Weekend update

David Ermer

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

Weekend update

David Ermer–CDC, Congress–

The FEHBlog is back inside the Capitol Beltway following a weekend trip. Congress remains in session on Capitol Hill this coming week. Fierce Healthcare reports that “Leaders of the Senate Finance Committee demanded Cigna and Optum produce critical documents over the pricing of insulin, with a subpoena threat looming.”

Here are links for the Centers for Disease Controls’ U.S. situation summaries for influenza and the COVID-19 viruses. Yesterday, Leap Day, the CDC reported regrettably about

three hospitalized patients [in the State of Washington] who have tested presumptive-positive for the virus that causes COVID-19, including one patient who died.

Two of the patients are from a long-term care facility (LTCF) where one is a health care worker. Additional residents and staff of the LTCF who have not yet been tested for COVID-19 are reportedly either ill with respiratory symptoms or hospitalized with pneumonia of unknown cause.

The patient who died, a male in his 50s, was being treated at the same hospital. He was not a resident of the LTCF.

This is the first reported death in the United States from COVID-19, as well as the first reported case in a health care worker and the first possible outbreak in a LTCF. These reports from Washington follow others of community spread in Oregon and two places in California earlier this week. While there is still much to learn about the unfolding situations in California, Oregon and Washington, preliminary information raises the level of concern about the immediate threat for COVID-19 for certain communities in the United States. Most people in the United States will have little immediate risk of exposure to this virus, but some people will be at increased risk depending on their exposures. The greatest risk is to those who have been in close contact with people with COVID-19. People with suspected or confirmed exposure should reach out to their state or local public health department.

ABC News adds today that

Two new cases of coronavirus have been confirmed in Washington state, according to health officials.

The cases include a male in his 60s, who has underlying health conditions but is stable, and another man in 60s with underlying health conditions but is in critical condition.

Both cases are in King County, bringing the total number of confirmed cases in the county to six. One of those cases is a U.S. postal worker, county’s health administration stated.

It appears that this unfortunate Postal worker is the first FEHB member afflicted by the disease. Good luck to all of the COVID-19 and influenza patients. We are lucky to live in a country with excellent healthcare.

TGIF

David Ermer–SCOTUS–

The FEHBlog is out of town this weekend. He did check the Supreme Court’s order list this afternoon and nothing came out on the U.S. v Texas cases (Nos. 19-840 and 19-841). Next update will be 9:30 am on Monday when all of the orders from today’s conference are posted. We are waiting to learn whether or not the Supreme Court has decided to review the cases at this interim stage.

In other news —

  • PhRMA issued its own list of low value care that doctors should not prescribe / order and health plans should not cover. It’s worth a look.
  • The Employee Benefits Research Institute issued a one page graphic report on 15 years of health savings accountholder behavior.
  • Kaiser Health News posted another level headed story on the COVID-19 virus titled — “Growing Concerns Of Coronavirus Should Spur Plans – Not Panic – In The Workplace.”

Midweek update

David Ermer–CDC, Congress, Rx coverage–

The Wall Street Journal recently published a story titled “How the Drug Lobby Lost its Mojo in Washington.” The story also is available on the Journal’s listener friendly podcast. The upshot of the story is that the bipartisan effort to enact a drug pricing law may have legs as they say on Capitol Hill.

“In the past PhRMA had a reputation for rolling the tanks against every proposal irrespective of industry impact,” says PhRMA Chief Executive Officer Stephen Ubl. “We are now taking a more proactive approach of coming to the table to offer policy makers solutions that would address patient affordability challenges.”

PhRMA’s Mr. Ubl says the drug industry could be open to a deal that combines elements of bills from Mr. Grassley, Mrs. Pelosi and House Republicans, saying there “are provisions in all three bills that have bipartisan support and could meaningfully improve affordability for patients without including price controls.” 

