As the FEHBlog mentioned on Sunday, the big HIMSS conference is underway this week in Orlando. Aetna’s CEO Mark Bertolini gave the first keynote speech. According to Healthcare Informatics   Mr. Bertolini  spoke about the need for payment reform, taking care of the chronically ill better, investing in wellness for the next 25-30 years and reducing waste in healthcare in order to control health care spending. Agreed.  The head of CMS Marilyn Tavenner speaks tomorrow but Modern Healthcare reports that she likely will not give any ICD-10 extension to the medical community. The Orlando Sentinel reports on some of the healthcare technology shown off at HIMSS, including one of OPM’s favorites, the Blue Button Connector.

Picking up on one of Mr. Bertolini’s points, the Wall Street Journal discussed various initiatives to create transparency in healthcare pricing. The article notes one the initiative that the FEHBlog likes — reference pricing:  

“[R]eference pricing” has yielded some savings. Where local prices differ substantially for a service like a colonoscopy, an insurer publishes a list of providers’ rates and agrees to pay a set amount. If patients choose a provider that charges more, they must pay the difference themselves.
In one pilot project, the California Public Employees’ Retirement System, found prices for hip and knee replacements ranging from $15,000 to $110,000 in the San Francisco area. It agreed to pay up to $30,000, and some 40 hospitals cut their prices to match. Such initiatives have helped Calpers save nearly $3 million in the past two years, one study found.

The Wall Street Journal and the Philadelphia Inquirer reported on the results of the first large scale study of patient centered medical homes. The FEHBlog thinks that PCMHs which involve greater coordination of primary care make sense but the study found “almost no benefits.”  Nevertheless, it’s not a matter of going back to the drawing board because according to the stories the PCMHs were making improvements to their operations as the study progressed. So perhaps this is just a baseline. The Wall Street Journal points out that the study may have focused too heavily on whether the PCMH achieved NCQA accreditation.

Speaking of medical homes, USA Today reports that the pediatrics association is complaining that convenient pharmacy based clinics are interfering with doctors’ medical home efforts. More likely the clinics are hitting the pediatricians bottom line but if this study creates better communication between the clinics which aren’t going away and the doctors offices all the better.

Finally the Wall Street Journal published a great article on how people can avoid falls in later years by improving their balance in young adulthood.  The article includes tips for older folks like the FEHBlog too. It’s important information because

In the U.S., falls are the leading cause of injury for people over 65, according to a 2005 report by the Centers for Disease Control and Prevention. Every 17 seconds, someone in this age group is treated in an emergency room for a fall. Every 30 minutes, one will die from injuries caused by falling.

On the health care quality front, the Centers for Medicare and Medicaid Services added quality measure scores related to the treatment of diabetes and heart disease for 66 group practices and 141 accountable care organizations to its Physician Compare website. Here are links to Modern Healthcare and Kaiser Health News reports on this development. Here is a link to the quality reporting page on the Physician Compare website.

This coming week, the big healthcare technology conference known as HIMSS will be held down in Orlando. As if to kick off that conference, yesterday’s Wall Street Journal offered an op-ed on digital medicine which included the following prognostications:

In a very real sense, your smartphone, loaded with a heuristic medical algorithm, is poised to become an avatar physician. You wake up at 3 a.m. on Christmas morning with a bout of chest pain. Your smartphone reads your ECG and reassures you that you are not having a heart attack—or tells you to call an ambulance and places the call, meanwhile instantly transmitting all the data to a hospital ER. And while you are at the hospital receiving treatment or care, your avatar doctor remains at your side as a constant adviser and ombudsman.
In the very near future, your avatar doctor may be able to warn you days in advance that you are going to have a heart attack by sensing certain genomic signals circulating in your blood stream and sending you to your cardiologist or to the ER. It can tell you if that sore throat you feel coming on is strep, and if it is, automatically send a prescription by email to the local pharmacy for an appropriate antibiotic. And with so many routine exams, labs, and aches and pains and handled by the avatar, your flesh-and-blood primary care physicians will have more time to talk to you when you do need to see them.
The other large benefit from this new world of digital medicine will come in lower costs. 

