Robert Pear in the New York Times has an interesting piece today discussing the consequences of OPM’s decision to provide Members of Congress and their official staff members with a government contribution for health insurance exchange coverage beginning next year. As Mr. Pear points out, a defect in the law and related regulation is the expectation these all of these folks to receive exchange coverage. However the exchanges are designed and priced to cover people under age 65. This cadre no doubt includes many people over age 65. The ACA anticipates that people aged 65 and older will receive Medicare coverage. Time will tell.

Earlier this year, the ACA regulators created a transitional safe harbor for complying with the ACA’s new out-of-pocket maximums.  The regulators are permitting plans that use a separate prescription manager, for example, to have separate out-of-pocket maximums for medical and prescription drug benefits. The consumer groups objected to the decision. Modern Healthcare reports that the ACA regulators have told the consumer groups to pound sand.

Modern Healthcare also is reporting that CMS is increasing pressure on health insurers to comply with the HIPAA 270 and 271 standard electronic transactions which are eligibility inquiries. Apparently there is a large insurer that is not cutting the mustard, as they say.

Finally voluntary.com has posted a Healthpocket.com list of the top 10 procedures not covered by health insurance. No big surprises in the list.

This morning OPM issued a proposed rule together with a Fact Sheet, Qs & As and a Benefit Administration Letter which “details how Members of Congress and Congressional Staff will be insured through the Health Insurance Exchanges” in 2014. OPM will continue to make a pre-tax government contribution toward exchange coverage based on FEHBA, rules and affected individuals can carry their exchange coverage over into retirement with the government contribution. OPM will allowed Congressional offices flexibility in designating personal (or official) staff members subject to this requirement.

In a related development, Sen. Tom Coburn removed the hold that he had placed on Senate consideration of the President’s nominee for OPM Director, Katherine Archuleta, according to the Federal Times.

Congress has adjourned until the week after Labor Day when it returns to address appropriations for the federal fiscal year that begins on October 1.  Before leaving DC, the Chairman and Ranking Member of the Senate Homeland Security and Governmental Affairs Committee, Sens. Tom Carper (D Del) and Tom Coburn (R Okla) introduced a postal reform bill .  Federal New Radio reports on highlights of the bill, which include changes that affect the FEHBP.

Reginfo.gov informs us that OPM submitted its 2014 Congressional coverage proposed rule (mentioned in Friday’s post) to OMB on Friday August 2.  OMB has at least 30 days to conduct its review but this puppy is on track to be issued this week as the White House was involved in developing the rule.

Also on Friday CMS released its final Medicare Part A inpatient prospective payment system (“IPPS”) rule for fiscal year 2014.  This massive rule making details the changes in the Medicare program’s payments to hospitals beginning October 1, 2013. “The final rule would increase IPPS operating rates by 0.7 percent after accounting for inflation and other adjustments required by the law.”  The rule also changes the readmission penalty program as follows:

In October 2012, Medicare began encouraging to hospitals with excess 30-day readmissions to lower 30-day readmission rates for heart attack, heart failure, and pneumonia patients by reducing a portion of the hospital’s payments by up to one percent, depending on their performance on key readmissions measures. As required by law, the FY 2014 IPPS rule increases the maximum reduction of payments to up to two percent.  It adds hip and knee surgery and chronic obstructive pulmonary disease to the list of conditions used to determine the reduction, effective in FY 2015.  CMS has increased the number and types of planned readmissions that no longer count against a hospital’s readmission rate.  

Kaiser Health News details the impact of the penalty program on hospitals. The total penalty is $227 million for the next federal fiscal year.  The penalty will be imposed on 2,225 hospitals, about the same number as last year.  The average penalty will drop nationally from .42% to .38%.  “Unlike other new programs created by the federal health law, the
readmissions program offers hospitals no rewards for improvements or the
opportunity to opt out.”  

The IPPS rule also implements a change in approach to coverage of hospital observation services. Those services generally are considered outpatient care covered by Medicare Part B. Under the new rule certain observation stays spanning two midnights will be considered an inpatient stay covered by Medicare Part A. BNA and Kaiser Health News report on an HHS Inspector General report on this practice issued last week.

Following up on the mid-week update, the New York Times (and Politico) reports today that

The Obama administration told Congress on Thursday that it would allow the federal government to continue paying a large share of the cost of health insurance for members of Congress and their aides, averting a problem for many who work on Capitol Hill.
However, under the arrangement, lawmakers and many of their aides will have to get coverage through new health insurance marketplaces, or exchanges, being set up in every state.

