A client reminded the FEHBlog that today is National Pi Day. Best wishes to all.

Following up on the FEHBlog’s diatribe about the ACA regulator’s decision to consider whether PHCS § 2706(a), the ACA’s provider non-discrimation law, creates a federal any willing provider rule, the FEHBlog noticed in the Drug Channels blog that believe it or not the Federal Trade Commission recently sent a detailed letter to CMS expressing its opinion that any willing provider laws push the cost curve up!  This letter was written in response to CMS’s now withdrawn proposal to imposed an any willing pharmacy requirement on Medicare Part D.

And while on the topic of diatribes, the FEHBlog has not been happy with the federal Office of Federal Contractor Compliance Program’s (“OFCCP”) efforts to treat FEHBP participating health care providers as federal subcontractors for purposes of affirmative action program requirements in the face of OPM’s long standing rule that health care providers are not FEHB plan subcontractors.  Hospitals and other health care providers already are heavily regulated and an additional burden like this only will discourage hospitals from contracting with FEHB plan carriers in the FEHBlog’s view.

OFCCP also has taken enforcement actions against TRICARE (military dependent health program) providers. Congress passed a law to stop those efforts but OFCCP was not deterred. OFCCP has encouraged a crabbed interpretation of the law. Rep. Tim Walberg (R Mich) has introduced a short bill (HR 3633) that is intended to shut down these OFCCP enforcement efforts once and for all..

Yesterday, Rep. Walberg who chairs a House Education and the Workforce subcommittee held a hearing on his bill which is titled the “Protecting Health Care Providers from Increased Administrative Burdens Act.” At his hearing Rep Walberg announced that the Secretary of Labor has decided to impose a five year long moratorium on OFCCP enforcement actions against TRICARE, but not FEHBP, providers of cares. During that moratorium, OFCCP plans to acclimate providers to the new enforcement scheme. Rep. Walberg welcomed the OFFCP action but further encouraged Congress to adopt his bill as a long term solution. Here is part of his opening statement:

If the secretary [of labor who is responsible for OFCCP] has accomplished anything, he has signaled to our TRICARE providers the day of reckoning is only delayed. Any sensible provider will use these few years to decide whether it’s in their best interest to continue operating in a TRICARE network. Many may decide the administrative burden looming on the horizon is simply too much to bear. As a result, veterans, service members, and their families will lose access to care. Let me repeat that: As a result of the department’s policy, veterans, service members, and their families will lose access to care. Maybe not now, but soon.

As policymakers, we shouldn’t accept political half-measures that merely kick the can down the road. The American people expect better. I am disappointed my friend and colleague, Representative Courtney [a Connecticut Democrat on the Committee], is no longer a cosponsor of this important legislation. However, it is my hope we continue working together to provide a lasting solution to this problem, not just for our active and retired military service personnel, but also for our seniors, and the men and women who serve in the federal workforce. H.R. 3633 provides the long-term solution they and their families deserve. 

Amen to that.

The FEHBlog nearly fell out of his chair when he read that the ACA regulators are seeking public comment on the scope of the law’s provider non-discrimination rule (Public Health Service Act § 2706(a)). This law essentially expands the FEHBA’s medically underserved area rule nationwide. OPM explained the medically underserved area rule (5 U.S.C. § 8902(m)(2) as follows:

If you live in a medically underserved area and are enrolled in a fee-for-service plan, your plan must pay benefits up to its contractual limits, for covered health services provided by any medical practitioner properly licensed under applicable State law.

On April 29, 2013, the ACA regulators in FAQ XV explained that Section 2706(a) is self-implementing and does not require a regulation. This was a political move in the FEHBlog’s opinion because the American Medical Association detests this provision. In any event, the ACA regulators explained that

Until any further guidance is issued, group health plans and health insurance issuers offering group or individual coverage are expected to implement the requirements of PHS Act section 2706(a) using a good faith, reasonable interpretation of the law. For this purpose, to the extent an item or service is a covered benefit under the plan or coverage, and consistent with reasonable medical management techniques specified under the plan with respect to the frequency, method, treatment or setting for an item or service, a plan or issuer shall not discriminate based on a provider’s license or certification, to the extent the provider is acting within the scope of the provider’s license or certification under applicable state law. This provision does not require plans or issuers to accept all types of providers into a network. This provision also does not govern provider reimbursement rates, which may be subject to quality, performance, or market standards and considerations.

Here are some Tuesday tidbits which are a little late because the FEHBlog was focused on the NFL draft and the FL 13 election last night.

