While many people have expressed concerns over the administrations delay in implementing the ACA limits on the maximum out-of-pocket (MOOP), the MOOP delay is a broader reflection of the tension in the ACA between coverage and cost containment. Delaying a requirement explicitly for data linkages either shows the difficulty of moving the complex fragmented US healthcare system or signals an administration that is still focused on coverage and doesn’t have a clear focus on how to solve the cost problem.
Short term cost control is the primary need to delay the requirement for a global MOOP. Large employers may contract separately for management of their major medical program and with a pharmacy benefit manager (PBM). Employers may be able to find that they are able to provide coverages cheaper by separately contracting a best of breed solution but this short term solution may belie a lack of a long term strategy.
Historically, the major medical and PBM separation has made sense but the ACA requirement is only one factor pushing for further integration between medical plans and PBMs. One of the few aspects of the ACA that the right grudgingly accepts is that the ACA pushes more consumer directed health plans (CDHPs). CDHPs have higher deductibles and often coordinate with a Health Savings Account (HSA) to help defray some of the deductible. Employers exploring this strategy would(or will) likely meet the statutory MOOP limits since to qualify as an HSA eligible High Deductible Health Plan (HDHP) a major medical plan and PBM already need to meet the requirements of the ACA MOOP limits.
However, the major cost control strategy in the ACA is care coordination. Historically care coordination has not focused on medications but for many conditions like hypertension, pharmaceuticals are often the most cost effective treatment. Leading edge medications for autoimmune disorders and oral oncology drugs can have treatment regimens north of ten thousand dollars (>$10,000). Care coordination will need to include the utilization of these types medications to provide an accurate picture of efficient effective treatments. Employers who continue to seek best of breed medical and PBM solutions may already be seeking best of breed care coordination system. However, these systems typically require some of the same data linkages as are required for CDHPs so these employers would also be likely to meet MOOP limits.
Delaying the MOOP limit was a practical reality. Large employers may adjust health benefits annually but consider the broader changes that an integrated system require over longer time scales. The danger is that the accommodation may be most beneficial for those employers who have thought least about the sustainability of their health plan and haven’t started down either of the cost containment strategies hinted at in the ACA.