Both Houses of Congress are in session this week. Last week the House of Representatives passed a continuing resolution bill (H.R. 933) that will fund the federal government through the fiscal year end (September 30, 2013) subject to the current sequestration with a few exceptions as the Hill explains

The bill is a continuing resolution for most federal agencies, but for the Defense Department (DOD) and Department of Veterans Affairs, it includes a full appropriations bill. That language gives the DOD some flexibility in dealing with the sequester, by shifting $10.4 billion to the operations and maintenance budget.
The bill tries to cushion the effects of sequestration in some non-military areas. It adds $2 billion for embassy security in the wake of last September’s attacks on the U.S. Consulate in Benghazi, Libya, and provides $363 million more for nuclear security and $129 million more for FBI salaries, among other things.
It also includes other policy mandates, including a prohibition on the use of funds to move Guantánamo Bay detainees to the United States and a freeze on federal worker pay.

According to the Hill’s Floor Watch, the Senate takes up the House bill this week in an effort to avoid the government shutdown that would occur if an impasse occurred. The Federal Times offers more perspective on the Senate’s efforts here.

In the good old days, OPM ran the FEHBP. However, particularly since enactment of the Affordable Care Act, OPM has shares that role with the three ACA regulators, HHS, the Labor Department and the Internal Revenue Service. Hence, it’s worth noting on the FEHBlog that President Obama according to the Washington Post and other sources is prepared to nominate Thomas Perez, the assistant U.S. Attorney General for civil rights, to be the Labor Secretary, replacing Hilda Solis who recently resigned.

In that regard, the FEHBlog further notes that last Friday, the Labor Department issued lucky ACA FAQ XIII which concerns the application of the ACA to expatriate plans.

Finally last week the National Business Group on Health released the 18th annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care.  The survey finds that

The best performers had an average health care cost increase of 1.7% in 2012, less than half the median increase and roughly in line with the general inflation trend. In 2013, this group took a number of significant steps to improve the efficiency of their health care programs. They:

• Consolidated vendors to improve delivery and coordination of health management programs, while also taking steps to incent providers to invest in new technologies to improve the coordination of care
• Focused more on communication to help employees make smarter health care decisions, leveraging popular culture technology like social media to make sure they have the best information on health care providers available
• Stepped up emphasis on transparency in provider prices as well as quality and results
• Invested in case management to more proactively and effectively manage their high-cost cases
• Placed more responsibility on employees, tying financial incentives to measurable improvements in their health, and extended incentives to spouses
• Started implementing new payment methods to providers, placing greater responsibility on them to deliver high-quality, efficient care.

FEHB plans which rank among these best performers use all of these strategies except for placing more responsibility on employees principally because of a statutory and thus inflexible government contribution formula.

The FEHBlog forgot to mention two items in last night’s post:

• Yesterday, Express Scripts, the large prescription drug manager, released its 2012 Drug Trend report which found that for the first time in 20 years the level of spending on traditional / small molecule prescription drugs decreased in 2012 compared to 2011 largely due to an explosion of brand name to generic conversions in block buster drugs like Lipitor. However, the level of spending on specialty / large molecule drugs continues to increase in part because there is still no regulatory pathway to generic or biosimilar versions of these specialty drugs. The European Union created such a pathway about ten years ago. The ACA gave the FDA the greenlight to create such a pathway here. Almost three years later, no such pathway has been established. 
• The Labor Department has created an ACA self-compliance tool for health plans. The tool illustrates the delightful complexity of the ACA. 

The Washington Post reports today that OPM Director John Berry is the leading candidate to be the U.S. Ambassador to Australia. Mr. Berry had been considered a candidate for Interior Secretary but he was not selected for that position.

The Hill’s Healthwatch reports on today’s House Ways and Means Committee hearing on Affordable Care Act taxes. Rep. Charles Boustany (R La.) explained his plan to include the repeal of the medical device tax and the health insurer fee as part of broader tax reform.   The article concludes that Repealing any of the healthcare law’s taxes would increase the deficit. The device tax is set to generate about $20 billion over the next decade, while the tax on insurance plans will raise roughly $100 billion.” Will someone pleae explain to the FEHBlog how imposing these onerous taxes — which will be passed onto consumers — can make healthcare more affordable?

