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Feldman explains how healthcare legislation and regulation play a pivotal role in shaping patient care and costs.
In the second part of an interview with HCPLive, Madelaine A Feldman, MD, FACR, delves into the intricacies of healthcare legislation and regulation, shedding light on key issues that influence patient care and costs.
Understanding the distinction between state and federal law is crucial, Feldman explained.
“The reason I bring up this differentiation is when a state enacts laws related to, let's say, step therapy reform, it only applies to fully funded insurance plans, not those sponsored or funded by employers,” she stated.
Utilization management tools, such as prior authorizations, have been used to validate and ensure that doctors prescribe the right drugs for the correct conditions. However, over the years, prior authorizations have led to care delays and increased expenses for patients. There is also evidence showing these delays may lead to patients using more steroids, which is not ideal.
Feldman also discussed prior authorization reform, which both federal and state legislations are tackling.
State-level legislation is making significant strides in addressing these issues. Step therapy reform, for instance, established criteria encouraging shared decision-making between doctors and patients. One important aspect of this reform is the "stability clause," which allows patients who have been stable on a medication to remain on it at the same cost share. Other criteria in these reforms address issues like patients having to retry medications they've previously failed.
At the federal level, the "Safe Step Act" is under consideration, aiming to address step therapy reform. However, moving through Congress can be a lengthy and uncertain journey.
Another critical area of focus has been the banning of copay accumulators and maximizers. Previously, copay cards counted towards a patient's deductible, but now, they are excluded from this calculation, which has a detrimental impact on patients, especially those with high deductible plans. For patients with chronic illnesses who require expensive medications and often have additional conditions that necessitate multiple medications, these copay cards were a lifeline for affording comprehensive healthcare.
“In response, numerous patient advocacy and professional groups, particularly those focused on diseases requiring high-cost drugs, have opposed these copay accumulators,” Feldman said. “Progress has been made, with 19 bans on copay accumulators. Additionally, federal legislation, such as the ‘Helping Ensure Low-income Patients have Access to Care and Treatment (HELP Act),’ aims to address this issue, though it hasn't been passed yet.”
This article was edited for clarity.
Feldman is president of the Coalition of State Rheumatology Organizations, chair of the Alliance for Safe Biologic Medicines, and a member of the Alliance for Patient Access.