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–CDC, Congress, COVID-19–

The Senate Health Education Labor and Pensions Committee held a COVID-19 hearing today featuring a number of federal government healthcare luminaries including Dr. Fauci. Here is a link to the hearing and the submitted testimony. The Wall Street Journal reports

Dr. Fauci said that with some states reopening before seeing a steady decline in cases and deaths, “there is a real risk you could trigger an outbreak…that could set you back rather than going forward.”

Adm. Brett Giroir, who is heading up the administration’s testing efforts, said an increased focus on testing in schools could be used as a means of surveillance to help ensuree students stay healthy.

Other health officials also emphasized the need for widespread testing to get a more accurate picture of how many people have fallen sick and to spot potentially undetected clusters of cases.

Here’s a link to the COVID Tracking Project site which provides a ton of state by state COVID-19 data, including testing data. As previously noted, GoodRx offers a complete, growing list of drive up COVID-19 test sites. Last week, one of the big U.S. lab test companies, LabCorp, began to offer “expanded access to COVID-19 antibody test through LabCorp’s wide network of doctors, healthcare providers, and online. Individuals have the ability to receive the COVID-19 IgG antibody test from their doctor, in person or through a telemedicine program, and now directly using www.LabCorp.com/antibody-testing.“

A friend of the FEHBlog pointed out this National Institutes of Health website which is chock-a-block full of COVID-19 research tidbits. For example, the FEHBlog noticed a NIH study finding “nearly everyone who recovers from COVID-19 makes coronavirus antibodies.” Check it out.

The Hill brings us to date on the four leading U.S. and European COVID-19 vaccine development efforts. “There are more than 100 potential vaccine candidates, according to the World Health Organization, but only eight have entered the crucial clinical trials stage. Four are in the United States and Europe, with the rest in China.”

Healthcare Dive reports that the American Hospital Association flipped out over new price transparency rules in the fiscal year 2021 Medicare Part A hospital PPS changes proposed rule released yesterday.

Monday Mishmash

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

Today, the Centers for Medicare and Medicare Services released its proposed rule describing changes to its Medicare Part A prospective payment system (“PPS”) changes for the federal fiscal year beginning October 1, 2020. This PPS applies to acute and long term inpatient care. Fierce Healthcare explains that the changes represent “an approximately 1.6% increase to inpatient hospital stay payments” that will add about $2.1 billion to Medicare spending next fiscal year.

A friend of the FEHBlog recommended a book called “Together: The Healing Power of Connection in a Sometimes Lonely World” written by former U.S. Surgeon General Vivek Murthy. It seems like a perfect read for the great hunkering down. The FEHBlog will let you know.

In other news:

  • Fierce Healthcare also discusses how CVS Health has adapted its specialty pharmacy to the COVID-19 emergency. According to the article, CVS Specialty is making greater use of digital tools, e.g., “a 30% increase in March alone in encounter volume through CVS Specialty’s secure messaging tool, which allows [their] pharmacists to text members directly to discuss their medications.”
  • The Wall Street Journal reports that “Atul Gawande is in advanced discussions to step down as chief executive and take on a less operational role as chairman of Haven, the health-care venture backed by Amazon.com Inc., Berkshire Hathaway Inc., and JPMorgan Chase JPM , according to people with knowledge of the matter.” Haven was the big new thing is 2018 when Dr. Gawande came aboard.
  • The HHS Office of Inspector General announced the availability of two “toolkits and the accompanying code can be used to analyze claims data for prescription drugs and identify patients who may be misusing or abusing prescription opioids and may be in need of additional case management or other followup. These toolkits and accompanying code can also be used to answer research questions about opioid utilization.”

Weekend update

David Ermer–Congress, COVID-19, HIPAA Privacy and Security Rules, Rx coverage–

Happy Mother’s Day.

Just like last week, the Senate will be in session this week while the House continues to fully hunker down. The Hill discusses five factors influencing when the House will return to Capitol Hill. It’s funny that the article does not list the Presidential election as a sixth factor. (Even the FEHBlog is entitled to have an occasional “DJT” moment. Lo siento.)