The AMA News reports that the Department of Health and Human Services has informed the American Medical Association that there will be no more extensions of the ICD-10 coding initiative’s October 1, 2014, compliance date. The FEHBlog sympathsizes with the AMA because the ICD-10 coding initiative will do nothing to speed electronic claims transactions — the objective of HIPAA — but the AMA should have tried to block this change at the end of the last decade and not after the final rule came out. Health plans already have spent millions of dollars coming into compliance with this rule.

Finally, the Chicago Tribune reports on an AMA Journal study about a mortality index developed for people older than 50 (which cadre includes the FEHBlog). “The researchers created the index by analyzing data on almost 20,000 Americans over 50 who took part in a national health survey in 1998. They tracked the participants for 10 years. Nearly 6,000 participants died during that time.” The researchers expect that doctors will administer the index and use the results to advise patients on course of treatments for chronic illnesses.

The House and the Senate will be in session this week according to the Hill’s Floor Action blog. On Tuesday morning, the House Ways and Means Committee’s oversight subcommittee will hold a hearing on the plethora of taxes created by the Affordable Care Act.

The Wall Street Journal published an article about OPM’s multi-state plan regulation in its weekend paper (in the FEHBlog’s view the best newspaper issue from week to week). Here’s the skinny:

Cigna Corp. said it has opted not to apply to be one of the national-plan carriers, saying it “does not align with our focused approach,” according to a spokesman.

Spokesmen for UnitedHealth Group Inc. and Aetna Inc. both said this past week that their companies were still reviewing the multistate plan opportunity. A spokeswoman for the Blue Cross Blue Shield Association said that Blues plans in the states were interested in banding together to try to become the nonprofit plan, with some coordination from the association.

OPM posted a notice explaining how to apply to become a multi-state plan carriers on the fedbizopps.gov website about six weeks ago. OPM also has an MSPP website here.

The Wall Street Journal also published an article about ongoing negotiations between insurers planning to participate in the exchanges / marketplaces and health care providers. Shockingly, the article reports that consumers are sensitive to premiums and for that reason the insurers are looking for deeper discounts in return for offering narrow provider networks.   “Plans with smaller choices of health-care providers are a big focus for insurers, partly because many other aspects of exchange plans, including benefits and out-of-pocket charges that consumers pay, are largely prescribed by the law, giving them few levers to push to reduce premiums.”  The FEHBlog expects this trend to pop up in the FEHBP as the ACA continues to roll out.

The FEHBlog was intrigued by a Wall Street Journal article about innovative pharmacy chain practices designed to make healthcare more widely available. For example,

Rite Aid Corp. will open 58 stores, across four markets, which contain in-store clinics providing virtual doctor visits conducted via Web camera. The walk-in clinics—which charge patients $45 for a 10-minute chat with a doctor on a computer monitor—will be rolled out Friday in Baltimore, Boston, Philadelphia and Pittsburgh. Previously, Rite Aid had piloted the virtual clinics in nine stores in the Detroit area.

No doubt health plans will be covering these virtual office visits.

Finally Kaiser Health News reports on “a study, published Thursday by the National Institute for Health Care Reform, researchers found that while so-called “scope of practice” laws did not appear to restrict the primary care services nurse practitioners can provide to patients, they do affect how the advanced nurses are paid.”  In a nutshell, health plans pay less to nurse practitioners in states which effectively require the plan also to pay a doctor for supervisory services.

Four major ACA regulations were issued today. The first two impact the FEHBP.

The Internal Revenue Service issued a proposed rule implementing the health insurer fee (Internal Revenue Code § 9010). When you see your health insurance premiums increase significantly next year, don’t blame the sequestration, blame this fee which for 2014 allocates $8 billion across all lines of health, dental and vision insurance, including insured FEHB plans. The fee increases annually thereafter. The fee is expected to add 2% to premiums next year according to AHIP.

The Department of  Health and Human Services issued its final 2014 parameters notice which provides guidance on the transitional reinsurance fund fee. The fee expected to be $63 per belly button (excluding annuitants with primary Medicare coverage) in 2014 is imposed on all health plans, including FEHB plans, to provide a reinsurance fund for qualified health plans operating in the health insurance exchanges next year and reimburse the Treasury for the $5 billion spent on the ACA’s early retiree reinsurance program. Ironically, FEHB plans which are loaded with early retirees were prohibited from participating in this program but are being required to refund the appropriations. This assessment sunsets after 2016 (unless Congress changes the law.)  Cost curve up.

The Office of Personnel Management released its final rule governing the multi-state plan program. The ACA expects OPM to contract with at least two carriers to sponsor multi-state plans in the health insurance exchanges. Lifehealthpro.com reports on the final rule here.

