Healthcare proposals are in state legislative chambers across the country, while federal lawmakers are outlining their priorities—many dealing with similar issues. Among them are containing or cutting medication costs for patients, insurance rules related to accumulator programs and legal authority for pharmacists to provide and be compensated for expanded services.
The implications of proposed changes in statehouses alone could be far-reaching for healthcare, touching patients, payers, pharmacists, providers and pharmaceutical manufacturers.
Medication affordability has been a prime focus for policy change by organizations representing patient needs. According to the latest CoverMyMeds patient survey, which informs the upcoming 2023 Medication Access Report, in the last year, nearly 6 in 10 patients said they learned at the pharmacy counter that their medication cost more than expected. Additionally, one third said they had to stretch out a prescription by taking it on a modified schedule. More than a quarter of patients have had to forgo paying bills or buying essential items to afford their medications in the past year, and 17% stopped buying their medications so they could afford to pay their household bills.
It’s not just household budgets that juggle significant healthcare costs. About a third of state budgets are dedicated to health. And Medicare, Medicaid, the Children’s Health Insurance Program and Affordable Care Act subsidies consumed 25% of the federal budget in 2022, about $1.4 trillion.
With so much at stake for patients, health systems and state and federal healthcare programs across the country, cutting through the noise can be a challenge. Here are three pieces of state and federal healthcare legislation to watch in 2023.
Granting pharmacists status as providers
The movement to expand pharmacists’ roles beyond counting and dispensing pills has been ongoing for some time. In the last couple of years, the pandemic put pharmacists in the spotlight as the most accessible healthcare provider and demonstrated not only the ability, but the need for pharmacists to have fewer barriers to working with patients.
In 2022, legislation impacting pharmacists’ scope of practice was introduced in 38 states, with 26 of those states enacting changes in law. Many of the laws grant pharmacists and their staff the ability to test for and treat infectious diseases, but barriers remain at the federal level. Pharmacists are unable to capture reimbursement for providing these services to federal Medicare patients.
Legislation introduced in the U.S. House of Representatives in March 2022 would have granted pharmacists provider status for Medicare Part B beneficiaries. The Equitable Community Access to Pharmacist Services Act, H.R. 7213, directed the government health insurance program to pay pharmacists for providing testing, drugs and vaccination for COVID-19, flu, strep throat and respiratory syncytial virus (RSV). The legislation also “generally provides for coverage of pharmacist services during a public health emergency or to address health equity.”
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H.R. 7213 failed to advance with the 117th Congress recessing before voting on the proposal. The issue of provider status continues to evolve at the federal level. McKesson, along with many stakeholders representing patients and providers, is a member of the Future of Pharmacy Care coalition. This coalition will continue the conversation with policymakers and regulators with a goal of helping patients gain access to the care they need.
On the other side of the issue, the American Academy of Family Physicians, American Academy of Pediatrics and American College of Physicians warned that the proposal could “undermine the physician-led, team-based care models that have been proven to be most effective in improving quality, efficiency and, most important, patient health.”
The case for compensating pharmacists to continue these services is compelling. Nearly 9 in 10 Americans live within 5 miles of a pharmacy. The 2022 CoverMyMeds Medication Access Report found 77% of patients received COVID-19 vaccinations from a pharmacist, and 39% received a vaccination other than COVID-19 from a pharmacist.
By conservative estimates, from February 2020 to September 2022, pharmacists’ provision of COVID-19 tests, vaccinations and antivirals in the U.S. avoided more than 1 million deaths, 8 million hospitalizations and $450 billion in healthcare costs.
Bringing transparency to healthcare benefits and costs
Providers routinely must prescribe medications without any information about how much they will cost the patient or whether they’re covered by the patient’s insurance.
In its annual survey of 1,000 providers, in fall 2022 CoverMyMeds found approximately half of respondents had plan-specific formulary information in their EHR. Just 20% could access pharmacy-specific pricing, a quarter could see the cost on the patient’s plan and 4 in 10 said they could see plan-specific prior authorization requirements within their EHR.
Forcing providers into blind decision-making leads to a series of interactions that can end with the patient leaving the pharmacy without their medication. About 40% of patients said insurance barriers were the top reason they experienced a delay in accessing their medications in the past year, and 29% said cost was the top reason. About a quarter of patients said they left the pharmacy without their prescriptions.
Forcing providers into blind decision-making leads to a series of interactions that can end with the patient leaving the pharmacy without their medication.
If providers had access to patient plan information at the point of prescribing, in the course of a two-minute conversation, they could tailor the prescription to a medication the patient could afford. They also could begin a prior authorization request, if necessary, rather than having the process kick off later at the pharmacy. Pharmacists wouldn’t have to play phone tag with the provider’s office seeking alternatives or restock the abandoned medication. And patients wouldn’t leave the pharmacy without their meds, facing the possibility that time off work, childcare and transportation may make it difficult to return.
Four states — Colorado, Tennessee, Ohio and Maine — adopted legislation in 2021 requiring payers to grant providers access to plan-specific benefit information within their EHRs. Two more, New York and California, passed in 2022. Virginia is expected to join those six states in 2023.
For patients’ part, sharing necessary data doesn’t seem to be a big concern: 88% of patients responding to CoverMyMeds’ 2022 survey said they were comfortable with different healthcare providers sharing their patient records via EHR systems.
Helping patients access medications without interference by accumulator programs
With the employer trend toward high-deductible health plans and the rise in chronic illness — 4 in 10 adults have two or more chronic conditions — many more patients are struggling with healthcare costs. The pain is especially acute for low-income families and people who suffer with serious conditions like cancer, which often require complex specialty medications that tend to cost more.
In 2018, out-of-pocket healthcare costs were more than 20% of disposable income for almost half of low-income adults on high-deductible plans. The historic levels of inflation since then surely have made things more difficult for many families.
With these trendlines, for some patients, pharma copay assistance programs can mean the difference between taking a life-extending medication or not. However, this financial help isn’t always applied to the patient’s deductible or out-of-pocket maximum. These so-called accumulator adjustment programs can cause patients to hit a wall a few months later, having used up the financial assistance that was meant to help them reach their deductible — but hasn’t.
The disruption has implications for treatment adherence and patient health. Patients subject to accumulator programs fill their medications 1.5 times fewer than patients who aren’t.
Machinations to block accumulator adjustment programs are growing. More than 12 states have enacted legislation nixing them from state health insurance exchanges and some private plans. At the federal level, a bill with bipartisan support in the 117th Congress failed to advance after being introduced in 2021.
The Help Ensure Lower Patient Copays Act will continue to be pushed by the All Copays Count Coalition, which includes major medical and patient advocacy organizations such as the AIDS Institute, Arthritis Foundation, Cancer Support Community, American Cancer Society and American Medical Association.
Healthcare policy has the power to change people’s lives. It also carries a significant financial impact to society. National healthcare spending grew 2.7% in 2021 to reach $4.3 trillion, which worked out to $12,914 per person. That was 18.3% of U.S. gross domestic product.
Stakeholders across the spectrum — patients, providers, pharmacies, pharma, payers and policymakers — have a vested interest in cultivating efficiency and driving down costs in healthcare. Their actions can help make people’s lives better and build a country where everyone can get the medicine they need. Innovation and cooperation are the keys to that future.
CoverMyMeds, part of McKesson, is a healthcare technology company dedicated to helping people get the medicine they need to live healthier lives. For more on how patients, providers and pharmacists are navigating the complex U.S. healthcare system, read the 2022 Medication Access Report.