A proposed rule defining association health plans has raised red flags for the American College of Rheumatology.
In particular, ACR is concerned that, if enacted, the proposed rule published by the Department of Labor on Jan. 5 could create access issues.
The rule as proposed would allow employers to form an association health plan (AHP) based on geography or industry, allowing plans to serve employees in a state, city, county, or multistate metropolitan area, and even employees in an industry nationwide.
“There is a marked lack of current data available related to the risk profile of existing and potential associations and how those intersect with the individual and small group markets,” ACR said in a March 6 comment letter to the Department of Labor. “We believe that moving forward with new policies without the totality of evidence can be dangerous and potentially harmful to patients with chronic diseases.”
The college also noted that, “we especially have concerns regarding patient access to care in rural and remote areas of the United States.”
The organization suggested that the Labor department write regulations to ensure network adequacy, particularly for specialty care, and address other reforms related to prior authorization.
Significantly, ACR expressed concerns that a kind of economic discrimination could occur under AHPs.
Discrimination could come from opting not to cover prescription drugs, extreme utilization management protocols, coverage caps, increased coinsurance for patients, and discriminatory tiering and other formulary designs for high-cost medications.
ACR “strongly opposes excessive patient cost sharing that results in untenable patient financial burden, thereby creating a de facto situation in which the patient does not have access to a medically necessary treatment,” the organization wrote. “For patients with complex conditions like rheumatoid arthritis, biologic medications are very expensive and excessive cost sharing can reduce adherence and patient access to treatment, leading to risk for irreversible damage, excess morbidity, and even mortality.”
Further, economic discrimination could be enhanced since the proposed rule would allow AHPs to determine their own essential health benefits, “thereby restricting patient access to care. Granting flexibility to this extent could lead to AHPs severely restricting or eliminating coverage for the biologic drugs that are critical for many people with rheumatic and musculoskeletal diseases.”
“The ACR is concerned that loosening these consumer protections will reduce our patients’ access to care, either through weaker coverage or by driving up their premiums,” ACR President David Daikh, MD, said in a statement. “Our patients require continuous access to specialized care to manage pain and avoid long-term disability. Therefore it is imperative that the administration ensure that Americans living with rheumatic diseases be afforded adequate protections under these new rules.”
The comment period for the proposed rule closed in early March. At press time, the Labor department had not published a timeline for publishing a final rule.