• The OPM director issued a strategic information technology plan yesterday.  The Federal Times provides an overview of the plan. The FEHBlog notes that OPM explains in the report  (p. 35) that the agency plans to roll out a new BenefitsPlus platform this year. The FEHBlog notes that many OPM information technology programs stem from unduly complicated retirement program laws. Simplify the laws first. 
• The FEHBlog at long last noticed yesterday that over a month ago OPM issued a 2015 call letter for the multistate program operating in the exchanges. This call letter provides some clues about what FEHB carriers may learn when OPM issues the FEHBP’s 2015 call letter on March 28. 
• Heads up! Under the final employer shared responsibility rule, employers who cover at least 70% of their full time employees next year will not be liable for the $2000 per uncovered FTE penalty. Nevertheless they can be held liable for the $3,000 penalty imposed for failing to cover a full time employee who receives subsidized coverage in the exchange. See Question 39 the IRS FAQs. The IRS will be able to identify these employees because the IRC 6055 and 6056 reporting requirements will be in effect for 2015. 

Congress is in session this coming week as the Hill’s Floor Watch blog reports. The Medicare Part B fix expires at the end of this month unless Congress takes action before then. Upon expiration, Medicare Part B payments to doctors will drop by around 20%.  There is a bipartisan fix on the table but how to pay for the fix remains an open question. The Congress always can kick the can down the road so the issue can be taken up in a lame duck session following the mid-term elections in early November. The Medicare Part B fix has a big FEHBP impact for two reasons. One, there is a large cadre of FEHBP annuitants with primary Medicare Part B coverage, and two, fee for service plans under the FEHB Act pay doctors for services rendered to annuitants over age 65 who have declined Medicare Part B using the Medicare schedule.

Drug Channels.net has an interesting report on the specialty pharmacy business. Specialty pharmacy are biologic or large molecule drugs that require special pharmacy handling because, for example, they often are injectables.  Biologic drugs are more expensive than small molecule / traditional drugs because the FDA still has not created a regulatory pathway for the approval of bio-similar drugs akin to small molecule generics. Drug Channels research

research shows a booming market:

• In 2013, retail, mail, and specialty pharmacies dispensed about $63 billion in specialty pharmaceuticals.
• Specialty drugs accounted for 22% of total pharmacy industry revenues.
• Three companies—Express Scripts, CVS Caremark, and Walgreens—accounted for 63% of revenues from pharmacy-dispensed specialty drugs. The next three largest players had a combined share of about 5%.

Specialty drugs also are dispensed in doctors’ offices and clinics.

Here are a couple of tid bits that caught the FEHBlog’s attention:

• Two major drug manufacturers — Ranbaxy in India and Pfizer here in the good old USA — have recalled drugs due to distribution mix-ups. How often does that happen?
• Healthday is reporting that  “A blood test has been developed that can predict with 90 percent certainty whether a senior will suffer from dementia within the next few years, researchers report.” Fingers crossed that the blood test could help researchers determine the cause of this disease. The Washington Post reported last week that “Alzheimer’s disease likely plays a much larger role in the deaths of older Americans than is reported, according to a new study that says the disease may be the third-leading cause of death in the United States.”

Following up on the CMS’s administrator’s ICD-10 or bust comments at the HIMSS conference last week, the American Medical Association is begging CMS for an ICD-10 contingency plan. Medical Economics reports that 

The President issued his FY 2015 budget proposal today. The Office of Personnel Management’s proposed budget include the following legislative initiatives that the agency also suggested last year:

The health insurance marketplace has changed significantly since the FEHBP was enacted in 1959 and the current governing statute leaves little flexibility for the program to evolve with the changing market. The 2015 budget proposes that beginning in 2016: domestic partners of Federal employees and new retirees would be eligible for health benefits; OPM would be authorized to contract with modern types of health plans rather than being limited to the current four statutorily-defined plans reflective of the 1950s insurance market; OPM would be authorized to contract separately for pharmacy benefit management services; and OPM would be given authority to make adjustments to premiums based on an enrollee’s tobacco use and/or participation in a wellness program.

Well, the FEHBlog was out of town this weekend, and his schedule was discombobulated this morning by winter storm Titan. So the FEHBlog posted the key weekend update this morning and now wants to add a few more points.

The FEHBlog received a tip from his friend and colleague Theresa Defino that on February 18, 2014, the Congressional Research Service issued not one but two FEHBP related reports.  The first is a report on the transition of members of Congress and their official staffs from FEHBP coverage to DC gold level SHOP exchange coverage.  The second is an updated report on law affecting the FEHBP or as the FEHBlog calls it “Thanks for the memories.”

Today, the consulting firm Truven Health Analytics released the results of its annual survey of top 100 hospitals. Check your PPO lists! One local hospital made the list, the Virginia Hospital Center in Arlington, VA. The Truven press release explains that

“Employers and payers are increasingly seeking network hospitals that consistently provide demonstrated value — hospitals that deliver higher quality, higher satisfaction and lower cost. The 100 Top Hospitals have been objectively proven to provide high value, and the majority of them have demonstrated year-over-year increased value, as well,” said Jean Chenoweth, Truven Health Analytics senior vice president, 100 Top Hospitals Programs. “The results show 100 Top Hospitals to be strong, well-managed hospitals with consistently high performance. This year, 59 percent of the 2014 100 Top Hospitals were winners last year. In 2013, 51 percent were repeat winners; in 2012, 42 percent were repeat winners.”

