Tuesday Tidbits

David Ermer

I am an attorney who practices law in Washington DC. My practice has involved the Federal Employees Health Benefits Program since 1983.

Tuesday Tidbits

David Ermer–COVID-19, Medicare, Mental health care, Telehealth–

While the FEHBlog has been discussing the progress of convalescent plasma to treat COVID-19, its time to turn to the Gilead drug remdesivir Fierce Pharma discusses today a recently released peer reviewed study that shows that the drug works well with patients suffering from moderate severity COVID-19.

The 1,063-patient study showed remdesivir’s benefits appear greatest for hospitalized patients in the middle of the disease-severity spectrum. For those who required oxygen supplementation but were not mechanically ventilated, remdesivir cut the time to recovery by 47% compared with placebo. But remdesivir didn’t much help patients with mild or moderate disease, and outcomes for patients on invasive ventilation or extracorporeal membrane oxygenation were nearly the same in both arms of the study.

According to the article, studies are continuing on the efficacy of the drug for patients with mild severity COVID-19.

The Wall Street Journal reports today that physicians are concerned over fact that anti-anxiety and anti-depression prescriptions have spiked during the great hunkering down. “Many physicians have a low threshold for prescribing them. It’s very problematic,” says Bruce J. Schwartz, deputy chair and professor of psychiatry and behavioral sciences at Montefiore Medical Center in New York. “Many people do develop a dependency on these medications.” The article offers alternate approaches, and FEHB plans now usually offer coaching services to help with the problems.

Speaking of healthcare coaching programs, CNBC reports that the great hunkering down has been good for companies that provide coaching or telehealth / digital health programs.

The Centers for Medicare and Medicaid Services announced that their 2021 pilot program to lower insulin costs for Medicare beneficiaries is bearing fruit.

Based on CMS’s estimates, beneficiaries who use insulin and join a plan participating in the model could see average out-of-pocket savings of $446, or 66 percent, for their insulins, funded in part by manufacturers paying an estimated additional $250 million of discounts over the five years of the model. With a robust voluntary response from Part D sponsors, CMS anticipates beneficiaries will have Part D plan options in all 50 states, the District of Columbia, and Puerto Rico, through either a standalone prescription drug plan (PDP) or a Medicare Advantage plan with prescription drug coverage. Beneficiaries will be able to enroll during Medicare open enrollment, which is from October 15, 2020 through December 7, 2020, for Part D coverage that begins on January 1, 2021.

Well done. Hopefully the Medicare approach will be translatable to employer sponsored coverage like the FEHBP.

Memorial Day Weekend Update

David Ermer–Congress, COVID-19, OPM–

Congress was scheduled to be out of town this week for State / District work periods. The House however has decided to be in town for votes and a few Committee hearings on Wednesday and Thursday. Congress is considering making some adjustments to the CARES Act’s Payroll Protection Program.

This is a big week for FEHBP carriers because their 2021 benefit and rate proposals are due at OPM by May 31. (Yes, next Sunday.) It is an complicated proposal year because the COVID-19 emergency has disrupted the normal claim payment rhythm.

The Wall Street Journal reports that on a randomized study of hospitalized COVID-19 patients in New York City finding the convalescent plasma (which includes the antibodies created by people who recovered from COVID-19) produced better outcomes. “In the study, the plasma recipients were more likely to remain stable or show improvement in their requirements for supplemental oxygen. They also had improved survival when compared to the control patients.”

The Wall Street Journal also reports tonight about “early signs the U.S. economy is, ever so slowly, creeping back to life.” “If this is the only wave [of coronavirus], it looks like we’ve bottomed out and the normalization process has begun,” said Beth Ann Bovino, U.S. chief economist at S&P Global Ratings.” Much greater testing, improved treatments, and controls on potentially super spreading events hopefully will place our medical system in a position to handle another wave without another great hunkering down.

Friday Stats and More

David Ermer–COVID-19, Federal employment benefits, Medicare, OPM–

The CDC’s COVID-19 cases in the U.S. website, which the FEHBlog tracks, added age demographic information this week. The basic infection mortality rate stabilized then dropped slightly then stabilized again over the past two weeks. That has to be good news. The CDC’s weekly COVIDview supports the FEHBlog’s layman analysis.

MedPage Today offers an interesting story about the downswing of the illness from the perspective of New York City clinicians who have been on the front line.

The Centers for Medicare and Medicaid Services finalized today a subset of proposed Medicare Advantage and Part D changes that the agency proposed earlier this year. CMS is releasing the final rule in two installments so that Medicare Advantage and Part D plans are not overwhelmed. That’s considerate.

OPM released additional COVID-19 guidance for federal agencies today. The guidance concerns the Families First Coronavirus Response Act’s paid leave program for employees affected by COVID-19.

