Weekend Update

David Ermer–Congress, Generative AI, Medical / Rx research, U.S. Healthcare–

From Washington, DC

  • Roll Call discusses likely Senate activities this week.
  • Congress in the July 4, 2025, budget reconciliation act (§ 90101, at 291) did enact a law requiring OPM to place more internal controls over family member eligibility.
    • – No later than 12/31/25, OPM must develop a process by which any [ineligible] individual enrolled in, or covered under, a [FEHB or PSHB] shall be disenrolled or removed from enrollment in, or coverage under, that plan.
  • This requirement should include implementation of the HIPAA 820 standard enrollment roster transaction. 
    • – No later than July 3, 2026, OPM must issue regulations and implement a process to verify – (1) the veracity of any qualifying life event through which an enrollee seeks to add a member of family to his/her coverage; and (2) that, when an enrollee in the Program seeks to add a member of family to his/her coverage, including during any open season, the individual so added is a qualifying member of family with respect to the enrollee.
  • It would be sensible for OPM to implement a program similar to TRICARE’s DEERS program which places the reporting burden on the TRICARE enrollee. 
  • HIPAA Suite explains,
    • “The HIPAA 820 transaction set [which has been around since 2008] handles the [electronic] communication between a sponsor that is an entity that pays for someone’s health care, and another entity that manages health care benefits, such as an insurance company.
    • “For example, a large employer that has a contract with an insurance company or a government agency that handles social and health benefits will use the 820 transaction to manage premium payments. This information can either be very detailed and contain demographic information on each individual that is covered or just contain a summary of the payment for all members.
  • The HIPAA standard transaction law requires health plans to be able to process the HIPAA 820. What’s more nearly half of FEHB and PSHB enrollees have self only coverage.

From the public health and medical reseach front,

  • MedPage Today reports,
    • “For years, we’ve told our patients that human papillomavirus (HPV) vaccination works best when administered before sexual debut — and rightfully so. But what happens when a woman has already developed high-grade cervical dysplasia and undergoes surgical treatment?
    • Our recent study, published in The Lancet Regional Health – Europe, explored that very question. And the results were striking: women who received the HPV vaccine after surgical excision (conization) experienced a 74% reduction in recurrent high-grade cervical lesions (CIN2+), with the most dramatic benefit seen within the first 6 months after surgery.
  • and
    • “Cases of “Ozempic mouth” and “Ozempic teeth” have recently been described in the news, with most of the problems — inflammation affecting the gums, tooth decay, and even bad breath — linked to a dry mouth.
    • “All of the GLP-1 agonists that we use now cause changes in how everything is secreted in your GI tract,” Ann Marie Defnet, MD, who specializes in obesity medicine and bariatric surgery at Northwell Health’s North Shore University Hospital and Long Island Jewish Medical Center in New York City, told MedPage Today. And this “definitely has an impact on saliva.”
    • “People taking GLP-1 drugs also tend to be a bit dehydrated because they are often not hungry or thirsty, she noted.
    • “I haven’t seen too many horrible cases of periodontal disease, gingivitis, or anything like that, nor have I had any patients really complaining about dry mouth,” she noted. “But definitely I have patients all the time that [say], ‘Oh yeah, I can tell I’m dehydrated.'”
    • “Defnet said she believes some of the serious oral health issues that have been reported are likely representative of “more of a later stage issue with patients who maybe just aren’t staying hydrated in general.”
    • “One of the big things I always counsel my patients on is they just have to remember to continue to drink water, even if they’re not thirsty, even if they’re not hungry,” Defnet said. “That seems to help with all of these symptoms.”
  • The New York Times discusses “Coronary artery calcium testing [which] can reveal plaque in arteries, offering a more precise estimate of a patient’s risk [of having a heart attack]. Yet the test remains underused.”
    • “A brief and painless CT scan, it would show whether the fatty deposits called plaque were developing in the arteries leading to her heart.
    • “When plaque ruptures, it can cause clots that block blood flow and trigger heart attacks. The scan would help determine whether Ms. Hollander would benefit from taking a statin, which could reduce plaque and prevent more from forming.
    • “The test is used by more people every year,” said Dr. Michael Blaha, co-director of the preventive cardiology program at Johns Hopkins University. Calcium scans quadrupled between 2006 and 2017, his research team reported, and Google searches for related terms have risen even more sharply.
    • “Yet “it’s still being underused compared to its value,” he said.
    • “One reason is that although the test is comparatively inexpensive — sometimes up to $300, but often $100 or less — patients must pay for it out of pocket. Medicare rarely covers it, though some doctors argue that it should.”

From the U.S. healthcare business front,

  • Radiology Business lets us know,
    • “Physicians are increasingly exiting Medicare, according to new research published in JAMA Health Forum. 
    • “Radiology and other specialties have expressed concern in recent years that inadequate payment rates could push practices to close or stop accepting the federal program for seniors. Since 2001, Medicare reimbursements to physicians have fallen 33%, when adjusting for inflation, according to the American Medical Association. 
    • “Researchers recently sought to test this theory, analyzing 100% of fee-for-service Medicare Part B claims logged between 2010 to 2024. They found the share of physicians exiting Medicare increased “significantly” from 1.8% to 3.6% by the end of the study period. 
    • “The findings may reflect multiple factors, including the greater burden of new communication methods (e.g., portal messages) and demands for clinical documentation,” Hannah T. Neprash, PhD, and Michael E. Chernew, PhD, healthcare policy experts with the University of Minnesota and Harvard Medical School, respectively, wrote July 18. “More rapid growth in exit[s] among small practices likely contributes to consolidated physician markets, given that new physicians increasingly work for large practices.”
    • “Researchers excluded docs who on average billed for fewer than 100 Medicare claims annually. They defined an exit as the absence of any claims in the payment program for 12 consecutive months. Altogether, the study sample included over 791,000 physicians at an average age of nearly 45. Physician Medicare exits displayed a gradual increase from 2010-2013 before stabilizing between 2014-2016. They saw another gradual increase from 2017-2019 and then spiked amid the COVID-19 pandemic in 2020-2021 before returning to regular levels by 2023.” 
  • The boilerplate in an FEHB or PSHB brochure (meaning its OPM policy) reads,
    • If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid.
  • MedCity News informs us that “Sentara Health has rolled out Regard’s AI-powered chart review and discharge summary tool across all 12 of its hospitals [located in Virginia and North Carolina]. The tool has delivered consistent benefits when it comes to patient safety and documentation accuracy, said Joseph Evans, Sentara’s chief health information officer.