The FEHBlog forgot last Thursday to provide a link to the Senate Health Education Labor and Pension Committees “shark tank” on new tests for COVID-19. Here you go. This Committee will be holding a hearing on how to pull out of the great hunkering down on Tuesday.

For the past two months, the FEHBlog has been tracking a simplified infection fatality rate (IFR) for COVID-19 based on the CDC’s statistics. The FEHBlog is not an epidimeologist but he figured things would be looking up if the rate plateaued. The FEHBlog’s statistics do show the IFR increase slowing down over the past month. In any event, here’s a new Health Affairs article on the COVID-19 IFR for your information.

CIGNA’s PBM Express Scripts has created a program called ParachuteRX which offers reasonably priced prescription drugs to the uninsured. Cool.

The FEHBlog has been a fan of genetics-based personalized medicine. It therefore was sobering for the FEHBlog to read in the Wall Street Journal that the popular focus on personalized medicine has detracted from public health efforts. The article explains that

the first national initiative launched to try to treat today’s severely ill patients is the National Covid-19 Convalescent Plasma Project. The project originated with a small nucleus of people who, it turns out, have been prominent critics of personalized medicine over the years, including Arturo Casadevall of Johns Hopkins University, Michael Joyner of the Mayo Clinic and Nigel Paneth of Michigan State University.

The idea of using antibody-rich plasma from recovered patients to try to neutralize a virus in those who are ill was first used more than 100 years ago. The project is designed to buy time and save lives until a vaccine can be developed and deployed or more targeted therapies can be identified and tested. It also offers a real-world test case for ideas that had largely been confined to academic journals and debates between scientists.

Indeed the FEHBlog learned in the Great Influenza book that small scale efforts to use this antibody approach found success in the 1918-19 pandemic. It’s encouraging to read that a large scale effort is underway now. In the aftermath of the great hunkering down, a Goldilocks compromise must be reached between personalized medicine and public health efforts.

Finally, Health IT Security does a good job putting the government’s COVID-19 related flexibilities with regard to enforcing the HIPAA Privacy Rule into focus.

Friday Stats and More

David Ermer–CDC, 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 1.2 million mark and the number of COVID-19 deaths exceeded 70,000 this week. The case mortality rate hit 6% on Thursday after being in the 5 to 6% range for 2 1/2 weeks. Before then the case mortality rate was increasing much faster. So we evidently are plateauing. The Wall Street Journal reports that the leading cause of death in our country remains heart disease. For an even better perspective, check out the CDC’s COVIDView which is released on Fridays.

The Wall Street Journal offers a perspective on State reopening here. The FEHBlog got a kick out of listening too this 20 minute long WSJ podcast on office reopenings titled “Welcome Back to the Office. Your Every Move Will Be Watched.”

The Wall Street Journal also has a regularly updated site on COVID-19 testing and treatments.

Health Payer Intelligence brings us up to date on the Texas v. U.S. case over the Affordable Care Act’s constitutionality. The Supreme Court will hear the case next fall.

Person using a laptop

Thursday Miscellany

David Ermer–ACA, COVID-19–

Today the Department of Health and Human Services finalized it major annual ACA notice — the 2021 notice of benefit and payment parameters. Here is a link to the fact sheet. Of note to all FEHB plan carriers —

  • The finalized 2021 maximum annual limitation on cost sharing [for in-network care] is $8,550 for self-only coverage and $17,100 for other than self-only coverage. This represents an approximately 4.9 percent increase above the 2020 parameters of $8,150 for self-only coverage and $16,300 for other than self-only coverage.
  • We finalized changes to the policy regarding how direct drug manufacturer support, including coupons, may accrue towards the annual limitation on cost sharing in response to stakeholder feedback indicating confusion about the regulatory requirement finalized in the 2020 Payment Notice. This new policy provides that, to the extent consistent with State law, issuers will be permitted, but not required, to count toward the annual limitation on cost sharing amounts paid toward reducing out-of-pocket costs using any form of direct support offered by drug manufacturers to enrollees for specific prescription drugs.

