and lower actual negotiated rates for a range of procedure types. And that’s something that you’re primarily going to get through independent Centers of Excellence.”

Site-of-care shifts also significantly impact costs. For example, hospital outpatient procedures can cost 5x more than the same surgery performed in an ambulatory surgical center. For in-hospital infusion therapies, costs are often marked up 300% above what the same treatment would cost in a different setting.

Additionally, consider improving access as a means to reduce costs. Someone with knee pain seen sooner could achieve positive outcomes with physical therapy and avoid a costly procedure. For cancer, quick diagnosis and treatment make a huge difference. One study found that people whose treatment for cancer is delayed by just one month have a 5% to 13% higher risk of mortality.

Ensure Solutions Offers the Highest-Quality Specialty Care

Do lower costs mean you have to settle for lower-quality care? Absolutely not.

“There’s a huge variation in costs for procedures like joint replacements depending on where patients get care, which would be understandable if outcomes at pricier locations were predictably better, but they’re not,” Tatar says. “However, this means it’s possible to secure higher-quality care at a lower cost.”

Your employees are the heart of your organization, so look for a specialty care solution that treats them well.

“We pride ourselves on taking great care of our clients. Because of that, our associates have very high expectations on what service looks like for the people who take care of them,” says Ryan McCracken, Director of Benefits at a leading financial services firm. “It was very important for us to be able to easily link our members with providers who were going to give them the best possible care in the location that worked best for them.”

When reviewing benefits solutions and determining quality, consider the Institute of Medicine Quality Framework:

Safe

Look for a commitment to ensuring safety. Consider complication rate and patient site of care.

“We keep our associates and their family members with us for their whole career in most cases,” McCracken says. “Having effective and safe outcomes was really important to us, because that’s what allows us to help bend the long-term cost curve — reducing complications, reducing readmittance and reducing repaired surgeries.”

Effective

Evaluate surgical avoidance rate and how care recommendations stack up with recommended guidelines. For example, 40% of cancer treatment plans aren’t consistent with current guidelines. At Lantern, each member is paired with an Oncology Nurse Navigator, who will review a diagnosis or treatment plan with the member and help facilitate a second opinion, if appropriate.

Patient-centered

Seek out solutions that offer Care Advocates who can help members navigate the treatment process. Compare a solution’s Net Promoter Score to the health insurance average of 30.

“When patients rate their experience higher, they actually have better functional status,” says Jason Tibbels, Chief Medical Officer at Lantern. “They have less complications and lower mortality. We want to know our providers are putting patients at the center of their care, both to optimize their experience and their outcomes.”

Timely

Ask vendors about the average wait time for an appointment within their solution.

“The more quickly you can get someone functional, you’ll see benefits,” Tibbels says. “Their functional status is going to improve, their mental health is better. They’ll be in less pain. You’ll see higher productivity and less absenteeism.”

Efficient

Cost containment comes into play here. Overall, employers and private health plans pay, on average, 254% of Medicare prices. At Lantern, we negotiate prospective bundles that are 50% to 60% less than commercial carrier rates. We also steer patients to a subset of facilities, which are willing to accept rates at 120% of Medicare.

Equitable

For care equity, consider how the specialty care provider removes common barriers to healthcare, including cost and distance.

“Being able to provide resources to connect people with surgeons all across the country was huge for us,” McCracken says. “Healthcare navigation is a constant struggle, and it’s really challenging to help educate members on how to find the care that’s right for them. We needed a solution that would be easy for our members to use. We needed it to be both highly effective at a competitive cost to incentivize members to engage with it.

“[Lantern] was one of those rare win-win type of scenarios where we can provide our members with the best possible care and also pass on savings,” McCracken adds. “Honestly, the hardest part was getting people to believe they could have both lower costs and higher quality.”

Determine if a Specialty Care Vendor will be a Good Partner

After you evaluate cost containment, quality and employee experience, there’s still a crucial consideration when it comes to healthcare partner selection: Will they be a good partner?

Consider how the benefits solution vendor will work to support your specific employee population’s needs. For example, we employ multilingual Care Advocates and can provide member education resources in multiple languages.

This was important to Suzanne Usaj, Senior Director of Total Rewards for The Wonderful Company.

“Rather than just supporting and managing a single episode of care, I found a partner who can meet employees and their families where they are on their journey, not just clinically but culturally and in their language,” Usaj says.

The platform should also integrate with other solutions in your overall employee benefits strategy. For example, a surgical solution could refer to a digital therapy solution and vice versa.
Because Lantern’s pricing model is based on utilization, we collaborate closely with our clients on engagement strategy, focus on quality and offer simple administration.

“In addition to all the great scrutiny that the providers are put under and all the great metrics that Lantern is providing, there’s this qualitative aspect where I knew the Lantern team would work as an extension of ours with service at the heart of everything,” says Tabitha Pittman, Director of Compensation and Benefits at Integrity. “The quality piece actually started with that high level of service and navigation that Lantern provides.”