Why specialty infusion therapy must be top of mind in your 2027 benefits planning

One of your employees has multiple sclerosis and requires ongoing infusion therapy. Meanwhile, your renewal numbers are climbing faster than they have in years. High-cost claims are surging, and if you're being honest, you're not entirely sure why. 

The C-suite, however, is asking questions about rising healthcare costs. 

What’s clear is that many of the specialty drugs your employees need are expensive. What's less clear to you could be: 

• How expensive is each drug dosage without markups?
• What happens to the price of the drug when it’s purchased?
• How much site of care adds to the costs absorbed by employers? 

Let’s examine what types of therapies we’re talking about, how much influence they have on national healthcare spending, and what benefit leaders like you can do to help contain rising healthcare costs. 

What is specialty infusion therapy?

Infusion therapy is medication delivered directly into the bloodstream, usually by IV, administered by a registered nurse on a recurring schedule that can vary from weekly, monthly, twice a year, or other frequency. 

Specialty drugs and infusion therapy are among the fastest-growing segments of healthcare. New infusion-delivered medicines are becoming available every year. They’re growing in popularity because:

• New therapies are being developed every year to treat chronic conditions and conditions previously considered incurable or difficult to treat.
• Treatment through infusion can improve absorption of the medication for the patient.
• At-home care has been shown to produce as good of results for many of these drugs as does receiving them in a hospital. 

Because these drugs require clinical administration, the claims don’t run through your pharmacy benefit. They run through your medical plan, billed as a single J-code or Q-code that covers the drug and the site's fee to administer it, with nothing separating one from the other.

Common types of specialty infusion therapy

The specialty infusion claims most benefits leaders will see most often include:

• Ocrevus and Tysabri, for multiple sclerosis
• Entyvio and Remicade (along with its biosimilars Inflectra, Avsola, and Renflexis) for Crohn's disease, ulcerative colitis, and related autoimmune conditions
• Immunoglobulin therapies, such as Privigen, Gammagard, and Gamunex-C, for primary immunodeficiency
• Krystexxa, for chronic, treatment-resistant gout
• Prolia, for osteoporosis
• Keytruda, Opdivo, and Darzalex Faspro, for various cancers

How specialty infusion therapy is influencing rising healthcare costs

WTW projects an 11.1% increase in healthcare costs in 2027 without any plan design changes. Aon projects the fourth straight year of near-double-digit increases, pushing average costs above $19,000 per employee. 

There are a number of factors driving these historic rises in U.S. employer healthcare costs. In a recent survey, drug prices (77%), high-cost claims (75%), and hospital prices (68%) were named as the top threats to healthcare costs by employers. 

Infusion therapy (and the specialty drugs delivered) intersect with all three of these top threats. At the same time, infusion therapy treatments have evolved significantly in recent years, presenting organizations with a new way to mitigate healthcare cost increases in all three of these areas. 

The International Foundation of Employee Benefit Plans' latest survey found that, among employers who named specialty drugs as their primary cost driver, autoimmune and inflammatory therapies ranked as the second most expensive category, which puts drugs like Remicade and Entyvio (among others) squarely in the story.

While a small share of your employees are on infusion therapy, often just 1% to 2% of a population, they drive an outsized share of total health plan spend, in part because there's no visibility into what markup is baked into that single bundled code.

The takeaway: The rising trend isn't only a drug-price problem. It's a markup-and-visibility problem layered on top of a real one.

The changing face of infusion therapy

A very small percentage of infusions happen in a member's home today, even though up to 40% are clinically appropriate for it. The rest still happen in hospital outpatient departments, which often carry the highest facility fees of any site of care.

On top of that, provider markups on specialty infusion drugs can exceed 400%, according to a PubMed study. 

However, published research in another PubMed study shows that employers and members are missing out on opportunities to better meet the needs of this employee population and contain rising costs. One study published in PubMed revealed that: 

• Patients overwhelmingly prefer receiving infusion therapy in the home.
• Home infusion patients were also no more likely to experience adverse drug events or side effects.
• Clinical outcomes were as good or better with home care.

Employers can provide better support for their employees by giving them access to at-home infusion therapy

5 considerations when evaluating specialty infusion therapy providers

Are you ready to consider a better approach to supporting your employees while also mitigating your rising healthcare costs due to high-cost claimants? If so, here are a few questions to ask when evaluating specialty drug (or infusion therapy) providers: 

• What happens before, during, and after the first dose? A registered nurse should be present for the first infusion of any new therapy, with a reaction protocol in place, regardless of where it happens.
• Can members choose home, an infusion center, or both? A provider that only offers one setting is putting their model first rather than your employees. Plus, the majority of your employees who receive infusion therapy prefer at-home treatment.
• How much are you marking up specialty drug purchases? In light of provider markups, ask any infusion therapy provider how much of a markup they’re applying to the purchase of specialty drugs.
• Is this priced to reward outcomes, not just enrollment? The best infusion programs are built so the provider's incentives point the same direction as yours: You're paying for value delivered, not a flat fee (such as a PEPM) that shows up whether or not anyone benefits.
• How is member experience actually measured? Ask for the specific satisfaction and engagement numbers when care is provided, not a general claim that people like it.

How Leap is revolutionizing specialty infusion therapy care

Leap bills every specialty drug at direct acquisition cost, with no markup and no shared-savings cut layered on top. Members can receive care at home or at one of Leap's ambulatory infusion centers, whichever fits their treatment and comfort level, with the same registered nurse and care team either way. 

And because Leap only gets paid when a member actually receives an infusion, there's no PEPM or flat fee sitting on your invoice regardless of engagement.

Your organization can cut specialty infusion spend by 60% or more. Click to find out how.