Hope springs eternal.

Mark the tape! Yesterday, the Affordable Care Act regulators issued a final rule on the law’s maximum 90 day waiting period for initial health insurance coverage. Compliance with this rule is not an FEHBP concern because FEHBP coverage begins on the first day of the first pay period after the employee’s SF 2809 enrollment form is received by the employing agency.  What’s remarkable is that this rule eliminates at the end of this year the long standing obligation imposed on health plans to providing terminating members with a HIPAA certificate of creditable coverage that could be used to reduce or eliminate a successor group health plan’s pre-existing condition limitation period. In the new ACA world, there are no pre-existing condition limitations. You have to wonder why the agencies did not terminate this burden as of the end of last year, but no one should look a gift horse in the mouth.  For once, the ACA reduces an administrative burden on health plans.

Yesterday evening, HHS’s Office for Civil Rights issued lengthy informal guidance on the HIPAA Privacy Rule and sharing information related to mental health. The FEHBlog found the information to be accurate and believes that OCR’s heart is in the right place. But the advice includes so many qualifications that he doubts that simply issuing the advice will open the information spigot to family members and friends. It’s always easier for the provider to clam up.

The Advisory Board reports on an AHRQ study that identifies the five costliest surgical procedures in 2011

•Heart valve procedures ($53,400 per hospital stay)
•Coronary artery bypass graft ($38,700);
•Small bowel resection ($34,500);
•Procedures related to cardiac pacemakers or cardioverters ($33,200); and
•Spinal fusion ($27,600).

According to the AHRQ study, “the average hospital stay with an OR procedure costs $3,300 per day and lasts about five days. By comparison, a hospital stay with no OR procedure costs an average of $1,700 per day and lasts about 4.4 days.”  Over 15.6 million surgeries were performed in U.S. hospitals in 2011. Cost curve up.

USA Today reports that the flu is hitting younger adults harder than seniors and children this year due to a lower vaccination rate for that group. “The good news was that this season’s flu vaccine did a good job. Being vaccinated reduced the chance of having to go to the doctor for the flu by about 60%, the CDC reported. That effectiveness rate is comparable with previous years. The CDC recommends that everyone 6 months and older get an annual flu vaccine.”  Of course, there is no enrollee cost sharing for a flu vaccination administered in-network under the ACA.

The press has been following up on CVS’s decision to stop selling tobacco products on October 1. Fierce Healthpayer predicts that CVS is trying to gain an edge over Walgreen’s in their battle to serve Accountable Care Organizations (“ACOs”). “ACOs predominately use primary care doctors, nurse practitioners and pharmacists, including those employed by CVS and other chain stores, to reach out to patients about their care and medications with the goal of reducing overall healthcare utilization.”  Health Data Management discusses several other pharmacy chain initiatives designed to burnish their credentials as health care providers. The FEHBlog’s interest was picqued by this statement in that report:

In January, HealthSpot, of Dublin, Ohio, introduced a walk-in telehealth kiosk that brings live video chats with physicians to retail clinics. The kiosk is outfitted with medical devices to take vital signs and other basic readings, then beam the data over the Internet to the remote doctor.

According to Healthspot’s CEO who was quoted in the article Healthspot may be announcing partnerships with at least one major pharmacy chain next month.

Also on the technology front, Modern Healthcare reports this afternoon that the Centers for Medicare and Medicaid Services evidently in response to industry and Congressional pressure plans to run Medicare claims with ICD-10 codes through “end to end” testing   End to end “testing will allow the participating providers and suppliers to submit test claims to the CMS with ICD-10 codes and receive a remittance advice explaining how the claims were processed, according to the CMS.”  “Notice of the testing program for ‘a small sample group of providers,’ was posted to the CMS’ Medical Learning Network newsletter.

