Triggered by ACA, health-plan changes are mushrooming

The Affordable Care Act (ACA) is drastically changing the way patients and employers pay for healthcare and prescriptions, according to speakers at this year’s NACDS Total Store Expo, which took place in Boston, Aug. 23–26. However, pharmacists still have a lot to learn about the effects of the ACA on employer health plans.

Katy SpanglerIn fact, when asked whether they understand the major provisions of the ACA, only 5.3% of pharmacists surveyed for a report titled “Research in Social and Administrative Pharmacy” said they “strongly agree.” To that end, Katy Spangler, senior vice president of health policy for the American Benefits Council, and Michael Johnsrud, BS Pharm, PhD, senior vice president of Avalere Health PhD, briefed show attendees in a presentation titled “ACA’s Impact on Community Pharmacies.”

Higher numbers

For example, Avalere Health predicts that pharmacy-covered enrollment in managed care organizations (MCOs) will increase by 37% between 2013 and 2016. And Express Scripts found that, from January through March, patients enrolled in healthcare exchanges had a 47% greater use of specialty medications than patients enrolled in commercial plans. “[There was] a greater volume in costs due to depression, pain, and seizure medications, and a higher cost-sharing as well. You think about who is using the exchanges: patients who are [having] a little more complex [health issues],” Johnsrud said.

In addition, the Centers for Medicare and Medicaid Services (CMS) estimates that 6.7 milion individuals joined Medicaid between January and May of this year, a likely consequence of the ACA. “We are still seeing pretty hefty increases in the Medicaid population. Some of it could be related to the economy… We think it could be the exposure: the marketing and promotion under the ACA,” Johnsrud said.

More business

Pharmacists may also obtain more business from Medicare patients because of the ACA. “The way that Medicare is structured to pay physicians, there is a really big emphasis on specialty care. As you see more people get insurance because of the healthcare law, you will see that become more of an issue, in that it is hard to see a primary care doctor,” Spangler said.

As a result, policymakers will encourage medication therapy management programs at retail clinics and medical clinics where “you will see pharmacists, physician assistants, and nurse practitioners really practice at the top of their license,” Spangler said. “You might see legislation on that at the federal or state level.”

Plan changes

Many U.S. employers are changing their employee health benefit plans because they face a 40% excise tax on health coverage in excess of certain thresholds ($10,200 for self-only plans; $27,500 for family plans), which takes effect for taxable years beginning after December 31, 2017.

 To avoid incurring the tax, many employers are adopting plans with higher deductibles and out-of-pocket costs. A recent survey from the National Business Group on Health found that there will be a nearly 50% increase in the number of employers who plan to offer a consumer-directed health plan as their only benefit-plan option next year. 

“This means that the only plan available to nearly one-third of Americans getting coverage from employers is a high-deductible plan,” Spangler said. These patients are also likely to pay 100% of their prescription costs for nonpreventive drugs until they meet their deductibles.

Some employers are also pursuing value-based insurance designs, eliminating or reducing co-pays on high-value prescriptions. Some plans have four or five different pharmacy tiers, in which the consumer is responsible for 25% to 35% of the cost of the specialty drug on the fourth or fifth tier.

A limited number of employers are also bypassing health insurance companies altogether and are contracting directly with providers. For example, in Seattle, Boeing contracts with Providence and the University of Washington for care provided directly to employees.

And, a few years ago, Lowes contracted with Cleveland Clinic for non-emergency heart care for its employees. “The employees loved it, and Lowes got a better value from Cleveland Clinic,” Spangler said. “You will see more of these types of innovative [arrangements], as employers look to increase quality and lower cost.”