This means that over 10,000 FEHBP enrollees will be leaving for the exchanges in January. Congress will not lose all interest in the FEHBP because the FEHBlog expects that the OPM rule will allow these people being booted out of the FEHBP to retain their right to FEHBP coverage at retirement (assuming five years of FEHBP or exchange coverage immediately pre-retirement). .

OPM is expected to issue a proposed rule next week.   Reginfo.gov does not show the rule having arrived at OMB for review yet but these ACA rules can move through OMB quickly plus the White House was involved in this matter.

Better late than never. The ACA regulators finally have issued their 2013 CLAS County Data List. The introduction to the list explains that

PHS Act section 2719 requires non-grandfathered group health plans and health insurance issuers offering non-grandfathered health insurance coverage to provide relevant notices in a culturally and linguistically appropriate manner. The regulations implementing section 2719 require these plans and issuers to make certain accommodations for notices sent to an address in a county meeting a threshold percentage of people who are literate only in the same non-English language. This threshold percentage is set at 10 percent or more of the population residing in the claimant’s county, as determined based on American Community Survey (ACS) data published by the United States Census Bureau. 26 C.F.R. § 54.9815-2719T, 29 C.F.R. § 2590.715-2719, and 45 C.F.R. § 147.136.

It would be more helpful if the list identified changes from 2012. In any event, nationwide plans tend to provide these translation services nationwide.

Finally, Mass Device reports that a “Washington, D.C., cardiologist was hit with a $17 million [False Claims Act] judgment after being found [liable for] submitting false claims for nuclear imaging tests to Medicare and state health programs — plus our beloved FEHBP! Here’s a link to the U.S. Attorney’s press release.

Have a good weekend.

Last Spring, the New York Times magazine featured an article titled “Our Feel Good War on Breast Cancer” The article addressed the problems created by overdiagnosis.

Many of those women [who undergo mammography] are told they have something called ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the milk-producing ducts. Before universal screening, D.C.I.S. was rare. Now D.C.I.S. and the less common lobular carcinoma in situ account for about a quarter of new breast-cancer cases — some 60,000 a year. In situ cancers are more prevalent among women in their 40s. By 2020, according to the National Institutes of Health’s estimate, more than one million American women will be living with a D.C.I.S. diagnosis.

D.C.I.S. survivors are celebrated at pink-ribbon events as triumphs of early detection: theirs was an easily treatable disease with a nearly 100 percent 10-year survival rate. The thing is, in most cases (estimates vary widely between 50 and 80 percent) D.C.I.S. will stay right where it is — “in situ” means “in place.” Unless it develops into invasive cancer, D.C.I.S. lacks the capacity to spread beyond the breast, so it will not become lethal. Autopsies have shown that as many as 14 percent of women who died of something other than breast cancer unknowingly had D.C.I.S.

There is as yet no sure way to tell which D.C.I.S. will turn into invasive cancer, so every instance is treated as if it is potentially life-threatening. 

I was reminded of this article when I saw articles such as this one from CNN pop up this week reporting that the medical community (and specifically a National Cancer Institute working group) is exploring the idea of redefining certain cancers in order to alleviate this type of problem.

Meanwhile Healthline reports that the U.S. Preventive Services Task Force has decided that asymptomatic tobacco smokers over the age of 55 should undergo an annual low dose CT scan to screen for the early stages of lung lung cancer. The CNN article notes that this is an example of focused not overtesting but it’s certainly cost curve up. This USPTF decision requires FEHB plans to cover such testing with no enrollee cost sharing beginning in 2015. (USPSTF recommendation changes to FEHB plan benefits take effect on the first day of the plan year that begins on or after the date that is one year after the date the recommendation or guideline is issued.)

Following up to the Weekend Update, the FEHBlog notes that last Thursday the Senate Appropriations Committee approved an FY 2014 financial service and general government administration bill for full Senate consideration by a 16-14 vote. The bill includes that routine FEHBP appropriation provisions exempting FEHBP contracts from full cost accounting standards coverage and adding a contraceptives coverage mandate. The Senate bill does not include the abortion coverage restriction found in the House bill but that provision historically winds up in the approved legislation when the House and Senate leaders confab.

OPM has posted a webpage full of benefit guides for federal employees, U.S. Postal Service employees, and Tribal employees.

OPM is getting ready for the 2014 Open Season this fall. It has begin to circulate benefit administration letters. The FEHBlog thinks that its worth posting this OPM attachment with frequently asked questions about certain services and another OPM attachment with a Venn diagram aligning and contrasting FEHBP, FEDVIP, and FSAFEDs benefits.