In the no good deed goes unpunished department, the Pharmacy Times reports that

Four FDA-approved products that face no competition may increase health care spending by as much as $20.25 billion, according to a new analysis by Vizient Inc.1

The report focused on the Unapproved Drug Initiative (UDI) and its unintended effects on the market. The UDI was an FDA mandate enacted in 2006 that required unapproved drugs in use prior to FDA review of safety and efficacy to be either approved or removed from the market. Once a previously unapproved drug receives FDA approval, the manufacturers of other unapproved versions are asked to remove their products from the market.1

Although the goal of the UDI was to remove potentially dangerous medications from the market, the report authors noted that most of the products are chemically well-defined, reuqire no research and development, and are widely used in health care settings.1

The researchers used the wholesale acquisition cost (WAC) for all calculations and then estimated and used IQVIA data for all US health care product units purchased.1

According to the authors, the UDI has resulted in $2.66 billion in increased costs already incurred, $8.75 billion in estimated cossts awaiting the UDI decision, and $17.59 billion in remaining exclusivity estimated costs.1

Hokey smokes, that’s a big bowl of wrong.

The FEHBlog who is not much of a world traveler was aware of the State Department’s international travel advisories. Today he learned about the Center for Disease Control’s travel health notices. It’s important to check both lists if you plan to travel internationally.

In the healthcare provider competition department, Fierce Healthcare reports that

The Urgent Care Association released its 2019 benchmarking report that showed the total number of centers had reached 9,616 as of November 2019, a 9.6% jump from the previous year.

The number of centers has increased steadily each year from 2013, when the total number of urgent care centers was 6,100. Both urgent care centers and retail clinics have continued to grow across the U.S. as patients look for convenience and affordability, creating competition with traditional hospital and physician practice services.

In the FEHBlog’s view, convenient access to care is great as long as the primary care provider is kept in the loop.

In the good public health news department, the Department of Health and Human Services announced today that

The Health Resources and Services Administration (HRSA) [has] awarded approximately $117 million to expand access to HIV care, treatment, medication, and prevention services. This investment is a critical component of the Administration’s Ending the HIV Epidemic: A Plan for America (EHE) initiative, which aims to reduce the number of new HIV infections in the United States by 90 percent by 2030.

The EHE initiative and today’s awards focus on 48 counties, Washington, D.C., and San Juan, Puerto Rico, geographic areas where more than 50 percent of new HIV diagnoses occurred in 2016 and 2017, as well as the seven states with a substantial rural HIV burden.

Finally, as she is the most influential healthcare policymaker in the U.S. per Modern Healthcare, take a gander at CMS Administrator Seema Verma’s speech to the annual CMS quality conference.

Tuesday Tidbits

David Ermer–CDC–

Here are takes from the Boston Globe’s StatNews and Fierce Healthcare on today’s Centers for Disease Control (“CDC”) discussion of a U.S. response plan to the COVID-19 disease if worse comes to worse. The StatNews article goes on to state

“Our efforts at containment so far have worked,” said Anne Schuchat, the CDC’s principal deputy director. At the same time, Schuchat said, “we don’t want to delay thinking about these other possibilities.”

Department of Health and Human Services Secretary Alex Azar said the government is committed to “radical transparency” in keeping the public informed about its response and preparedness planning. [Dr. Nancy] Messonnier, he said, was “just previewing for the American people” the strategies that health officials have in their toolbox as additional cases appear.

The CDC also today released their National Diabetes Statistics Report, 2020.

More people are developing type 1 and type 2 diabetes during youth, and racial and ethnic minorities continue to develop type 2 diabetes at higher rates. Likewise, the proportion of older people in our nation is increasing, and older people are more likely to have a chronic disease like diabetes. By addressing diabetes, many other related health problems can be prevented or delayed.

In this regard, Drug Topics reports that

Patient access to portal self-management tools through mobile devices may help significantly improve diabetes care, according to a new study [published in JAMA Network Open].

Patient portals work to enhance communication with the health care team and offer a convenient means to viewing laboratory test results and ordering prescription refills. In chronic conditions such as diabetes, ongoing disease self-management is crucial for optimal patient outcomes, and technology can help further support this.

