Medical

The Affordable Care Act’s primary objectives are to transform the current U.S. healthcare ecosystem into one that is:

1. good for patients, who can enjoy better health, share in their health decisions, and manage their expense effectively
2. good for the industry, leading to overall cost-effective healthcare
3. good for physicians and other healthcare professionals, enabling them to focus on delivery of optimal medical care
4. good for healthcare practices, aligning practitioners, fostering collaboration, and working toward a single goal of delivery of optimal care

If we were to rate the current progress of ACA, the healthcare sectors would have a lot going for them, but looking ahead, it may be a bumpy ride over the next few years with a lot more work required. As we benchmark the financial outlook for the first quarter of 2018, the positive indicators show healthcare companies’ balance sheets are strong, overall cost structures continue to improve, and stocks have good dividend yields. Continued demand appears to be on the rise for healthcare products and services, partly as a result of the growth of our aging population. Unfortunately, these positive factors are being countered by several negative indicators, including political volatility and uncertainty facing ACA and growing national deficit that could change some of the funding sources currently earmarked for the healthcare sector.

Prior to the implementation of ACA, it was well recognized by both the public and private sector that our healthcare system was not sustainable and we were on the road toward the “perfect storm.” The growing swell was influenced by 18% of GNP directly attributed to healthcare and expected to rise to 30% of GNP by 2050; care demand on the rise with over 25% of the population having multiple chronic disease and growth of chronic disease predicted to grow 1% per year until 2030; a

Long before the opioid epidemic was thought to be a public health emergency, prescription drug abuse and misuse were steadily increasing in the U.S. 

To combat this, states and hospitals have been building technological platforms to enable prescription drug monitoring programs that can the track habits of both prescribers and patients. But use of PDMPs varies by state, with some states mandating its use and others merely recommending that hospitals and medical groups opt-in. 

With the Trump administration saying it will crack down on opioid abuse, it begs the question: Could these data-heavy platforms make a dent in the crisis?

Every state but Missouri

As it stands, every state has its own PDMP, outside of Missouri -- the state has made multiple attempts and failures to implement a statewide platform. And 46 of U.S. states are part of the collaborative PMP InterConnect, an interstate group started by Appriss Health in 2011 that fosters prescription drug data sharing across state lines.

But whether PDMP use can truly impact the opioid crisis is yet to be determined. A 2017 study by University of Texas Health Science Center at San Antonio and Northwestern researchers found PDMP use effects remain mixed.

On the one hand, researchers found an underlying link between PDMPs and a reduction of misuse and diversion. Further, many of the programs provide a detailed prescribing history of a patient over the course of the past three months.

While the use of PDMPs obviously reduces the number of opioids prescribe

Pharmacists, how many times have you seen a patient pay for more their medication than they should, all because you’re prohibited from telling them about ways to save money?

How often have you had to tell a patient that the cost for their chronic medication has gone up yet again? This probably happens multiple times a day, leaving you frustrated and reaching for your own antacid or pain reliever.

These situations are now being heard by legislators, who are introducing bills that will address some of the related activities behind these situations, including price increases by manufacturers and contract provisions that prevent pharmacists from sharing information about less expensive alternatives.

Many states are introducing legislation, often referred to as “The No Gag Rule on Pharmacists Act” that will prohibit health insurance companies and pharmacy benefits managers (PBMs) from contractually preventing pharmacists from telling their customers about cheaper ways to buy prescription drugs. These bills generally have bipartisan support and would allow pharmacists to tell patients when their usual and customary (cash) price is less than the copay determined by the patient’s insurer. This situation often arises when the prescription is for a generic drug but could also apply to therapeutic alternatives. Too many times, a less expensive alternative is available, yet patients don’t know or aren’t comfortable enough to ask their doctor or pharmacist.

Current Pharmacy-PBM Relationship

Pharmacies have been subject to DIR fees and claw backs when the difference between the actual cost and the copay is “recouped” by the pharmacy benefit manager. As an example, if the patient’s copay is $25 and the pharmacy’s cash price is $15, the PBM expects that the $25 would have been collected and will charge the pharmacy the $10 difference. Multiply that $10 by hundreds of patients and thousands of pharmacies, and it’s easy to understand the motiva