Thursday Miscellany

David Ermer–COVID-19, COVID-19 testing, HSA–

In accordance with law, the Internal Revenue Service released today 2021 inflation adjustments to health savings account contribution limits and minimum deductibles for related high deductible health plans as described in Section 223 of the Internal Revenue Code. Only high deductible benefit plan participants may contribute to health savings accounts.

According to Fierce Healthcare, CVS Health today announced a major expansion of their drive up COVID0-19 testing sites.

Starting Friday, the retail and pharmacy giant will open nearly 300 additional test sites across 14 states for a total of nearly 350 available test sites in Arizona, California, Connecticut, Florida, Georgia, Illinois, Indiana, Louisiana, Maryland, Massachusetts, New Jersey, New York, Pennsylvania and Texas.The company said it plans to establish up to 1,000 locations across the country by the end of May with the goal of processing up to 1.5 million tests per month.

Finally, there will be a drive up testing site located in Montgomery County, MD, where the FEHBlog lives.

Healthcare Dive wrote a follow up report on the Commonwealth Fund study mentioned in yesterday’s post.

Telehealth visits that exploded in recent months are starting to plateau and in some cases decline in popularity as doctor’s offices reschedule backlogged patients for more in-person appointments, according new data from The Commonwealth Fund. Telemedicine visits accounted for about 14% of all total visits the week of April 19, according to the report, but that number dropped to 13% the next week and 12% the week after that. Telehealth visits held at 12% for the first two weeks of May.

In this regard, a Health Affairs Blog article discusses how primary care can be rejuvenated in the wake of the COVID-19 emergency. The number one suggestion is

Ending the hegemony of the face-to-face visit and rebalancing the appointment template toward 50 percent distance visits are likely to improve patient access while reducing work and burnout.

Studies are mixed but suggest that e-visits and phone visits reduce the number of face-to-face visits and take less time for clinicians and staff. When the Kaiser Permanente system in Hawaii massively changed its primary care model in 2004—with e-visits and phone visits increasing sixfold and eightfold, respectively—office visits decreased 26.2 percent.

Multiple studies demonstrate that these visits can provide high-quality care for a large number of medical conditions. 

It should be easier for the physician community to redirect patient care in this manner.

Midweek update

David Ermer–COVID-19, Uncategorized–

Yesterday, the FEHBlog noted a study from late March to early April showing a big drop in non-COVID healthcare. (After all it is a lawyer’s job to belabor the obvious.) Today, Fierce Healthcare reports on a Commonwealth Fund study finding a “slight” pick up in that care later in April. “The rebound occurred across all specialties, although the decline in visits remains largest among surgical and procedural specialties alongside pediatrics, the study said.”

The Wall Street Journal reports that

A study published this week found that banning mass gatherings had the biggest contribution to bringing the epidemic under control in Germany.

Superspreading events could even reignite the epidemic when the situation appears under control, said Prof. Cristopher Moore, a physicist with the Santa Fe Institute.

Dr. Streeck, the German virologist, agrees. While most experts expect a deadly second wave of coronavirus infections in the fall, he thinks a sharper focus on preventing superspreading events and vigilant monitoring could help avoid such a scenario.

The FEHBlog would gladly take a ban on mass gatherings over the great hunkering down. Add fake crowd noise to sporting events with fans just like TV shows add canned laughter.

In the same vein, Healthcare Dive informs us that

Apple and Google have launched software allowing public health agencies to create contact tracing apps that will notify users if they’ve been close to a person who has tested positive for COVID-19. The infrastructure, dubbed Exposure Notification, uses the Bluetooth radios within iOS and Android systems for contact tracing apps and will be part of a software update the companies are pushing out Wednesday. Amid privacy concerns, Apple and Google say the apps will be fully opt-in and have other built-in consumer protections.

22 countries and several U.S. states have requested and been given access to the technology so far.

Beckers Hospital Review unfortunately lets us know that U.S. births hit a 35 year low in 2019. No bueno.

Monday Roundup

David Ermer–COVID-19, COVID-19 testing, COVID-19 vaccine, HIPAA Privacy and Security Rules–

Fierce Biotech reports on today’s positive but not definitive results from Moderna’s early COVID-19 vaccine testing. “With eyes on a phase 3 study this summer, Moderna posted promising early data for its COVID-19 vaccine. The jab prompted an immune response similar to those seen in patients who have recovered from the disease.” Fingers crossed.

CVS Health, Walgreen’s and Rite Aid / Verily continue to expand their drive up COVID-19 testing capabilities. Healthcare Dive reports that the Food and Drug Administration (“FDA”) last Friday “authorized multiple laboratories to test for coronavirus in nasal samples collected by consumers using an at-home kit” produced by Everlywell. This is the second FDA approved at home kit.