That’s encouraging.

Monday Musings

David Ermer–Federal employment benefits, SCOTUS, Uncategorized–

Today’s U.S. Supreme Court order list from its February 21 conference made no mention of the Texas v. U.S. cases (Nos. 19-840 and 19-841) concerning the Affordable Care Act’s constitutionality, one way or the other. This means that the Court will take up (or continue consideration of) the cases at a later conference. At this stage the Court is deciding whether to review the Fifth Circuit’s decision now or wait for further proceedings in the lower courts. The Court’s docket sheet states that the cases have been re-distributed for the February 28, 2020, conference.

The Federal Employees Dental and Vision Programs’ (“FEDVIP”) laws requires OPM to bid out all of the FEDVIP contracts every seven years. Currently OPM has contracted for 10 FEDVIP dental plans and four FEDVIP vision plans. Last week, OPM released its request for proposals for the next seven year FEDVIP contract cycle which begins on January 1, 2021. OPM states in the RFP document that it has capped the upper limit of dental plans at 12 and vision plans at 5. The deadline for submission of proposals is March 23, 2020. OPM expects to announce the successful contractors in May.

The Washington Post reports that the focal point of the national drug overdose crisis has shifted to the California and other western states. The drugs causing overdose deaths are principally two illicit drugs — fentanyl and methamphetamine.

In California, fatal drug overdoses over the previous 12 months increased 13.4 percent between July 2018 and July 2019, the last month for which the CDC has compiled provisional data — an additional 728 deaths.

Fentanyl delivers an immediate, powerful high but can also render the user unconscious and unbreathing almost instantly. * * * [San Francisco based harm reduction worker Kristen Marshall] noted that thousands of overdoses have been reversed by peers on the street who were supplied with naloxone as part of harm reduction efforts. For many years, San Francisco saw a growing population of drug users but had a strikingly low rate of fatal overdoses. But that was before fentanyl showed up.

In contrast, Illinois’ fatal drug deaths were down 8 percent, Pennsylvania’s down 10 percent, Michigan’s down 13 percent and Maine’s down 20 percent.

Weekend update

David Ermer–CDC, Congress, Rx coverage, Uncategorized–

Congress is back at work on Capitol Hill this week. The FEHBlog did find an easy to read list of upcoming Congressional hearings on Congress.gov. The FEHBlog did not find any hearing relevant to the FEHBP coming up.

The FEHBlog is following news about the COVID-19 epidemic. The Wall Street Journal reports that the number of cases outside China is growing particularly in South Korea (602 cases) and Italy (155 cases). There are 34 cases in the U.S. In a Centers for Disease Control conference with the press last Friday, Dr. Nancy Messonnier explained that

We are making our case counts in two tables.  One only tracks people who were repatriated by the state department, and the second tracks all other cases picked up through U.S. public health network.  CDC will continue to update these numbers every Monday, Wednesday, and Friday.  We are keeping track of cases resulting from repatriation efforts separately because we don’t believe those numbers accurately represent the picture of what is happening in the community in the united states at this time.  As of this morning, when you break things up this way, we have 13 U.S. cases versus 21 cases among people who were repatriated [here].  The repatriated cases include 18 passengers from the “diamond princess” and three from the Wuhan [China] repatriation flights

The Wall Street Journal confirms the growing trend of large health insurers to offer their own primary care delivery services to their health plan members [previously documented by the FEHBlog].

“It’s very worrisome for hospitals,” said Chas Roades, a health-care consultant. “Suddenly, the plan you’re relying on for payment is also competing with you at the front end of the delivery system.”

Hospitals’ biggest concern may be the power that primary-care doctors have over where their patients go for care such as imaging scans and specialist procedures. Hospitals rely on doctors to direct patients to them for such services—one reason they have bought up physician practices. Insurer-owned clinics might refer patients away from certain hospital systems, cutting off important revenue. 

