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This Week in Health Care Reform - October 10th, 2014

As open enrollment approaches, worries persist over the website’s readiness; the latest court decision brings the health care law one step closer on a return trip to the Supreme Court; a light is shined on payments to providers, to middling reviews; telehealth and its potential to transform health care is a game-changer; and, the next generation of Gilead’s hepatitis C drug portends the continuation of an unsustainable trend.


Week in Review

ACA Year 2: By this time last year, we were a little more than a week into the first open enrollment period on the Affordable Care Act’s new insurance exchange marketplaces.  And, for those that may have forgotten, the rollout was anything but smooth.  Front- and back-end glitches on the website led to a user experience that left many on the outside looking in.  Fast-forward a year, and, with the next open enrollment period set to begin in less than six weeks, there’s a lingering sense that, despite the numerous technological fixes and assurances that improvements have been constructed, we’re not quite out of the woods, yet.  Nevertheless, the website’s administrators opened up the platform this week for broad testing by insurers, with the stipulation that all testers would have to “acknowledge the confidentiality of this process to access the testing environment” – a stipulation that left some outside observers wringing their hands.  Beyond the technological issues that plagued last year’s open enrollment, year 2 offers up the chance to take a look back and assess how the health care law has performed, thus far, and to take a look at what it needs to do next.  Regardless of one’s views of the polarizing law, it’s clear that there are many challenges still ahead.  States, for one, have as big a role in realizing the law’s success as any other stakeholder.  And, practically speaking, the messaging landscape presents its own set of obstacles on the eve of open enrollment. 

OK Court Decision:
Early last week, a federal judge in Oklahoma ruled that the tax subsidies extended to individuals in states that elected not to set up their own health insurance exchanges represented “an invalid implementation” of the health care law and were, thus, unlawful.  Citing the Affordable Care Act itself, U.S. District Judge Ronald White defended his decision as the court “upholding the act as written.”  Two separate rulings handed down by federal appeals courts offered split decisions of their own earlier this summer.  With a fourth case pending in the Federal District Court in Indianapolis, it’s looking like the Supreme Court may be poised to take up the issue once again, despite overtures to the contrary from the Department of Justice.

Open Payments: A new website was launched last week which allows consumers to look up their doctors to see what payments, if any, they may have received from pharmaceutical companies and medical device manufacturers.  The site, called Open Payments, was established under the Affordable Care Act as a means of disclosing the financial relationships that exist between providers and these industries – a not insignificant amount, it turns out, as the database revealed some $3.5 billion in payments to providers last year.  However, detailed analysis found significant problems with the website, including disputed data and missing information.  In fact, one estimate pegs the total value of the flawed or unpublished data at approximately $1 billion, converting many transparency advocates into critics of the system, given the perceived dilution of the data that was, in fact, made available.

With so much energy being devoted to finding ways in which we can improve the health care system in this country, it stands to reason that every avenue would be explored.  Whether through increased collaboration, enhanced benefit design, or value-based payment reforms, no stone, it would seem, is being left unturned.  So, if you were to be told that new, game-changing technologies, with the power to transform the health care system, were not just on the horizon, but already here, it’d be a no-brainer, right?  Unfortunately, if health IT’s bumpy path to ubiquity has taught us anything, it’s that telehealth has a long road ahead.  But, there’s hope.  Already we’ve seen health plans, employers, and providers embrace technology in the delivery of care.  Industry groups, health care stakeholders, and even lawmakers are also taking up the cause.  With new evidence coming out every day, highlighting just how valuable the application of new technologies can be to improved health outcomes, we stand ready to realize the promise of telehealth.

As Gilead Sciences awaits FDA approval of its next generation hepatitis C drug, Harvoni, anticipation mounts for how, exactly, the pharmaceutical company plans on pricing it.  As has been widely discussed, Gilead’s current hepatitis C drug, Sovaldi, continues to cripple budgets across the country – from state and federal programs to, most recently, the Department of Veterans Affairs (VA).  Perhaps most troubling of all, though, is the near-unanimous belief that Sovaldi’s $1,000-a-pill price reflects a growing trend across the drug industry, rather than an exception to the rule – a battle that’s already playing out in other areas of the market, including cancer drugs, which are facing new hurdles in getting to patients.  Even generic drugs aren’t immune from the caprices of the industry, as prices for these health care workhorses have also begun to spike.  As the debate continues to reverberate across the health care spectrum, there’s a real urgency to addressing the unsustainability and ‘financial toxicity’ of the pricing trend currently at work in the specialty drug market, which is projected to make up half of all pharmacy spending by 2018.

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