Fedsmith reports on NARFE’s reaction to the House Oversight and Government Reform Committee’s bipartisan postal service reform bill.  NARFE is opposed to the idea of auto-enrolling Postal annuitants in Medicare.  That train, however, has left the station because auto-enrollment is the surest path to lowering the Postal Service’s liability for post-retirement health benefits.  The article notes that

To help offset these new mandatory cost, the House legislation provides a transition fund with the Postal Service paying 75 percent of the enrollee’s share of their premium for the first year of Medicare enrollment, 50 percent the second year, and 25 percent the third year. In the fourth year and thereafter, postal retirees would have to pay the full amount of their share of Medicare premiums like most other Part B participants.

NARFE’s legislative director believes that the House bill could be marked up by the Committee within the next 30 days.  “It is possible that the House version could receive a floor vote after Congress returns from its August recess, setting up a final vote in the House and Senate during their final session of the year after the November elections.”  Of course, the FEHBP-related provisions are only one aspect of this over-arching bill.

John D. Rockefeller, the oil baron from the 19th Century, built his fortune in the first fifty years of his life.  He devoted the second half of his long life (he lived to age 97) to philanthropy.  Much of his philanthropy focused on public health issues.  Bill Gates, the softward baron, has ripped a page out of the John D. Rockefeller playbook. Stat has an interesting interview with him here.  

The annual AHIP Institute has taken place in Las Vegas this week. Here are articles from Fierce Heathcare and Healthcare Finance about that conference.

The House bill would require postal retirees electing to receive federal health insurance to enroll in Medicare parts A and B as their primary care provider. The bill would phase out the Postal Service’s share of retirees’ Medicare premiums over four years. Most postal employees enrolled in the Federal Employees Health Benefits Program would have to select a plan specific to USPS workers. 

The Medicare integration would largely solve the issue of prefunding future retirees’ health care, as required by a 2006 law. The issue has been a sticking point in previous attempts at postal reform, as the cash-strapped agency has struggled to make the payments and defaulted on them in recent years. USPS would make actuarial payments toward the remaining liabilities over the next 40 years.

The draft House bill is available on the Committee’s website.

Also today, the House Energy and Commerce Committee unanimously cleared for floor consideration a significant mental health care reform bill (HR 2646).  Morning Consult reports that

[Rep. Joe] Kennedy [(D. Mass.)]withdrew an amendment aimed at strengthening parity in mental health coverage after [Committee Chair Fred] Upton committed to further look into the issue. “No matter what improvements we make to our mental health system, no matter how many resources we commit, if we do not ensure that those suffering from mental illness are treated fairly by their insurance companies then we leave treatment and care out of reach for far too many patients in need,” he said in a statement. “I appreciate Chairman Upton’s promise to hold a hearing dedicated specifically to parity this fall and look forward to working across the aisle to address this significant gap in our efforts to date.”

The American Medical Association is holding its annual convention this week. Dr. Andrew Gurman is succeeding Dr. Steven Stack as the AMA’s president.  Modern Healthcare reports that the AMA at its conference called for a relaxation of pressure placed on doctors to prescribe opioids.  Health Data Management and Healthcare IT News report on the AMA’s conference’s embrace of telemedicine, which the FEHBlog finds interesting.

And last but not least,  Healthcare Dive tells us that “Aetna and Humana are experiencing smooth sailing as they work to incorporate Humana into buyer Aetna in anticipation of approval for their pending merger.” The parties expect to close the deal in the second half of this year.

Kaiser Health News, which supports the Affordable Care Act, had an interesting headline for a summary of ACA-related news article — “Even with the Health Law in Plan, Costs Keep Going Up. ” This FEHBlog has documented the fact that costs keep going up because of that law.  It’s worth noting that a House energy and commerce subcommittee held a hearing last Friday on several bills to fix the ACA’s marketplaces, a sensible idea.

As the FEHBlog was taking a low dose aspirin last night, he thought of a Wall Street Journal opinion piece discussing the use of a polypill that would treat several chronic health conditions that affect older people, e.g, cholesterol, blood sugar, etc.

