A patient's journey to accessing life-saving therapies is rarely linear, and while much of that is due to factors within the healthcare system, many external influences are also at work. Social determinants of health are an example of these outside forces that play a crucial role in patient care, for better or for worse.

Given the spotlight that COVID-19 has shone on the glaring holes within the U.S. healthcare system, it’s not surprising that the current Biden administration has placed considerable importance on addressing key issues head-on. The focus on solving these issues has manifested as the Inflation Reduction Act (IRA), which passed along party lines in the Senate as well as the House of Representatives and was signed into law by President Biden on Aug. 16, 2022. The IRA attacks several major issues currently facing the U.S., with healthcare being among the most important. While the healthcare provisions within the IRA cover various issues, they all address—directly or indirectly—the same theme: greater access to healthcare.

With the continuation of the COVID-19 pandemic and resulting policy changes, the health plan landscape is facing some complex challenges ahead.

A key factor contributing to these challenges is the Public Health Emergency (PHE) that was declared in January 2020 and renewed on July 15. As a condition of receiving enhanced federal funds during the PHE, states have been required to ensure continuous Medicaid and CHIP coverage for most enrollees by pausing eligibility redeterminations—a process in which the state determines if a member is still eligible for coverage due to factors such as income level.

At age 19, my stepson has run the gamut of therapeutic options—combination therapies, cognitive behavioral therapy, you name it—for treating his attention deficit hyperactivity disorder (ADHD). After 10 years of searching, we have yet to find a treatment that truly works for him.

However, there’s one option that we haven’t tried: prescription digital therapeutics (PDTs). More specifically, an app-based video game called EndeavorRx. The game, which was approved by FDA in June 2020, is a first-of-its-kind treatment that uses stimuli and motor conditioning to target areas of the brain that control attention function. And the results are impressive: 68% of parents reported improvement in ADHD-related impairments after two months of treatment.

In oncology, clinical pathways—recommendations of specific treatments for a specified group of patients—have long been used to help control costs and treatment variation while improving outcomes. Clinical pathways may be payer-driven or provider-driven based on the organization that develops and controls the pathways, and financial incentives and policing mechanisms encourage provider buy-in and adherence.

Much has been said about healthcare’s shift from a fee-for-service model to a value-based care (VBC) model—and for good reason. With 50% of clinical interventions resulting in unknown effectiveness, and 20-40% of health expenditure wasted on unproven or unnecessary treatments, VBC models can help reduce costs and inefficiencies for patients, providers and manufacturers.

Yet while many industry stakeholders are quick to support the idea of tying compensation to a model that delivers more value and better outcomes for patients, the conversation stalls when discussing the particulars of reimbursement. After all, how do you measure value?

There are many moving parts when it comes to helping ensure that patients can get access to the therapies they need, but the role of medical billing and coding isn’t always top of mind. To be fair, medical billing seems to grow more complex by the day, and keeping abreast of the changes can be a monumental task.

However, getting billing and coding right can result in fewer claims denials and, most importantly, speed up the time it takes to get a patient onto therapy. Investing time and resources into preventing incomplete or inaccurate claims is critical.

We sat down with Chris Webb, the director of product development at RJ Health, an MMIT company, to learn more about the impact of billing and coding on patient access.  

From drug pricing to health equity to digital therapeutics, the healthcare industry had a lot to talk about at this year’s America’s Health Insurance Plans (AHIP) conference, held June 21-23 in Las Vegas—the first in-person AHIP event since the start of the COVID-19 pandemic.

Getting a life-saving therapy into the hands of a patient who needs it is much easier said than done. While overcoming the numerous hurdles to adequate access typically falls to manufacturers, there are many stakeholders involved in this effort, from providers to payers to patients themselves.

Pharmacists, too, play a key role in helping patients get the medications they need, yet most aren’t taught the ins and outs of managed care or market access in pharmacy school. Instead, their training revolves around clinical education and is oftentimes geared toward earning a spot in residency.

Today’s healthcare world is seeing a shift from acute medicine to health management. A contributing factor to this has been the COVID-19 pandemic. A recent report shows that 66% of respondents with chronic conditions were more interested in taking a proactive approach to health than prior to the pandemic. People are taking a more vested interest in their health and are starting to focus more on preventative medicine instead of symptom management. Rather than waiting for a heart attack to happen, an individual can use health management—like healthy eating and exercise—to prevent that heart attack from happening in the first place.