The Department of Health and Human Services also released a proposed rule governing an adjunct to the health insurance exchanges for small businesses called the SHOP program. The Hill explains that “Through the SHOP system, workers will be able to compare plans side-by-side, and employers will have the option of making a monthly payment to SHOP rather than multiple insurance plans.”

Following up on Friday’s post about the CDC’s Solving the Outbreak app, the FEHBlog has learned that the app is only available for the Ipad. You can’t play it on your smart phone.

Last week, Standard & Poors released its latests Healthcare Economic Indices:

All nine S&P Healthcare Economic Indices posted deceleration in their annual growth rates in December 2012. As measured by the S&P Healthcare Economic Commercial Index, healthcare costs covered by commercial insurance plans increased by 5.39% over the year ending December 2012, down from +6.19% reported for November 2012. Annual growth rates in Medicare claim costs rose by 1.20%, according to the S&P Healthcare Economic Medicare Index, down from +1.81% recorded in November 2012. It is the lowest growth rate in the history of the Medicare Index.

Following along with the healthcare costs topic, the FEHBlog ran across this California Healthline story about a series of Congressional Budget Office reports with health care cost projections.

Business Insurance reports that Aetna and CIGNA announced the results of studies finding that employers
sponsoring consumer-directed health plans have been substantially more
successful in controlling medical costs than traditional HMO and PPO
plans over the past several years.

Not surprisingly as well Modern Healthcare reports that the mental health parity act caused mental health care treatment costs to increase according to a Healthcare Cost Institute study. “The results, an analysis of five years of mental health and substance abuse spending by four giant insurers, found hospitalization for mental illness increased 5.9% in 2011 from the prior year. Substance abuse hospital stays increased 19.5% in the same period.”

Finally Truven Health Analytics released its report of the 100 top hospitals in the U.S. Two hospitals in the Washington DC metropolitan area, Virginia Hospital Center and Fair Oaks INOVA Hospital, made the list.

Both Houses of Congress will be in session this coming week. The Hill’s closer look at next week is here.  The Senate Homeland and Govermental Affairs Committee recently announced its subcommittee structure. Here’s the blurb on the subcommittee with FEHB Program oversight responsibilities:

The Subcommittee on the Efficiency and Effectiveness of Federal Programs and the Federal Workforce, under the Chairmanship of Jon Tester (D-Mont.) and Ranking Member Rob Portman (R-Ohio), will oversee the management, efficiency, effectiveness and economy of all agencies and departments in the federal government, including the federal workforce and federal programs. The subcommittee has a broad authority for conducting oversight across the federal government and for seeking to improve the efficiency of federal programs. In addition, the Subcommittee is responsible for exploring policies that promote a skilled, efficient and effective federal workforce which will, in turn, work to ensure efficient and effective management of federal programs.

The full Committee will hold an organizational business meeting on Tuesday.  On the House side, the Energy and Commerce Health Subcommittee will hold a hearing this Wednesday on fostering innovation to curb fraud, waste, and abuse in health care.

Federal News Radio reported last week that OPM Associate Director for Human Resources Nancy Kichak resigned last month. Ms. Kichak for many years was the FEHB Program’s chief actuary and she performed admirably in that capacity. The FEHBlog is sure that OPM will miss her.

Finally, take a look at this AMA News article about the difficulties that doctors face in getting patients to adopt good health care habits. The article describes a technique called “motivational interviewing.”

The FEHBlog hopes the everyone enjoys the FEHBlog’s new look and its updated / corrected links. Following up on the mid-week post, here’s a link to the CMS press release about the essential benefits rule. The press release illustrates the fact that the rule covers a lot of ground beyond essential health benefits. HHS released more ACA rules today that principally concern the individual and small group markets.

The FEHBlog wishes to clarify that the out of pocket maximum discussed in the last post applies only to in-network coverage.  This OOP maximum applies to all in-network deductibles, co-payments, and co-insurance – including Rx benefits, but not premiums. The ACA’s OOP maximum is in fact the same OOP maximum that currently applies to high deductible health plans. The 2013 HDHP maximums are $6250 self only and $12,500 self and family. The IRS will update these amounts for 2014 in May 2013.

The IRS’s latest ACA FAQ XII issued on Wednesday also addresses the scope of the ACA’s often vague preventive care mandate. For example,

Q15: Do the HRSA Guidelines include contraceptive methods that are generally available over-the-counter (OTC), such as contraceptive sponges and spermicides?
Contraceptive methods that are generally available OTC are only included if the method is both A15 FDA-approved and prescribed for a woman by her health care provider. The HRSA Guidelines do not include contraception for men.

