HHS has announced that Dr. Karen DeSalvo will continue to serve as National Health Care IT Coordinator while she also acts as an assistant HHS Secretary for Ebola matters.  The American Medical Association is pleased with this news.

The Hartford Courant confirms what the FEHBlog noted earlier this month — Aetna has announced that all 2015 health plans it offers to federal workers will provide coverage for sex-change operations, a decision that follows a shift in U.S. government policy allowing insurance to pay for gender reassignment surgery..

The New York Times has an opinion piece in which a health care economist describes consumer difficulties in selecting a health plan during the open enrollment period. The writer complains

A crucial feature of health plans is not as easily or widely accessible: the extent to which each covers services provided by one’s favorite doctors and hospitals. Except on a handful of Affordable Care Act exchanges and for federal-employee participants in the Washington area, such network information is typically available only on plans’ websites, making gathering and comparing plan networks prohibitively difficult. Moreover, which doctors are in a plan’s network can change over time.

The health care provider knows. Ask the provider. In any event, the OPM website links to plan websites. It’s not that difficult. Moreover, the FEHBlog thinks that Congress missed an opportunity in the ACA when it failed to require providers to give patients information about the health plan networks in which they participate (and their pricing?).

Finally, Reuters reports that “pharmacy benefit manager Express Scripts Holding Co said it may quickly change its preferred drug formulary to favor an expected new hepatitis C drug from AbbVie if it is clinically equivalent and less costly than Gilead Science Inc’s $84,000 Sovaldi and $94,500 Harvoni treatments.” Hope spring eternal. According to the article, the FDA is expected to approve AbbVie’s drug which is equivalent to Harvoni, later this year but AbbVie has not announced its pricing. A speaker at the ESI conference that the FEHBlog attended last week explained that the difference between big Pharma, e.g., Pfizer, and biotech companies like Gilead Sciences is that big Pharma has a lot of irons in the fire while the biotech company only has a few. So when the biotech company hits the jackpot, it has to cash in big time.

Congress remains on the campaign trail this week.

Last Friday, OPM released its 2014 Government-wide Federal Employee Viewpoint Survey results. This report concerns employee attitudes toward their jobs, Federal New Radio has a two useful articles that review and analyze the survey results.

At last week’s Express Scripts conferernce, I heard a futurist J.D. Kleinke express his opinion that the cost curve is down because of among other factors a public backlash against high cost care, e.g., see use of retail clinics. Of course, health plans are in the vanguard encouraging this trend. According to this Fierce Health Payer article, insurers are pushing back against “Rolls Royce” treatments. However, because no good deed goes unpunished, members of the FEHBlog’s profession, who represent the doctors are criticizing this practice:

“I think the Affordable Care Act has really helped in many ways,” William Shernoff, a healthcare attorney in Beverly Hills, California, told the Daily News. “But I think they left one big loophole.”

Shernoff is referring to the fact that the ACA allows insurers to deny procedures, even ones recommended by doctors, if they consider them unreasonable or not up to the standard of care. “There doesn’t seem to be anything in the ACA that lays down any guidelines or standards on who determines medical necessity,” he added.

The Washington Post reports that

Federal retirees will receive a cost-of-living adjustment to their annuities of 1.7 percent in January, which translates into an increase of about $50 a month on average for those who retired under the older of the two main federal retirement systems, and about $20 a month on average for those retired under the newer system.

Today, the pay.gov website initiated a new page to collect headcount data from FEHB and other health plans so it can invoice those plans for the ACA’s transitional reinsurance fee.  The deadline for submitting the necessary information on this site is November 15, 2014.  This fee is designed to collect $25 billion over three to support the carriers in the ACA’s health insurance marketplaces and reimburse the U.S. Treasury for $5 billion spent on an early retiree reinsurance fund which the government prohibited FEHB plans from accessing.

