Thursday Thoughts

David Ermer

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

Thursday Thoughts

David Ermer–COVID-19, Federal employment benefits, Medicare, Rx coverage–

Fedweek reports that

The largest FEHB carrier, Blue Cross-Blue Shield, has loosened several policies, for those diagnosed with COVID-19, the respiratory condition caused by the COVID-19 virus including waiving:

prior authorization requirements for diagnostic tests and for covered services that are “medically necessary and consistent with CDC guidance”;

any copays or deductibles for diagnostic tests or treatment under that same standard;

early medication refill limits on 30-day prescription maintenance medications and cost sharing for prescriptions for up to a 14-day supply; and

copays for telehealth services related to COVID-19.

The FEHBlog was pleased to see that FEP is waiving telehealth cost sharing related to COVID-19. OPM’s carrier letter mentioned in yesterday’s post overlooked telehealth which is an important tool to mitigate the spread of COVID-19. If your plan offers a telehealth benefit, it is important to pre-register for that benefit before you need to use it. The FEHBlog found his plan’s pre-registration program to be quite efficient.

You will find that FEHBP plans prominently have links to their special COVID-19 coverage features on their websites.

The Wall Street Journal has put its helpful COVID-19 update website outside its general website paywall.

In other news,

  • The Centers for Medicare and Medicaid Services announced earlier this week “the Part D Senior Savings Model, a voluntary model that enables participating Part D enhanced plans to lower Medicare beneficiaries’ out-of-pocket costs for insulin to a maximum $35 copay per thirty-day supply throughout the benefit year. Beneficiaries who take insulin and enroll in a plan participating in the model should save an average of $446 in annual out-of-pocket costs for insulin, or over 66 percent, relative to their average cost-sharing for insulin today.” This program will launch next year. Time will tell whether the prescription benefit plan can extend this discount to FEHBP and other commercial health plans.
  • The National Cancer Institute released the Annual Report to the Nation on the Status of Cancer. The report presents good news
    • Overall cancer incidence rates are leveling off among males and increasing slightly among females.These trends reflect population changes in cancer risk factors, screening test use, diagnostic practices, and treatment advances. 
    • This year’s Special Section focused on progress toward select Healthy People 2020 objectives related to four common cancers (lung, colorectal, female breast, and prostate). The Healthy People 2020 target death rate (161.4 deaths per 100,000 persons) for all cancers combined was met overall and in most sociodemographic groups.
    • During 2007-2017, cancer death rates decreased 15% overall, and the percent improvement target (-10%) was met in many sociodemographic groups.
    • Many of the Healthy People 2020 objectives for death rates, cancer screening, and major risk factors related to lung, colorectal, female breast, and prostate cancer were met.
  • Becker’s Hospital Review provides an overview of seven key dates of the HHS interoperability rule released earlier this week.
  • Healthcare Dive discusses the five additional healthcare apps that CVS/caremark has added to its curated app “formulary” for the benefit of plan sponsors. “Livongo Health, Hinge Health, Hello Heart, Torchlight and Whil are now available for CVS’ PBM clients to use, in addition to Sleepio, a personalized digital sleep program and the first participating program when the service launched in 2019.”

Midweek Update

David Ermer–AHRQ, COVID-19, OPM, Uncategorized–

The Office of Personnel Management issued a guidance letter to FEHB carriers on the COVID-19 virus today.

The Internal Revenue Service today issued a Notice 2020-15 which permits high deductible health plans used with health savings accounts (under Internal Revenue Code Section 223) to cover COVID-19 testing on a first dollar basis. To its credit, OPM references the IRS notice in the above linked carrier letter.

The U.S. Labor Department also issued FAQ guidance on COVID-19 or Other Public Health Emergencies and the Family and Medical Leave Act.

As noted on Monday, this is Patient Safety Awareness week. The patient safety organization ECRI Institute released a list of top 10 patient safety concerns. The Safety Week’s key sponsor HHS’s Agency for Healthcare Quality and Research issued

Making Healthcare Safer III, a comprehensive report whose pages are filled with practical information on how today’s clinicians can keep patients free from harm.

The report reviews roughly four dozen practices that target patient safety improvement across a variety of settings. If appropriately applied, many of these practices can dramatically reduce high-impact healthcare-related harms.

