The 2020 Election results were considered by many to be one of the most important to the U.S. Not only were there the highest number of votes, but several looming healthcare issues such as COVID19, the opioid crisis and drug pricing were top of mind for many Americans.

President elect Biden will be inaugurated later this week.

How will a Biden Presidency impact prior authorization and reimbursement?

1. Improved Drug Pricing and Healthcare Costs

Healthcare costs continue to be a major driver politically. Everyone agrees that the current healthcare system needs improvement, but what policy changes to implement remain controversial. Drug pricing has been a hot topic for years and with the last presidency focused on drug pricing, there will likely be a ripple effect moving forward. Biden plans to implement reforms to reduce prescription drug prices – manufacturers first to market price gouging, limiting price increases to inflation rates, removing pharmaceutical tax breaks for advertising, allowing international drug acquisition, and improving generic implementation. All of these will make the market more competitive and can lead to more prior authorizations for non-preferred products.

As a major contributor to the Affordable Care Act (ACA), Biden has made it clear that those initiatives will be continued during his presidency. The biggest complaint for ACA was and continues to be affordability and Biden is taking this one head-on.

For the last few years, ACA enrollment has been down but many of the original components have been dismantled and funds have been reallocated. The mandated tax for those not enrolled in healthcare was repealed by President Trump, no longer dissuading the young and healthy from forgoing health care coverage. By removing this population from the health insurance pool, risk pooling becomes more difficult and affordability continues to be unattainable.

In the proposed stimulus plan for combating the economic effects of COVID-19, Biden aims to lower healthcare costs through federal subsidies and tax credits. To further combat the reviews of ACA, he aims to target two groups to alleviate the expense of healthcare.

First, expansion of the existing cap for the premium subsidy limits to include all who are contributing more than 8.5% of an individual or family’s income on healthcare premiums. The goal of this expansion is to provide economic relief to families spending nearly 20% of their income on health insurance.

The second expansion in the stimulus plan is to increase subsidies for those who already qualify. The proposal suggests increasing tax credits or even removing premiums for qualified individuals.

2. Increase Accountability

There is an increased interest in value-based care models and improving the accountability of the healthcare system. Seema Verma, Centers for Medicare and Medicaid Services Administrator has stated that the agency would like to move forward with value-based care models and require providers take on more financial risk. There is speculation if the Biden administration will support this to the extent that the Trump administration had.

Biden’s campaign is supportive of removing surprise billing. Biden plans to “bar health care providers from charging patients out-of-network rates when the patient doesn’t have control over which provider the patient sees.” In year-end negotiations, Congress beat Biden to it and banned surprise billing after two years of negotiations. This ensures that patients will not be caught off-guard by having ‘surprise’ bills at an in-network hospital because the staff that treated them were out of network. This holds the insurance companies and the health systems responsible for this operational dilemma, rather than the patient.

The momentum of healthcare reform and value-based care will likely be continued throughout the next four years, especially in light of the pandemic.

3. Expanded Access

Biden’s campaign has been a staunch supporter of expanded access to healthcare. Continuing the legacy of his time as Vice President, the idea of healthcare for all continues to thrive and populate many aspects of Biden’s policy.

Some of the proposed policies include adopting auto-enrollment, long-term care tax credits, and increasing funding for rural health and mental health services. There is even a proposal to offer a new public option for ACA for those in the individual market or those who have employment coverage.

In addition to all of the other policies aimed at increasing access, Biden plans to adjust the Medicare age of eligibility from 65 years of age to 60 years of age. Lowering the age of Medicare beneficiaries can make a huge impact on healthcare costs. The elderly population, which is the largest generation of healthcare consumers, is growing. By lowering the age for eligibility, the number of federally covered citizens increases overnight. Expanding access to this many people can make impactful changes in health outcomes nationally. This is not lost on the Centers for Medicare and Medicaid Services (CMS) as they have been implementing more utilization management procedures into their benefits. We continue to see an increase in prior authorizations which could be attributed to the fact that the federal Medicare budget continues to decrease while the population it needs to serve increases.

In addition to expanded access to the elderly, Biden’s platform makes other considerations for the racial disparities in healthcare. His healthcare team aims to support millions of Black and Latino Americans who are uninsured, underinsured, and receiving poorer outcomes. Biden plans to double the federal investment in community health centers that serve these populations to enhance access to quality healthcare.

Overall, Biden’s policies could extend health care coverage to an additional 15-20 million people, out of 30-35 million who are currently uninsured.

4. COVID-19 Access

Biden’s campaign is focused heavily on COVID-19 response. He made many statements to support expanded testing and vaccination across the country. By relying on scientist and expert recommendations, we see that continuing to focus on widespread testing will be part of the solution.

Expanded testing and access may come with more reimbursement hurdles. At the start of the pandemic, we saw pressure for payers to pick up the cost of COVID-19 care and testing costs. This includes waivers for prior authorizations, which provided a temporary alleviation of administrative burden followed by an avalanche of retrospective reviews for those who were hospitalized for COVID-19. Many claims were retrospectively denied with no reimbursement.

Additionally, the Families First Coronavirus Response Act required employers to grant sick leave for COVID-19 related illnesses for the employee or family. While many of the regulations requiring this had met their expirations over the summer or at the end of 2020, there is a possibility that they would be coming back as a function of the COVID-19 response from Biden’s administration.

As healthcare policy continues to evolve with the pandemic response and the new president’s administration, all stakeholders will have to spend considerable time keeping up. Expanded access to care goes beyond ensuring each individual has health insurance, but also includes what benefits and services are included in those plans. Ensuring timely access to care improves long-term outcomes for the entire population.

Despite the efforts to streamline the administrative processes so clinicians can provide quality care to patients, there is an overwhelming need to navigate the payer policies and prior authorization requirements. Prior authorization specialists are an investment for providers and health systems.

The National Board of Prior Authorization Specialists (NBPAS) offers PACS – The Prior Authorization Certified Specialist program to help healthcare and life science professionals better understand the payer landscape.