Idaho has been active in antitrust enforcement, as the Idaho Attorney General joined with the FTC to challenge the acquisition of Idaho’s largest independent, multi-specialty physician group by St. Luke’s Health System. In that case, the Ninth Circuit held that the acquisition violated Section 7 of the Clayton Act and the Idaho Competition Act.
In the 2016 legislative term, Idaho proposed but did not pass healthcare transparency legislation that would have required health insurers on the state’s ACA exchange to disclose a range of specific information. Idaho also currently has a ban on most favored nation clauses. A most favored nations clause is an agreement between a payer (such as an insurance company) and a provider that typically requires a provider to give the payer the lowest rate that it gives to any other comparable payer, which can be anticompetitive as it encourages oligopolistic pricing by large payers and increases barriers for new entrants.
Idaho’s current regular legislative session runs from 1/8/2018 – early April 2018.
Recent Legislative Developments
|2018||SB 1289||Would require that pharmacy benefit manager register with the Director of the Idaho Department of Insurance. Would require pharmacy benefits manager to disclose any conflicts of interest. Would allow pharmacy beneift manager to substitute a lower priced generic or therapeutically equivalent drug for a higher priced prescribed drug but only if substitution is made for medical reasons or for reasons that benefit the covered individual. Would require the pharmacy benefit manager to disclose payment, or benefit derived from payment, or other financial benefit for from the dispensing of prescription drugs. Would require pharmacy benefit manager to disclose all financial matters that apply between it and any prescription drug manufacturer or labeler. Would prohibit pharmacy benefit manager from restricting a covered individual’s choice of pharmacy. Would establish transparency of covered drug lists and methodology that determines how reimbursement to pharmacies is calculated.||Active – referred to Commerce & Human Resources|
|AN ACT MAKING CERTAIN HEALTH INSURANCE EXCHANGE INFORMATION AVAILABLE: would require the health insurers on the Idaho Exchange to make available the following information: (i) prescription drugs covered by the plan, including restrictions on use or quantity; (ii) out-of-pocket expenses; (iii) network providers; (iv) coverage for out-of-network providers; (v) rights of appeal when coverage is denied; and (iv) other information deemed pertinent by the Exchange.||Dead|
|2018||SB 339||This bill amends the Pharmacy Practice Act to enable prescriber-authorized substitution for drug products that are in the same therapeutic class and are expected to have a substantially equivalent therapeutic effect, provided certain conditions are met. Specifically, both the prescriber and patient must opt-in to the drug product substitution, and the substitution must intend to lower the cost to the patient. In addition, the pharmacist must notify the original prescriber when a substitution occurs.||Passed – sent to Governor for signing|
- None identified.
We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.
Transparency in Healthcare
- Idaho Code Ann. § 56-1054 creates a Health Quality Planning Commission within the Department of Health and Welfare to promote improved quality of care and improved health outcomes “through investment in health information technology and in patient safety and quality initiatives in the state of Ohio.” The Commission is charged with monitoring the Idaho Health Data Exchange, which facilitates clinical sharing of patient information between providers. The Commission is also recommending the creation of a hospital discharge database and an APCD (see below).
- Idaho Code Ann. § 41-3443 prohibits most favored nation clauses, or clauses having a similar effect, in an agreement between an insurance carrier and a participating provider. A most favored nations clause is an agreement between a payer (such as an insurance company) and a provider that typically requires a provider to give the payer the lowest rate that it gave to any other comparable payer, which can be anticompetitive by encouraging oligopolistic pricing by large payers and increasing barriers for new entrants.
- Idaho Code Ann. § 39-4903 permits the state attorney general to authorize cooperative agreements between health care providers by issuing a “certificate of public advantage” if the “likely benefits resulting from the agreements outweigh the disadvantages attributable to a reduction in competition that may result from such agreements.”
- Idaho Code Ann. § 56-263 directs the Department of Health and Welfare to present a plan for Medicaid managed care geared towards high-cost populations to sixty-first Idaho legislature (2011). The plan is to include, among other things, improved coordination of care through primary care medical homes, contracts based on risk-sharing or capitated payments, and the elimination of duplicative practices that result in unnecessary utilization and costs.
- The Idaho Competition Act can be found at Idaho Code Ann. § 48-01 et seq.
FY 2018 BUDGET
The fiscal year runs from July 1 to June 30. To view Idaho’s FY 2018 spending on health programs, click here.
- In February 2015, the Ninth Circuit Court of Appeal affirmed a district court opinion finding that the acquisition of Idaho’s largest independent, multi-speciality physician group by St. Luke’s Health System violated Section 7 of the Clayton Act and the Idaho Competition Act. The FTC and the Idaho Attorney General filed a complaint against St. Luke’s in March 2013, alleging that the acquisition would create a dominant single provider of adult primary care physicians in the Nampa, Idaho area, with almost 60 percent market share. For details, read the Source’s case summary and Blog post.