The 47 patient safety practices and evidence highlighted in the report include technological and staffing-related practices, a series of specific hygiene and disinfection interventions for reducing healthcare-associated infections, and several practices designed to prevent medication errors and reduce opioid misuse and overdoses.

Tuesday Tidbits

David Ermer–COVID-19, Electronic health records, Uncategorized–

The FEHBlog listened to the federal government’s COVID 19 press conference on the drive home from work. The Surgeon General urged listeners to visit coronavirus.gov. When the FEHBlog arrived home, he checked out the website and it turns out to be another url for the Centers for Disease Control’s COVID-19 website that he takes a peak at daily. At least the FEHBlog hasn’t been misdirecting readers. Here is today’s COVID-19 scorecard:

Travel-related83
Person-to-person spread36
Under Investigation528
Total cases647

The FEHBlog learned late this afternoon that COVID-19 concerns have caused OPM and AHIP to cancel the annual FEHBP carrier conference which was scheduled to run from April 1 to April 3 in lovely Crystal City Virginia. The FEHBlog while disappointed understands the decision because the event jams hundreds of people together in one hotel ballroom.

Yesterday’s Health and Human Services rules on electronic health record (“EHR”) interoperability and data blocking gave a big boost to HL7’s FHIR specification. “FHIR (Fast Healthcare Interoperability Resources) Specification is a standard for exchanging healthcare information electronically.” The FEHBlog was excited to hear about the FHIR specification early last year because it appeared to be a solution to the nagging EHR interoperability problem. HHS appears to have jumped into the FHIR specification pool with both feet.

This morning the FEHBlog listened to a HIMSS webinar on FHIR accelerators. The four HL7-designated FHIR accelerators are leading the FHIR charge to solve interoperability problems in different spheres:

  • The DaVinci Project is focused using FHIR to fix healthcare business to business exchange issues.
  • The Carin Alliance is focused on using FHIR to fix healthcare business to consumer exchange issues.
  • CodeX is focused on using FHIR to share clinical trial appropriate data found in EHRs with researchers in an effort to find cancer cures.
  • The Gravity Project is focused on sharing social determinant of health data found in EHRs with healthcare businesses for care coordination and SDOH benefit purposes.

Good luck to them all.

Monday Musings

David Ermer–AHRQ, CDC, COVID-19, Electronic health records, OPM–

The U.S. Office of Personnel Management issued additional COVID-19 guidance and FAQs on Saturday March 7. The Federal News Network summarizes OPM’s issuances here.

Here are the Centers for Diseases Control’s March 9 COVID-19 statistics for the U.S.

  • Travel-related 72
  • Person-to-person spread 29
  • Under Investigation 322
  • Total cases 423

The CDC has issued guidance for people at risk of contracting serious illness from COVID-19. According to the CDC,

Early information out of China, where COVID-19 first started, shows that some people are at higher risk of getting very sick from this illness. This includes:

  • Older adults
  • People who have serious chronic medical conditions like:
  • Heart disease
  • Diabetes
  • Lung disease

Becker’s Hospital News reports on a study recently published in the Journal of American Medical Association. The study which was conducted in Singapore finds that from a contagion standpoint the COVID-19 virus does not linger in the air but it does contaminate surfaces.

As predicted, the Trump Administration released its final electronic health record interoperability and data blocking rules today. The objective of the rules is to give patients better access to their health records. The rules take effect as early as January 1, 2021. The implementation of the interoperability rule is staged over time.

Here are links to the government fact sheets on the final interoperability rule and the final data blocking rule. WEDI, which an information technology advisor to the HHS Secretary, prepared a helpful comparison of the proposed and final data blocking rules.

Healthcare Dive reports on industry reaction to the final rules. Healthcare Dive explains

The CMS rule requires Medicaid, the Children’s Health Insurance Program, Medicare Advantage plans and Affordable Care Act exchange plans to provide their collective 125 million patients with free electronic access to their personal health data, including medical claims and encounter information including cost, by 2021.

MA plans, state Medicare and CHIP programs, CHIP managed care entities, Medicaid managed care plans and qualified health plans in the federal exchanges now have to “implement, test, and monitor” a Health Level Seven FHIR-compliant API, which the government has selected as the new national standard.

Those plans also have to make their provider directories available to current and potential enrollees through the API technology, too (excepting the federal exchanges, which already do so), by 2021, with the hope insurers will carry over those practices to private plans as well.