The FEHBlog in contrast is delighted with this trend which will hold down costs while improving health care quality. Competition itself is healthy. “’Health care has got to be more seamless and more integrated,” said Rob Falkenberg, chief executive of UnitedHealthcare’s California operation.” Agreed.

Fierce Healthcare reports that Oscar Health has creating a $3 per prescription formulary of about 100 popular prescription drugs and insulin. The formulary went into effect on January 1, 2020 for about half of Oscar’s health plan members. The other half if covered by Medicare or live in certain states like New York which have not approved the formulary. The article explains that

Oscar was able to price the drugs so low through plan design.“The price we pay to acquire the drug for our members has not changed,” [Oscar spokesperson Jackie] Kahn said. “Instead, we chose to have our members pay $3 and we are covering the rest.”

TGIF

David Ermer–OPM, SCOTUS–

The U.S. Supreme Court was scheduled to consider the cert petition in the Texas v. United States case (Nos. 19-840, 19-841) at today’s conference of the justices. That case of course concerns the constitutionality of the Affordable Care Act. If the Court decides to accept cert / review the lower court decision in a prominent case like this, the order frequently is announced on the same day. The Supreme Court, however, released no orders today. The Court is scheduled to issue orders at 9:30 am. The FEHBlog will be keeping watch.

The FEHBlog drove up to Long Island today to visit with family. On the way, he pondered OPM’s performance measure for its FEHB operations — “Percent of FEHB enrollees in quality affordable plans.” The FY 2017 result was 74.2% and the FY 2018 result was 70.9%. The FY 2020 result will be announced next month. Why the drop from one year to the next? Why doesn’t OPM explain how quality and affordability are measured for this purpose? By the way OPM’s target was 72% for FY 2020 and is 73% for FY 2021.

In other news –

  • The Centers for Medicare and Medicaid Services yesterday “issued a proposed rule in the Federal Register which proposes a three-year extension and changes to the episode definition and pricing in the Comprehensive Care for Joint Replacement (CJR) Model.” “This proposed rule proposes to change certain aspects of the CJR Model, including incorporating outpatient hip and knee replacements into the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirements, gainsharing caps, and the appeals process. Additionally, to allow time to evaluate the proposed changes, the rule proposes to extend the length of the CJR Model for an additional three years, through December 31, 2023, for certain participant hospitals. “
  • Today, the Department of Health and Human Services “released a comprehensive strategy to reduce the regulatory and administrative burden related to the use of health IT, including EHRs.” “”The taxpayers made a massive investment in EHRs with the expectation that it would solve the many issues that plagued paper-bound health records,” said CMS Administrator Seema Verma. “Unfortunately – as this report shows – in all too many cases, the cure has been worse than the disease. Twenty years into the 21st century, it’s unacceptable that the application of Health IT still struggles to provide ready access to medical records – access that might mean the difference between life and death. The report’s recommendations provide valuable guidance on how to minimize EHR burden as we seek to fulfill the promise of an interoperable health system.”

Good luck with those efforts.

Thursday Miscellany

David Ermer–CDC, Federal employment benefits, OPM–

Fedweek noticed another tidbit in the agency’s FY 2021 budget that’s worth noting :

OPM is seeking authority from Congress to offer federal employees what it calls “voluntary benefits” such as short-term disability insurance, prepaid legal plans, emergency short-term childcare, and personal accident insurance.

The purchasing employee or annuitant would be responsible for paying 100% of the premiums for these coverages. What’s more the FEHBlog knows that prepaid legal plans cannot be offered on a pretax basis like FEDVIP can.

In other news,

  • Milliman posted an interesting infographic on various aspects of organ transplantation in the U.S. Average wait times are up and survival rates are down. That’s puzzling.
  • Healthcare Dive reports that “The [federal] Health Information Technology Advisory Committee on Wednesday unanimously approved its second annual report to Congress on the state of health IT landscape, recommending fixes to improve the electronic access, exchange and use of medical information.”
  • The Centers for Disease Control announced today that this year’s flu vaccine is having an efficacy rate of 45%.
  • Health Affairs offers an interesting study on the impact of administrative costs on U.S. healthcare spending.