I tend to favor this sort of blunt, comprehensive approach to public health. Much as I like menacing cigarette-package warnings, urging personal responsibility, I like cigarette taxes more (despite their regressive impact). I love “Drive Carefully” signs, but I like seat belts better. And I like air bags best: No judgment, no decision, no defiant will. As for driving under the influence, breathalyzer tests and taking keys away beat the heck out of admonitions to be sober and find a designated driver. 

Human nature is not our ally in maintaining health. With heart disease and stroke, many millions of lives are at stake, and for me it comes down to this: Will popping a polypill work better than willpower? I suspect that the answer may turn out to be yes.

Assuming this makes sense, people would have to take the pill.  In the end, you can’t avoid the importance of personal responsibility.

Here’s a link to the Week in Congress’s report on this week’s activities on Capitol Hill.  Also here’s a link to Prof. Tim Jost Health Affairs blog entry on the major ACA rule released earlier this week and noted in Wednesday’s post.

In an interesting development, the Charlotte Observer reports that the Justice Department has sued a large North Carolina hospital system Carolinas Healthcare for anti-trust law violations. Carolinas Healthcare controls about 50% of the hospital service market in the Charlotte NC region.

The lawsuit alleges that Carolinas HealthCare uses its market power to negotiate “unlawful contract restrictions,” which prevent consumers from taking advantage of lower prices at other hospitals.  The lawsuit also contends that CHS encourages insurers to steer patients its way and uses its influence to prevent insurers from giving the same deal to competing hospitals.

Federal agencies are seeking to help consumers understand the complicated federal laws on health information privacy and mental health and substance abuse parity.  HHS’s Office for Civil Rights which enforces the privacy law has created three consumer education video’s on HIPAA’s consumer / patient / enrollee rights.  The Labor Department has created an information flyer on the mental health parity law.

HHS also created a website for the Obama Administration’s new Mental Health and Substance Abuse Disorder Parity Task Force.  OPM is one of the members of this Task Force, which is obligated to report back to the White House by October 31, 2016.

Another week, another massive government regulation concerning the Affordable Care Act. Today, according to Kaiser Health News, HHS proposed a rule aimed at forcing healthier people into the marketplace plans. “Simultaneously, the government announced refinements to the methods by which it gauges financial risk of insurance populations. It plans to begin factoring in people who held plans for part of the year and also include prescription drug use. The government will take those costs into account when the government redistributes money from insurers with people who tend to be sicker to plans filled with healthier people.”  The law simply is too complicated.

Stat reports on Vermont’s passage of a law requiring pharmaceutical manufacturers to support price hikes.  The FEHBlog is not a believer in government price controls. He has more confidence in the efforts of the private sector Campaign for Sustainable Rx Pricing to promote market based reforms. “The Campaign recommends promoting more competition in the prescription drug market and advises providing the U.S. Food and Drug Administration (FDA) with additional resources so it can approve generic drugs more quickly – especially in cases where an expensive drug has no alternative on the market.CSRxP also believes it should be easier to bring a drug to market and exclusivity protections should only be used for new, innovative products. Additionally, the group recommends that patients have access to more information about how different medications compare in efficacy to help bring prices down and empower patients to pay for what works.” Makes sense to the FEHBlog.

Closing tidbits —

• Joe Davidson of the Washington Post interviews OPM’s acting Director Beth Cobert about the one year anniversary of the OPM data breach announcement. 
• AMA President Steven Stack makes reasonable suggestions on how to better measure electronic health record interoperability per Healthcare IT News. “Instead of using data exchange as the metric for measuring interoperability, Stack urges CMS to focus on usefulness, timeliness, correctness and completeness of data, as well as the ease and cost of information access.” Of course, as Health Data Management points out, the lack of interoperability, which can be laid at HHS’s feet in the FEHBlog’s opinion, “continues to bedevil” the healthcare industry. 
• Ambulatory healthcare providers give good marks to Medicare, Tricare, and major commercial carriers according to Fierce Health Payer. 

Congress is back in session on Capitol Hill this coming week.  The Hill updates the status of FY 2017 appropriations.

Recently, the Centers for Medicare and Medicaid Services implemented a rule requiring providers to accept bundled prices for joint replacements.  Medicare only covers joint replacements performed inpatient. Modern Healthcare reports on a new trend toward performing joint replacements in outpatient facilities at a lower cost.