Finally it’s worth noting that HHS’s Agency for Healthcare Quality and Research has deemed this to be Patient Safety Awareness Week.

Weekend update

David Ermer–Congress, COVID-19–

Welcome to Daylight Savings Time! Congress remains in session on Capitol Hill this week. Federal News Network reports that the President signed into law the $8.3 billion COVID 19 funding bill (H.R. 6074) on Friday.

Notwithstanding the cancellation of the HIMSS conference

  • Modern Healthcare reports that the Trump Administration plans to release the final electronic health records interoperability and data blocking rules tomorrow, and.
  • DaVinci, “a private sector initiative that addresses the needs of the Value Based Care Community by leveraging the HL7 FHIR platform,” with the FHIR API, plans to go ahead with virtual HIMSS presentations via an online format. Thanks DaVinci.

Fierce Healthcare reports on an interesting flu vaccine study in the Annals of Internal Medicine.

The researchers said continued vaccination of seniors, particularly with high-dose vaccines, still seems appropriate, as the study results did not preclude modest effectiveness of the flu vaccine against severe outcomes.

“Our findings raise questions, however, about the overall effectiveness of a vaccination strategy that is limited to standard vaccines and focuses too much on elderly persons. Supplementary strategies, such as vaccinating children and others who are most likely to spread influenza, may also be necessary to address the high burden of influenza-related complications among older adults,” the researchers concluded.

The researchers measured hospitalization and mortality rates by month of age. Their data included 170 million episodes of care and 7.6 million deaths. Flu vaccination rates increased sharply at age 65, but there was no matching decrease in hospitalizations or death.

TGIF

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

OPM now has a prominent page on its website that gathers together the agency’s COVID 19 guidance. Just in time for a group of Democrat Senators to criticize that guidance as Govexec reports. In salient point the Senators state that

OPM work with health insurance providers to ensure that federal employees can affordably access the preventive care and treatment they may need as a result of COVID 19.

Here are today’s COVID 19 statistics for our country from the Centers for Disease Control

Travel-related36
Person-to-person spread18
Under Investigation110
Total cases164

Here’s a link to the CDC’s latest statistics for another coronavirus, the flu.

  • Pneumonia and influenza mortality has been low [this flu season], but 136 influenza-associated deaths in children have been reported so far this season. This number is higher for the same time period than in every season since reporting began in 2004-05, except for the 2009 pandemic.
  • CDC estimates that so far this season there have been at least 34 million flu illnesses, 350,000 hospitalizations and 20,000 deaths from flu.

Modern Healthcare discusses an interesting Humana social determinants of health program in the Medicare Advantage program. The program kicked off this month with Oschner Health in New Orleans. The FEHB Act and the Internal Revenue Code don’t allow FEHBP plans to copy this program but they can take steps to emulate it, in the FEHBlog’s view.

The Boston Globe’s StatNews provides an interesting overview of the state of the biosimilar drug market in our country. Biosimilars are the specialty drug equivalent of generic drugs. Congress opened the door to biosimilar development in the Affordable Care Act. Biosimilars are poised to create a substantial amount of drug cost savings over the next five years according to the article.

COVID-19

David Ermer–COVID-19–

The FEHBlog usually calls the Thursday issue, Thursday miscellany, but today everything is going to be about the COVID-19 situation (picture of the virus above).

The Senate approved the House bill (H.R. 6074) to provide $8.3 billion in funding for the COVID-19 situation by a 96-1 vote.

Healthcare Dive discusses an AHIP policy directive that will lead health plans without delay to cover COVID-19 testing when ordered by a physician with few if any strings attached. Good call.

The Boston Globe’s STATNews discusses potential treatments for COVID-19.

Medical literature published during the Spanish flu pandemic of 1918 includes case reports describing how transfusions of blood products obtained from survivors may have contributed to a 50% reduction in death among severely ill patients. In 1934, a measles outbreak at a Pennsylvania boarding school was halted when serum harvested from the first infected student was used to treat 62 fellow students. Only three of the 62 students developed measles — all mild cases.

