Happy Easter! Congress remains on its state / district work period for the week following Easter which coincides mostly with Passover.

Govexec.com provides us with background on the President’s pick to lead the Office of Personnel Management, Ms. Dale Cabaniss. Her nomination was received by the Senate on March 5, 2019. The nomination was referred to the Senate Homeland Security and Governmental Affairs Committee.

Ledger Insights provides an overview of the numerous alliances that have developed among health insurers, prescription benefit managers, and clearinghouses to implement blockchain technology.  The article adds that

NASCO has been exploring blockchain with BCBS since 2018. It has already executed a successful pilot that aimed to address several issues. For example, there are problems identifying patients across BCBS entities, stale or incomplete data, and inconsistent data formats. The ultimate goal is to make the process more efficient and improve member experiences.

“As both a co-owner and customer of NASCO, we recognize the value of interoperability as a key pillar of our strategy,” said Bill Fandrich, Senior Vice President and CIO for BCBSM. “Our recent success leveraging blockchain, in partnership with several other Blue plans [and NASCO] in the [new] Coalesce Health Alliance, is one step in that journey.

Yesterday, the Centers for Medicare and Medicaid Services issued the final 2020 notice of benefit and payment parameters under the Affordable Care Act. Two provisions of this lengthy notice impact FEHB and other large group health plans. Per the Fact Sheet:

Employee Benefit News offers a perspective on how employer sponsored health plans can help with the opioid epidemic. The article focuses on improving addiction treatment coverage. It also mentions at the top that employers and plans should encourage members to safely dispose of unused prescription drugs. In that regard,

• The Drug Enforcement Agency is holding an semi-annual National Take Back Day on April 27. 
• The nation’s pharmacies are supporting and supplementing this effort as explained in the CVS Health press release from last October. 
• A Health Affairs blog article discusses controlling opioids in the senior population sector. 

The Federal Times reports that government payroll offices have notified federal employees that generally they can expect to receipt their retroactive 2019 pay raise in their next paycheck for the period covering April 1 through April 14.

The FEHBlog learned from Fortune Brainstorm Health (a useful daily email) that the Journal of the American Medical Association published a clinical study on the efficacy of employer wellness programs.

Question  What is the effect of a multicomponent workplace wellness program on health and economic outcomes?

Findings  In this cluster randomized trial involving 32 974 employees at a large US warehouse retail company, worksites with the wellness program had an 8.3-percentage point higher rate of employees who reported engaging in regular exercise and a 13.6-percentage point higher rate of employees who reported actively managing their weight, but there were no significant differences in other self-reported health and behaviors; clinical markers of health; health care spending or utilization; or absenteeism, tenure, or job performance after 18 months.

Meaning  Employees exposed to a workplace wellness program reported significantly greater rates of some positive health behaviors compared with those who were not exposed, but there were no significant effects on clinical measures of health, health care spending and utilization, or employment outcomes after 18 months.

Healthcare Dives riffs on a RAND study finding low primary care utilization in Medicare.

A dearth of primary care physicians (PCPs) starts a chain reaction leading to lessened care access, more emergency department visits and more spend for payers and providers overall. A recent Premier analysis found that primary care has a bottom line impact for hospitals. More PCPs could help patients better control chronic conditions, resulting in fewer ED visits (and billions in savings for cash-strapped hospitals).

The problem stems at least partially from the fact that health plans, particularly Medicare, underpay primary care providers compared to specialists. It would be interesting to learn whether patients who pay extra for primary care providers who don’t participate in Medicare have better health outcomes.

As the Wall Street Journal and Fortune report, last week, Sen. Bernie Sanders (I Vt) introduced a new version of his Medicare for All bill which would expand Medicare coverage to include dental and vision coverage and eliminate patient cost sharing but at what cost?  Contemporaneously, a group of Republic Senators lead by Sen. Thom Tillis (R NC) introduced a bill that would use the 1996 Health Insurance Portability and Accountability Act as a backstop to preserve the ACA’s protections for people with pre-existing conditions in the unlikely event that the ACA is struck down by the courts.

It’s worth noting in this regard that the appellee’s briefs in the Texas v. U.S. case raising the ACA constitutionality issue will be due on May 1, and the Justice Department has asked the U.S. Court of Appeals to hear oral argument in the case in July 2019. According to articles which the FEHBlog has read this scheduling is feasible.

