Patient access is at the forefront of healthcare policy and mainstream media as the pandemic and vaccination distribution continues.

In 2020, we saw vast attention on prior authorization, patient access, and related-issues making appearances in healthcare policy. We saw time spent on Step Therapy, Copay Accumulators, Prior Authorizations, and Out-of-Pocket Costs at the local and federal level. We will continue to see advocacy for these areas to ensure patient access to much needed care.

Despite the advocacy efforts on these fronts, we continue to see these challenges impede patients access. Patients, providers, and other supportive professionals have to overcome obstacles to healthcare that are often created for profitability with no cost-savings passed on to the patient.

Patient access in 2021 has already encountered challenges and will continue to do so. Effectively enhancing patient access starts with understanding the top 5 challenges for patient access in 2021.

1. Pandemic focused healthcare

The COVID-19 pandemic will have a lasting impact on healthcare and the world. The international focus is on mitigating the spread of the virus and preventing deaths. The global toll is over 2 million deaths and continues to rise. There is no denying we need as many resources as possible on the pandemic, but that takes a toll on patient access in other areas.

The pandemic protocols and recommendations require fewer patients in a medical office at one time and more effort in disinfecting surfaces. This cuts into a practice’s profitability as time equals money in healthcare. Profits are dependent on how many patients a physician can see.

According to the Physicians Foundation study conducted in July 2020, physicians are leaving their practices. 8% of participants said they closed their medical practices and nearly half reduced their staff.

Additional regulations have limited elective procedures and appointments. Patient access to necessary care is restricted due to the limitations put on surgery centers. This includes “elective” exploratory and diagnostic surgery for cancer.

Despite the efforts in keeping the doors open, patients are wary of healthcare facilities with the pandemic. Patients are forgoing medical care for various reasons – financial, emotional, or physical as we work for a solution.

2. Delay in implementation of e-PA

Prior authorizations continue to be a challenge for patients to gain access to care. While the process isn’t going anywhere and its use is increasing, there are ways to streamline the process and enhance patient access. These solutions include implementing training, certification, and technology solutions.

The Centers for Medicare and Medicaid Services have been working to eliminate the use of fax machines in the prior authorization process since 2018. Faxes contribute to approximately 50% of the prior authorization submissions, which slow the process and inhibit accessible status updates that online platforms can provide. When submitting via fax, to obtain a status update you must wait on the phone, potentially for hours.

At the end of 2020, the Trump administration finalized a rule intending to streamline communications for providers and payers. This rule required payers to use digital interfaces for data exchange and prior authorization by January 1, 2022. This will allow providers to see that a drug may require a prior authorization at the time of prescribing.

The Biden Administration has implemented a 60-day regulatory freeze to review all policy that has not been enacted. The Trump policy of implementing electronic prior authorization submissions (e-PA) legislation may be delayed and possibly reversed.

3. Accumulators and Maximizers are expanding

Copay accumulators and maximizers are a widespread challenge for patient access and eliminate the altruistic nature of the patient assistance programs. They continue to be a burden on patients. Prior to these programs, patients’ financial burden associated with high copays could be alleviated with the help of pharmaceutical manufacturers. This allowed for enhanced patient access to treatments that have optimal outcomes.

Since the implementation of the copay accumulator and maximizer programs, cost sharing is no longer mitigated by the help from the pharmaceutical manufacturers. The patient is responsible for their deductibles and copays. The pharmacy benefit managers continue to see payment from pharmaceutical companies, essentially getting paid twice for the same product and care.

Patients who experience accumulators will see high copays and may abandon therapy when their medication becomes too costly. Even though copay maximizers distribute the financial responsibility over each month of the year, patients are still finding care too expensive to continue. The American Society of Clinical Oncology (ASCO) recently issued a statement opposing copay accumulator and maximizer programs for these reasons.

Despite the opposition, the Centers for Medicare and Medicaid Services announced in the Notice of Benefit and Payment Parameters for 2021 that insurance plans may use these programs starting in 2023. This rule increases the patient access to copay assistance programs because those enrolled in federal health programs cannot participate currently. But implementation of the accumulators and maximizers may not have enough of a benefit for patients.

