The escalation governance gap exists because three conditions are simultaneously true.
Condition 1
No trajectory-level reassessment interval exists
Individual services are authorized in isolation. A cancer case receives twelve sequential authorizations across eighteen months — surgery, chemotherapy, radiation, second-line, hospitalization, third-line — and the trajectory as a whole is never assessed.
Condition 2
Escalation signals are dispersed across systems
Claims data sits in the TPA. Clinical data sits in the EHR. Pharmacy data sits in the PBM. Stop-loss exposure data sits in the carrier. Nobody assembles these into a trajectory view. The information exists. The assembly does not.
Condition 3
Authorization tools are being asked to perform governance work they were never designed to do
PA governs access — whether a patient qualifies for a service. It was not designed to govern trajectories — whether the cumulative pattern of services constitutes evidence-aligned care. Asking PA to govern escalation is like asking a security guard at the front door to audit the building's operations.
02 / 10
The Six-Barrier Map
Six entities touch a catastrophic case. None can produce independent governance intelligence.
Entity
Structural Barrier
Independent?
Advisory-Only?
Population-Level?
TPA
Administrative contract. Service-level UM, not trajectory governance.
—
—
Partial
Stop-Loss Carrier
Clinical review tied to reimbursement decision. Financial conflict.
—
—
—
Case Management
Clinical relationship creates duty to act on any finding.
—
—
—
PBM
Pharmacy claims only. Cannot see medical, surgical, facility spend.
—
✓
—
Employer
No clinical governance capability. Reviews reports after money is spent.
—
—
—
Provider
Internal review. Revenue interest. Findings never reach plan sponsor.
—
—
—
Cadence Sentinel
No clinical relationship. No financial stake. Published standard.
✓
✓
✓
The barriers are structural, not practical. An external auditor's opinion carries weight precisely because the auditor has no financial stake in the entity being audited. Independence is not a feature. It is the architecture.
03 / 10
The Corridor
What an ungoverned trajectory looks like.
Composite Case — Metastatic Non-Small Cell Lung Cancer
Cumulative cost$1,247,000Duration18 monthsSequential authorizations14Trajectory-level reassessments0Treatment lineThird-line. No documented response assessment from second-line.Site escalationOutpatient → inpatient → ICU (day 387). No transition governance.Therapeutic compoundingPembrolizumab + carboplatin + pemetrexed. Prior regimens not discontinued.Goals-of-care assessmentNone documented.
LINESCSITESCCOMPOUNDNORESPONSEDURESC
Every individual service was authorized. The trajectory was never assessed. Fourteen UM reviews. Zero governance reviews. The TPA approved each door in the corridor. Nobody looked at the corridor itself.
De-identified composite. Representative of the trajectory assembled from claims data for a flagged case.
04 / 10
The Architecture
Six required triggers. Each identifies a specific escalation pattern.
ESCVEL
Escalation Velocity
Cost acceleration exceeding expected trajectory for diagnosis and treatment phase.
LINESC
Treatment Line Escalation
Progression to next treatment line without documented response from the prior line.
SITESC
Site-of-Care Escalation
Transition to higher-acuity setting without documented transition governance.
NORESPONSE
No Documented Response
Active treatment exceeding $100K with no clinical response assessment in the trailing period.
COMPOUND
Therapeutic Compounding
Addition of high-cost therapies without discontinuation of prior therapies.
DURESC
Duration Without Reassessment
Case exceeding 12 months and $250K with no trajectory-level reassessment.
All triggers configured in a versioned configuration fingerprint, locked before cycle start. Threshold-based, not subjective. Additional optional triggers available: GENETHERAPY, NICUEXT, TRIALGAP, GOCSNA.
05 / 10
The Standard
CCGS v1.0 defines what a valid catastrophic case governance cycle is.
Eight sections. Six required triggers. Subspecialty-matched MD reviewers. A published specification.
Population Definition
Minimum 1,000 total plan members. Payer type documented.
Trigger Architecture
6 required categories. All configured and documented.
Reviewer Qualifications
Minimum 2 external MDs. Subspecialty match required. No single reviewer >40%.
Outcome Taxonomy
Aligned, Redirect, Transition, Reassess. No fifth category.
Measurement
EIR, DAR, GPR, GSV. Formulas documented.
Audit Trail
Immutable. Sealed at cycle close. No post-seal modification.
Configuration Fingerprint
Versioned and locked before cycle start.
Governance Certificate
Credential issued upon CCGS-compliant cycle completion.
06 / 10
What You Hold
The governance artifact is a new object. No existing process produces it.
Configuration fingerprint. Outcome distribution. Measured EIR and DAR. Immutable audit trail. Governance narrative per case. Sealed at cycle close.
Board Room
Your CFO presents documented evidence that every catastrophic case trajectory was independently reviewed for evidence alignment. No other document in the room does that.
Stop-Loss Renewal
Your broker slides the Governance Certificate across the table. The underwriter sees structured trajectory oversight for the first time. No other employer they underwrite can produce this.
ERISA Fiduciary
Documented evidence that structured oversight was exercised over your catastrophic claims under an external published standard. The answer to the question your board has not yet asked but will.
07 / 10
The Market
$3M claims are the new $1M claim.
Employers with $1M+ claimants
49%
Up from 23% in 2019
U.S. stop-loss market
$26.9B
15.1% CAGR through 2034
Gene therapy per administration
$2M+
Zolgensma, Hemgenix, Skysona
Every entity in the catastrophic case ecosystem sells coverage, coordination, or analytics. Nobody sells governance. The corridor is longer and more expensive than it has ever been. Sentinel is the first product that governs what happens inside it.
08 / 10
The Platform
Two ungoverned segments. One governance methodology.
Cadence Sustain
Continuation Governance
Specialty pharmacy. GLP-1s, biologics, behavioral, oncology maintenance. Is anyone confirming this therapy is still working?
65,234 patients validated 58–60% RIR across three populations CGS v1.1 published standard NIH All of Us validation
Cadence Sentinel
Escalation Governance
Cancer, cardiac, NICU, transplant, gene therapy. Is anyone confirming this trajectory is still evidence-aligned?
CCGS v1.0 published standard 6 required trigger categories Subspecialty matched MD reviewers Methodology validated through Sustain
Same independence. Same artifact. Same sealed audit trail. Same Governance Certificate. The healthcare system governs the gate and abandons what follows. Cadence governs the corridor.
09 / 10
See what governance would have found.
Twelve to twenty-four months of your claims history. Trigger logic applied retroactively. A written assessment showing which catastrophic trajectories escalated without governance, when they would have been flagged, and the economic exposure. Most organizations that see the retrospective analysis decide the prospective governance cycle is obvious.
Start with the exposure analysis.
pilot@showyourwork.health
showyourwork.health
Cadence, LLC
Methodology: Catastrophic Case Governance Standard (CCGS v1.0) — published at showyourwork.health
Governance methodology validated across 65,234 patients in three independent populations (Cadence Sustain).
Built by a 15-year healthcare operator who founded and ran a health system, then led specialty risk product strategy inside a Fortune 25 payer.