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Healthcare arbitrage #6: Clinical trials


Sometimes, when proven treatments for a member’s condition have limited outcomes or a new technique is being explored, the member’s doctor may recommend an experimental or investigational treatment. Because experimental/investigational treatments haven’t yet been proven to be more effective than the alternatives, health plans typically don’t cover them, meaning that the member will be responsible for the entire cost. However, if a member can enroll in a clinical trial for the experimental/investigational treatment, then they’ll receive it for free, providing a way for them to receive the preferred treatment without taking on a large financial burden.

Disruption: Medium

Frequency: Low

Impact to quality: Varies (depending on whether there are equally effective, non-experimental treatments)

Impact to cost: High

The clinical trial operating playbook

  1. Have a strong Medical Management team in place that can work with members and providers to confirm that experimental/investigational treatment is the best course of action.
  2. Engage with the member to help them understand their various treatment options and the associated costs.

What can go wrong

  • Lack of available trials. There’s no guarantee that a trial will be available for the treatment in question, or that the member will meet the criteria for available trials. In this case, the member will have to either pay for the care themselves or pursue a course of treatment that is already known to produce positive clinical outcomes.

The role your TPA should play

  • Vendor coordination: Identify and incorporate an effective Medical Management team into the plan.
  • Member engagement: Engage with members to help them understand their options and the costs associated with each option.