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3 payer issues to focus on in wake of King v. Burwell ruling

Prescription drug costs, value-based care are two of many conversations that must take center stage

Last week the Supreme Court saved the Affordable Care Act for the second time since its implementation--this time by upholding federal subsidies. Moving forward, it's time to shift gears and change the healthcare conversation.

Here are three topics that the industry must now address, according to an Associated Press article:

Prescription drug costs

Due to the the soaring costs of specialty drugs to treat hepatitis C and certain types of cancer drugs, nearly three-fourths of Americans believe prices for prescription drugs are unreasonable, notes the AP.

While these costs are "unsustainable," Economist Len Nichols of George Mason University tells the AP, government-controlled pricing impairs altering costs. However, many consumers aren't affected by these pricey drugs since most prescriptions are for lower-priced generic drugs.

Earlier this year President Barack Obama proposed allowing Medicare officials to negotiate prices with drug manufacturers, FierceHealthPayer previously reported. The rising costs of speciality drugs could bankrupt the healthcare system, John D. Bennett, president of the Capital District Physicians' Health Plan, told the New York Times at the time, stating "What good is a miracle drug if you can't afford it."

Paying for value

The Centers for Medicare & Medicaid Services announced back in January it would fundamentally change how it pays providers. The new payment model--which capitalizes on online medical records and data analysis--will focus on paying providers for the quality of care as opposed to the volume of care.

But as the AP notes, defining what constitutes as value is proving to be more difficult than anticipated. Additionally, it's unclear if this new approach will generate actual savings.

Health policy expert Paul Keckley, Ph.D., managing director of the Navigant Center for Healthcare Research and Policy Analysis, in his Pulse Weekly column, noted that part of the problem is there is no consensus on how to calculate costs not a regulatory methodology to determine the comparative effectivenes of the care we provide. 

Covering more Americans

Currently, the uninsured rate is an an all-time low of 11.5 percent. When the ACA was first passed, 80 percent of Americans under the age of 65 had health insurance; that number is now up to 90 percent.

But providing coverage to the remaining uninsured will continue to be an uphill battle, especially as states mull the idea of expanding Medicaid. The Court's ruling may convince states to expand the program, says the AP, but probably not big, Republican-led states like Texas.

For more:
- here's the AP story
- read Keckley's column

Related Articles:
Focus turns to Medicaid expansion in wake of King v. Burwell ruling
Payers push for pay-for-performance prescription prices
How to control prescription drug costs
Feds speed plans for value-based payments
Uninsured rate drops to 11.5 percent