Experts discuss HMO mandates for prescription drugs

February 1, 2005

In a continuing trend by legislators across the country to "mandate" coverage and access when the marketplace has moved on from these issues while focusing on the cost of healthcare, the California Department of Managed Care issued rules requiring HMOs to provide broad coverage of medically necessary prescription drugs.

NATIONAL REPORTS-In a continuing trend by legislators across the country to "mandate" coverage and access when the marketplace has moved on from these issues while focusing on the cost of healthcare, the California Department of Managed Care issued rules requiring HMOs to provide broad coverage of medically necessary prescription drugs.

"Many states, Ohio included, have instituted administrative positions that dictate no further passage of coverage 'mandates' without proper actuarial review and analysis to determine the cost of such mandates and the impact that these increased costs will have on the ability of the consumer and employers to afford healthcare coverage," according to the Ohio Association of Health Plans' Board Chairman Bill Epling, also regional vice president and CFO, The Health Plan/HomeTown Health Network in Massillon, Ohio.

MARKET MOVES ON "Access and any-willing-provider arguments are topics of the 1990s that have been surpassed in the market by: 'How can we afford to offer healthcare benefits to our employees?'" Epling says. "Unfortunately, many state legislative bodies are still operating under the old perceptions that the health insurance industry must be fixed to save the consumer and the physician."

At face value, Jack McClurg, CEO, HealthTrans, Greenwood Village, Colo., does not believe that it is in the best interest of a patient, health insurance consumer or the employer to have government restrict the ability of plans to negotiate with drug manufacturers.

"If every drug that is marketed must be made available without weighing efficacy and cost, the cost for drugs will go unchecked," McClurg says. "Currently the most effective method to make patients and physicians aware of costs is through variable copays which don't deny a drug therapy of choice, but shifts the cost for inefficient therapies."