Healthcare World Living “Month-to-Month” While Congress Debates Reform

While the Republican-led Congress debates which pieces of the Affordable Care Act (ACA) it will scrap and which it will keep, the players in healthcare must operate in the condition they hate most of all: uncertainty.

Stakeholders from across healthcare and pharmacy shared what it’s like to serve customers large and small while waiting for answers during a panel discussion at the 12th annual meeting of the Pharmacy Quality Alliance in Baltimore, Maryland.

Featured were Clay Alspach, JD, principal of Leavitt Partners; Mike Anderson, PharmD, chief pharmacy officer for UnitedHealthcare Medicare and Retirement; Jonah Houts, MBA, vice president of Corporate Government Affairs, Express Scripts; Tripp Logan, PharmD, vice president, Logan & Seiler Inc, and senior quality consultant, MedHere Today Consulting; and Lori Reilly, JD, executive vice president, Policy, Research, and Membership, for the Pharmaceutical Research and Manufacturers of America (PhRMA). Clifford Goodman, PhD, of the Lewin Group moderated the panel.

The group gathered as the Senate takes up a version of the American Health Care Act (AHCA) that has passed the House but is almost certain to change. Meanwhile, the Trump administration weighs what to do about subsidies for health plans in the individual market that were approved under the ACA, but challenged for years by Republicans. Insurers have said without those subsidies they won’t stay in the market, and United Healthcare and now Aetna have already left.

Goodman noted that Alspach had described the situation as a “month-to-month scenario,” and the panelists nodded in agreement. These are challenging times for an industry accustomed to planning months, years or even decades ahead. 

Houts said, for example, that CMS formulary deadlines will soon arrive for 2018, and “We’re not sure what schema we’re operating under.” Tax reform might come, but it might not. “It’s that cloud of uncertainty,” he said. “Your clients say, ‘what’s the best advice?’ and we have to be creative.”

Reilly agreed, but also painted the picture as slightly more dire. PhRMA found its head spinning last week when White House Budget Office Mick Mulvaney said, without warning, the administration was weighing mandatory rebates in Medicare. “Clay was being generous when he said it was month to month," she said. "It’s more like hour to hour.”

PhRMA members are especially vexed because deciding whether to invest in research is a 10- to 15-year commitment, Reilly said. That makes it important to understand what the rules and incentives are, she said.

Goodman asked Logan how uncertainty affects planning at the community pharmacy level. Today, Logan said, the challenges manifest themselves at the individual level. “There may be access issues because of cost, or a patient can’t receive care because of network issues. The patient may get a referral, but they can’t use that pharmacy, which is a problem in rural areas.”

Anderson said while there’s more stability in Medicare, “Cost pressures are everywhere.” Especially for Medicare patients with standalone prescription drug plans (PDPs), the likelihood of narrow pharmacy networks is high.