6 Policy Updates Health Systems Should Keep an Eye on in 2021

As today’s healthcare teams broadly advocate for patient care and more granularly support care continuity and patient empowerment, they need proper infrastructure in place. Recent healthcare IT legislation and regulations focus on drug pricing, transparency, diversification of benefits and interoperability. These priorities support a person-centered, connected care environment that can still allow secure health information access and exchange.

Below, read policy updates from the state and federal level that may impact health systems this year and beyond. For a bigger picture of these updates and how they impact the healthcare ecosystem, read our Medication Access Report: Legislative & Regulatory Edition.

1. Scope of practice policies could open the care team door for pharmacists Fifty-one percent of patients said they relied on their pharmacist more in the last year, for anything from medication and condition information to immunizations.^[1]CoverMyMeds Patient Survey, 2020 Currently, 37 states allow pharmacists provider status under Medicare Part B rules.^[2]Provider Status for Pharmacists: It’s About Time, Pharmacy Times, 2020 Many state legislatures have introduced legislation regarding pharmacist provider status, ranging from prescriptive authority to COVID-19 medication administration.^[2]Provider Status for Pharmacists: It’s About Time, Pharmacy Times, 2020 Improved patient care options and making permanent the pharmacist role as part of the overall care team support the ever-growing area of value-based arrangements in healthcare.

2. The interoperability ball is rolling again

In a recent survey, 81 percent of patients supported enabling different healthcare providers to share patient health record information between their EHR systems.^[3]PEW HIT National Survey, PEW Charitable Trusts, 2020 This year marks the beginning of the Office of the National Coordinator (ONC) 21st Century Cures Act: Interoperability, Information Blocking and Health IT Certification Program Final Rule implementation. This rule established application program interface (API) requirements and requires clinical data to be exchanged through Fast Healthcare Interoperability Resources (FHIR). This will enable hospitals, providers and health systems to select the apps and EHRs that best suit their needs in ease of access and exchange of patient healthcare information, improving continuity of care and access and adherence to their needed medications.

3. The ONC has more plans for health IT

In November 2020, ONC released their final 2020-2025 Federal HIT Strategic Plan, which outlines federal health IT (HIT) goals and objectives, focusing on individuals’ access to their electronic health information.^[4]2020-2025 Federal Health IT Strategic Plan, Office of the National Coordinator, 2020 Over 25 federal organizations helped develop the plan which will serve as a five-year framework to prioritize and execute on issues related to healthcare cost, access and burden challenges through interoperability in the healthcare ecosystem, enabling secure data exchange.

4. The Centers for Medicare and Medicaid Services (CMS) Final Rule deadlines will enforce patient access and provider directory APIs

Similar to the ONC Final Rule, the CMS also released regulations to allow for more liquid, secure patient data exchange. On July 1, enforcement began for CMS-regulated payers to implement and maintain an API where patients can easily access claims and as well as clinical information through third-party applications (apps) of their choice.^[5]Policies and Technology for Interoperability and Burden Reduction, Centers for Medicare & Medicaid, 2020 CMS-regulated payers must also make provider information available through a standards-based API, allowing patients greater choice and enabling expanded care coordination.

5. State policies are addressing CAAPs

Many states were set to address copay accumulator adjustment programs (CAAPs) before the COVID-19 pandemic began in 2020. Now back on the table, 18 states currently have proposals to restrict CAAPs, which prevent the value of a manufacturer copay card from being used toward a patient’s deductible or out-of-pocket maximum. In a 2018 study, the average copay card value per claim was $229.33.^[6]Prescription Drug Coupon Study, Commonwealth of Massachusetts Health Policy Commission, 2018 If patients were to pay this out of pocket, nearly 50 percent are likely to abandon these prescriptions.^[7]Medicine Spending and Affordability in the United States, IQVIA, 2020

6. State are also taking charge on prescription price transparency

Legislators in multiple states want to ensure patients and providers have patient-specific coverage and out-of-pocket cost transparency at the point of care. The lack of this information in workflow has been part and parcel of the prescription abandonment issue we have in healthcare today: A recent survey shows when a prescription costs more than expected, over a third of patients leave the pharmacy without it. Limited real-time data from payers and PBMs could lead to lower provider adoption or use of real-time benefit tools. Innovations in the healthcare market today are only usable to the extent that the data is patient-specific, real-time and easily understandable and consumable. The art of the possible in healthcare interoperability is about prioritizing data fluidity. Several states have or are planning to introduce legislation requiring patient specific, eligibility, benefit and coverage information be shared and made available for patients and their care team in real-time.

To learn more about state and federal measures aimed at open access, improved interoperability and data fluidity, including ePA mandates and standards, read the 2021 Medication Access Report: Legislative & Regulatory Edition.