When your board asks about continuation oversight, what will you show them?
Your organization governs therapy initiation with rigor — prior authorization, step therapy, formulary placement. But once a patient is on therapy, the oversight stops. And right now, that continuation spend is flowing with no structured governance around it.
Cadence is the first structured, advisory-only governance layer for high-cost chronic therapy continuation — it makes the oversight gap visible, measurable, and auditable before your board asks why it doesn't exist.
What Cadence Produces
Documented configuration fingerprint, measured RIR™ (Reviewer Influence Rate), immutable audit trail. The artifact your board needs — that nothing else produces.
$864K governance signal on a 2,500-member pilot cohort. Not a savings projection — a documented shape of continuation that has economic implications.
40% of reviewed cases confirmed appropriate continuation. The governance cadence doesn't force change — it finds the truth and documents it.
Why now: CMS's BALANCE Model launches GLP-1 coverage for Medicare and Medicaid mid-2026. Millions of new continuation members entering the system. The governance gap is about to get dramatically wider — and your board will ask what you're doing about it.
Where does your organization stand?
12 questions. Five minutes. No data required, no commitment. Get your Governance Readiness Score and see exactly where the gaps are.
Continuation is a lifecycle phenomenon, not a prescribing event.
Once a patient is initiated on a GLP-1, a biologic, or any high-cost chronic agent, the structural expectation is indefinite continuation. Discontinuation requires an event. Continuation requires nothing. That imbalance is the blind spot.
The Three-Condition Diagnostic
The blind spot exists because three conditions are simultaneously true:
Unlike lab monitoring or PA renewal, continuation itself has no consensus interval for structured review. A patient may continue for years without a governance touchpoint beyond the initial authorization.
Claims show utilization. Labs show response. Notes show rationale. Pharmacy data shows fill patterns. No single system pulls these together into a structured reassessment prompt. The intelligence exists — it's just scattered across silos.
Step therapy, PA renewal, UM referral — these are eligibility tools repurposed for continuation governance. Binary, adversarial, friction-generating. They were never designed for nuanced, advisory, cadence-based reassessment.
Continuation Inertia
Patients stay on therapy not because someone decided they should — but because nobody asked. That's continuation inertia. It's not fraud. Not waste. Not abuse. It's what happens when a system heavily governs initiation and then looks away.
Inertia is not pejorative. The reference pilot showed 40% of reviewed cases resulted in continued therapy — appropriate continuation, confirmed by a human reviewer. Inertia becomes a problem only when it's invisible, undocumented, and unexamined.
So the question becomes: how do you make continuation visible without triggering the compliance machinery that comes with calling it fraud or waste?
Cadence tells the governance story, never the fraud story.
When a payer identifies fraud, waste, or abuse, they're compelled to act — and that compulsion triggers legal exposure and political fallout. Cadence breaks that bind. It doesn't look for fraud. It looks for the absence of structured reassessment.
Three Properties of the Shape
When a board member asks "what is your continuation oversight posture?" the plan has a documented answer. Not "we found problems" — but "here is our structured cadence and here is the governance signal it produces."
If RIR™ shows 60% trajectory influence, that is information, not a compliance trigger. The organization can use it to inform strategy without the legal and political machinery that activates when something is labeled fraud or waste.
The 40% Continue rate is the proof. Four in ten flagged cases, upon structured review, showed continuation was clinically appropriate. That documented neutrality — the evidence that governance was exercised and found nothing to change — is the value.
The Seven Non-Negotiables
These constraints are the trust architecture. They make deployment possible where every other approach gets killed in committee.
The Seven-Step Governance Loop
One complete cycle = one governance cadence. Repeats every 90 days. Each cycle compounds governance value.
Step 4 produces recommendations, never denials. Humans always decide.
Every action in every step is logged in an immutable audit trail.
Triggers, thresholds, queue priority — the plan owns the governance logic.
What Cadence Measures
Four governance metrics and one entry diagnostic. Here's what they are and what the pilot found.
The first governance metric designed to measure whether structured reassessment correlates with clinical trajectory change. Non-causal by design. The 40% Continue rate confirms neutrality.
Did the trajectory change stick into the next cycle? Requires two cycles. Target: ≥60%.
Directional economic signal. Pilot: $864K. Never a savings projection.
Starting at ~$6/member/month — governance at as little as 1% of therapy cost. The $864K is TAF-weighted by outcome type (Adjust, Taper, Switch). Not a savings guarantee — a measured, directional signal.
Reference Pilot Results
Three converging evidence streams: direct observation across ~50,000 members, published literature, and this operational pilot.
Where is your organization?
The Cadence Maturity Model. GRS™ maps your score to these levels.
Most large payers will self-assess at Level 2 or Level 3. Level 2 is understandable — analytics without action is a known limitation. Level 3 is uncomfortable — because it reveals that escalation, the tool you rely on most, was never designed for continuation governance.
That discomfort is where the conversation begins.
RIR™ Laboratory
Adjust the variables. The math updates in real time. See how governance signal works.
Your Cohort Size
Set your population size. The numbers flow through: cohort → 25% flagging → 92% completion → review base for outcomes.
Adjust the Outcome Distribution
Drag the sliders to model different scenarios. The formula updates in real time.
≥35% indicates the system is not engineered to force change
Complement: RIR™ + Continue Rate = 100.0% always — mathematical certainty by definition.
✓ Neutrality confirmed. Continue rate of 40% demonstrates the governance cadence is not engineered to maximize trajectory change. The system identifies both cases that should change and cases that should not.
GSV at This RIR™
= (144 × $7,242 × 0.25) + (115 × $7,242 × 0.50) + (86 × $7,242 × 0.30)
Directional governance signal, not a savings projection. ATC = $7,242.