Congress remains at work in Washington this week before taking its August recess.  The Hill’s Floor Watch has more details.

AHIP posted an infographic from the Agency for Healthcare Research and Quality showing 30-day readmission rates to U.S. hospitals. “Of particular note: the privately insured have lower readmission rates than Medicare and Medicaid beneficiaries.”  OPM has been encouraging FEHB plans to take steps to reduce 30 day hospital readmission rates.

 Kaiser Health News reports that the ACA “boost status of alternative medicine — at least on paper.” The article discusses how California and a few other states are requiring patients to pay out of pocket for chiropractic care next year, notwithstanding the new Public Health Service Act § 2706 discussed in ACA FAQ XII.  The ACA regulators punted on this provision, declining to issue an implementing rule because in the FEHBlog’s view it’s a political hot potato. The American Medical Association detests it while the alternative provider associations love it.  No doubt the lawyers will love it too as the controversy will spur litigation.

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Here are a few interesting studies and tools for weekend reflection:

Fierce Healthcare reports that a study published in the Mayo Clinic Proceedings identified 146 contemporary medical interventions that either are ineffective or do patients more harm than good.  Health plans get ready to expand your list of medically unnecessary procedures.

The list of medical “reversals” includes:
 • Screening and treating for asymptomatic bacteriuria in women with diabetes–While recommended in the United States, this study found the practice did not reduce complications.
 • Anticonvulsant drugs during pregnancy–Despite doubts in medical textbooks, the study found anticonvulsants taken during pregnancy increase the risk of fetal malformation.
 • Prone positioning in ventilated patients with acute lung injury–As utilization increases, this study found no proof of prone position’s survival benefit compared to the supine position.
 • Anti-arrhythmic drugs for rate and rhythm control in patients with atrial fibrillation–The study failed to prove treating patients with atrial fibrillation with costly anti-arrhythmic drugs to maintain sinus rhythm improves survival.
 • Percutaneous coronary intervention for treatment of multivessel disease–PCI has been increasingly used to treat multivessel disease but, according to the study, coronary-artery bypass grafting is still superior.

The Leapfrog Group has created an online tool that allows health plans, employers, and other purchasers to calculate the surcharge they pay as a result of hospital errors.

According to InsuranceNewsNet.comhttp://insurancenewsnet.com/oarticle/2013/07/26/20-episodes-drive-employer-health-costs-a-388447.html?lifehealth#.UfKN7W39x8E, Truven Health Analytics, an actuarial consulting firm, has determined that twenty specific “medical episodes” account for 41% of overall growth in employer healthcare spending.

According to the company, the study examined medical claims data for over 8 million commercially insured individuals under the age of 65 from 2006 to 2011, including those covered by large employers who are self-insured. It found that during the five year period, employer healthcare costs increased by an average of 4.3 percent per year, driven by spending on preventive health services; osteoarthritis (except spine); multiple sclerosis; childbirth (Cesarean section); and complications of surgical and medical care. The majority of spending growth was driven by an increase in the cost per case, primarily attributable to medical and surgical procedures. Other cost drivers that show up in the data are the steadily increasing cost of specialty drugs and the ongoing obesity epidemic, which is an underlying driver of many of the diseases noted in the report. 

Finally, the Society for Human Resource Management has posted a report with suggested best practices for wellness program design. Have a good weekend.

While trolling the internet for tidbits to post, the FEHBlog noticed that the Obama Administration released its Spring 2013 unified regulatory agenda earlier this month. Of note is that OPM is working on the following proposed rules for the FEHB and FEDVIP programs:

FEHBP; Tribes and Tribal Organizations 3206-AM40
FEHBP; Disputed Claims and External Review Requirements 3206-AM42
FEHBP: Miscellaneous Changes Proposed by the Affordable Care Act 3206-AM46
Federal Employees Dental and Vision Insurance Program: Miscellaneous Changes 3206-AM57
FEHBP  Members of Congress and Congressional Staff 3206-AM85

OPM has been developing the second and third rules for several rotations of the unified agenda in the FEHBlog’s recollection.  The last rule is the eagerly anticipated rule explaining what happens when members of Congress and their personal staff members (about 10,000 people) are booted out of the FEHBP at the end of this year. OPM projects (and these projections are unreliable) that this rule will be published in October after the exchange open enrollment period begins.