Karen DeSalvo, who spoke at the WEDI conference on Tuesday as head of the Office of National Coordinator of health information technology switchted jobs today. She is now HHS’s point person for Ebola according to this ihealthbeat.com report. Her deputy also is resigning effective at the end of next month.

Drug Channels adds perspective to CVS Health’s new business venture, a PBM retail pharmacy network composed entirely of pharmacies like CVS Health and Target which don’t sell tobacco products.

Yesterday, the FEHBlog attended an Express Scripts Federal Pharmacy Symposium. Here are some tidbits from that conference:

• Express Scripts expects that the Hepatitis C biotech drug Sovaldi will add 5% to the prescription drug trend for this year (20% trend in total). Speakers noted that while Sovaldi does cure Hepatitis C, it is not a vaccine. The disease can reoccur. 
• Best of times / worst of times (?) — 5400 new drugs currently are in the development pipeline. Express Scripts expects FDA approval next year of a new biotech cholesterol drug PCSK9( (?) and a new biotech drug that “revs up the immune system” in an effort to control cancers (BPI Inhibitor). Express Scripts projects that the cholesterol drug which will be used over the patient’s lifetime could add 5% to trend. 
• Biosimilars will hit the marketplace next year. 
• While the number of people taking opioids (oxycodone, etc.) is down, the users are taking more of these drugs. 259 million painkiller prescriptions were written in 2012. 60% of users take dangerous combinations of drugs. Express Scripts thinks that doctors, pharmacies, and patients need to be better educated about pain treatment, e.g., use longer acting pain killers for people with chronic pain, Express Scripts has an interesting program under which it can lock in a member to using particular pharmacies and/or doctors for their prescriptions, e.g., discourages doctor and pharmacy shopping. 

Since Monday afternoon, the FEHBlog has been attending (on and off) the Workgroup for Electronic Data Interchange’s fall conference in lovely Reston Virginia (near Dulles Airport).

Monday afternoon was a privacy and security summit. The speakers focused on risk assessments. The HIPAA Security Rule requires covered entities and business associates to conduct periodic risk assessments of the organization’s electronic protected health information. At a conference earlier this year, the FEHBlog heard a speaker discussing the extension of risk assessment to all forms of PHI. A speaker at Monday’s session noted that it’s a prudent measure for businesses also to conduct assessments of risk to people and property/money.

Risk assessments involve the following steps code named FARM

1. Frame the risks, e.g., where is my ePHI?, how is it used?, what are the threats?
2. Assess the risks
3. Respond to the risks, and
4. Monitor the risks

These are simply sound internal controls. The FEHBlog also learned that October is Cybersecurity Awareness Month.  Here is a link to HIPAA Security Rule Guidance.

Yesterday morning, the FEHBlog listened to talks about interoperability. The basic problem is that when Congress in 2009 made $30 billion available for “free” electronic health records, the manufacturers focused on selling hardware and software that would meet the government’s meaningful use requirements. Evidently, interoperability meaning that the electronic health record systems can talk to each other was not a meaningful use requirement. So now it’s time to do some backfilling. There was talk of a new interoperability law. Here’s a link to a Fierce Health IT article about the main interoperability talk yesterday.

The best talks were today’s. The first talk was by the American Medical Association’s President-elect Dr. Steven Stack  Dr. Stack bemoaned the “incredible morass of statutory and regulatory burdens” imposed on his profession. So the problem is the same on both sides of the fence — healthcare provider and healthcare payer.

He explained why the AMA wants to kill the ICD-10. He noted that the ICD-9 has 13,000 codes while the ICD-10 has 68,000 codes. He doubts that the explosion of codes will provide better detail on the population health because doctors don’t understand all of the detailed coding. (As an anecdote, he noted that death certificate information is not particularly reliable because absent an autopsy the coroner may default to heart disease.)  Doctors were not closely involved with creating the coding. He added that Canada’s ICD-10 which had more doctor involvement in its development has only 17,000 codes.