4. Growing Medicare population and utilization management

The growing Medicare population may not seem like a challenge for patient access on the surface. But as the population ages, there will be more qualified beneficiaries of Medicare. Shouldn’t more people qualifying for Medicare result in more access to care and health coverage? In theory, yes.

But we see that the population that qualifies for Medicare will rise from 44 million currently to 79 million by 2030. That is a 180% increase in beneficiaries without much of a budget increase.

For 2019, the federal spend on Medicare was $644 billion to cover the costs for those 44 million beneficiaries. To provide the same level of care at the same cost, by 2030 Medicare will cost over $1.1 trillion.

So what is being done to manage the growing costs and increasing numbers of qualified beneficiaries? Utilization management and making it harder for patient access. By implementing more administrative hurdles, it will be harder to access care. With these processes in place, costs can be managed and maybe when the time comes, the projected spend won’t be trillions of dollars.

5. PA growing for medical services

We’ve already seen the impact of utilization management for Medicare and federal programs. In July 2020, Medicare implemented new rules imposing prior authorization on procedures. This included vein ablation and other “cosmetic-adjacent” procedures.

While vein ablation may be used to remove varicose veins (or spider veins), it can also be used to minimize the risk of bleeding in high risk patients. A procedure that did not need prior authorization before is now requiring it. Even in emergent situations, patient access is gated.

Prior authorizations for medical services are growing. This is just the start.

2020 was the precipice of utilization management. The pandemic brought huge profit margins for health insurance and pharmacy benefit managers. People were home and not using health care. How does the healthcare industry maintain this even after the pandemic and things “go back to normal?” Utilization management, prior authorization, and administrative burdens to limit patient access to care.

Undoubtedly, patient access is in danger now that COVID-19 has shown the profitability of limiting healthcare use. Moving forward, we need to be able to navigate payer policies and ensure better health outcomes.

The National Board of Prior Authorization Specialists (NBPAS) improves the prior authorization process by reducing denials and enhancing patient access to necessary medications and services. So, set your team apart with prior authorization and reimbursement knowledge with the Prior Authorization Certified Specialist program (PACS).

Patient access is at the forefront of healthcare policy and mainstream media as the pandemic and vaccination distribution continues.

In 2020, we saw vast attention on prior authorization, patient access, and related-issues making appearances in healthcare policy. We saw time spent on Step Therapy, Copay Accumulators, Prior Authorizations, and Out-of-Pocket Costs at the local and federal level. We will continue to see advocacy for these areas to ensure patient access to much needed care.

Despite the advocacy efforts on these fronts, we continue to see these challenges impede patients access. Patients, providers, and other supportive professionals have to overcome obstacles to healthcare that are often created for profitability with no cost-savings passed on to the patient.

Patient access in 2021 has already encountered challenges and will continue to do so. Effectively enhancing patient access starts with understanding the top 5 challenges for patient access in 2021.

1. Pandemic focused healthcare

The COVID-19 pandemic will have a lasting impact on healthcare and the world. The international focus is on mitigating the spread of the virus and preventing deaths. The global toll is over 2 million deaths and continues to rise. There is no denying we need as many resources as possible on the pandemic, but that takes a toll on patient access in other areas.

The pandemic protocols and recommendations require fewer patients in a medical office at one time and more effort in disinfecting surfaces. This cuts into a practice’s profitability as time equals money in healthcare. Profits are dependent on how many patients a physician can see.

According to the Physicians Foundation study conducted in July 2020, physicians are leaving their practices. 8% of participants said they closed their medical practices and nearly half reduced their staff.

Additional regulations have limited elective procedures and appointments. Patient access to necessary care is restricted due to the limitations put on surgery centers. This includes “elective” exploratory and diagnostic surgery for cancer.

Despite the efforts in keeping the doors open, patients are wary of healthcare facilities with the pandemic. Patients are forgoing medical care for various reasons – financial, emotional, or physical as we work for a solution.

2. Delay in implementation of e-PA

Prior authorizations continue to be a challenge for patients to gain access to care. While the process isn’t going anywhere and its use is increasing, there are ways to streamline the process and enhance patient access. These solutions include implementing training, certification, and technology solutions.