What’s more, Fierce Biotech reports that Verily’s Project Baseline “has launched a new clinical research effort focused on COVID-19 antibody testing and exploring the body’s immune response to the novel coronavirus.” Fierce Healthcare adds that the American Medical Association is offering guidance on COVID-19 antibody testing for physicians. “Although many are using these tests to determine whether an individual had COVID-19, we encourage physicians to only use antibody tests authorized by the FDA and only for the purposes of population-level studies [like the Project Baseline study], evaluating recovered individuals for convalescent plasma donations, or along with other clinical information as part of a well-defined testing plan for groups or individuals.”

A friend of the FEHBlog called his attention to this federal government list of top ten routinely exploited cybersecurity vulnerabilities and mitigations over the period 2016 through 2019 and this year.

Weekend update

David Ermer–Congress, COVID-19, COVID-19 testing, COVID-19 vaccine, Uncategorized–

The House of Representatives returned to Capitol Hill on Friday to pass a resolution (H.R. Res. No. 965) permitting remote Committee hearings and proxy voting during a federal declared emergency like the COVID-19 pandemic. The House also passed a wide-ranging, $3 trillion COVID-19 relief bill known as the HEROES Act (H.R. 6888) by a narrow 208-199 vote. The House thereby laid down its wishlist before the Senate and the President in the looming negotiations over what would be the fourth COVID-19 relief bill.

The FEHBlog’s favorite podcast Econtalk featured a special edition in which the host Stanford economist Russ Roberts interviewed Nobel in Economics laureate Paul Romer about the COVID-19 pandemic. Mr. Romer supports much less hunkering down and a lot more testing. It’s worth the hour or so to listen to the interview.

In other news:

  • The Washington Post reports that “Four months into the U.S. coronavirus epidemic, tests for the virus finally are becoming widely available, a crucial step toward lifting stay-at-home orders and safely returning to normal life. But while many states no longer report crippling supply shortages, a new problem has emerged: too few people lining up to get tested.” This word needs to get out.
  • Healthcare Dive discusses health insurer and tech company efforts to help their employer plan sponsors to safely reopen their businesses.
  • The Wall Street Journal reports on the state of the race to develop a safe and effective COVID-19 vaccine. Eight investigational versions have begun human testing trials. “Testing of early vaccines could show the way for subsequent shots by giving researchers a better idea of the level of immune response needed to provide protection against the virus, Emory’s Dr. Orenstein said.”
  • Fierce Healthcare discusses J.D. Powers 2020 analysis of consumer attitudes toward commercial health plans. “Consumers want a coordinated, integrated experience that their health plan may be unwilling or unable to provide, [James Breen from J.D. Power] said. “Health plan members have an expectation that health insurance companies do that, but I’m not certain whether or not health insurance companies feel that’s part of their major role, so there’s a disconnect there,” Beem said.

Friday Stats and More

David Ermer–ACA, COVID-19, SCOTUS–

Per the CDC’s COVID-19 Cases in the U.S. that the FEHBlog tracks, the number of COVID-19 cases crossed the 1.4 million mark and the number of COVID-19 deaths exceeded 85,000 today. The CDC’s COVIDView confirms that the rate of increase continues to slow. For what it’s worth, the FEHBlog-calculated COVID-19 case mortality rate has been pretty stable for the past month. The Wall Street Journal’s Numbers columnist discusses COVID-19 stats her latest column.

Dividing fatalities by the number of confirmed illnesses produces the case fatality rate. [That’s FEHBlog’s approach] A better estimate of lethality divides fatalities by the number of people infected. But no one knows how many people are infected with Covid-19.

“Right now the death rate is a guess,” Dr. [Fred] Brauer said. “I’ve seen ranges from one-tenth of a percentage point to 3%.”

The FEHBlog has been tracking the simple case mortality rate to find a plateau and the FEHBlog thinks we may be there.

Recently, the filing of Supreme Court briefs defending the Affordable Care Act’s constitutionality have lead some press outlets to raise an alarm. The best chill pill is to read this Reason article by Prof. Jonathan Adler who filed on the 38 friends of the Court briefs supporting the statute’s constitutionality. The article’s title says it all — “The Penalty-less Individual Mandate Is Severable from the Rest of the ACA No Matter How You Look at It.” Amen to that.

A friend of the FEHBlog brought to his attention this C-SPAN interview with Dr. David Kimberlin. Dr. Kimberlin is pediatric infectious diseases chair at the University of Alabama at Birmingham. He talked about how the COVID-19 pandemic is impacting children. He expresses concern that the COVID-19 pandemic is discouraging parents from taking their children to pediatrician for routine childhood vaccinations. He encourages parents to contact their pediatrician to learn how the vaccinations can be obtained safely. That’s important advice.