OPM is preparing to finalize the following rules:

FEHBP Coverage for Certain Firefighters 3206-AM66
FEHBP Coverage for Certain Intermittent Employees 3206-AM74
FEHBP Eligibility Expansion to Certain Temporary and Seasonal Employees 3206-AM86
FEHBP and FEDVIP Coverage of Children Federal Flexible Benefits Plan: Pre-Tax Payment of Health Benefits Premiums 3206-AM55

The last rule is one proposed last year to extend coverage to the children of same sex domestic partners based on step child status. OPM projects that it will finalize that rule in September 2009.

The FEHBlog notes with interest that there is no rulemaking case at the proposed (or final) stage for extending coverage to employees who qualify as full time employees (work on average 30 hours or more per week). Although the employer mandate penalties have been postponed until 2015, the FEHBlog expected OPM to take the lead by extending coveragee to this group for 2014.  Evidently, that’s not the case.

Standard and Poor’s recently released its May 2013 healthcare cost indices.

All nine S&P Healthcare Economic Indices showed lower annual growth rates for May 2013 compared to April 2013. As measured by the S&P Healthcare Economic Commercial Index, healthcare costs covered by commercial insurance plans rose by 4.34% in May, down from +4.59% reported in April. Annual growth rates  in Medicare costs increased by 0.85% in May, according to the S&P Healthcare Economic Medicare Index, down from a +1.07% rate recorded last month.

Also of note, less than one month after the Supreme Court declared Section 3 of the Defense of Marriage Act unconstitutional, a federal district court in Ohio has overridden Section 2 of that law in a temporary restraining order granted to a gay couple who had married in Maryland.  Maryland recognizes same sex marriage but Ohio doesn’t.. Section 2 provides that a state is not obligated to give full faith and credit to a same sex marriage officiated in another state. The Washington Post provides more details.  The FEHBlog bets the ranch that the Supreme Court will find Section 2 (the only remaining substantive provision of DOMA) unconstitutional when given the opportunity. Section 2 is particularly problematic because states have residency requirements for divorce (which was not the issue in this case).  While on the topic Business Insurance notes that OPM was first out of the gate in providing definitive guidance implementing the Supreme Court’s decision. Business Insurance reports that “The American Benefits Council has urged federal regulators to update employers on benefit plan changes they must make in light of the U.S. Supreme Court’s partial overturning of the Defense of Marriage Act.”  Good for OPM.

Since the early 1990’s Medicare has paid doctors based on a resource based relative value schedule (“RBRVS”) developed at Harvard.  Congress sets the dollar value that is multiplied times the scheduled value — the product essentially is the Medicare payment. In the late 1990s Congress adopted the flawed sustainable rate of growth (“SGR”) formula, The SGR for the past decade has produced doctor pay cuts that Congress has overridden.

California Healthline reports that last week a bipartisan doctor fix was introduced in Congress. “Under the new bipartisan draft proposal [in lieu of the SGR], Medicare physician reimbursements would grow by 0.5% annually over five years. Starting in 2019, Medicare would switch to an enhanced fee-for-service system that would provide physicians with updates and payment incentives based on their performance on certain quality measures.”  Now Congress has to figure out how to pay for the fix — $139 billion over 10 years.  Congress has until the end of this year to pass a permanent or temporary fix.

The FEHBlog was flabberghasted today by a lengthy Washington Post article that everyone should read.  It turns out that after Congress adopted the RBRVS the AMA offered to update the RBRVS annually at no cost to the Government. This is the same AMA that sued the dickens out of United Healthcare and its then Ingenix subsidiary for maintaining a usual, customary, and reasonable charges database used to pay out-of-network providers. The Washington Post reports that

Unknown to most, a single committee of the AMA, the chief lobbying group for physicians, meets confidentially every year to come up with values for most of the services a doctor performs

Those values are required under federal law to be based on the time and intensity of the procedures. The values, in turn, determine what Medicare and most private insurers pay doctors.

But the AMA’s estimates of the time involved in many procedures are exaggerated, sometimes by as much as 100 percent, according to an analysis of doctors’ time, as well as interviews and reviews of medical journals.

Between 2003 and 2013, the AMA and Medicare have increased the work values for 68 percent of the 5,700 codes analyzed by The Post, while decreasing them for only 10 percent.

While advances in technology and skill should have reduced the amount of work required, the average work value for a code rose 7 percent over that decade, largely because officials raised the value of doctors’ visits. The rise came in addition to allowances for inflation and other economic factors.

When discussing the rise in the nation’s bills for physicians, AMA officials note that they only assign points to procedures — so the Medicare bill depends upon how much the federal government decides to spend for each point.