In the insurance industry, there is always something new to learn. Regulations and rules within the United States are constantly changing, which affects how health insurance companies do business. The five areas that were of most interests to insurance companies in 2023 include:
- Prescriptions
- Individual Insurance coverage
- Advanced Payment Models
- Opioid epidemic
- Pricing
Prescription – Changing prescription drug pricing policies
Rising healthcare costs have been a challenge for the United States since the early 2000s. The Patient Protection and Affordable Care Act (also known as the ACA and “Obamacare”), as well as other state-level cost containment measures, have targeted pharmaceutical companies to control costs for American consumers. In recent years, increasing scrutiny has been devoted to rising prescription drug prices.
The U.S. government is considering legislation that would impact the way drug pricing is treated in Medicare Part B and state Medicaid programs. Currently, the House and Senate are considering legislation that would impact the way drug pricing is treated not only in private and commercial insurance policies but in Medicare Part D and Part B. The inclusion of Medicare and Medicaid services in legislation is important because those programs aim to help the most financially vulnerable Americans afford the healthcare they need. As pharmaceutical technology improves and drug companies continue to focus on treating and curing more severe, and rarer, conditions, we should expect even more regulations that target prescription drug prices.
Individual Health Insurance Coverage
The Patient Protection and Affordable Care Act of 2010, commonly known as the ACA, is an act of legislation intended to expand health coverage to more Americans. With the full implementation of the ACA, the United States has a comprehensive individual insurance market for the first time in its history. The regulations the ACA puts on both individuals and employers have encouraged both to pursue cost-containment measures such as high-deductible health plans with lower monthly premiums. One way employers have compensated employees for a perceived reduction in benefits is by creating health reimbursement arrangements (HRAs). By using an HRA, employers can partially fund their employees’ individual health plan choices, which relieves some of their cost-sharing burdens, and also allows them to keep the tax-advantaged position of providing employees with health insurance.
Advance Payment Model –
New payment models, such as capitation, provide healthcare providers with new opportunities. Physicians, insurers, and other healthcare providers have been increasingly squeezed by government regulations. In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), which changed the way physicians were paid through Medicare. In 2019, the Centers for Medicare & Medicaid Services (CMS) released new payment models that will focus on the enhanced role of primary care providers in order to control costs. These regulations also include provisions that incentivize and reward providers for patient outcomes and quality of care. As the population ages and our healthcare system continues to strain under its own weight, CMS will continue to issue regulations aimed at curbing excessive costs and improving patient outcomes.
Opioid Crisis – Addressing the regulation
The rise in deaths caused by opioid abuse has been devastating. In 2019 alone, more than 50,000 Americans died from overdoses involving opioids, with similar numbers for each of the past several years. Even those who do not die from use of opioids pay a steep price, both in terms of lost productivity and health problems caused by addiction. The financial cost is enormous when you account for the involvement of the criminal justice system, treatment costs, and lost productivity.
Following action by the Drug Enforcement Agency (DEA) and the Department of Justice, many state and local governments as well as the U.S. Congress have created new laws and programs to fight the opioid epidemic on multiple fronts. These regulations include stricter requirements on controlled substances, prevention of over-prescribing, and non-law-enforcement support for those struggling with addiction. Until the opioid crisis is under control, health insurers can expect tighter scrutiny and regulation of prescription opioids.
Pricing – Setting limits on hospital pricing to protect consumers
Hospital prices are usually a source of frustration for patients and their families. Some people have heard horror stories about surprise hospital costs—such as a toothbrush charged at $1000 or surgical screws at $15,000, insulin costs —and most people have experienced small-scale price increases when billing notices arrive months after medical procedures. The latest healthcare government regulations intend to put an end to these practices by requiring every hospital in the United States to provide clear pricing information to patients before services are provided. By January 2021, hospitals must be in compliance with this new regulation or face monetary penalties and public embarrassment for their failure to comply.
2023 and beyond
Healthcare industry regulatory bodies will impose monetary penalties on non-compliant organizations, and publicly shame those who do not comply with regulations. Healthcare regulations will continue to be a focus in the years to come. If recent trends are any indication, consumer protection laws will continue to be a priority. Health insurance companies and those who work with them as agents will be subject to increasing regulation, and the expectation of compliance.
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