The AMA did not ask for the additional one year delay in the ICD-10. That was a Congressional bone thrown to the AMA because Congress punted on Medicare Part B sustainable rate of growth formula reform again. He had hoped (as the FEHBlog did) that HHS would implement the ICD-10 at the beginning of a calendar year not October 1. The AMA hopes that payers will providers a grace period while the providers and payers get used to the ICD-10.  He wants the government to do a better job implementing the ICD-11.

He said that the government’s meaningful use standards are a barrier to effective electronic health records.  Developers are focusing their bandwidth on meaningful use compliance rather than effective user design.

He also expressed a concern that the growing use of credit cards to pay doctors (due to higher enrollee cost sharing) is cutting into physician practice margins. The FEHBlog is not sure what health plans can do about that.  A Humana representative asked Dr. Stack what the AMA is doing to encourage doctors to accept electronic fund transactions from payers. Apparently the answer is bumpkus,

The final speaker that the FEHBlog heard today was Dr. Harry Greenspun from the Deloitte Center for Health Solutions. He pointed out that healthcare consumers seek the best service from their health care providers, not the best quality. Consumers need an incentive to use high quality providers. That is where health plans fit in. .

The FEHBlog received comments on last weekend’s entry concerning coverage of gender reassignment surgery. Joe Davidson in the Washington Post had announced that AFSPA will cover gender reassignment surgery next year. AFPSA / the Foreign Service Benefit Plan is open to  Foreign Service personnel  and employees of the State Department, the Defense Department and a few other agencies (as well as annuitants).  The FEHBlog received comments asking whether other plans would be covering the procedure next year. He discovered that Aetna’s FEHB plans also will cover the procedure for 2015.  Other plans may offer the coverage too.

The weekend update is coming out on Monday morning because the FEHBlog returned to DC from the Nutmeg State last night. Fall in Connecticut is quite enjoyable.

Congress remains on the campaign trail. The mid-term election is now only 15 days away.

FEHB plans are starting to unveil their 2015 benefit  changes on their websites as the 2015 Federal Benefits Open Season is a mere three weeks away. Last week, Joe Davidson in the Washington Post reported that the Foreign Service Benefit Plan will be covering gender reassignment surgery next year. The column notes that

But it is not a reality for other plans in the OPM-administered federal health-benefits program. OPM said it “removed its requirement that carriers exclude ‘services, drugs, or supplies related to sex transformations’ ” beginning in 2015, but it did not order health insurance companies to do so.

Readers will recall that in June 2014 OPM made this announcement after 2015 benefit and rate submissions had been submitted. The agency allowed carriers to modify their submissions to add this coverage. We may learn that other carriers took advantage of this opportunity for 2015, As we lawyers say, the Post column assumes facts not in evidence.

Health Data Management reports on an interesting CIGNA effort to engage participants in employered sponsored health plans with a “new technology ‘ecosystem’ platform that combines online, mobile, social media, gamification, and web-based incentives to help customers and their families get the most out of the benefits.” The article explains that

The platform, branded Cigna Health Matters, will be available to approximately 14 million consumers, Cigna executives said. Cigna Health Matters starts with a gamified health assessment that customers engage with as they enroll in their health plan. Cigna’s gamified version delivers completion rates of 90 percent compared to typical industry-wide rates of 30 percent, according to the company.

Fierce Health Payer discusses other approaches to incenting employees to take an interest in their health care here.

The FEHBlog is currently on a flight to Hartford for a weekend in the Nutmeg State. Aon Hewitt released an employer survey finding that employers are focusing on the ACA’s Cadillac tax which takes effect in 2018. You can’t start too soon to plan for this 40% excise tax on premiums above the law’s thresholds — $10,200 for self only and $27,500 for self and family, subject to certain adjustments. Employers are anxious for the IRS to issue proposed rules on the tax.

OPM has encouraged FEHB plans to keep an eye on community health concerns. The Trust for America’s Health has posted a new interactive map on state obesity rates here.

Enjoy the weekend.