Modern Healthcare has an informative article about efforts to cut the cost of healthcare in the U.S. The hospitals and doctors associations are reluctant to cut prices because they think that the reductions will benefit the insurers. This argument reminds me of the prescription benefit manager’s reluctance to drop their manufacturer rebates because there’s no assurance that the manufacturers will reduce their prices in line with the amount of the avoided rebates.  However, insurers have been under ACA price controls since 2011 so the hospital and doctor association concerns are much weaker.

In this regard, Healthcare Dive reports on a recent California-situated study finding the provider capitation can cut costs while improving quality. The silver bullet??

In the Ruh Roh department, Healthcare Dive further reports that

Emergency departments in rural areas are busier than those in urban areas, which is putting a strain on safety net hospitals, according to a new JAMA study.  Rural ED visit rates increased more than 50% between 2005 and 2016 despite a 5% population drop in that time. The increase was a huge jump compared to urban ED visit rates, which saw only a slight increase, according to the report that reviewed National Hospital Ambulatory Medical Care Survey data.

This presumably must be related to the relative absence of urgent care centers and pharmacy clinics in rural areas.

Congress is out of town on a state / district work period this week leading up to Easter and Passover. Here’s a link to the Week in Congress’s report on last week’s actions on the Hill.

The FEHBlog was encouraged by reading this MD Magazine report that “51% of [American College of Physicians] ACP internal medicine physicians and subspecialists have at least 1 form of telehealth service available at their work.” As physician utilization of telehealth grows, the odds increase that patients who seek internist or pediatric telehealth care will receive care from a physician in the primary care practice that they use. That will curb the higher dispensing of antibiotics by telehealth providers recently noted here.

The Boston Globe’s STAT provided a Stanford Medical School professor the opportunity to discuss how electronic medical records can be improved. The FEHBlog heard the American Medical Association’s then President-elect express dismay that the government did not solicit medical profession comment on the development of electronic medical record “meaningful use” standards before shelling out $34 billion to popularize those government approved systems.

Not surprisingly, the good doctor’s number 1 wish is for EMR interoperability. The FEHBlog was encouraged o hear a talk two weeks ago about a developing interoperability technology called the Da Vinci project that would us HL7 code transmitted through what’s known as an FHIR server to connect health plan and provider systems to better coordinate patient/member care.  Health Data Management informs us that

Kansas City-based Cerner has embraced the latest version of HL7’s Fast Healthcare Interoperability Resources [FHIR] standard to encourage third-party developers to build apps on top of its platforms. By adopting FHIR Release 4, the normative version of the interoperability standard, Cerner contends that it is positioned at the “leading edge” in creating healthcare apps and opening its application programming interfaces (APIs) to developers to foster innovation.

Da Vinci is one such API.

CVS Health released its 2018 drug trends report today.

Employee Benefit News (“EBN”) reports that HHS Secretary Alex Azar is urging employers to support the Administration’s programs to control health care and particularly prescription drug spending.  The FEHBlog holds the opinion that high deductible plans should pass along prescription drug rebates to members at the point of sale. In this regard, EBN further reports that “Health savings accounts [which typically are paired with high deductible plans in the employer sponsored coverage environment] continue surging on all fronts. The number of accounts grew 13% over the past year to top 25 million while assets grew 19% to $53.8 billion, according to research firm Devenir. Looking further, Devenir projects the number of HSAs to hit 30 million by 2020, with $75 billion in total assets and $16.7 billion in investment assets.”

Health Affairs blog discusses the efforts of accountable care organizations to care for high need, high cost individuals. All types of health plans must consider these issues.

Health Data Management informs us that “Anthem Blue Cross is joining a Stanford University initiative that aims to advance the development of artificial intelligence for use within healthcare.”

Advancements in patient literacy, patient engagement and healthcare transparency have been identified as the first areas to be addressed through the relationship. Exploring these initial topics is an important step in Anthem’s efforts to create solutions to simplify healthcare for consumers.

In same vein, the Wall Street Journal this evening provides an essay on innovative approaches to help people with dementia stay at home for as long as possible.