Fierce Health.com featured an interesting story headlined “Patients opt for expensive care when given a choice.

Based on interviews with 22 focus groups of insured people, researchers found four barriers to patients considering lower-cost care options, according to the study abstract:

• Patient preference for what they perceive as the best care, regardless of expense
• Inexperience with making trade-offs between health and money
• Disinterest in costs borne by insurers and society as a wholePeople’s tendency to act in their own self-interest despite recognizing they are depleting limited resources

That’s disturbing. Thank heavens then for the Choosing Wisely campaign which applies evidence based medicine to encourage doctors to eliminate unnecessary tests and procedures. Choosing Wisely came out with a new set of recommendations. For example one of those recommendation is to not to automatically use CT scans to evaluate children’s mild head injuries (observe first) and another is to schedule non-medically indicated inductions or C-sections before the 39th week of pregnancy, which also is an OPM initiative   Good work. Moreover, the Leapfrog Group reported yesterday that

the national rate of early elective deliveries dropped for the second year, according to data submitted to its annual Leapfrog Hospital Survey.

 Early elective deliveries – performing elective inductions or cesarean procedures prior to 39 completed weeks gestation without medical necessity – have been decreasing since 2010 when the Leapfrog Group became the first to publicly report hospital rates. This year, 46% of the 773 reporting hospitals met Leapfrog’s early elective deliveries target rate of less than 5%, an increase from 39% in 2011. Data from the Leapfrog Hospital Survey is the only national source of this data by hospital.

Finally, if you have some free time this week, you might want to try out the CDC’s new “’Solve the Outbreak’” app which allows mobile device gamers to fight one of three fictional outbreaks as an investigator in the agency’s Epidemic Intelligence Service,” according to Modern Healthcare. Now there’s a sequestration target for you.

Following up on Sunday’s FEHBlog about the sequestration, the Washington Post’s Federal Eye published a column discussing the latest Simpson / Bowle’s recommendations on cutting the deficit. Former Sen. Alan Simpson and Clinton White House chief of staff Erskine Bowles chaired a Presidential Commission in 2010 whose report was ignored but they keep trying. Anyway, the Federal Eye comments on the first report’s proposal to try out the premium support approach with the FEHBP.  Simpson / Bowles and House Budget Chairman Paul Ryan also have suggested using the defined premium approach for Medicare.

The FEHBP has used a defined contribution approach to setting the Government contribution in one form or other since its inception. Until about 15 years ago, the FEHB Act included a so-called Big Six formula which was 60% of the average of the Big Six plans (two government wide plans, two largest employee organization plans, and two largest HMOs). Since the FEHBA Act has included a so-called Fair Share formula which is 72% of the enrollment weighted average premium. The difference between premium support and the status quo is that premium support would be adjusted by an economic inflation factor rather than a plan premium adjustment factor. The outcome of premium support would be to accelerate the move of enrollees into lower cost plans.

2014 continues to be shaping up to be a year of steep premium increases for all health plans, including FEHB plans, due to Affordable Health Care Act mandates.  HHS unveiled the latest mandate yesterday — the final essential health benefits rule. The Wall Street Journal reports that

If anything, the final regulations released Wednesday beefed up the requirements for certain services beyond what regulators proposed in November. Neil Trautwein, a vice president at the National Retail Federation, said language regarding the scope of mental-health service that insurance plans must cover appears stronger than previously proposed.
“Just because you require an insurance plan to cover it doesn’t mean you can buy that coverage,” said Katie Mahoney, executive director, health policy at the U.S. Chamber of Commerce. Insurance plans offered by most large employers aren’t affected by the requirements.

While employer sponsored plans including the FEHBP are directly subject to these requirements. Those plans cannot impose annual or lifetime dollar limitations on those essential benefits.  The FEHBP already is in compliance with this rule. However, brand new DOL ACA FAQ XII explains that the rule turns the screw a little tighter by apply a new out of pocket maximum to all group health plans for 2014.

The Washington Post’s head scratching tribute to President James A. Garfield this morning caused the FEHBlog to think let’s pay tribute to the great American leader (WWII General of the Armies and President) who signed the Federal Employees Health Benefits Act into law in 1959, President Dwight D. Eisenhower (Sept. 28, 1959, Pub. L. No. 86–382).  A short, practical law that has stood the test of time.