Economics Translator
Input your population size and therapy cost. See what governance looks like in your context.
Cost of Governance Absence
The real question isn't "what will Cadence save me?" — it's "what am I exposed to without structured governance?"
Estimated manual review equivalent: 1,250 flagged × 92% reviewed = 1,150 × 20 min = 383 hrs × $150/hr
Produces no framework, no RIR™, no configuration fingerprint, and no immutable audit trail.
Includes framework, triggers, audit trail, configuration fingerprint, RIR™ benchmark, and governance summary.
Plus a directional GSV of $1.72M
You're about to manage a population you've never had.
CMS's BALANCE Model launches GLP-1 coverage in Medicaid (May 2026) and Medicare Part D (January 2027). A bridge demonstration begins July 2026 at $50/month copay. Millions of new continuation members are entering the system.
Every participating agency starts from zero on GLP-1 continuation governance. No baseline RIR™. No documented cadence. No artifact. That's not a weakness — it's exactly the condition Cadence was designed for.
BALANCE also requires manufacturers to provide lifestyle support programs, which creates an expectation of structured monitoring — but no governance layer exists to connect that monitoring to oversight. Meanwhile, the plans absorbing this new spend will face immediate board-level pressure to demonstrate stewardship. "We covered them because CMS told us to" is not a governance narrative.
And the persistence problem scales with access. Half discontinue. Two-thirds regain the weight. More coverage without governance means more invisible inertia.
Cadence for BALANCE Entrants
Duration, dose escalation, lab gaps, and outcome absence — calibrated for GLP-1 continuation patterns.
Governance cycle designed to complement the mandatory lifestyle support requirements.
Pilot pricing designed for state Medicaid budgets and Part D economics.
Before your GLP-1 population arrives: identify your data extract source, designate 1–3 clinical reviewers, brief your CMO on advisory-only architecture, confirm de-identification protocol, and set a pilot start date aligned with your BALANCE enrollment timeline.
Beyond GLP-1
Cadence is governance infrastructure, not a GLP-1 tool. The same framework applies to any high-cost chronic category where continuation is the default and structured reassessment is absent. Each category gets adapted triggers — the governance architecture stays the same.
TNF, JAK, IL-17/IL-23 inhibitors. $40K–$80K/year per member. Patients often continue for years after achieving remission with no structured governance checkpoint. Biosimilar availability creates trajectory change opportunities that go unexercised without a cadence.
Trigger adaptations: biosimilar availability signal, disease activity absence, duration threshold calibration for biologic-specific timelines.
Maintenance immunotherapy, CDK4/6 inhibitors, PARP inhibitors. Indefinite continuation after initial response is standard of care — but "indefinite" without reassessment means no documented governance of whether maintenance is still clinically indicated.
Trigger adaptations: progression-free interval tracking, imaging absence signal, treatment-free interval protocols.
Long-acting injectable antipsychotics, adult ADHD stimulants, buprenorphine maintenance. Some of the longest continuation durations in pharmacy — patients on LAIs for decades without a structured governance touchpoint beyond medication refill.
Trigger adaptations: adherence gap detection, dosing stability assessment, cross-class polypharmacy signals.
Post-administration monitoring for CAR-T, gene replacement, and cell therapy. These are one-time treatments costing $500K–$3M with no standardized governance of long-term follow-on monitoring — a new category of continuation that didn't exist five years ago.
Trigger adaptations: monitoring interval governance, biomarker surveillance signals, long-term efficacy checkpoint cadence.
Run a Pilot
A defined cohort. A data extract. One governance cycle. The framework scales from a 2,500-member pilot to an enterprise-wide deployment — the architecture is the same at any size.
| Parameter | Specification |
|---|---|
| Duration | 90-day governance cycle (repeatable) |
| Cohort | Minimum 2,500 members. No upper limit — framework scales to enterprise populations. |
| Data Required | De-identified claims CSV: 4 required fields + 8 optional |
| Reviewers | 1–3 qualified clinical reviewers |
| Review Burden | ~20 min/case. ~2.3 hrs/day (1 reviewer) or ~1.2 hrs/day (2 reviewers) |
| Investment | Starting at ~$6 PMPM over the governance cycle (as little as 1% of therapy cost). Scales with cohort size. |
| Technology | None. No EHR integration. No software installation. CSV in, governance artifact out. |
| Deliverables | Configuration fingerprint, governance summary, RIR™ benchmark, immutable audit trail, transparency report |
Data Extract: What You Need
| Field | Required | Format | Purpose |
|---|---|---|---|
| member_id | Yes | String | De-identified unique identifier |
| drug | Yes | String | Therapy name or NDC |
| dose | Yes | String | Current dose with units |
| therapy_start | Yes | YYYY-MM-DD | Therapy initiation date |
| last_review | Optional | YYYY-MM-DD | Enables NORV6 trigger |
| last_lab | Optional | YYYY-MM-DD | Enables LABPEND trigger |
| dose_escalated | Optional | Y/N | Enables DOSEUP trigger |
| comorbidity_change | Optional | Y/N | Enables COMCHG trigger |
| weight_baseline / weight_current | Optional | Numeric (kg) | Clinical delta + NOOUT trigger |
| a1c_baseline / a1c_current | Optional | Numeric | Clinical delta + NOOUT trigger |
A defined cohort. A data extract. One cycle.
The governance artifact doesn't exist until someone builds it. Whether that's 2,500 members or 250,000 — the architecture is the same and it starts with a single governance cycle.
Opens your email client with a pre-formatted message to joe@cadencegovernance.com
Frequently Asked Questions
Real questions. Direct answers.