In other news —

  • Becker’s Hospital Review discusses each of the fifteen hospital closures that have occurred in the United State this year.
  • STAT News reports that “fueled by the Covid-19 pandemic, remote heart monitoring could become tech’s next big target.
    • “Both Apple and Alphabet spinout Verily have watches equipped with EKGs that detect the heart abnormality atrial fibrillation, or A-fib. Apple and Amazon have recently hired prominent cardiologists to fill their ranks, while Facebook is hiring for a team overseen by Freddy Abnousi, a cardiologist and the social network’s new head of health technology. Among the new roles: an expert in the same type of technology used to monitor the heart in Fitbits and Apple Watches.”
Person using a laptop

Thursday Miscellany

David Ermer–COVID-19, OPM, Rx coverage–

A few posts ago, the FEHBlog favorably mentioned the National COVID-19 Convalescent Plasma Project. “Researchers hope transfusions of antibody-rich plasma from recovered Covid-19 patients can help neutralize the coronavirus in patients who are sick.” Today the Wall Street Journal reports that

A [Phase 2] study of thousands of Covid-19 patients who received blood plasma transfusions from recovered patients indicates the experimental therapy appears to be safe, paving the way for future studies and clinical trials.

A team of researchers at Mayo Clinic, Michigan State University and Johns Hopkins University examined health outcomes of 5,000 hospitalized patients around the U.S. who received convalescent plasma treatment, and found the transfusions resulted in few serious side effects and there wasn’t an excessive mortality rate.

Let’s go.

In other upbeat news, the Wall Street Journal reports that “More patients are turning to mail or courier to get their prescription drugs during coronavirus lockdowns, a shift from the traditional visit with a pharmacist that is expected to endure after the pandemic subsides.” Mail order delivery of maintenance medications is known to create a cost savings for health plans and their members.

Health Payer Intelligence discusses a fascinating PriceWaterHouseCoopers healthcare consumer survey conducted during the great hunkering down. The survey’s “results signal that US businesses could play an even bigger role in protecting the health of their workers, that the health system likely will make more room for telehealth and other forms of virtual care, and that the American consumer may take a more active role in managing health and participating in a system that is being remade.”

In other news —

  • The FEHBlog ran across this American Medical Association website of its COVID-19 resources.
  • Fierce Healthcare calls to our attention the Medscape Physician Compensation Report 2020. “Primary care docs brought in about $243,000, up 2.5% from $237,000 reported a year earlier. Specialists earned about $346,000 on average, up 1.5% from the $341,000 they made a year earlier.”
  • OPM issued additional COVID-19 guidance to federal agencies today. It’s not FEHBP related.

Midweek Update

David Ermer–AHRQ, COVID-19, HSA–

Yesterday, the Internal Revenue Service created in view of the COVID-19 emergency new flexibilities for flexible spending account (FSA) holders, health savings account (“HSA”holders and cafeteria plan members by

  • extending claims periods for taxpayers to apply unused amounts remaining in a health FSA or dependent care assistance program for expenses incurred for those same qualified benefits through December 31, 2020.
  • expanding the ability of taxpayers to make mid-year elections for health coverage, health FSAs, and dependent care assistance programs, allowing them to respond to changes in needs as a result of the COVID-19 pandemic.
  • applying earlier relief for high deductible health plans to cover expenses related to COVID-19, and a temporary exemption for telehealth services retroactively to The notice increases the limit for unused health FSA carryover amounts from $500, to a maximum of $550, as adjusted annually for inflation.January 1, 2020.

The IRS also increased “the limit for unused health FSA carryover amounts from $500, to a maximum of $550, as adjusted annually for inflation.”

The Board of Directors of America’s Health Insurance Plans issued a statement on “Safely Re-Opening America’s Health Care System and Resuming Needed Procedures and Treatments, Routine Care, and Preventive Services” in the wake of the COVID-19 emergency. The statement encourages continued use of telehealth and sensible applic ation / waivers of health plan prior authorization requirements.

HHS’s Agency for Healthcare Research and Quality has created its own COVID-19 resources webpage. Among other things the site “provides links to research funding opportunities, AHRQ Views blog posts about the Agency’s COVID-19 activities, and examples of new AHRQ-funded research findings.”

Benefits Pro reports that “A Social Security policy analyst for the advocacy group The Senior Citizens League is estimating the cost-of-living adjustment for 2021 will be zero based on consumer price index data through April and the continued impact of COVID-19 on the economy.” A zero COLA, which occurred in 2009, 2010, and 2015, will trigger the protection of Medicare Part B premium hold harmless clause for certain but not all federal annuitants.