The FEHBlog is safely ensconced within the Capital Beltway again after a weekend in New York City. Congress will be in session on Capitol Hill this week before a long break.  On Tuesday July 12, at 2 pm, the House Oversight and Government Reform Committee will mark up several bills, including its bipartisan Postal reform bill.

Last week, The Centers for Medicare and Medicaid Services proposed a host of 2017 changes to its rules for Medicare Part B payments to doctors and its rules for its outpatient hospital prospective payment system (“OPPS”). “CMS estimates that the updates in the proposed rule would increase OPPS payments by 1.6 percent and [ambulatory surgical center] payments by 1.2 percent in 2017.”

The Wall Street Journal reports that “surprise” medical bills create battles between providers and insurers.  This problem arises when doctors who work in insurer network hospitals, such as emergency room doctors, anesthesiogists, pathologists, etc., are out of network.  The Journal’s lead places blame on narrow insurer networks. But the FEHBlog is aware that this problem exists in all types of insurer networks.  Hospitals should be making a better effort to bring all of their doctors into the insurer networks in which they participate.

The FEHBlog is up in New York City. Down in DC, according to the Washington Post, the House of Representatives passed by a wide bipartisan margin a bill intended to combat the opioid abuse crisis.  Here is a link to The Week in Congress’s report on this past week’s other actions on Capitol Hill.

The Hartford Courant reports that Connecticut’s ACA co-op HealthyCT is under state supervision. Ironically, the co-op is in hot water because HHS is requiring the non-profit to pay $13.4 million to the ACA’s risk adjustment program because it’s population is too healthy.  WSOC TV adds that Illinois’s ACA co-op is sueing HHS in response for HHS’s demand for $72 million for the same risk corridor program.  As the FEHBlog noted many years back, the co-ops are indeed the ACA’s Solyndras.

The National Diabetes Education Program has refreshed its website. It’s good link for health plans to use.

Healthcare IT News reports on a $650,000 HIPAA data breach settlement between a HIPAA business associate and HHS’s Office for Civil Rights. This marks the first settlement with a business associate, rather than, a covered entity (a health care provider, a health plan, or a healthcare clearinghouse).  For over five year, business associates who perform services for covered entities became subject to these penalties over five years ago.

My this workweek has been moving along rapidly. The House of Representatives did pass a significant mental health reform bill yesterday by a wide bipartisan margin as reported in the Pittsburgh Post Gazette.  In this regard, the FEHBlog notes this Modern Healthcare article reporting that the Medicaid program has begun to cover short term stays for adults at mental health institutions. Since its enactment in 1965, Medicaid has excluded this coverage because at that time the States provided this mental healthcare. Why it took fifty years to make this change is mystifying.

Employee Benefits News reports that according to an ADP Research Institute study employer-sponsored health benefit plan costs have been stable since the ACA marketplace opened in 2014.

Here are several tidbits:

• Hospitals are adding experienced nocturnal doctors to their ranks according to FierceHealthcare 
• Stat reports on a U.S. Court of Appeals decision that a biosimilar manufacturer cannot sell its new less costly specialty drugs for 180 days after receiving FDA marketing approval.
• Home Health News reports that False Claims Act penalties are nearly doubling on August 1.
• The New York Times Upshot compares the dietitian and public opinions on whether particular foods are healthy or unhealthy. 

Happy 4th of July!  Congress returns to Capitol Hill this week. Congress will be in session there for the next two weeks.  According to the calendars for the House and Senate,  the legislative bodies will be busy attending to party convention and reelection campaigns until following Labor Day.  Congress then will return for the remainder of September and then be off until after the election on November 8 (assuming a lame duck session is held).

Health Data Management reports on the status of efforts to make electronic medical records communicate with one another or in one word interoperable.  It’s not encouraging and that’s discouraging because the federal government hurled $34 billion at the electronic medical records industry without first requiring interoperability.  “The lack of interoperability is one of the major reasons why the
promise of electronic health records has not been fulfilled,” said [immediate past] AMA
President Steven J. Stack, MD. “Vendors have been incentivized to meet
the flawed benchmarks under the Meaningful Use program. We need to
replace those benchmarks with ones that focus on better coordinated
care.”

Pharmalot reports that the major pharmaceutical manufacturers, including Pfizer and Gilead, continue to engage in routine product price increases. “To avoid a torrent of public criticism, some makers are raising prices only by modest amounts, but in some cases doing that multiple times a year.”

• Today CMS finalized a rule allowing the agency to sell Medicare data to qualified entites in an effort to improve health care quality. CMS has approved 15 qualified entities. Modern Healthcare explains that 

four of the 15 have nationwide reach. They include two for-profit companies, Amino, a startup based in San Francisco and funded by venture capital and OptumLabs, a collaborative led by Optum, the health information technology, data mining and analytics arm of health insurance giant UnitedHealth Group based in Minnetonka, Minn. 

Also serving the entire nation is the Health Care Cost Institute, a not-for-profit that is funded in part by for-profit insurers UnitedHealth Group and Aetna, as well as not-for-profit giant Kaiser Permanente. The other national organization is FairHealth, a not-for-profit insurance claims data miner  . . . .