My how time flies! Today begins the Medicare open enrollment period. The FEHB Open Season begins on November 10, and the ACA health insurance marketplace open enrollment period begins on November 15..

In preparation for the FEHB Open Season, OPM has finalized its rule that brings the federal government into compliance with the ACA’s employer shared responsibility mandate by extending coverage to temporary, seasonal, and intermittent employees who work on average at least 130 hours per month over at least 90 days. Because the early bird usually does catch the worm, OPM exempted the Postal Service from this rule. The Postal Service began a health benefit program for its part time employees at the beginning of this year. OPM also created an easy opt out process for Indian tribal employers. LifeHealthPro reviews civilian agency comments on the rule here.

Since the Supreme Court decided on October 6 not to review several lower court decisions finding a constitution right to same sex marriage, nine States have started to issue marriage licenses to same sex couples joining 21 other States and the District of Columbia. More States are sure to follow.  The interesting twist here is that beginning this year OPM has allowed federal employees to add the children of their same sex domestic partners to their self and family coverage if the employee lives in a State that does not license same sex marriages. If during the course of the year but before the first day of the Open Season, here November 10, the State of residence begins to license same sex marriages, then the domestic partner’s children lose coverage at the end of the year unless the employee and domestic partner marry.

The FEHBlog has no idea how many domestic partner children have been added to self and family coverage in the fourteen States that have begun to license same sex marriage just this year.One of the States that just began to license same sex marriages is Virginia. There are a lot of federal employees who live in Virginia. But same sex couples residing in these 14 States may be in for a rude awakening on January 1 when the domestic partner’s children are no longer covered under the FEHB plan because they decided on a Spring 2015 wedding, for example. No good deed goes unpunished as they say.

Congress remains on the campaign trail. The FEHBlog is rather despondent because the Washington NFL team is 1 and 5.

Following up on the FEHBlog’s entry last Friday about the new ACA guidance restricting reference pricing (also discussed in this Health Affairs blog entry), the FEHBlog noticed this Kaiser Health News article about a National Institute for Health Care Reform study questioning the utility of reference pricing. The FEHBlog continues to find the idea attractive because it places pressure on health care providers to tow the line.

Another idea that the FEHBlog has advocated is using Medicare’s RBRVS as the benchmark for paying out of network providers because after all how can the providers challenge Medicare’s schedule when the AMA plays a large role in its construction?  Today, a Washington Post columnist hammered on a local health insurer for using the RBRVS as its out of network payment benchmark. Of course the real problem is created by providers who don’t participate in provider networks. It’s unfortunate that Congress in the ACA did not require doctors to publicize the networks in which they participate similar to the summary of benefits and coverage obligation that the law imposes on insurers.

Finally, the Washington Post reports that on Friday the Food and Drug Administration approved a new Gilead Sciences pill dubbed Harvoni to treat Hepatitis C that combines its blockbuster drug Sovaldi with two related drugs that form the complete treatment. Gilead plans to charge $94,500 for a 12 week course of treatment. The Wall Street Journal provides some additional background:

Harvoni’s price is comparable to the cost of the Sovaldi regimen, and is less than the roughly $150,000 paid for an unapproved combination of Sovaldi and a Johnson & Johnson JNJ -0.83%  pill called Olysio that many patients have been taking this year, according to Gregg Alton, a Gilead executive.
Also, Mr. Alton said Harvoni will cost a third less–$63,000—for patients requiring eight weeks of treatment. Gilead estimates that about 35% to 40% of hepatitis C patients fall into this category, because their infections haven’t progressed far enough to scar the liver.
Insurers could “look at using the eight-week regimen more proactively as a way to reduce cost” long term because they wouldn’t have to pay for more longer and more expensive drug therapy later or for even costlier liver transplants after that, Mr. Alton said.
Yet insurers are counting on competition from other drug companies to reduce their costs. AbbVie Inc. ABBV -2.36%  says the U.S. Food and Drug Administration is scheduled to decide on approving its new treatment before the end of the year.