The Workgroup for Electronic Data Interchange has posted a succinct white paper for health care providers and payers on the unsecured protected health information breach process.

Finally, health plans get ready to expand your list of medically unnecessary procedures.  Fierce Healthcare reports that “Healthcare providers could significantly reduce costs if they eschew five low-value, often unnecessary emergency medicine procedures, according to a new study published in JAMA Internal Medicine.” Here are that study’s top five:

•  Post-traumatic computed tomography (CT [or CAT scan]) of the cervical spine for patients who are not high-risk;

•  CT of the head for mild traumatic head injury patients who are not high-risk;

•  Use of CT to diagnose pulmonary embolism without first assessing patient risk;

•  Anticoagulation studies for patients who do not have hemorrhage or suspected clotting disorder; and

•  Magnetic resonance imaging (MRI) of the lumbar spine for lower back pain among patients who do not have high-risk features.

Happy Presidents’ Day. At lunch today, the FEHBlog learned to his great surprise that for official federal government purposes (5 U.S.C. § 6103(a)) today is Washington’s Birthday, not Presidents’s Day. Live and learn. Congress is not in session this week.

The Wall Street Journal, the New York Times, and others are reporting an investment group lead by former AIG CEO Maurice Greenberg is planning to purchase Multiplan from its current investment group owners for around $4.4 billion.  Multiplan is a preferred provider network developer and administrator. In the last decade, another independent PPO network vendor, PHCS, was merged into Multiplan. Several FEHB plans use Multiplan as a secondary network.

Following up on FEHBlog post last week about the ICD-10 code set, EHR Intelligence writes about the American Medical Association’s latest efforts against the code set, including a twitter campaign and another letter to the HHS Secretary. The Washington Post featured a humorous article about the code set yesterday titled “When squirrels attack, there’s a medical code for that.”  The article explains that

Two key factors help explain the explosion in medical codes. First, ICD-10 adds in the ability to differentiate between left and right sides of the body. This can help insurers, for example, to root out fraud. A hip replacement on both the left and right side might not raise any red flags — but two hip replacements on the left side probably would.
Second, the new codes categorize whether a trip to the hospital was the first round of treatment or a subsequent encounter. This is important for reimbursement purposes, as first visits to the doctor tend to require more resources.

That’s a pretty weak justification for this enormous expense. FYI, people do receive replacement hip transplants.

The Hill reports that Senate followed the House’s lead yesterday by passing a bill to suspend the federal debt ceiling until March 15, 2015. The next deadline which impacts the FEHBP is the March 31, 2014, expiration date for the current Medicare Part B fix. Congress has settled upon a solution to the problem but has not announced how they plan to pay for the solution. Modern Healthcare has more on this issue here.  

Health Data Management reports that the American Medical Association is taking asking the Secretary of Health and Human Services to reconsider the looming ICD-10 code set compliance date.  Under HIPAA, health plans must implement electronic claims transaction changes mandated by HHS like the ICD-10 code set.  The ICD is a code set that all healthcare providers use to provide diagnosis codes on electronic health claims and hospitals also use to provide procedure codes on those claims. The current ICD-9 uses five digit codes. The ICD-10 uses 6 digit codes. Just adding a digit to a field can be expensive. However, the digit was added in order to permit the explosion of codes and that explosion requires more system reprogramming and retraining for coders.

Health plans have spent millions on implementing the ICD-10, and HHS has extended this compliance date once from October 1, 2013, to October 1, 2014. HHS’s principal stick is that larger medical offices must submit claims electronically to Medicare, and HHS has said that Medicare will reject electronic claims with ICD-9 codes for services provided on or after October 1, 2014.  Smaller practices can use paper claims but HHS has changed the paper claim form so that providers can fill in the ICD-10.  It’s a mess. The FEHBlog does expect that HHS will delay the Medicare claim rejection date for a few months when push comes to shove later this year.