The notice also makes changes to the medical loss ratio rules applicable to health insurers. The entire annual notice is available at this link.

The Government Accountability Office today released a timely report titled “Congressional Action Is Essential to Enable a Sustainable Business Model.” In pertinent part —

Regarding USPS, reassessing its business model should start with the level of required postal services. For example, delivery is USPS’s most costly operation; USPS officials estimate annual savings of $1.4 billion to $1.8 billion if delivery of mail were reduced to 5 days rather than 6 days per week. Second, USPS is to function as a financially self-sustaining entity; however, it does not. A reassessment could include determining whether some of USPS’s costs and liabilities should be borne by taxpayers. Third, alternative institutional structures for USPS range from a federal agency to a private company. A bankruptcy proceeding is not an effective or appropriate means to address the issues associated with a potential USPS restructuring, according to the National Bankruptcy Conference [whose report is an appendix to the GAO report].

The Wall Street Journal in its story on the GAO report noted that “The Postal Service’s governance board said Wednesday it would tap Louis DeJoy, the chief executive of a North Carolina consulting and project-management firm, to be the next postmaster general.” He is “expected to take over as postmaster general on June 15” at which point the current Postmaster General Megan Brennan will begin her well deserved retirement.

Also today UnitedHealth Group announced the large health insurer

will provide more than $1.5 billion in initial assistance, including customer premium credits, to its UnitedHealthcare customers as many people have been unable to access routine or planned care due to the COVID-19 pandemic. Consequently, UnitedHealthcare has seen a lower volume of medical care being delivered than was anticipated when pricing was initially established.

For UnitedHealthcare commercial fully insured individual and employer customers, credits ranging from 5% to 20% — depending upon the specific plan — will be applied to premium billings in June.

For people served by UnitedHealthcare Medicare Advantage plans, all specialist and primary physician cost sharing will be waived at least through the end of September, helping remove barriers for seniors needing to access care.

The FEHBlog is quite proud to represent health insurers and plans for the way that they have stepped up in this crisis for their members.

Midweek update

David Ermer–Congress, COVID-19–

Fierce Healthcare and Healthcare Dive report on CVS Health’s positive first quarter 2020 results. According to Fierce Healthcare,

[CVS Health] CEO Larry Merlo said that utilization of telehealth and virtual visits through its MinuteClinic locations was up 600% compared to the first quarter of 2019, while home delivery of prescriptions was up 1000%.

In addition, he said, the company is seeing a fourfold increase in the number of customers adding other items from the front of their stores to home pharmacy deliveries. CVS is also seeing increased engagement with customers and members through its app, Merlo said.

Healthcare Dive adds

Though coronavirus had “minimal impact on the quarter,” CVS does expect a “big impact in April,” CFO Eva Boratto told investors on a Wednesday morning call. Consumers increasingly stayed at home in April, resulting in a sharp reduction in foot traffic to stores, and filed fewer prescriptions due to fewer doctor visits, according to CVS’ preliminary results from the month. Those headwinds could persist throughout the second quarter.

Interesting links —

  • The Senate Health Education Labor and Pensions Roundtable on COVID-19 policy was held today. Among the speaker was the FEHBlog’s favorite health policy expert Avik Roy whose testimony reads in pertinent part as follows:

[T]raffic fatalities is a good mental framework for thinking about how to live with COVID-19. Instead of abolishing cars, we enforce traffic laws and speed limits, and prohibit drunk driving. We set a minimum standard for car safety. But, most of all, we expect individual drivers to be responsible for their own conduct.
Something similar can work for COVID-19. Businesses can deep-clean their surfaces and provide hand sanitizer and masks to their workers and customers. People can wash their hands regularly, and minimize close contact with strangers. This is, in fact, what East Asian countries did after the original SARS outbreak in 2003, and it enabled them to gradually return to normal life, despite the absence of a vaccine or effective treatments.

