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Health Care Issues in Washington Presentation to Washington State Medical Oncology Society March 27, 2015 Jim Freeburg, Special Assistant to the Commissioner Office of the Insurance Commissioner • Only statewide, independently elected official not created by the state constitution • Regulatory authority is granted by the legislature Regulatory authority • Authority over “insured” market only – Primarily individual and small group • No authority over Medicaid, Medicare, self-insured What we can do • Enforce the law. – Financial penalties, stop the sale of an insurance policy, pull a license • • • • Review insurance plans for compliance with law. Help consumers with complaints. Investigate patterns that may indicate violations. Write rules to explain the standards and requirements for insurance companies. What we can’t do Address issues we can’t legally enforce. Negotiate reimbursement rates. Help providers get onto closed panels. Make medical judgments or determine if further treatment is necessary. • Establish the facts surrounding a claim (for example: who is being truthful when there are differing accounts of what happened, or he said/she said situations). • Tell a company to pay a claim, refund a premium, or reinstate or issue a policy (if they followed the law and the terms of the policy). • • • • Commissioner’s interest in simplifying health care • 2007 – OIC assessed avenues to reduce administrative cost of health care • 2008 – legislature directed and funded OIC to identify 5 target areas, and create action plans • 2009 – SB 5346 required common and consistent timeframes for medical management approvals Senate Bill 5267 (2013) • As introduced: common prior authorization form to be developed by OIC, requests deemed approved if no answer within 2 days • As passed: work group to create recommendations and be adopted by OIC • End result: no consensus Senate Bill 6511 • As introduced: OIC work group to create recommendations, OIC to review recommendations and revise as necessary • As passed: OneHealthPort work group to create recommendations, OIC to adopt exactly as recommended OneHealthPort • A project of Washington Healthcare Forum to “streamline and simplify healthcare financing and delivery” • Work groups of providers and carriers who create best practices for operational processes. Administrative simplification Assumptions Reality • Technology is the answer – • EHR is bulky and inefficient • Lowest-common “future state” • Consensus creates ideal solutions • Voluntary adoption is best denominator only provides incremental progress • Voluntary adoption doesn’t achieve goal • Tremendous burdens still exist OneHealthPort work group focus: What can be done so that medications are ready for dispensing when the patient arrives at pharmacy? 1) Prior-authorization (PA) must be requested prior to the patient leaving the prescribers office rather than after they arrive at pharmacy. 2) Relevant formulary and PA information must be available and used by prescribers. Work group recommendations • • • • Transparent PA process-Set of health plan web tools and data for industry standard transactions defined to make it easier for prescribers to get PA information and to communicate about PA Consistent electronic prescribing process-industry standard transactions to be used by prescribers and pharmacies to exchange information about Rx. PA Processing Timeframes: -Urgent: 48 hours after getting information from prescriber -Standard: 5 days from getting information from prescriber Emergency Fill Policy-require health plans to have policy with at least a set of defined medications that are guaranteed for emergency fill. Health plans can go beyond baseline. Impact on Prescribers Challenges Current State • Transition from fax/phone preauth to browser pre-auth after notification from pharmacy Future State • Change workflow and technology to ensure a preauthorized medication is approved before sending prescription to pharmacy Improvements Current State • Emergency fill • Online, interactive submission of PA • Improved access to PA information Future State (additional) • PA seamlessly integrated into eprescribing process • Higher assurance that patient gets med dispensed without delay • No back-end reprocessing of PA 13 Challenge • Health plans have varied, paper-based PA requirements Recommendation -transparency • Health plans to create automated, online PA process and portal maintained by OneHealthPort Challenge • Industry standard transactions are in place, but are not always used, or used in a standardized way Recommendation - consistency • Users will “turn on” transactions and communicate and process PA via specific data elements Challenge • Communication of Rx denial, need PA Recommendation • New timeline standards for non-urgent and urgent decision notification Timeframe for health plan to decide or request more info Urgent Standard review (nonurgent) Timeframe for provider to supply requested info Timeframe for health plan to make final decision 24 hours 48 hours 48 hours 5 days 5 days 5 days* Challenge • Insurer may not be available to check Rx to verify formulary and coverage Recommendation • Health plans will have emergency fill policy with list of covered medications and publish online • Emergency fill medication will be approved and paid, but not necessarily a covered service • Benefit determination will be made as part of PA process How do we move forward? The “issue” isn’t settled – solutions to “current state” are still needed Scope of OIC authority is limited Legislative direction likely required 2015 Legislature • Post-Affordable Care Act • Provider-leaning session – Telemedicine – Grace period – PBM regulation How you can help: • Direct pertinent consumer complaints to OIC • Collect data and stories to share with legislators, re: impact of administrative burdens on your practice • Work with OneHealthPort on recommendations • Contribute targeted written comments on OIC rulemaking