• Yesterday, CMS’s Medicare Innovation Center launched its Oncology Care Model which engages oncologists and healthcare payers in an experiment with episodic payments for cancer care. Becker’s Hospital Review provides nine interesting details about the effort here.

• Also yesterday, CMS updated its Open Payments Program database with 2015 data.  “The Open Payments program (sometimes called the “Sunshine Act”) requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.” There certainly is a lot of money circulating in the health care industry.  Fierce Healthcare has more details here. 

The Hartford Courant has the latest news on the state of the Anthem-Cigna merger here.

In the weekend update, the FEHBlog noted a report that hospitals like health plans are focused on expanding the use of telemedicine.  The FEHBlog wondered why. The Wall Street Journal provided the answer in this article published on Monday.   The article looks at hospital use of telemedicine from several angles including

In the woods outside St. Louis, shifts of doctors and nurses work around the clock in Mercy health system’s new Virtual Care Center—a “hospital without beds” that provides remote support for intensive-care units, emergency rooms and other programs in 38 smaller hospitals from North Carolina to Oklahoma. Many of them don’t have a physician on-site 24/7.

and

The Cleveland Clinic is working to create a “Cleveland Clinic in the Cloud” that would allow patients across the country to access its physicians without going to Ohio. Dr. [Peter] Rasmussen [from the Cleveland Clinic] also foresees joining with local pharmacy clinics, labs and imaging centers to provide in-person exams as needed. “This will open up a world of relationships across a spectrum of health-care providers that we haven’t seen to date,” he says. 

The Centers for Disease Control released 2016 ICD-10 changes last week according to this ICD-10 Monitor report.  “There are 1,974 additions, 311 deletions, and 425 revisions. The resulting total for diagnosis codes is 71,486.”

Health Data Management reports that the federal government is encouraging the use of ethical hacking by healthcare organizations. “Ethical hackers are computer and networking experts who attempt to penetrate information systems on behalf of its owners to find security vulnerabilities that a malicious hacker could potentially exploit.” What next?

Finally, Employee Benefit News reports on a survey finds that a majority of employees cannot define common health insurance cost sharing terms.  The FEHBlog finds that hard to believe. In any event, employees should be concerned with those terms because according to this International Foundation of Employee Benefit Plans website, “The International Foundation’s new report, 2016 Employer-Sponsored Health Care: ACA’s Impact, finds that about one-third of organizations have increased out-of-pocket limits, in-network deductibles or employees’ share of premium costs in response to ACA.”

It’s also worth noting that the U.S. Supreme Court wraps up its October 2015 term tomorrow.  The Hill provides a summary here.

Avik Roy offers his useful insights into the Republican’s alternative approach to health care reform that Speaker Paul Ryan released last week.

OPM provided details on the transition of the flexible spending account administrator role from ADP to WageWorks on September 1.

Healthcare IT News reports that according to a recent KMPG survey “nearly half of responding healthcare [system] executives expect that the [government mandated] move from volume to value will adversely impact revenue, which makes investing in technologies  [e.g., telemedicine] even more critical to competing in the market.”

Louisville Business First reports that Aetna and Humana have agreed to extend the deadline for completing their merger to December 31, 2016, which is consistent with previous management projections for a second half of 2016 close.

Kaiser Health News reports on the demise of the nasal flu vaccine — FluMist — that until recently had been favored for use by young children.

On Wednesday [June 22, 2016], an advisory panel to the Centers for Disease Control and Prevention voted that — though it continues to be important to be vaccinated against the flu — the spray version was so ineffective that it should not be used by anyone during the 2016-2017 flu season.
Just two years ago, that same Advisory Committee on Immunization Practices recommended FluMist as the preferred alternative for most kids ages 2-8, after reviewing several studies from 2006-2007 that suggested the spray was more effective in kids than the injectable forms of the vaccine.
What changed to make the spray so much less effective than studies had shown it to be in the past? The bottom line is that right now “we don’t understand what it is,” said David Kimberlin, a professor of pediatrics at the University of Alabama at Birmingham, who said academic researchers and those at MedImmune, a subsidiary of Astra Zeneca that makes the vaccine, are working to get answers. 

The Social Security program trustees issued a report earlier this week projecting that Social Security beneficiaries will receive a 0.2% cost of living increase in their benefits next year. according to a USA Today report.

There was no cost of living adjustment for 2016. The upshot was that under a modified federal hold harmless law federal and postal annuitants under the FERS program, who elect Part B, saw no Medicare Part B premium increase while federal and postal annuitants under the CERS program, who elect Part B, saw a 16% increase in that premium.

A Wall Street Journal analysis of the new Social Security trustees report states that

Those who are paying the standard $121.80 a month for Medicare Part B this year [the CSRS annuitants and people who recently joined Medicare] would be charged $149 a month in 2017 if the trustees’ predictions come to pass. [The article does not explain how the FERS annuitants would be affected, but there would be a Medicare Part B premium increase.]