  • As the FEHBlog aims to be a voice of calm and reason in the FEHBlog storm he notes that PsychHub has created a COVID-19 Mental Resource Hub and that the Atlantic has debunked, to his satisfaction, an unsubstantiated claim that the COVID-19 virus has mutated.
  • The CARES Act created a Pandemic Response Accountability Committee which has its own website. The site’s purpose is “to foster greater accountability and transparency in the use of these [CARES Act relief] funds” totaling $2.3 trillion.

Tuesday Tidbits

David Ermer–Congress, COVID-19, Medicare–

Theme for Cinco de Mayo — Ball of confusion that’s what the world is today. The Temptations (1970)

The American Hospital Association reported today that hospitals are losing $50.7 billion monthly from March through June due of course to the COVID-19 emergency. That’s a lot more than the $175 billion that Congress has appropriated so far for grants to hospitals and other healthcare providers. The FEHBlog doubts that most hospitals have strong balance sheets. No wonder health plans are stepping up to offer support as noted on Sunday.

Healthcare Dive discusses a study that reminds us about the large extent to which private payers including FEHB plans subsidize hospitals and other providers due to the insufficient payments from Medicare. “It’s unlikely Washington would take concrete measures to shrink hospitals’ toplines during the pandemic.”

Fierce Healthcare informs us that after reaching out to 500,000 Medicare Advantage members Humana has decided to waive Medicare Advantage member cost sharing for primary and behavioral healthcare this year whether the care is delivered in office or virtually. “William Shrank, M.D., chief medical officer at Humana, told FierceHealthcare that the insurer is tracking member behavior in this area and has gathered plenty of anecdotal evidence that patients are deferring potentially necessary care due to the pandemic.”

Catalyst for Health Reform has created a new state by state report card on healthcare price transparency laws. “Sixteen states [including the FEHBlog’s home state of Maryland] received passing grades this year, up from only seven when CPR last graded states in 2017.”

Lincoln Memorial

May the Fourth be with you

David Ermer–Congress, COVID-19–

The FEHBlog saw that line several times today. It’s cute.

Healthcare Dive reports that the Department of Health and Human Services decided last Friday to divvy up $22 billion of CARES Act funding by send $12 billion to hospitals in COVID-19 hot spots and another $10 billion to rural hospitals. The American Hospital Association is happy.

RevCycle Intelligence informs us that “Outpatient visits for more than 50,000 providers declined by nearly 60 percent in mid-March when COVID-19 cases started to rise exponentially, researchers from Harvard University recently reported in a Commonwealth Fund study. The volumes have remained low through mid-April.” Here are a couple more tidbits from the study:

  • The decline in visits was generally larger among surgical and procedural specialties and smaller in other specialties such as adult primary care, obstetrics/gynecology, oncology, and behavioral health.
  • As the number of in-person visits dropped, telehealth visits increased. But the increase in telehealth visits only partially offset the drop in in-person visits.
  • Nearly 30 percent of all visits at these ambulatory practices are now provided via telemedicine.
  • The decline in visits was largest among school-age children and older adults.

Health Payer Intelligence informs us that America’s Health Insurance Plans and AHIP member medical directors have proposed a course for health plans to follow while we come out of the great hunkering down. That course includes continuing expansive coverage of COVID-19 testing and care, promoting telehealth, and engaging members, particularly those in need.

In that regard, Medical Economics provides physicians with advice on best practices for billing health plans for telemedicine services during the COVID-19 emergency. The advice strikes the FEHBlog as a bit complicated. It’s therefore not surprising to the FEHBlog that, according to an mHealth Intelligence report, members of Congress “Reps. Kim Schrier (D-WA) and Phil Rose (R-TN), say they want private payers to operate under the same rules as the Centers for Medicare & Medicaid Services, which last month established telehealth payment and coverage parity for the duration of the emergency.” The two representatives have introduced a bill for this purpose H.R. 6644).

Weekend Update

David Ermer–Congress, COVID-19, OPM, SCOTUS–

The Senate, but not the House of Representatives, returns to Capitol Hill tomorrow. On Wednesday, the Senate Homeland Security and Governmental Affairs Committee is holding a roundtable discussion about how new COVID-19 information should drive policy. On Thursday, the Senate Health Education Labor and Pensions Committee is holding a “Shark Tank” about new tests for COVID-19.