The Ambulatory Surgery Center Association says close to 40 centers around the country are performing outpatient joint replacements, and outpatient surgery companies such as Surgical Care Affiliates are aiming to increase them.
Moving these procedures to outpatient settings poses a major threat to hospital finances, since total joint replacements are one of the largest and most profitable service lines at many hospitals. In 2014, more than 400,000 Medicare beneficiaries received a hip or knee replacement, costing the government more than $7 billion for the hospitalizations alone—over $50,000 per case. The financial threat will be even greater if the CMS changes its rules and allows Medicare and Medicaid payment for these outpatient procedures, which observers expect will happen in the next few years.

The new Medicare pricing law, MACRA, is pushing Medicare providers to use population based and episode based payment methods. Modern Healthcare is reporting that the accountable care organization (“ACO”) industry is complaining over the fact that HHS’s proposed MACRA rules does not consider a “low risk” ACO to be one of these acceptable alternative payment method.  MACRA is pushing Medicare providers to use population based and episode based payment methods.

ACOs are extremely concerned about the direction the CMS is going not only in the proposed MACRA rules but also with the conflicts created by its other value-based payment programs such as bundled payment,” NAACOS [ACO trade association] President and CEO Clif Gaus said in a statement. “And when you add that to how much it costs to run an ACO, there’s a significant number of ACOs ready to leave the [Medicare Shared Savings Program].

According to Healthcare Dive, population health experts are concerned over a report that the U.S. death rate rose in 2015 for the first time in a decade.   “The increase came largely from higher rates of drug overdoses, suicide and Alzheimer’s disease, with a slight increase in heart disease, The New York Times reported.”  The FEHBlog recalls the AMA President Steven Stack saying during a speech that heart diseases is a default cause of death in America.

The Wall Street Journal reported earlier this week on the development of a

predictive tool, which pops up on the screen of electronic medical records, prompts the doctor to answer a short series of questions about the patient’s condition. Based on that information, a calculator predicts the probability that the person has the suspected ailment. It may also recommend a course of action.

The idea behind the tool which a physician developed is reduce the amount of unnecessary care. The FEHBlog recalls hear the AMA President Steven Stack complain that doctors did not have any significant input in the development of electronic medical record systems. Better late than never? But

As would be expected, many doctors balk at the idea of a computer program telling them how to do their job. The calculator makes diagnosis and treatment decisions seem simple when they really aren’t, says John Beasley, a family doctor for more than 40 years whose Verona, Wis., clinic is participating in one of the trials. He says he ignores the tool when it pops up on his screen.

It seems to the FEHBlog that just like information received from a computerized mapping tool like Google Maps, you would be making a mistake to rely exclusively on the tool. But it helps to consider the information.  The FEHBlog expects that most doctors take that approach.

Drugs Channels offers an analysis of specialty drug pricing here.  Employee Benefits News discusses the ACA’s impact on employee benefit enrollment here. Both articles are worth a gander.

The New York Times reports that the Internal Revenue Service denied an income tax exemption to an accountable care organization (“ACO”) — owned by a non-profit health system — because the ACO provides care to commercially insured patients – yet Medicare patients would be OK.  ACO’s are blooming in the commercial insurance market because commercial insurers offer more contracting flexibility than the Centers for Medicare and Medicaid Services.  HHS is promoting ACO’s as a favored alternative payment method.  The ACO cost curve is bound to go up if the ACO is a taxable entity.

The IRS also released a general counsel opinion throwing cold water on wellness rewards paid to employees in cash — the great incentor. Taxable wages says the Service.  That’s a proper outcome under the current tax law in the FEHBlog’s opinion. It begs the question why doesn’t Congress change the tax law to exclude low dollar cash wellness rewards from taxation?  What’s wrong with saying it in green?  An alternative is to position the wellness rewards as premium or deductible reductions. The latter approach is available to FEHB plans, but the former is not according to OPM.

The Delaware Business Times tells us the Blue Cross licensee Highmark is offering their members the opportunity to use internet-based tricks to “nudge” family members and friends to undergo cancer screening tests.  (No doubt due to HEDIS quality measure requirements.)  “The nudges, available at www.allforhealth.com, include notes, coupons, bribes, social nudges and nudge-o-grams that can be customized with personal video, photos and special effects.” Tax consequences of nudging are unknown.