More recently, plasma-derived therapy was used to treat patients during outbreaks of Ebola and avian flu. And on Wednesday the Japanese drugmaker Takeda Pharmaceutical Co. said it was developing a new coronavirus drug derived from the blood plasma of people who have recovered from Covid-19. Its approach is based on the idea that antibodies developed by recovered patients might strengthen the immune system of new patients.

That’s hopeful news.

The President will not be speaking at next week’s HIMSS conference after all because HIMSS today announced its decision to cancel the conference due to the COVID-19 situation. The FEHBlog also has had two conferences cancel on him over the past two days.

Here’s a link to a Journal podcast on whether COVID-19 will cause a recession in our country. Wall Street Journal chief economics reporter John Hilsenrath thinks not comparing the current situation to the state of the country after the 9-11 attacks. Check it out — it’s only 20 minutes long.

Midweek update

David Ermer–Congress, COVID-19–

This afternoon, the House of Representatives passed a funding bill for the COVID-19 situation (H.R. 6074) by a 415-2 vote. Fierce Healthcare breaks down the key elements of H.R. 6074 here.

Federal News Network reports on OPM’s latest “preliminary” COVID-19 guidance. The top line is that “OPM advised agencies to incorporate telework in their continuity of operations plans (COOP). Those emergency plans supersede an agency’s previous telework policies, according to OPM.”

CMS also announced agency actions to address the spread of COVID-19. The top lines are that CMS wants “health care providers across the country to ensure they are implementing their infection control procedures, which they are required to maintain at all times. Additionally, CMS is announcing that, effective immediately and, until further notice, State Survey Agencies and Accrediting Organizations will focus their facility inspections exclusively on issues related to infection control and other serious health and safety threats, like allegations of abuse – beginning with nursing homes and hospitals.”

The Journal podcast explains why this second action is quite necessary.

Healthcare Dive reports that

Uber Health is attempting to address provider gripes with its non-emergency medical transportation platform through a handful of new features that began rolling out late last year, the San Francisco-based rideshare company said Wednesday.

Providers can now select specific pickup and drop-off sites at large hospitals, similar to how the app is used in airports, and people can receive details of their ride like driver name, make and model of car and time of arrival over a landline phone, instead of just text messages.

Uber Health has grown 300% year over year since its launch in 2018 and plans to double the size of its team this year.

Lyft has a similar product.

Tuesday Tidbits

David Ermer–ACA, CDC, HIPAA Privacy and Security Rules–

Fierce Healthcare reports on how health insurers are communicating with their members and the public about COVID-19. This is a good idea.

The U.S. Preventive Services Task Force has decided to expand its Hepatitis C screening B level recommendation to all asymptomatic people aged 18 to 79. “This recommendation incorporates new evidence and replaces the 2013 USPSTF recommendation, which recommended screening for HCV infection in persons at high risk for infection and 1-time screening in adults born between 1945 and 1965.” The Task Force took this action because among other factors “Since 2013, the prevalence of HCV infection has increased in younger persons aged 20 to 39 years.” “The USPSTF concluded that broadening the age for HCV screening beyond its previous recommendation will identify infected patients at earlier stages of disease who could greatly benefit from effective treatment before developing complications.” The ACA requires health plans to cover the expansion of this service with no patient cost-sharing when provided in-network beginning January 1, 2022. It occurs to the FEHBlog that there may be practical difficulties distinguishing claims from the original and expanded group members.

Forbes reports that Anthem, a Blue Cross licensee, has closed on its acquisition of behavioral health services provider Beacon Health Options.

Beacon manages mental health, substance abuse and other behavioral health services for more than 36 million people across the U.S. Anthem, which owns Blue Cross and Blue Shield plans in 14 states, didn’t disclose a price it is paying Bain Capital Private Equity and Diamond Castle Holdings for Beacon Health, which is privately held. 

The AP informs us that “The Justice Department said Monday [March 2] that pharmaceutical company Sandoz Inc. will pay a $195 million penalty to resolve criminal charges of conspiring to fix prices and rig bids to stifle competition for generic drugs.” “The price-fixing affected more than $500 million in Sandoz’s generic drug sales, the Justice Department said. It involved drugs used to treat a range of chronic problems and pain conditions including arthritis, hypertension, seizures, various skin conditions and blood clots, according to officials.”

The Department of Health and Human Services announced that its Office for Civl Rights has reached a HIPAA Security Rule settlement with an Ogden Utah medical practice.