Modern Healthcare reports that

HHS Secretary Alex Azar on Wednesday redoubled his support for a rule to eliminate the safe harbor protections for Medicare Part D and Medicaid managed-care drug rebates.
Hospital and insurer groups complained in comments on the rule, which replaces the safe harbor for rebates with one for discounts delivered at the point of sale, that it doesn’t give drug companies an incentive to lower prices. Another concern was that the Jan. 1, 2020 implementation date is far too soon.  But Azar said getting rid of rebates one way or another is a linchpin to the Trump administration’s blueprint for lowering drug prices.

The Washington Post offers a lengthy report on the Trump Administration’s efforts to dismantle the Office of Personnel Management.  The article notes that “An executive order directing parts of the transition by the fall is in the final stages of review, administration officials said, with an announcement by President Trump likely by summer. OPM employees were briefed at a meeting in March.”

Acting OPM Director Margaret Weichert discussed this Administration’s initiative at the OPM FEHB carrier conference at the end of last month. According to the FEHBlog’s notes, of that event Ms. Weichert explained that

The Mission of OPM continues. The Administration is committed to merit system principles, diversity and inclusion, and world class benefits. OPM’s structure needs to change. The current structure is not up to the task. We are in a period of restructuring that is required to modernize OPM’s programs so that they are sustainable for the 21st Century. Folks driving the change are business oriented. It’s not about cost cutting. It’s about creating a better structure for the achieving the mission. 

Healthcare Dive informs us that Walgreens is stepping up the pharmacy clinic business by “partnering with provider group VillageMD to operate primary care clinics next to five of the pharmacy chain’s stores in the Houston area.”

VillageMD’s patent-pending data integration docOS system, released in April of last year, is a key part of the collaboration’s benefits for Walgreens, according to the company. The tech, meant to help doctors and patients manage chronic care conditions, identifies and flags gaps in health or missed diagnoses and can be accessed via phone, kiosk, home-based monitoring or telemedicine.

VillageMD has more than 120 primary care physicians in its Houston medical group. If Walgreens wants to explore a deepening of the partnership and scale Village Medical at its stores further, VillageMD already contracts or employs more than 2,500 physicians in eight markets across the U.S.

Who knew?

• The Centers for Medicare and Medicaid Services is proposing to expand Medicare coverage for 

Ambulatory Blood Pressure Monitoring (ABPM).  ABPM is a non-invasive diagnostic test that uses a device to track blood pressure over 24-hour cycles. Ambulatory monitoring allows blood pressure to be measured over entire days rather than at a single moment in time.  ABPM may measure blood pressure more accurately and lead to the diagnosis of high blood pressure (hypertension) in patients who would not otherwise have been identified as having the condition. 

• Becker’s Hospital Review tells us about Optum’s list of five costly drugs that are rolling out this year.  

While the end of HealthVault is an admission of failure for the company’s initial forays into health, Microsoft has refocused its efforts in the industry toward the enterprise market.

The Senate Finance Committee held its prescription benefit manager hearing today. CNBC reports on the hearing here.

Healthcare Dive reports on the comments that were filed on the CMS proposed rule to eliminate prescription drug rebates from Medicare, among other federal health programs offered to the public. The drug manufacturers favor eliminating the rebates. However, they have been unwilling to assure the PBMs and health plans that the rebate savings will lower prescription drug pricing dollar for dollar.

From skimming through the Senate testimony, it’s clear to the FEHBlog that the Medicare rebate rule needs to be withdrawn and re-evaluated. Removing rebates would not create overall healthcare savings even if rebates are fully traded for lower drug prices. It would benefit plan members with high deductibles or co-insurance arrangements for their prescription drug coverage.

Ironically, the commercial PBMs did not originate the rebate idea. The PBMs ripped a page out of the federal government’s playbook which included prescription drug rebate arrangements for Medicaid, the Veterans Administration, and the Defense Department going back at least into the 1980s.

The most effective step that Congress can take to lower prescription drug prices is to reform the patent system for prescription drugs, including specialty drugs.  The UnitedHealthcare witness at today’s hearing explained (p. 6)

An effective intellectual property environment plays an indispensable role in both promoting drug discovery and ensuring innovations are affordable and sustainable. Today’s intellectual property system does not work as intended. The most important step Congress can take to address the high cost of prescription drugs is to modernize the intellectual property system for the 21st century and eliminate drug manufacturers’ ability to manipulate the patent and regulatory system and thereby prevent lower-cost genericsand bio-similars from reaching consumers more quickly 

Amen to that.  If the rebate debate leads Congress to take action to reform the patent laws, the debate will have served its purpose.