I reviewed Android and iPhone/iPad Apps that I’ve found that can improve clinical outcomes through better medication compliance. Every IPA, PHO, ACO physician should know about this innovative approach to make it happen. Your ACO will benefit from the increased likelihood that medications are purchased, taken correctly, on time, and in full.
Initial data suggest that exchange plans under the Affordable Care Act (ACA) will include high out-of-pocket costs for enrollees—including deductibles and cost-sharing for medical services and prescription drugs—before consumers reach their out-of-pocket maximum.
Pharmacy benefits are skimpier in exchange plans.
PROBLEM: For a single individual enrolled in a Silver plan, the average annual deductible before any plan coverage begins will be $2,550, which is more than twice the average deductible in employer-sponsored coverage. Most exchange plans also rely on coinsurance for drugs on Tier 3 and 4 of the pharmacy benefit (typically for non-preferred brand drugs and higher-cost specialty drugs), with average patient contributions around 40 percent of the drug cost. Despite this comparatively high cost-sharing, exchange enrollees with high healthcare spending will benefit from the $6,350 out-of-pocket maximum for single coverage.
Drug Coinsurance:
Approximately 90 percent of Bronze plans will rely on coinsurance, which is calculated based as a percentage of drug costs rather than fixed dollar co-payments, for higher pharmacy tiers. Based on the rate filings, average coinsurance rates for drugs in Tier 3 and Tier 4 are approximately 40 percent. Interestingly for Silver plans—just like for Bronze plans— average coinsurance is 40 percent for Tier 3 and Tier 4. The biggest difference is that several Silver exchange plans utilize copays (as opposed to coinsurance) for Tiers 3 and 4 in which the averages were $70 forTier 3 and $270 for Tier 4. By comparison to today’s employer-sponsored market, only 29 percent of those with employer coverage have coinsurance on their highest pharmacy tier.
ACOs can help their patients to be smart shoppers for a penny a member. Plans that use benefit designs with flat dollar copays rather than coinsurance could significantly reduce out-of-pocket costs for patients who regularly take prescription drugs. Physicians and other healthcare practitioners that prescribe medications need to understand how different health plans will cover the services and medicines that they prescribe most often to determine if there will be an affordability issue with purchasing and adhering to the prescribed pharmacotherapy. If you document in the EMR that you prescribed the medication and the outcome doesn’t happen – it could be because the patient didn’t buy it, was pill splitting, or bought it and didn’t take it properly.