“All health care providers, large and small, need to take their HIPAA obligations seriously,” said OCR Director Roger Severino. “The failure to implement basic HIPAA requirements, such as an accurate and thorough risk analysis and risk management plan, continues to be an unacceptable and disturbing trend within the health care industry.” 

Monday Musings

David Ermer–CDC, Congress, SCOTUS, Uncategorized–

The FEHBlog got to work this morning around 8:30 am. Before he knew it, it was past 9:30 am, the time at which the Supreme Court releases online its orders from the latest conference of the Justices. He clicked on the Adobe Acrobat PDF link to the Court’s order list — no go. Bad PDF. He tried different browsers — same result. Twitter ho and there it was “blue State victory” the Supreme Court had agreed to review the Texas v. U.S. case holding the ACA’s individual mandate unconstitutional. The political comment did not make sense to the FEHBlog because only four Justices need to approve a petition for certiorari / review and there are four Democrat appointees on the Court. However, you need five Justices for a final victory. In any event by then the FEHBlog was able to open the Court’s order list and he found the following on page 3:

CERTIORARI GRANTED

19-840 CALIFORNIA, ET AL. V. TEXAS, ET AL.

19-1019 TEXAS, ET AL. V. CALIFORNIA, ET AL.
The motion of 33 State Hospital Associations for leave to file a brief as amici curiae in No. 19-840 is granted. The petitions for writs of certiorari are granted. The cases are consolidated, and a total of one hour is allotted for oral argument.

Case No. 19-1019??!! The FEHBlog was aware of the unmentioned Case No. 19-841 which is the House of Representative’s cert. petition. But what is Case No. 19-1019? It turns out that on Valentine’s Day the red states had filed a cross motion for review / cert with the Supreme Court. So it appears that both sides won at the first stage of the Supreme Court proceedings.

The Supreme Court will hear oral argument in the cases early in its next Term which begins on the first Monday in October 2020. There is no way the Court will decide the case before the Presidential election day on November 3. Hopefully, to avoid a political kerfuffle at the oral argument, the Court will schedule the argument for later in November.

Meanwhile the federal district court for the Northern District of Texas will hold off reconsidering the unconstitutional individual mandate’s proper degree of severance from the remainder of the massive law. The Fifth Circuit in its December order vacated the lower court’s initial decision that the remainder of the law was inseparable and therefore equally unconstitutional. The FEHBlog’s guess is that the Supreme Court took the case in order to short circuit that remand. But time will tell.

In another surprise, the FEHBlog learned along with the healthcare world today that President Trump will speak on the issue of electronic health record interoperability at the next Monday’s opening day of the monstrous HIMSS conference in Orlando, Florida. Health IT News reports that while former Presidents Clinton and Bush 43 have spoken at this conference, President Trump’s appearance will be the first by a sitting President.

Trump’s speech will touch on various aspects of interoperability, innovation and digital health. If past HIMSS conferences are any indication, his appearance may also be timed with the long-awaited final rules on information blocking and patient access from the Office of the National Coordinator for Health IT.

Another probable topic of discussion will be an update on the Trump Administration’s ongoing response to the COVID-19 coronavirus outbreak.

Again time will tell.

Medicare provides coverage for Americans under age 65 with end stage renal / kidney disease for Americans. However,

Medicare is the secondary payer to group health plans (GHPs) [including FEHB plan] for individuals entitled to Medicare based on ESRD for a coordination period of 30 months regardless of the number of employees and whether the coverage is based on current employment status.  Medicare is secondary to GHP coverage provided through the Consolidated Omnibus Budget Reconciliation Act (COBRA), or a retirement plan.

Given the FEHBP’s role in the early stages of this serious disease, the FEHBlog wanted to point out this Centers for Disease Control page on understanding chronic kidney disease. End stage renal disease is a later stage of chronic kidney disease. The CDC explains that

The two main causes of CKD are diabetes and high blood pressure. About 1 in 3 adults with diabetes and 1 in 5 adults with high blood pressure have CKD.

People may not feel sick or notice any symptoms until CKD is advanced. The only way people find out if they have CKD is through simple blood and urine tests. The blood test checks for creatinine (a waste product) in the blood to see how well the kidneys work. The urine test checks for protein in the urine (an early sign of kidney damage).

Here’s another reason why annual physical exams are important.