Evaluate healthcare point solutions with 5 simple questions

If every healthcare point solution delivered the return in its sales deck, employer health costs would be falling. Instead, health spend growth is running near 9% in 2026, the highest rate in 20 years, while the ROI pitches keep coming. 

But all too often, benefits leaders are left with a lingering question: 

“If all of these healthcare point solutions are promising savings, how come our healthcare costs keep going up?”

That gap between promised and realized savings is why the evaluation of healthcare point solutions matters so much. The framework below is for benefits leaders sorting through healthcare point solutions to ensure you have a savings number you can defend to a board room, CFO, benefits committee, and your plan participants.

Why the healthcare point solutions market got so crowded

The volume of healthcare point solutions reflects the appetite employers have for real change to help contain perennial increases in healthcare trend. 

Additionally, the increase in volume reflects how the healthcare system’s ability to treat patients has evolved. Specialty medicine is a clear example: Fewer than 30 specialty drugs were on the market in 1995. Today, nearly 1,000 are available, and roughly 75% of the 7,000 drugs in development are specialty medicines. The innovation is good news for patients, but the system that delivers those treatments has barely changed, which leaves room for a vendor to fix each broken piece.

5 questions every point solution should be able to answer

1. Can you help me identify my current costs you’re solving for?

Before a vendor can lower a cost, you need to be able to see it, and in some categories that’s harder than it sounds. Specialty infusion is a good example. When a hospital outpatient department or provider clinic administers an infusion drug, it typically buys the drug, marks it up, and bills the health plan through a single J-code or Q-code claim (the standardized billing codes for provider-administered drugs). 

The employer sees one allowed amount on that claim, with no breakdown of how much was the drug, how much was administration, and how much was margin added on top. Under this buy-and-bill model, that margin can reach as much as 400% of what the provider paid for the drug.

The spend is also easy to miss because it’s spread across conditions. Infusion costs show up in multiple sclerosis, rheumatoid arthritis, Crohn’s disease, and cancer, so a condition-by-condition review rarely adds them up in one place, even though just 1 to 2% of members can drive 10 to 15% of healthcare costs.

A vendor worth your time should be able to show how to evaluate these opaque, hard-to-understand claims and deliver a more transparent view of your spend with them.

What to ask:

• Can you break our claims down into drug cost, administration, and markup?
• Which codes, drugs, or sites of care are driving the spend you’d address?
• What share of our total spend does your solution address?

2. How does the vendor get paid?

A vendor’s fee structure tells you what it’s actually motivated to do. A per-member-per-month (PMPM) fee gets paid whether or not anyone uses the program, so the vendor gets paid for enrollment rather than outcomes. A fee tied to delivered care or completed services puts the vendor’s revenue on the same side of the table as your savings.

It’s also worth asking whether the vendor earns money on the cost you’re trying to reduce. A solution that takes a margin on the same claims it promises to lower has a conflict built into the very performance it’s hoping to drive for your organization.

What to ask:

• What do you earn if none of our members use the program?
• Are there implementation, platform, or integration fees beyond the core service?
• Do you take any margin on the drug, procedure, or service your program is meant to make cheaper?

3. Is the savings number cost avoidance or a hard-dollar reduction?

Cost avoidance is an estimate of money you would have spent on something that didn’t happen, such as a surgery, an ER visit, or a hospitalization, usually calculated with the vendor’s own model. Those programs can have real value, but the savings figure is a projection, and your CFO will treat it as one.

A hard-dollar reduction is something you can see in your claims, such as a claim that cost one amount before and a lower amount after, for the same member and the same care. When savings work this way, the explanation is simple. It cost this much last year, and it costs this much now.

Getting the data to check that math can take some effort. Some carriers resist sharing detailed claims information at first, but employers often have more right to their own plan’s paid-claims data than they’re initially told, so it’s worth asking for.

What to ask:

• Can you show a specific claim before and after, side by side?
• Can we audit your savings against our own paid claims after the fact?
• Which parts of your savings estimate are modeled, and which parts are observed?