The Labor Department is offering a cheat sheet to help health plan members (and their lawyers) sniff out health plan violations of the complex rule implementing the federal mental health parity law.  Simplifying the rule would be preferable in the FEHBlog’s view.

The Washington Post offered a follow-up report on the antiobiotic-resistant e. coli superbug that first appeared in the U.S last week last Friday’s post].  Significantly the infectious disease doctor who is interviewed in the story concludes that

Q: How likely is it for someone to pick up this antibiotic-resistant strain of E. coli from food?
A: Even if you ingest some resistant E. coli, most of it would be dead as it goes through the stomach because the stomach is highly acidic and designed to sterilize what we ingest. Most of it is gone by the time it comes out of the stomach. Even if some of it makes it through, it can hang out in your gut for a while and disappear. Only a very small portion of those people may become sick. So to summarize, you are starting at a very low risk in food, and then it goes through the stomach, and most will disappear in the digestive tract. I don’t think there is anything to be super worried about.

He advises cooking meat thoroughly and washing your hands when you cook.  This is the same maternal advice that everyone receives.  The point remains that doctors and hospitals need to curb utilization of antibiotics. As the expert explains

Q: Should doctors and hospitals be doing anything differently now that we know this resistance gene has been found in the United States?
A: It’s always prudent for doctors, when treating a bacterial infection with colistin, to make sure it works against the bacteria in a test tube when they need to give this antibiotic to their patients, instead of assuming that it should work. Many hospitals already do this, including ours [the University of Pittsburgh Hospital].

Last week, HHS’s Office for Civil Rights clarified its recent rule on maximum charges for providing copies of health records to individuals under HIPAA.  Health IT Security reports that “as the healthcare industry becomes more digitized, more patients are requesting electronic copies of PHI [(“ePHI”)]. For  [HIPAA] covered entities that do not wish to calculate the labor and supply costs for providing ePHI, organizations can charge a flat fee of $6.50 or lower, which includes labor, supplies, and postage fees.”

The New York Times reports today that the number of opioid prescriptions is finally dropping nationwide.

For much of the past two decades, doctors were writing so many prescriptions for the powerful opioid painkillers that, in recent years, there have been enough for every American adult to have a bottle. But for each of the past three years — 2013, 2014 and 2015 — prescriptions have declined, a review of several sources of data shows.
Experts say the drop is an important early signal that the long-running prescription opioid epidemic may be peaking, that doctors have begun heeding a drumbeat of warnings about the highly addictive nature of the drugs and that federal and state efforts to curb them are having an effect.

Experts have been worried about over-prescription of antibiotics for years.  Modern Healthcare reports that

A little more than one-third of acute care hospitals in the U.S. adhere to best practices to promote appropriate use of antibiotics, according to a new report. An analysis of more than 4,100 U.S. acute-care hospitals recently published in the journal Clinical Infectious Diseases found that 39% had an antibiotics stewardship program that met all seven of the core elements recommended by the Centers for Disease Control and Prevention.   

This is not a tsk tsk situation.  We have reached a true “ruh-roh” moment on the antibiotic over-usage front.  According to Reuters

U.S. health officials on Thursday reported the first case in the country of a patient with an infection resistant to a last-resort antibiotic, and expressed grave concern that the superbug could pose serious danger for routine infections if it spreads.
“We risk being in a post-antibiotic world,” said Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention, referring to the urinary tract infection of a 49-year-old Pennsylvania woman who had not traveled within the prior five months.
Frieden, speaking at a National Press Club luncheon in Washington, D.C., said the bacteria was resistant to colistin, an antibiotic that is reserved for use against “nightmare bacteria.

Let’s wrap up this post with a few tidbits on topics that the FEHBlog has been following —

• Drug Channels digs into the CALPers PBM contract recently awarded to OptumRx. 
• The OPM Inspector General issued another report on OPM’s efforts to better secure its computer systems. Here’s a link to the Washington Post’s report thereon. 
• Beckers Hospital Review reports that Ohio’s health insurance co-op, Coordinated Health Mutual, has failed. The Hill adds that “Just 10 of the original 23 [ACA creations] will now remain.