Full- and Shared-Risk Value-Based Care Providers
- Value-based care is built on a simple premise: intervene upstream, before high-acuity, high-cost illness takes hold.
- Nowhere is that logic more consequential — or more actionable — than diagnosing and treating cancer.
- Late-stage cancer is the single highest per-member cost event in any Medicare population — a single case can move your financial position against your benchmark or capitation rate by $90,000–$228,000 in Year 1.
LEAD Model Participants
- For LEAD participants, the financial case for early cancer detection is structurally different from any prior CMS model.
- In every previous ACO model, savings generated by preventing a late-stage cancer case were partially or fully absorbed into a rebased benchmark the following year.
- Under LEAD, those savings are never clawed back — they compound across the full 10-year performance window without interruption.
Medicare Advantage Plans
- Every late-stage cancer diagnosis absorbed is a claims event that premium structures and Medical Loss Ratios were not designed to absorb efficiently.
- Depending on cancer type, a late-stage diagnosis costs $59,000 (breast) to $228,000 (lung) more in Year 1 than the same cancer caught at Stage I.
- Every late-stage cancer diagnosis absorbed is a claims event that premium structures and Medical Loss Ratios were not designed to absorb efficiently. Early detection does not just save lives — it protects your financial position.
Self-Insurers
- Cancer is the #1 and #2 most expensive conditions driving stop-loss claims — accounting for 35.1% of all stop-loss claim costs in 2024, up from 26.8% in prior years.
- Most employer health programs invest in cancer screening awareness campaigns or EAP resources, but lack mechanisms to identify which specific employees in their covered population are currently at elevated risk for undiagnosed cancer.
- OptiStrata provides that mechanism to proactively manage risk.
Medicare Supplement
- Late-stage cancer treatment generates precisely the kind of high-frequency, high-cost utilization that drives Medigap claim severity: multiple chemotherapy infusion cycles, immunotherapy regimens, inpatient admissions for complications, and palliative radiation all generate substantial coinsurance obligations that fall to the supplement plan.
- OptiStrata reduces the coinsurance and deductible exposure your plan absorbs on every late-stage treatment — without requiring your organization to build or operate a care management function.
Patients
- 4 out of 10 US citizens are expected to receive a cancer diagnosis in their lifetime.
- Early detection leads to more effective and less debilitating treatments, saving lives, protecting families, and improving quality of life.
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