4. Does the solution remove the cost or just move it somewhere cheaper?

Many cost-containment programs work by steering members from a high-cost setting to a lower-cost one. That can help, but it often leaves the underlying pricing problem in place. In specialty infusion, moving a patient from a hospital to a freestanding infusion center typically reduces the drug markup, but it often doesn’t eliminate the cost markup.

Rob LaHayne, co-founder and chief commercial officer at Leap, describes the limit of that approach this way: “You’re sending patients from one provider marking the drug up 200 to 300% to a provider marking it up 50 or 60%. There’s still fundamentally a markup on the drug.”

The difference shows up quickly in real claims. In one example, an Ocrevus encounter billed at about $89,000 in a hospital outpatient setting came to about $39,000 when the drug was billed at true acquisition cost, with care coordination and clinical administration listed as separate charges.

What to ask:

• Does your savings come from changing where care happens or from changing how it’s priced?
• If a member stays with their current provider, do we still save anything?
• What markup remains in the claim after your program is in place?

5. Does the solution actually improve the member experience?

Every healthcare point solution eventually reaches a person. With specialty medicine, that person may be managing a serious condition, a demanding treatment schedule, or both. The routine of receiving care can include:

• Hours of travel to a hospital.
• A long treatment in a waiting-room chair.
• Phone calls about prior authorizations, pharmacy deliveries, and scheduling, usually handled with little or no help.

Employee benefits, by design, should be of benefit to the employee. Onboarding a healthcare point solution that doesn’t improve the member experience can have a significant impact on whether the solution actually delivers results. Point solutions are often voluntary, and members tend to choose the option that fits their lives. 

A program that saves money on paper but adds friction will see members drift back to what they know. A program that asks members to give up a doctor they trust will lose them even faster. 

When the experience works, members are also more likely to stay on their care plan, and fewer of them spend the workday coordinating care or bringing questions to HR. Look for specifics. Participation should be optional, and members should keep their prescribing physician, plan, and ID card. A named person should help with prior authorization, prescriber coordination, pharmacy logistics, scheduling, and follow-up after each treatment, rather than leaving members to manage a portal and an 800 number. 

What to ask:

• Do members have to change their doctor, plan, or ID card?
• Who is the member’s main point of contact, and what does that person take care of?
• How long does it typically take a member to start care?
• How much time does your program save members per treatment, and how do you measure it?
• How do you measure member satisfaction, and how often?

The takeaway

Evaluating healthcare point solutions has become part of a plan sponsor’s fiduciary role. Transparency requirements under the Consolidated Appropriations Act (CAA) and closer attention to how plans are managed have made “we didn’t know what we were paying for” a weaker defense than it used to be. The questions above apply to any category, and together they lead to the same result: A savings number you can defend.

For specialty infusion, Leap built its model to answer each of those questions. 

• A claims-based impact analysis built from your own data breaks bundled J-code and Q-code claims into drug cost, administration, and markup, so you can see what you’re paying for before you commit to anything. 
• Leap bills drugs at true acquisition cost and lists care coordination and clinical administration as separate charges, with no PMPMs and no fees unless care is delivered. 
• Because the savings show up in paid claims instead of a projection, you can audit them after the fact, and 100% of Leap clients have hit their stated ROI within 12 months. 
• The program also works inside your existing carrier relationship, and members keep their plan, their ID card, and their prescribing physician.

Leap coordinates infusion care at home or close to home through a national network of partner infusion nurses, with evening and weekend appointments when available. Every member is paired with a Leap Care Guide who helps with prior authorization, prescriber coordination, pharmacy logistics, scheduling, and follow-up after each infusion. 

A Leap analysis of its own data shows that members save about three hours per treatment, the median time to first treatment is under two weeks, and Leap members report 98% satisfaction.

That combination turns a savings estimate into a savings number you can defend, through an infusion benefit your members will choose to use.

A claims-based savings analysis shows, drug by drug and member by member, where markup sits in your specialty infusion spend and what those same encounters would cost without it. Get yours!