The Centers for Medicare and Medicaid Services have been working to eliminate the use of fax machines in the prior authorization process since 2018. Faxes contribute to approximately 50% of the prior authorization submissions, which slow the process and inhibit accessible status updates that online platforms can provide. When submitting via fax, to obtain a status update you must wait on the phone, potentially for hours.

At the end of 2020, the Trump administration finalized a rule intending to streamline communications for providers and payers. This rule required payers to use digital interfaces for data exchange and prior authorization by January 1, 2022. This will allow providers to see that a drug may require a prior authorization at the time of prescribing.

The Biden Administration has implemented a 60-day regulatory freeze to review all policy that has not been enacted. The Trump policy of implementing electronic prior authorization submissions (e-PA) legislation may be delayed and possibly reversed.

3. Accumulators and Maximizers are expanding

Copay accumulators and maximizers are a widespread challenge for patient access and eliminate the altruistic nature of the patient assistance programs. They continue to be a burden on patients. Prior to these programs, patients’ financial burden associated with high copays could be alleviated with the help of pharmaceutical manufacturers. This allowed for enhanced patient access to treatments that have optimal outcomes.

Since the implementation of the copay accumulator and maximizer programs, cost sharing is no longer mitigated by the help from the pharmaceutical manufacturers. The patient is responsible for their deductibles and copays. The pharmacy benefit managers continue to see payment from pharmaceutical companies, essentially getting paid twice for the same product and care.

Patients who experience accumulators will see high copays and may abandon therapy when their medication becomes too costly. Even though copay maximizers distribute the financial responsibility over each month of the year, patients are still finding care too expensive to continue. The American Society of Clinical Oncology (ASCO) recently issued a statement opposing copay accumulator and maximizer programs for these reasons.

Despite the opposition, the Centers for Medicare and Medicaid Services announced in the Notice of Benefit and Payment Parameters for 2021 that insurance plans may use these programs starting in 2023. This rule increases the patient access to copay assistance programs because those enrolled in federal health programs cannot participate currently. But implementation of the accumulators and maximizers may not have enough of a benefit for patients.

4. Growing Medicare population and utilization management

The growing Medicare population may not seem like a challenge for patient access on the surface. But as the population ages, there will be more qualified beneficiaries of Medicare. Shouldn’t more people qualifying for Medicare result in more access to care and health coverage? In theory, yes.

But we see that the population that qualifies for Medicare will rise from 44 million currently to 79 million by 2030. That is a 180% increase in beneficiaries without much of a budget increase.

For 2019, the federal spend on Medicare was $644 billion to cover the costs for those 44 million beneficiaries. To provide the same level of care at the same cost, by 2030 Medicare will cost over $1.1 trillion.

So what is being done to manage the growing costs and increasing numbers of qualified beneficiaries? Utilization management and making it harder for patient access. By implementing more administrative hurdles, it will be harder to access care. With these processes in place, costs can be managed and maybe when the time comes, the projected spend won’t be trillions of dollars.

5. PA growing for medical services

We’ve already seen the impact of utilization management for Medicare and federal programs. In July 2020, Medicare implemented new rules imposing prior authorization on procedures. This included vein ablation and other “cosmetic-adjacent” procedures.

While vein ablation may be used to remove varicose veins (or spider veins), it can also be used to minimize the risk of bleeding in high risk patients. A procedure that did not need prior authorization before is now requiring it. Even in emergent situations, patient access is gated.

Prior authorizations for medical services are growing. This is just the start.

2020 was the precipice of utilization management. The pandemic brought huge profit margins for health insurance and pharmacy benefit managers. People were home and not using health care. How does the healthcare industry maintain this even after the pandemic and things “go back to normal?” Utilization management, prior authorization, and administrative burdens to limit patient access to care.

Undoubtedly, patient access is in danger now that COVID-19 has shown the profitability of limiting healthcare use. Moving forward, we need to be able to navigate payer policies and ensure better health outcomes.

The National Board of Prior Authorization Specialists (NBPAS) improves the prior authorization process by reducing denials and enhancing patient access to necessary medications and services. So, set your team apart with prior authorization and reimbursement knowledge with the Prior Authorization Certified Specialist program (PACS).