Members of the PCG Health team spent last week meeting many of our clients and colleagues at the 31st annual National Academy for State Health Policy (NASHP) conference in Jacksonville, FL. This conference provides the opportunity to learn from attendees about innovative projects underway at the state level. #NASHPCONF2018 highlighted policy changes that many states addressed in the past year and provided insights into topics such as efforts to stabilize health insurance markets, progress reports on delivery system reforms, and updates on efforts to pass prescription drug cost control measures—to name just a few.
One session of particular interest, entitled “Shifting Sands at the Provider Level—What’s a State to Do?” discussed first-in-the-nation efforts to regulate and protect consumers, including Massachusetts’ recent enactment of provider treatment decision appeal rights for certain consumers. For those commercially insured individuals enrolled in an Accountable Care Organization (ACO) or Risk-Bearing Provider Organization (RBPO), Massachusetts grants appeal rights for coverage decisions—for example, decisions related to referrals, the intensity of the services, and timely access to care.
The appeal is referred to a binding third party and reviewed against the standard of whether the requested service, provider referral, or course of treatment is “likely to produce a more clinically beneficial outcome to the patient than was recommended by the ACO.” The timeline associated with the appeal encourages a quick resolution—setting forth a 14-day review period, with an urgent appeal timeline of 3 days. David Seltz, Executive Director of the Health Policy Commission, stated that he believes the new appeal process will reduce the number of external appeals and work to further protect Massachusetts consumers.
For the past few years, NASHP has been very active in the effort to enact both legislation and additional regulatory oversight over prescription drugs, convening the leading state experts on the topic to serve on the Pharmacy Cost Work Group, as well as establishing a Center for State RX Drug Pricing. For #NASHPCONF18, the workgroup released and presented information related to a model act aimed to regulate pharmacy benefit managers (PBMs) that may be of interest to our clients. States had success during this past legislative cycle on efforts to regulate PBMs, including the passage of the Arkansas Pharmacy Benefit Manager Licensure Act, which tracks closely to ideas presented in the NASHP model act. We will continue to follow this topic closely and track state movement, including how the licensure of PBMs in Arkansas has progressed (as the act requires PBMs to be licensed by September 1st). Health Policy News reported on state movement on this topic recently, and released a report on state efforts to tackle rising prescription drug costs this past spring.
If you would like more information on any topics addressed at #NASHPCONF18, all presentations and conference materials will be available next week.