Q&A: Predictions for healthcare costs, patient access, and reform in 2021

By Brad Tallamy

What can community physician practices expect from the first year of the Biden administration?
Group of doctors standing and talking

We sat down with Brad Tallamy, Senior Director, Government Affairs, to discuss predictions for 2021 around health costs, patient access, ACA reform, and COVID relief.

Q: What is the biggest policy topic affecting community physician practices right now?

Brad Tallamy: Far and away the top issue facing not only community practices, but all healthcare providers, is the duration of the COVID pandemic. The viability of individual practices during the pandemic continues to be top priority. We don’t know how long the pandemic and secondary effects will last. Community physicians handled the worst of the worst when hospitals were overrun and patients shifted to their practices. Ensuring the short and long-term viability of practices should be a top policy concern so that all patients can receive the care they need. 

Q: What can community physician practices expect from the first year of the Biden administration?                   

Brad Tallamy: In short, more structure. Biden and congressional Democrats are very clear about the health policies they want to implement and the order in which they want to implement them. At the top of the list is a strong COVID response. Congress is expected to pass the $1.9 trillion stimulus bill which President Biden will sign into law. Funding for testing, tracing and unemployment benefits are all included. They're running into the March 14th enhanced unemployment insurance benefit expiration deadline, so they must act quickly.

The federal government has previously enacted policies to help address physician practices’ financial needs arising from the pandemic. Opportunities like paycheck protection program (PPP) loans, provider relief funds, and Medicare advance payments all helped practices stay afloat.

The problem for community physician practices is what’s not in the upcoming relief bill – an extension of the Medicare sequestration moratorium that expires at the end of March. Community practices have been adamant that this is a huge omission, and we have strongly echoed their concerns. SPS launched a grassroots campaign through our Community Counts advocacy program to get our practices engaged, and we are strongly encouraging all of our practices to participate to ensure their elected officials hear first-hand how critical it is for them to address this issue.  

There are also conversations around increasing the provider relief fund which (originally created in the CARES Act last March.) 

After Congress deals with COVID-19, the conversation is going to shift to health coverage. The Supreme Court is expected to rule on the constitutionality of the Affordable Care Act (ACA) in June or July. They’ll decide if the individual mandate portion of the ACA is constitutional. If the mandate is deemed unconstitutional, the court could strike down the entire law, though it appears more likely specific provisions will stand.

Q: How might potential policy changes around health coverage impact our community physician practices? 

Brad Tallamy: The conversation in Washington will soon shift to Medicare for All and the public option; potentially expanding the ACA; and lowering the Medicare age.

All of these policies would absolutely affect community physician practices one way or another. If you increase the Medicare population, to the extent our practices treat Medicare patients, that can potentially be helpful as an additional revenue source for practices. More importantly, President Biden’s goal of giving people ages 60 and older the option to buy into Medicare would give more Americans access to healthcare coverage.

At a minimum, President Biden will be rolling back some of the Trump administration's ACA executive orders. Removing Trump's Medicaid block grants and public work requirements are low hanging fruit for Democrats.

There are a lot of health care stakeholders, though, that worry about Medicare for All or a public option. Would that be the beginning of the end of commercial insurance, for example?  Given strong industry and Republican opposition, I think implementing these policies would mean a tough road ahead.

Q: Are there other ways that the administration might address the issues of cost and patient access?

Brad Tallamy: This is where the whole drug pricing conversation comes into play. People are very frustrated when they show up at the pharmacy counter and have to pay hundreds of dollars out of pocket for their prescriptions. A Harvard/Politico poll asked Democrats and Republicans to rank the top 23 issues they want the Biden administration to address in 2021. The top issue was a strong COVID response. Drug pricing was number two on the list, at 87 percent. My prediction is after we talk about health coverage, the drug pricing conversation is going to come right back around because it's a political winner for both Democrats and Republicans.

A big problem for community physician practices is some politicians don’t like the way Medicare Part B is structured. They think that by paying physicians the cost of the drug plus a percent add-on, you're incentivizing them to prescribe expensive drugs, despite all data to the contrary. We’re continuously fighting against Medicare Part B misinformation and harmful policies such as international reference pricing or most favored nation policies, moving away from ASP or eliminating buy and bill. Ironically, these policies do not address actual drug prices. They're just cutting physicians’ reimbursement. As we head into the fall, I worry most about Part B being on the table because both Democrats and Republicans believe that it needs to be “fixed” and the “fixes” appear problematic for our practices.

"2020 was a terrible year but I think one of the good things that has come out of it is a renewed focus on health disparities and making sure we have equity in terms of ensuring affected populations have access to care."

Brad Tallamy 

Q: How might payers and PBMs influence practices?

Brad Tallamy: Another theme for our practices is navigating a post-COVID world where payers and pharmacy benefit managers have more experience implementing policies that could affect practices and patients’ access to certain drugs.

For example, the pandemic allowed payers to test out policies that they've wanted to implement for a long time like mail order, white bagging, in-office infusion, etc. How will community physician practices adapt if payers are able to mandate, for example, that patients in a certain coverage area or a certain plan have to receive their drugs from a specialty pharmacy owned by the payer?  

Under white bagging, when a drug comes in, it's intended for a specific patient. The physician can’t give it to another patient or change the dose. Not to mention problems with efficiency, because it can take a week or so for specialty drugs to get delivered. 

White bagging should very much be on every practices’ radar. Doctors don't get reimbursed for the drug, they just get reimbursed on the medical benefit like an administration fee and the specialty pharmacy captures those dollars. If a physician practice says, “I’m not playing this game anymore,” it gives the payer pause. If our customers fight back that weakens the payer networks when they negotiate with employers. 

And, unfortunately, our physician practice customers continue facing additional challenges with payer/PBM mandates, including Direct and Indirect Remuneration fees (DIR), step therapy, and prior authorization.  We are working on myriad policy solutions that address these challenges to ensure payers & PBMs do not interfere with the patient/provider relationship.  

Q: What are healthcare experts doing to address racial disparities in healthcare?

Brad Tallamy: This is a huge problem with the COVID vaccine rollout. Issues with education, trust, and access lean into community physician practices. I think it’s actually a huge opportunity for all of us because when you look at the data, it's very concerning and there’s clearly room for improvement. 

New analysis shows discrepancies by race and ethnicity, with Black and Hispanic populations receiving smaller shares of COVID vaccines as compared to the wider population. I know a lot of community practices have reached out to governors saying, "please utilize us in vaccination efforts so we can be helpful.” One survey found that 85 percent of African Americans trust their own doctor as the most reliable source of information on the COVID vaccine, showing the role community practices can play in education and trust.

Beyond COVID, we see discrepancies when we look at the outcome data for our specialties, especially oncology. It is a real challenge. 2020 was a terrible year but I think one of the good things that has come out of it is a renewed focus on health disparities and making sure we have equity in terms of ensuring affected populations have access to care.

I think just a general rule of thumb is that to the extent more patients have access to quality health coverage, that's going to be beneficial for our practices.

I would close with this – the resiliency our practice customers have shown during such a difficult time has truly been inspirational, and AmerisourceBergen’s Government Affairs and Policy team is committed to helping them navigate these challenges to ensure they can continue doing what they do best – making a huge difference in their patient’s lives.  

 

 

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About the Author

Brad Tallamy

Senior Director, Government Affairs
AmerisourceBergen
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