11/13/2023

Massive CAA Shake-up Looming for Health Benefits, Empowering Patients

Every day, providers and patients struggle with health plan, pharmacy benefit manager (PBM), specialty pharmacy, and other intermediary coverage and reimbursement policies that adversely affect individuals with cancer. These challenges may include coverage delays, step edits, prior authorizations, nonmedical switching, high out-of-pocket costs, and/or the intrusion of intermediaries into care or the drug chain, leaving patients confused, frustrated, and reeling from financial, physical, and emotional distress. Practices and patient-focused organizations that support these patients are equally frustrated. Why can’t something be done?

Fortunately, it appears that help is on the horizon—and from the government of all places. Years ago, retirement benefits were in a similar state of chaos. There was little common or fiscal sense in sight. The handling of employee retirement funds was masked behind multiple layers of administration, and the fees charged for the management of retirement accounts were out of control. Now, the federal government has turned its attention to the high costs associated with health benefits, which have skyrocketed for both employers (their second largest expense after salaries) and employees (the average family premiums exceeded $22,000 per year in 2021).

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