HEALTH INSURANCE POLICY DESIGN

To advocate that all health insurance policies be designed and coverage decisions made in a way that preserves the patient–practitioner relationship; further,

To advocate that health insurance payers and pharmacy benefit managers provide public transparency regarding and accept accountability for coverage decisions and policies; further,

To oppose provisions in health insurance policies that interfere with established drug distribution and clinical services designed to ensure patient safety, quality, and continuity of care; further,

To advocate for the inclusion of hospital and health-system outpatient and ambulatory care services in health insurance coverage determinations for their patients.

Rationale

Evolving practices by health insurers are negatively affecting patient care decisions and impacting the relationships between patients and their care providers. One common health insurance practice restricts management of and access to certain drugs to specialty suppliers. Another problematic practice is that certain drugs are not reimbursed by the insurer when used as part of the patient’s hospital or health-system care. Medicare, for example, deems certain drugs as self-administered drugs, which are not reimbursed when provided to a patient because they are not considered integral to the reason for admission. These practices increase the number of patients that “brown bag” medications when they are admitted to a hospital to avoid being charged personally for the uncovered medications. ASHP has identified a number of concerns about these practices, including impact on continuity of care, integrity of the drug supply, patient satisfaction, and public perception of healthcare organizations.

It is the responsibility of the pharmacist to ensure the integrity of drugs used in the care of patients in the healthcare facility in which he or she practices. Having to verify products that patients bring with them from multiple suppliers disrupts the care process. Having patients go unreimbursed for a medication because it was administered in and supplied by the healthcare organization is confusing to the patient and damaging to the patient–provider relationship. More broadly, lack of understanding of the differing payment systems in different care settings leads to public relations challenges. In addition, the lack of transparency regarding how payers make certain coverage determinations and apply performance penalties (e.g., direct and indirect remuneration fees) creates a significant challenge for healthcare providers as they care for patients.

ASHP advocates reforming these insurance practices. Coverage of medications should not interfere with the safe and effective provision of care and should recognize the responsibility of pharmacists to ensure product integrity for care provided where they practice. In addition, ASHP advocates that the Centers for Medicare & Medicaid Services, commercial payers, and others include hospital and health-system outpatient and ambulatory care services in health insurance coverage determinations for their patients.