Midweek Update

David Ermer–OPM, Uncategorized–

Thanks to a Govexec.com article, the FEHBlog ran across the joint General Services Administration / Office of Personnel Management Fiscal Year 2021 budget justification for the benefit of our Congress. OPM’s FEHBP discussion may be found on pages 69-70 and its FEHBA legislative proposals may be found on 30 of the OPM section of the document. The OPM Inspector General budget discussion begins on page IG-24 of the document. The FEHBlog is waiting for OPM to release the revised FEHBA language for its FEHBA legislative proposal, which is a retread from the FY 2020 budget proposal. (No such detailed language was released last year.)

Federal News Network reports that “an estimated 200,000 military family members and retirees would lose their ability to get health care through military hospitals and clinics under a ‘rightsizing’ plan the Defense Department sent to Congress on Wednesday.” The details may be found in this plan document. This proposal if implemented would impact the FEHB because many military retirees are active federal employees / FEHB enrollees. Thank you veterans for your double service to our Country. The FEHBlog will keep an eye on this one too.

Finally, Healthcare Dive calls attention to a new trend:

  • Private equity firms acquired 355 physician practices from 2013 to 2016, accounting for a total of 1,426 sites of care and more than 5,700 physicians, according to the latest research in JAMA.
  • Acquisitions accelerated each year over that time period, from just 59 acquisitions in 2013 to 136 in 2016.
  • Off the 355 acquisitions, the most targeted area was anesthesiology with 69 practices acquired, followed by emergency physicians at 43, the report published Tuesday showed.

As noted in the article, these investors in turn are pressing for surprise billing proposals that would keep out of network practices profitable.

Tuesday Tidbits

David Ermer–OPM, Rx coverage–

The Office of Personnel Management released today its 2019 report on the outcome of Health Care Quality, Customer Service, and Resource Utilization measures (“QCR”) applied to the FEHB plan carriers. The good news is that “A significant number of FEHB carriers demonstrated improvement across a number of QCR measures showing that efforts to improve care and customer service are producing positive results.” The FEHBlog can tell you that carriers put a lot of effort into boosting these scores.

The chart from this report that most impressed the FEHBlog is the chart on page 5 showing steady improvement in the diabetes type 2 control measure. In the FEHBlog’s view, credit for that improvement principally belongs to the plan members who confront this disease by following their doctor’s advice and health plan input.

The FEHBlog also wants to readers to know that yesterday’s FEHBlog tirade was directed at the CMS civil monetary penalty proposal and not at the FEHB plans members with primary Medicare A and B coverage. Those members go along way toward controlling everyone’s FEHBP premiums by picking up Part B. Coordination of benefits with Medicare is a major and necessary part of the carrier’s workload and in the FEHBlog’s experience they pay close attention to it just like the QCR scores.

Express Scripts has issued its annual 2019 Drug Trend report. Fierce Healthcare reports that “[Cigna’s] pharmacy benefit manager found that medications for inflammatory conditions such as psoriasis and rheumatoid arthritis drove 43.7% of spending, by far the highest among the different classes.” This report always is interesting reading.

It’s also worth calling readers’ attention to HHS’s Agency for Healthcare Research and Quality’s (“AHRQ”) TAKEheart Initiative which was launched in the Spring of 2019.

Currently, only 1 in 5 of eligible patients with serious cardiac conditions enroll in cardiac rehabilitation (CR), which has been shown to improve health and prevent hospital readmissions. TAKEheart takes aim at these missed opportunities by spreading two evidence-based practices shown to boost rates of CR referral of eligible patients. These strategies involve automatically referring patients to CR through electronic health record prompts and ensuring that a staff member or lay navigator helps coordinate the patient’s referral process.

Recently, TAKEheart reached an important milestone. We’ve recruited the first of two waves of 50 hospitals and have begun the training and support needed for implementing automatic electronic referral to CR as well as care coordination.

That good news to hear in American Health Health MonthP.