Cadence — Continuation Governance Intelligence

Thesis

Utilization management was built for the front door. Prior authorization decides whether a therapy starts. Nothing decides whether it should still be running eighteen months later.

Cadence sits in that gap. Not prior auth. Not step therapy. Continuation governance: a systematic, clinically-grounded review of therapies that were approved correctly and never reassessed. The savings are real because the problem is real. Every plan has it. None are watching.

The Instruments

01 / Governance

Governance Cycle

90-day structured reassessment. Population-level continuation review. Seven clinical triggers. Sealed governance artifact. Every cycle produces a finding.

02 / Modeling

RIR Lab

Adjust cohort size, therapy mix, and cost assumptions. See what governance finds in your book. Pre-filled with validated defaults.

03 / Standard

CGS v1.1 — Open, Published

Eight sections. Seven required triggers. The methodology is public. The falsification criteria are explicit.

04 / Cell & Gene

Durability Economics

The OBA enforcement gap modeled in real time. Eight inputs, explicit confidence tiers. The swing across the unknown is the argument.

Interactive Model

Model your population.

Adjust cohort size, therapy cost, and influence rate. See what governance finds in your book.

Cohort Size

5,000

Avg Therapy Cost

$7,200

Influence Rate (RIR)

60%

GSV

Governance Cost (3-mo pilot)

PMPM Rate

Cost-to-Signal Ratio

0:1

GSV = (Adjust × ATC × 0.25) + (Taper × ATC × 0.50) + (Switch × ATC × 0.30)

Evidence

The data, fully disclosed.

Cohort 1 — Commercial Payer (25,000)

▼

Metric	Value	Tier	Method
Cohort Size	25,000	Measured	Direct count
Flagged	6,250 (25%)	Measured	Trigger-based
Reviewed	5,750 (92%)	Measured	Completion rate
RIR	60.0%	Measured	Adj + Tap + Sw / Reviewed
DAR	40.0%	Measured	Continue / Reviewed
ATC	$7,242	Measured	Claims-weighted avg
GSV	$8,640,430	Derived	TAF-weighted formula

Cohort 2 — Self-Funded Employer (9,500)

▼

Metric	Value	Tier	Method
Cohort Size	9,500	Measured	Direct count
Flagged	2,375 (25%)	Measured	Trigger-based
Reviewed	2,185 (92%)	Measured	Completion rate
RIR	58.0%	Measured	Adj + Tap + Sw / Reviewed
DAR	42.0%	Measured	Continue / Reviewed
ATC	$11,840	Measured	Claims-weighted avg
GSV	$5,293,312	Derived	TAF-weighted formula
Category RIR: GLP-1	56%	Measured	By therapy class
Category RIR: Biologics	61%	Measured	By therapy class
Category RIR: Behavioral	54%	Measured	By therapy class
Category RIR: Oncology	59%	Measured	By therapy class
PA Blind Spot	62% no PA	Measured	PA status check
Flag Rate (no PA)	34%	Measured	No-PA subgroup
Flag Rate (with PA)	19%	Measured	PA subgroup

Cycle 2 — Governance Persistence

▼

Metric	Value	Tier	Method
Governance Persistence Rate (GPR)	50%	Measured	Cycle 2 / Cycle 1
Adjust Persistence	60%	Measured	863 / 1,438
Taper Persistence	45%	Measured	518 / 1,150
Switch Persistence	40%	Measured	345 / 862
Cycle 2 RIR	52%	Measured	Repeat assessment

Cadence Governance Standard v1.1

The standard, section by section.

Eight sections define how a governance cycle operates. Every requirement is published. Every threshold is explicit.

Cohort Definition

Min 2,500 members. Defined by therapy class, not cost.

▼

Cohorts are scoped by therapeutic category (GLP-1, biologics, behavioral, oncology) and require a minimum of 2,500 attributed members to produce statistically meaningful governance signals.

Trigger Architecture

7 required categories. Threshold-based, not random.

▼

DUR12, DOSE, LABGAP, COMORBID, NOOUT, BIOSIM, PA_BLIND. Each trigger fires on explicit clinical criteria. No random sampling. No cost-threshold selection.

Reviewer Qualifications

External PharmD/MD. Two independent reviewers minimum.

▼

All reviews are conducted by independently credentialed PharmD or MD reviewers. Minimum two reviewers per cohort. No payer employees in the review chain.

Outcome Taxonomy

Continue (DAR), Adjust, Taper, Switch. All advisory.

▼

Every reviewed case produces exactly one outcome. Continue maps to DAR. Adjust, Taper, and Switch map to RIR. All findings are advisory — no prescription is changed without prescriber action.

Measurement Methodology

RIR + DAR = 100%. GSV = TAF-weighted.

▼

RIR (Reviewer Influence Rate) + DAR (Documented Appropriateness Rate) always equals 100%. GSV is computed using Therapy Adjustment Factors: Adjust 0.25, Taper 0.50, Switch 0.30.

Audit Trail

Sealed at cycle close. No records altered post-seal.

▼

The complete governance artifact is sealed upon cycle completion. No individual records, outcomes, or trigger configurations may be altered after the seal date. The audit trail is the product.

Configuration Fingerprint

Versioned. Locked before first review.

▼

Every governance cycle operates under a versioned configuration fingerprint that specifies trigger thresholds, reviewer assignments, and outcome definitions. The fingerprint is locked before the first review begins.

Cycle Requirements

90-120 days. ≥90% completion target.

▼

Standard cycle length is 90 days, with a maximum extension to 120 days. Completion target is 90% or greater of flagged cases reviewed. Below 90%, the cycle is flagged for remediation.

The Standard

Cadence Governance Standard v1.1. Eight sections. Seven required clinical triggers.

DUR12 Therapy duration exceeds 12 months without documented reassessment.
DOSE Dose escalation or maximum dose reached without clinical review.
LABGAP No relevant laboratory monitoring during the continuation period.
COMORBID New comorbidity or contraindication emerged since therapy initiation.
NOOUT No documented therapeutic outcome or response assessment.
BIOSIM Biosimilar or therapeutic alternative available but not considered.
PA_BLIND Prior authorization absent — continuation proceeding without initial gate.

The prescription
was approved.
It kept refilling.
Nobody watched.

Start a conversation.

The prescription was approved. It kept refilling. Nobody watched.

Start a conversation.

The prescription
was approved.
It kept refilling.
Nobody watched.