Higher earners would pay more. The trustees project individuals earning between $85,001 and $107,000 and couples earning between $170,001 and $214,000 would have their 2016 monthly premiums rise from $170.50 a person this year to about $204.40 in 2017. For those earning more than $214,000, or $428,000 for couples, the projected increase is to about $467.20 a month, from $389.00 in 2016.

Medicare Part B deductibles and Part D premiums also would be affected.

If the trustees’ predictions come to pass, all Medicare beneficiaries will see their annual Part B deductibles rise from $166 in 2016 to $204 in 2017. “Everyone on Part B will be liable for the full increase,” says [Tricia Neuman, senior vice president and an expert on Medicare at the Kaiser Family Foundation]. 

The report projects that monthly Medicare Part D premiums—which cover prescription drug costs—will rise from $34.10 to $40.59, while the annual Part D deductible will jump from $360 to $400. Those increases will apply to all Medicare Part D beneficiaries.

These changes are important to the FEHBP because the Program covers a large cadre of Medicare Part B eligible annuitants.

CMS has created a new HIPAA administrative simplication website — no doubt in celebration (?) of the law’s upcoming 20th anniversary of enactment in September. My how time flies.

Greetings from Corolla NC.  Yesterday, the ACA regulators issued FAQ 32 which concerns the relationship between COBRA continuation coverage (TCC is the FEHBP analog to COBRA) and the ACA marketplaces.  FAQ 32 begs the question why didn’t Congress simply repeal COBRA and TCC when it implemented the marketplace. That would have simplified the system and added more people to the marketplace.

On Monday, the U.S. Supreme Court decided to review the D.C. Circuit’s decision on which the now retired OPM Inspector General relied to challenge Beth Cobert’s authority to serve as acting OPM Director while the Senate considered her permanent nomination.  We won’t see a Supreme Court decision for several months and the Obama Administration which asked the Supreme Court to take this action disagreed with the retired OPM Inspector General. The FEHBlog sides with the Obama Administration here (at least with respect to the Director’s authority).

PriceWaterhouseCoopers (“PwC”) released its 2017 healthcare cost projection.  “PwC’s Health Research Institute projects the 2017 medical cost trend to be the same as the current year – a 6.5% growth rate.” That’s quite a bit above inflation.

The Health Care Cost Institute released a report on diabetes spending.

The report, 2014 Diabetes Health Care Cost and Utilization Report, examines how much is spent on health care for adults and children with diabetes, where those dollars are spent, and how that compares to people without diabetes. It is based on the health care claims of more than 40 million Americans younger than 65 covered by ESI from 2012 to 2014. People diagnosed with type 1 or type 2 diabetes accounted for five percent of the ESI population in 2014. 

Similarly, Fierce Healthcare reports on an AHIP Insitute panel last week which discussed approaches to covering health plan members with chronic illnesses like diabetes.

A couple months ago, the Washington Post reported the health care problems afflicting rural America.  Stat offers an interesting article on a public health worker who is trying to tackle these problems.

Finally the Speaker of the House Paul Ryan offered his party’s health care reform task force report.

Last week, a Senate appropriations subcommittee on June 15 and the full committee the following day approved the FY 2016 financial services and general government appropriations bill which funds OPM and the FEHBP. The bill now heads to the Senate floor.  Here’s a link to the Week in Congress’s report on other Capitol Hill activities from last week.

The Street offers a pessimistic report on the prospects for the Anthem-Cigna merger, which is now under regulatory review.

As confidence wanes that Anthem’s (ANTM) $54.2 billion acquisition of Cigna  (CI) will survive regulatory scrutiny, analysts are already considering what the target will do if the deal falls apart.
Ana Gupte of Leerink Partners LLC believes that Cigna could look to acquire a smaller managed-health care company, such as Long Beach, Calif.-based Molina Healthcare (MOH) or Tampa, Fla.-based Wellcare Health Plans (WCG) if the deal doesn’t push through.
Thanks to the $1.85 billion break-up fee Anthem would pay to Cigna, the Bloomfield, Conn.-based company would have extra cash on hand to make an acquisition.

The FEHBlog looks for the tea leaves, but he certainly can’t read them.

Fierce Healthcare offers a report which confirms the FEHBlog’s thinking on hospital readmissions, which is of course gratifying:

Many 30-day readmissions may not be linked to poor care, but instead to mental health issues, homelessness or substance abuse, according to a new study published in JAMA Surgery.
The research team analyzed data for 2,100 patient discharges at one Level 1 trauma center and safety-net hospital and found 173 of those patients were readmitted.
In close to one-third of the cases, patients fell into two groups, according to the study: injectable drug users who had new infections (about 17 percent of the readmissions) or people who did not have access to social support services, which led to issues with discharge and follow-ups (about 15 percent of the readmissions).

Health plan case managers are sure to be on the lookout for such high risk candidates for readmission.

Becker’s Hospital review tells us about the latest IBM-Ponemon report on data breaches, which not suprisingly is uglier than last year’s report.  Verizon’s data breach report is another useful resources.