The ACA regulators are at it again. The FEHBlog has written about reference pricing which involves health plans setting a benchmark price for surgeons (think knee replacements) or pharmacies (think specialty drugs). If plan members use those providers the bill is paid in full. If members use providers who don't accept the benchmark, they have to pay the difference between their provider's price and the reference price. And according to an ACA FAQ that came out in the springtime, the out of pocket cos would not count toward the ACA's out of pocket maximum. Cost curve down right? Not exactly, for today the ACA regulators weighed in with consumer protections in ACA FAQ XXI
OPM has been militating in favor of transferring FEHB prescription drug benefits administration from the carriers to the agency. This change requires legislative approval. It does not make a lot of sense to the FEHBlog because integrating medical and pharmacy benefit administration can and does lower the cost curve. BCBSA just released a major study that included FEP claims confirming the validity of the FEHBlog's working assumption.
The study examined yearly medical costs of 1.8 million members of Blue Cross® and Blue Shield® (BCBS) independent companies, whose pharmacy benefit services were divided between “carve-in” and “carve-out,” which is the term used when an employer chooses a pharmacy benefit manager to manage prescription benefits separately from the insurance company administering medical benefits.
Blue System members covered under insurance plans that integrate pharmacy benefits within their overall product offering had nine percent fewer hospitalizations and four percent fewer emergency room visits than members with a pharmacy benefit administered separately from the insurer. Those with integrated pharmacy benefits also incurred 11 percent lower medical costs, with an average savings of $330 in yearly medical costs. The study, conducted with data spanning 2010 and 2011, showed patients with integrated pharmacy benefits incurred total medical costs of $3,176 versus $3,506 for members with a separate pharmacy benefit.*
That;s solid evidence for integration. And of course the ACA's qualified health plans have integrated medical and pharmacy benefit administration too. .