The FEHBlog also was reminded today that the Choosing Wisely campaign which OPM has endorsed is continually updating its member medical association lists of medically unnecessary procedures. The most recent posts were from the American Geriatrics Society and the American Academy of Allergy, Asthma, and Immunology.

The Obama Administration is expected to release its FY 2015 budget proposal tomorrow. Federal New Radio reports that OPM’s Director hinted on Friday about OPM initiatives in that proposal which focus on employee training. Congress is in session this week, and the Hill’s Floor Blog reports that major Congressional committees will be questioning Administration officials about their budget proposals.

Moreover, TGI the end of February.

Recently, the FEHBlog wrote about a New York Times article concerning a study on the value of mammography.  A Wall Street Journal op-ed by two physicians explaining that

Every three or four years, a “new” announcement about the usefulness of mammograms leads to a flurry of news reports. Most recently making the rounds is an update of one Canadian study that suggested mammograms do not reduce breast cancer mortality. [The study discussed in the NY Times article.] Mammogram studies continue to yield competing results, which has led some countries such as Switzerland to discontinue recommending their regular use. Women are left to worry whether to undergo a procedure debated among doctors, expert panels and advocacy groups.
The confusion and angst are unnecessary. Women can find relief in reviewing what we already know about mammography: Screening works for all women 50 to 74, helping to reduce breast-cancer mortality and making treatment less onerous. Given the current data for women under 50, any age to begin mammographic screening will be controversial, but at least to us, starting at 45 seems to be a reasonable compromise.

The FEHBlog discussed the New York Times article with his doctor earlier this week and his doctor made the same point.  The FEHBlog’s concern is that the ACA’s preventive care mandate like mandates is not sufficiently flexible given the science (about which the FEHBlog claims no expertise).

In recognition of the HIMSS conference The FEHBlog also wrote last Sunday about a Wall Street Journal op-ed about advances in digital medicine — virtual doctor apps. He noticed a letter to the editor from a Portland Oregon doctor who makes the point in response to this op-ed that

The things that enhance and maintain our health that have been proven effective for decades are, not surprisingly, very low-tech efforts: Eat a low-fat diet, maintain a nonobese body weight, don’t smoke, use alcohol only in moderation and exercise daily. 

Personal responsibility is key, and it cannot be mandated.

Finally, the FEHBlog was heartened by a Wall Street Journal story published today about a teenage girl, Elana Simon, the daughter of a medical researcher, successfully helped research her own disease, a rare form of cancer.

When she turned 16, she landed an internship at a lab at Mount Sinai School of Medicine in New York through a science program at the Dalton School, a private school in Manhattan where she is a student. “I wanted to go off and be my own scientist,” she said of the idea, which she pursued without consulting her father.
Her project: to compare genetic data sequenced from tissue from eight pancreatic cancer patients to hunt for mutations that might separate cancerous samples from normal ones. But the tissue was from older patients who through normal aging had accumulated thousands of harmless mutations that made spotting one or two potentially meaningful ones difficult.
For Ms. Simon, a light went on. Younger people have far fewer potentially confounding mutations. Maybe performing a similar study on tissue from young fibrolamellar patients [her disease] would yield the genetic secrets of the disease.

First, he expected that OPM would implement the self plus one option for the FEHBP which Congress OKed in December for 2015 because after all it was OPM’s idea. Wrong. The Washington Post reports this morning that OPM will postpone implementation of the self plus one option to 2016.

Second, he expected that the Centers for Medicare and Medicaid Services would give health care providers some leeway on the October 1, 2014, compliance date for the ICD-10 code set, particularly given the AMA’s Twitter campaign.  Wrong again. Information Week reports from the HIMSS Conference that

The ICD-10 deadline will not change, the administrator of the Centers for Medicare and Medicaid Services [Marilyn Tavenner] told HIMSS14 attendees at a keynote on Thursday.

* * *
“There are no more delays and the system will go live on Oct 1. Let’s face it guys, we’ve already delayed it several times and it’s time to move on. It’s a standard in the rest of the world,” said Tavenner.
CMS won’t offer a 90-day window where it operates both ICD-9 and ICD-10, something several health IT professionals requested. Their fear: Hospitals won’t receive Medicare or Medicaid payments on time.
“The onus is going to fall on healthcare facilities, not the government. A three-month window is not unreasonable, given the amount of data involved,” said one clinical engineer manager from a Texas hospital who asked not to be named. “Anything would be better than, ‘Hey, we’re going live on Oct. 1.'” 

The federal government evidently plans to give us another train wreck on the first anniversary of the healthcare.gov failed launch.

Accordingly the FEHBlog is on the market for a new crystal ball.