Federal News Network reports that George Nesterczuk who was President Trump’s first nominee to be OPM Director, has become a senior advisor to OPM’s current acting Director Michael Rigas. In 2017, Mr. Nesterczuk asked the President to withdraw the nomination in the face of criticism from federal employee unions.

The Wall Street Journal estimates the revenues that major health insurers will receive at some point due to the Supreme Court’s favorable decision in the Affordable Care Act risk corridor case last Monday. The Supreme Court begins its series of May telephonic oral arguments tomorrow.

The Journal further reports

The promise of new payments comes as the health-insurance industry has seen little financial pressure from the pandemic. In earnings calls over the past few weeks, insurers said they’d seen minimal impact on first-quarter results, and they were benefiting from reduced health-care costs due to the widespread cancellation of elective procedures and patients steering clear of routine care.

But the insurers said they could see costs ramp back up later in the year. Overall, several big companies including UnitedHealth Group Inc., Anthem Inc. and Humana left their financial guidance on earnings for 2020 in place despite the coronavirus impact.

A WSJ article posted today adds that

With fewer claims to pay out, some health insurers are using their improved balance sheets to help struggling providers secure loans, pay claims earlier and, in some cases, underwrite patients’ outstanding bills. And they have good reason to ensure providers survive the pandemic: “There is a risk that there is a smaller provider network after this,” said Brad Ellis, a senior director at Fitch Ratings. “So health insurers are trying to maintain the network.”

Well done.

Friday Stats and More

David Ermer–CDC, COVID-19–

At this point, according to the Centers for Disease Control’s COVID-19 cases in the United State website, which the FEHBlog tracks, the number of confirmed cases topped one million on Wednesday and the number of confirmed deaths topped 60,000 on Thursday. Interestingly, the case fatality rate (deaths over cases) has remained between 5 and 6% for the last fourteen days after jumping from 2% on April 1 to 5% on April 17. The case fatality rate (“CFR”) should drop as the number of confirmed cases increases due to antibiotic testing. The American Spectator observes

To put this in perspective: Last winter 250,000 people tested positive for the flu. 25,000 died. If these numbers are right, the CFR for the flu is 10 percent … but that can’t be right.

And, in fact, it isn’t. The Centers for Disease Control and Prevention (CDC) estimates that, although only 250,000 people tested positive for the flu last year, 39 million people actually got it. Generally only those who are older or otherwise unhealthy, or those who have a severe case, go to the doctor and get tested for the flu; everyone else just takes Motrin and Tylenol and stays home. This drives up the CFR dramatically.

Also check out the CDC’s weekly COVIDView.

The Boston Globe’s STAT offers a pessimistic view of the COVID-19 emergency over time. If the STAT’s view is correct, then we have experienced no progress in medical care since 1918-1919 when the flu decimated the world. The FEHBlog has confidence in our healthcare system to pull us through this crisis.

America’s Health Insurance Plans discusses the steps that health insurers take to expand coverage in the face of the COVID-19 emergency. Health benefits did not exist in 1918-19.

For those interested, the American Medical Association reviews advocacy efforts for its membership during the crisis.

The Harvard Business Review called the FEHBlog’s attention to

Kanter’s Law: that everything can look like a failure in the middle. Unexpected obstacles and difficult predicaments can arise in the middle of any human and organizational endeavor. Give up, and by definition it’s a failure. Persist, pivot, and persevere, and there’s hope for finding another successful path.

In closing Happy Law Day. ” Law Day is held on May 1st every year to celebrate the role of law in our society and to cultivate a deeper understanding of the legal profession.”

The Law Day 2020 theme is “Your Vote, Your Voice, Our Democracy: The 19th Amendment at 100.” In 2019-2020, the United States is commemorating the centennial of the transformative constitutional amendment that guaranteed the right of citizens to vote would not be denied or abridged by the United States or any state on account of sex. American women fought for, and won, the vote through their voice and action.