Transcript Formulary transparency and discrimination

Health Care Issues in
Washington
Presentation to Washington State Medical Oncology
Society
March 27, 2015
Jim Freeburg, Special Assistant to the Commissioner
Office of the Insurance
Commissioner
• Only statewide, independently elected
official not created by the state
constitution
• Regulatory authority is granted by the
legislature
Regulatory authority
• Authority over “insured” market only
– Primarily individual and small group
• No authority over Medicaid, Medicare,
self-insured
What we can do
• Enforce the law.
– Financial penalties, stop the sale of an insurance
policy, pull a license
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Review insurance plans for compliance with law.
Help consumers with complaints.
Investigate patterns that may indicate violations.
Write rules to explain the standards and
requirements for insurance companies.
What we can’t do
Address issues we can’t legally enforce.
Negotiate reimbursement rates.
Help providers get onto closed panels.
Make medical judgments or determine if further treatment is
necessary.
• Establish the facts surrounding a claim (for example: who is
being truthful when there are differing accounts of what
happened, or he said/she said situations).
• Tell a company to pay a claim, refund a premium, or reinstate
or issue a policy (if they followed the law and the terms of the
policy).
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Commissioner’s interest in
simplifying health care
• 2007 – OIC assessed avenues to reduce
administrative cost of health care
• 2008 – legislature directed and funded OIC to
identify 5 target areas, and create action plans
• 2009 – SB 5346 required common and consistent
timeframes for medical management approvals
Senate Bill 5267 (2013)
• As introduced: common prior authorization
form to be developed by OIC, requests
deemed approved if no answer within 2 days
• As passed: work group to create
recommendations and be adopted by OIC
• End result: no consensus
Senate Bill 6511
• As introduced: OIC work group to create
recommendations, OIC to review
recommendations and revise as necessary
• As passed: OneHealthPort work group to
create recommendations, OIC to adopt
exactly as recommended
OneHealthPort
• A project of Washington Healthcare
Forum to “streamline and simplify
healthcare financing and delivery”
• Work groups of providers and carriers
who create best practices for operational
processes.
Administrative simplification
Assumptions
Reality
• Technology is the answer –
• EHR is bulky and inefficient
• Lowest-common
“future state”
• Consensus creates ideal
solutions
• Voluntary adoption is best
denominator only provides
incremental progress
• Voluntary adoption doesn’t
achieve goal
• Tremendous burdens still
exist
OneHealthPort work group
focus:
What can be done so that medications are ready for dispensing when
the patient arrives at pharmacy?
1) Prior-authorization (PA) must be requested prior to the patient
leaving the prescribers office rather than after they arrive at
pharmacy.
2) Relevant formulary and PA information must be available and
used by prescribers.
Work group recommendations
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Transparent PA process-Set of health plan web tools and data for industry
standard transactions defined to make it easier for prescribers to get PA
information and to communicate about PA
Consistent electronic prescribing process-industry standard transactions to
be used by prescribers and pharmacies to exchange information about Rx.
PA Processing Timeframes:
-Urgent: 48 hours after getting information from prescriber
-Standard: 5 days from getting information from prescriber
Emergency Fill Policy-require health plans to have policy with at least a set
of defined medications that are guaranteed for emergency fill. Health plans
can go beyond baseline.
Impact on Prescribers
Challenges
Current State
• Transition from fax/phone preauth to browser pre-auth after
notification from pharmacy
Future State
• Change workflow and
technology to ensure a preauthorized medication is
approved before sending
prescription to pharmacy
Improvements
Current State
• Emergency fill
• Online, interactive submission of PA
• Improved access to PA information
Future State (additional)
• PA seamlessly integrated into eprescribing process
• Higher assurance that patient gets med
dispensed without delay
• No back-end reprocessing of PA
13
Challenge
• Health plans have varied, paper-based
PA requirements
Recommendation -transparency
• Health plans to create automated,
online PA process and portal
maintained by OneHealthPort
Challenge
• Industry standard transactions are in
place, but are not always used, or
used in a standardized way
Recommendation - consistency
• Users will “turn on” transactions and
communicate and process PA via
specific data elements
Challenge
• Communication of Rx denial, need PA
Recommendation
• New timeline standards for non-urgent and
urgent decision notification
Timeframe for health
plan to decide or
request more info
Urgent
Standard review
(nonurgent)
Timeframe for
provider to supply
requested info
Timeframe for health
plan to make final
decision
24 hours
48 hours
48 hours
5 days
5 days
5 days*
Challenge
• Insurer may not be available to check Rx to
verify formulary and coverage
Recommendation
• Health plans will have emergency fill policy
with list of covered medications and publish
online
• Emergency fill medication will be approved
and paid, but not necessarily a covered
service
• Benefit determination will be made as part of
PA process
How do we move forward?
The “issue” isn’t settled – solutions to
“current state” are still needed
Scope of OIC authority is limited
Legislative direction likely required
2015 Legislature
• Post-Affordable Care Act
• Provider-leaning session
– Telemedicine
– Grace period
– PBM regulation
How you can help:
• Direct pertinent consumer complaints to OIC
• Collect data and stories to share with legislators,
re: impact of administrative burdens on your
practice
• Work with OneHealthPort on recommendations
• Contribute targeted written comments on OIC
rulemaking