The New York Times reports that a large scale, longitudinal study that evenly split 90,000 participating women between breast exam and mammogram screening groups over a 25 year period found equivalent results in terms of identifying breast cancer and death rates. “The death rate from breast cancer was the same in both groups, but 1 in 424 women who had mammograms received unnecessary cancer treatment, including surgery, chemotheraphy, and radiation.” The article concludes

In the United States, about 37 million mammograms are performed annually at a cost of about $100 per mammogram. Nearly three-quarters of women age 40 and over say they had a mammogram in the past year. More than 90 percent of women ages 50 to 69 in several European countries have had at least one mammogram.
Dr. Kalager, whose editorial accompanying the study was titled “Too Much Mammography,” compared mammography to prostate-specific antigen screening for prostate cancer, using data from pooled analyses of clinical trials. It turned out that the two screening tests were almost identical in their overdiagnosis rate and had almost the same slight reduction in breast or prostate deaths.
“I was very surprised,” Dr. Kalager said. She had assumed that the evidence for mammography must be stronger since most countries support mammography screening and most discourage PSA screening.

The FEHBlog’s concern is that the ACA’s “free” preventive care mandate politicizes the practice of medicine even more than it had been.

Health insurers, including FEHB plans, must implement and report on NCQA HEDIS quality metrics, but so do health care providers. A pediatrician writing in the Wall Street Journal this morning reports on quality metric overload.

There are certainly good metrics. “Med reconciliation,” reviewing and updating medication lists when a patient meets with a physician, is well-accepted as a good metric. But many other measures have little bearing on improving patient health. Would you rather your doctor won the “quality” contest by doing good list management and robust box checking or spent that time listening to you?

Word.

These are not exactly tidbits, but I like the title.

In an unexpected denouement, discretion being the better part of valor, the House of Representative just voted to suspend the federal debt ceiling until March 15, 2015, according to the Hill.  The Senate is expected to approve the measure tomorrow, and the threat of a government shutdown vanishes for a year or so.

The FEHBlog nearly fell off his chair yesterday when the Internal Revenue Service announced a further delay of the employer shared responsibility mandate. The employer shared responsibility / pay or play mandate is the part of the Affordable Care Act that applies to employers with 50 or more full time employees. Full time for purposes of this law is considered to average 30 rather than 37.5 or 40 hours per week.  Such a large employer’s failure to offer minimum essential coverage to at least 95% of its full time employees would subject the employer to a $2,000 per employee (over the first thirty) penalty. (Of course as with all things ACA there are more penalties but let’s just stick with this one.)  On July 3, 2013, the IRS delayed the effective date for this mandate from January 1, 2014, to January 1, 2015

The FEHBlog had expected OPM to lead the way by expanding FEHBP coverage to federal and postal employees who work on average more than 30 hours per week but are not eligible for contributory FEHBP coverage for 2014, notwithstanding the delay. OPM evidently did not have the resources for this initiative as it was engaged in expanding the FEHBP to Indian tribal employers and adding multi-state plans to the health insurance exchanges. But the FEHBlog notes that OPM has undertaken efforts to so expand the FEHBP for 2015.

Now the IRS has said that employer with 100 or more full time employees do not have to comply with the full employer shared responsibility mandate until 2016 if they cover 70% of their full time workforce in 2015 (and then 95% in 2016).  This mandate is hideously complicated by considerations of temporary and seasonal employees, etc. The bottom line here is that the IRS has allowed OPM a grace period of another year. We will have to wait and see whether or not OPM accepts the offer.

The IRS also extended another year’s grace period to all employers with 50 more but less than 100 employees. Here is a link to the IRS’s Qs & As on the final employer shared mandate rule and here’s a link to the 227 page rule if like the FEHBlog you are a glutton for punishment.

Congress is in session this coming week. However, according to the Hill’s Floor Action blog, it’s unlikely that Congress will resolve the debt ceiling this week due to scheduling issues. The Politico notes that Congress recesses this week on Wednesday, then takes a week off and comes back Feb. 25 — just two days ahead of the [the Treasury Secretary’s debt ceiling increase] deadline.

The FEHBlog ran across (via twitter of all things) this interesting Businessweek chart suggesting that the reported demise on independent medical practices is in error. “The share of self-employed doctors has leveled off at around 60%.” That’s down from 75% from thirty years ago but much higher than Accenture’s prediction that the self-employed doctor percentage would be at 36% in 2013.

The FEHBlog also found this Drugchannels.net article about the “explosive” growth of specialty drug pharmacies.  Specialty drug pharmacies dispense expensive “large molecule” biotech drugs which often are injectable or infused and require special handling. According to the article,

In 2008, only two companies—CuraScript (4 locations) and Optum Rx (2 locations)—had achieved [URAC] “Full Accreditation.”  As of December 2013, 59 companies with 114 specialty pharmacy locations had achieved “Full Accreditation” from URAC. An additional 51 companies are “In Process” and will likely be accredited shortly. 

Despite the accreditation boom, market share for dispensing specialty drugs remains highly concentrated—for now. (See New Drug Channels Institute Study Finds Three Companies Dominate Specialty Pharmacy, Identifies Key Trends Affecting Profitability.) The specialty industry is becoming much more competitive, which will compress margins for undifferentiated pharmacies.

Cost curve up.

The FEHBlog just watched his beloved UConn Huskies men’s basketball team lose a heartbreaker to Cincinnati. But the FEHBlog has a lot of news to share so he has to soldier on.

The FEHBlog was too pessimistic about Congress reaching an agreement on the Medicare Part B fix. The House and Senate announced today a bipartisan measure to repeal and replace the faulty sustainable growth rate (“SGR”) formula that is used to calculate Medicare Part B payments to doctors. According to Medpage, the pay go funding for the bill has not been worked out yet. But there’s reportedly a lot of confidence that this issue will be resolved too.

According to the Congressional press release, the bill would

• Repeal the SGR and end the annual threat to seniors’ care, while instituting a 0.5 percent payment update for five years.
• Improve the fee-for-service system by streamlining Medicare’s existing web of quality programs into one value-based performance program. It increases payment accuracy and encourages physicians to adopt proven practices.
• Incentivize movement to alternative payment models to encourage doctors and providers to focus more on coordination and prevention to improve quality and reduce costs.
• Make Medicare more transparent by giving patients more access to information and supplying doctors with data they can use to improve care.

(1) expressly allows [federally regulated / most medical] labs to provide patients direct access to their lab test results and (2) requires labs covered under HIPAA [again practically all medical labs] to provide test results directly to patients in the form or format requested, (i.e., paper or electronic) if it is readily producible in that manner.
Today, patients’ access to clinical lab information is determined by the states. Only seven states and the District of Columbia allow such direct reporting and thirteen states prohibit it. Twenty-three states have no laws addressing the issue. The new rules will preempt state laws and regulations that prohibit medical laboratories from providing patients access to their test reports.

The federal debt ceiling will be reimposed on Friday and the Treasury Secretary has advised that extraordinary measures to avoid a default will not last beyond late February due to the need to make tax refund payments. The Hill and Politico are reporting that the House leadership is not planning on a fight with the President over a debt ceiling increase. The Politico suggests that House leadership may try to attach an extension of the Medicare Part B payment fix from March 31 to December 31, 2014.

Progress is being made on a bill to repeal and replace the statutory sustainable growth rate formula that is the cause of the Medicare Part B payment fix. The fly in the ointment (besides finding the funding) is the fact that the legislator who is leading these negotiations, Sen. Max Baucus (D Mont), is expected to be confirmed as the next U.S. Ambassador to China tomorrow. Therefore he will be leaving the Senate and the country soon. Bloomberg reports that Sen. Ron Wyden (D Ore.) will replace Sen. Baucus as the chair of the Senate Finance Committee. In any event, the FEHBlog expects peaceful resolutions of these issues as we head toward the November elections.